Running head: REDUCING PAIN USING DISTRACTION TECHNIQUES 1

Pain Reduction in Pediatric Patients using Distraction Techniques

Christine Olinger

University of South Florida

REDUCING PAIN USING DISTRACTION TECHNIQUES 2

Abstract

Clinical Problem: Pediatric patients who undergo painful procedures are at risk for future

physical and psychological results if the treatment of their pain is not timely and effective

(Gamze & Sevil, 2019).

Objective: The objective of this synthesis is to discuss the use of various non-pharmacological

distraction techniques as a method of reducing pain in pediatric patients undergoing a painful

procedure. PubMed was used as a method of searching randomized controlled trials (RCT) that

studied the use of distraction techniques to reduce pain in pediatric patients. Terms that were key

to finding relevant studies were distraction techniques, pediatric patients, non-pharmacological,

and pain.

Results: During painful procedures, pediatric patients who receive non-pharmacologic distraction

techniques present with statistically significant reduced levels of pain compared to patients who

did not receive distraction techniques. Binay, Bilsin, Gerceker, & Bal-Yilmaz (2019)

demonstrated a decrease in pain felt by patients who received external cold and vibration and

blew soap bubbles (p<.05). Gamze & Sevil (2019) demonstrated a decrease in pain felt by

patients who watched cartoon movies, played video games or had parental-support during the

procedure (p<.05). Karakaya & Gozen (2016) demonstrated a decrease in pain felt by patients

who were distracted using a kaleidoscope during the procedure (p=.001).

Conclusion: Distraction techniques when used on pediatric patients, are a non-pharmacological,

effective method that can be utilized to reduce pain felt during painful procedures. Even though

non-pharmacological distraction techniques have been shown to reduce pain felt by pediatric

patients undergoing painful procedures, research must be done to determine which distraction
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technique is the most effective. Additionally, future research is warranted in which all

participants are exposed to the same level of distraction.

Running head: REDUCING PAIN USING DISTRACTION TECHNIQUES 4

Pain Reduction in Pediatric Patients Using Distraction Techniques

Physical and psychological impairments can be a long-term result of pain that is not

treated quickly and effectively (Gamze & Sevil, 2019). Reducing the pain felt during a minor

procedure can ultimately establish pediatric patients’ acceptance of health care and how they will

react to future procedures that are more painful (Karakaya & Gozen, 2016). The use of non-

pharmacologic methods has been the preferred choice for distraction techniques as they have

been found to be as effective in reducing pain and produce minimal side effects compared to

pharmacologic methods (Binay, Bilsin, Gerceker, Kahraman, & Bal-Yilmaz, 2019). Overall, the

use of non-pharmacological distraction techniques may be an effective method of reducing pain

during procedures. In pediatric patients, how does using distraction techniques, compared to not

using distraction techniques, affect pain reduction, during painful procedures?

Literature Search

PubMed was the source that presented the most relevant RCT related to distraction

techniques for pain reduction. Key terms that were searched to find these trials included

distraction techniques, pediatric patients, non-pharmacological, and pain. The range of

publication years was from 2014 to 2019.

Literature Review

Three RCTs were accessed to examine the usefulness of using distraction techniques to

reduce pain in pediatric patients undergoing a painful procedure. No set guidelines have been

created for this intervention. Binay et al. (2019) demonstrated that external cold and vibration

and blowing soap bubbles reduced pain felt by pediatric patients during phlebotomy. The sample

size was 129 children, aged three to six years old. The sample group was randomly divided into

the external cold and vibration group (n=42), the blowing soap bubbles group (n=43), and the
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control group (n=44). The participants in the external cold and vibration group had a Buzzy Bee

placed on the arm while receiving the phlebotomy procedure, the blowing soap bubbles group

were given a bubble machine in the hand of the arm not receiving phlebotomy, and the control

group was not given any interventions. Pain levels were measured using the Wong-Baker Faces

Pain Rating Scale (W-BFS). The W-BFS was used to assess the pain felt in the patients during

the phlebotomy procedure. Data was collected over four months. The researchers concluded that

the pain scores measured in the two experimental groups were significantly lower than the pain

scores in the control group (p<.05). Strengths of this study included the randomization of group

placement for all participants, the study was single-blinded from the providers, participants were

analyzed in the group to which they were randomly assigned, the control group was appropriate,

and measures used were valid and reliable. All participants had similar baseline data and

demographics, and children were excluded from the study if they did not agree to participate, had

a chronic or genital/congenital disease, had an unsuccessful phlebotomy attempt, or had missing

data. Weaknesses of the study included patients and providers were not blind to the intervention

being used, and no follow up assessments took place.

Gamze et al. (2019) demonstrated that using video games, cartoon movies, or parent-

supported distraction was effective in reducing pain and anxiety in children receiving

venipuncture. The sample size was 180 children, aged six to ten years old. The sample was

divided randomly into four groups including: video games group (n=45), cartoon movie group

(n=45), parent-supported distraction group (n=45), and control group (n=45). Participants in the

video games group were given a video game to play with one hand, the cartoon movie group

watched funny animated films, the parent-supported distraction group used the patients mothers

to talk to their children about anything that would hold their attention during the procedure, and
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the control group did not have any distraction method. The Children’s Fear Scale (CFS)

measured anxiety levels in the participants before and during the procedure, and the W-BFS was

used to determine the level of pain felt during the venipuncture. Data was collected over four

months. There was a significant decrease in pain and anxiety felt by participants between using

the distraction methods when compared to the control group with no distractions (p<.05).

Strengths of this study included the randomization of all participants placed in their groups, the

assignments were first concealed to all participants and providers, participants were analyzed in

the groups to which they were randomly assigned, the control group was appropriate, and the

measures used were valid and reliable. The patients all had similar demographics and baseline

data, and any unwilling patients and their families were excluded from the study as to not skew

the results. Weaknesses of this study included patients and providers were not blind to which

intervention was being used, and that no follow up assessments occurred.

Karakaya et al. (2016) demonstrated that the use of a kaleidoscope as a non-

pharmacological distraction technique in children receiving a short-term painful procedure

was effective when attempting to minimize pain. The sample size was 144 children, aged

seven to twelve years old. Of these children, the participants who met the criteria to be

included were divided into two groups that consisted of the experimental group (n=72) and

the control group (n=72). Participants included in the experimental group were handed a

kaleidoscope to look through while receiving the venipuncture and did not hold their

mothers’ hand. The children in the control group practiced the routine method of just having

the mother hold their hand. Before the procedure, the participants were educated on the Faces

Pain Scale-Revised (FPS-R) and assessed their current level of pain, then were assessed for a

fever, and had their heart rate and oxygen saturation measured. After the procedure, children
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in both groups marked their pain on the FPS-R and had their heart rate and oxygen saturation

measured again. Data was collected over four months. The final report of the study stated

that pain felt in the experimental group was significantly lower than in the control group

(p=.001). Strengths of the study included the random group assignment for each participant,

each participant was analyzed in the group to which they were randomly assigned, the

control group was appropriate, and the measures used were valid and reliable. All

participants had similar baseline data and demographics, and children were excluded from

the study if they had a venipuncture in the last six months, had a chronic disease, had pain

before the procedure, took an analgesic in the last six hours, or had a fever. Weaknesses of

the study included lack of description of whether the participants and providers were blind to

their placement as well as non-blinding to which intervention they were receiving, and no

follow up assessments taking place.

Hua et al. (2015) demonstrated that virtual reality as a method of distraction significantly

reduced the pain felt by pediatric patients with chronic lower limb wounds during dressing

changes. The sample size was 65 children, aged four to sixteen years old. This group was then

divided into the experimental group (n=33) and the control group (n=32). Participants who were

included in the experimental group were given virtual reality equipment and were initially

assessed for pain before, during and after the procedure. The control group was given standard

methods such as parental comforting, toys, books, and television. Before, during, and after the

procedure, the children were assessed for pain using W-BFS, visual analogue scale (VAS), and

the Face, Legs, Activity, Cry, Consolability pain behavior scale (FLACC). Data was collected

over 12 months. Children distracted with virtual reality felt significantly less pain than children

in the control group (p=.034). Strengths of the study included the random assignment of each
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participant into their group, every participant was analyzed in the group to which they were

randomly assigned, the control group was appropriate, and each measure used was reliable and

valid. Although patients had different types of chronic leg wounds, it was determined that each

participant had similar baseline data and demographics, and children were excluded from the

study if they had visual or auditory disabilities, a diagnosed illness, had taken a sedative, or had

wounds that needed surgical intervention. Weaknesses of the study included the participants and

providers blind during the randomization or blinded to the intervention that was being used, nor

were there any follow up assessments.

Synthesis

Binay et al. (2019) presented that pediatric patients who received a method of distraction

experienced significantly less pain during phlebotomy than patients in the control group (p<.05).

Similarly, Gamze et al. (2019) presented that pain and anxiety felt by pediatric patients during

venipuncture was significantly reduced through the use of distraction techniques compared to the

control group (p<.05). Karakaya et al. (2016) presented pain felt by pediatric patients during

short-term painful procedures can be reduced using distraction techniques when compared

against the control group (p=.001). Hua et al. (2015) presented that through using a distraction

method, pain felt by pediatric patients during dressing changes was reduced significantly

compared to patients in the control group (p=.034).

Weaknesses of all four of these studies was the difference in the pediatric patients’

experience with similar painful procedures. For a majority of the patients used in each study, it

was not their first time receiving the procedure, which may have affected their overall reaction to

the pain that they felt. Prior experience with the expected pain felt during these procedures could

skew results as they could have higher anxiety along with the pain. Therefore, further studies are
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needed in order to more appropriately analyze how distraction techniques reduce pain felt in

patients who are undergoing a procedure for the first time. Additionally, there are currently no

proper guidelines to administering a distraction technique, such as when to begin using

distraction and when to stop it at the end of the procedure. Finally, studies need to be completed

regarding which technique is the most effective.

Clinical Recommendations

The research presented suggests that non-pharmacological distraction techniques as a

method to reduce pain in pediatric patients receiving a painful procedure may be highly

effective. No guidelines have been created regarding the use of distraction techniques to reduce

pain; however, they produce no side effects, and are a non-invasive method that does not require

medications. These methods are useful in patients who are alert and who have no visual or

auditory disabilities. This research validates that using distraction techniques on pediatric

patients can reduce the amount of pain felt during a painful procedure (Binay et al., 2019; Gamze

et al., 2019; Karakaya et al., 2016; Hua et al., 2015). Clinical practice should change to reduce

pain by incorporating the use of non-pharmacological distraction techniques that are catered to

the individual needs of pediatric patients who are undergoing painful procedures.
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References

Binay, S., Bilsin, E., Gerceker, G., Kahraman, A., & Bal-Yilmaz, I. (2019). Comparison of the

effectiveness of two different methods of decreasing pain during phlebotomy in children:

A randomized control trial. Journal of PeriAnesthesia Nursing, 35(2), 140-147. doi:

10.1097/AJP.0000000000000666

Gamze, I., & Sevil, I. (2019). The impact of 3 different distraction techniques on the pain and

anxiety levels of children during venipuncture. The Clinical Journal of Pain, 35(2), 140-

147. doi: 10.1097/AJP.0000000000000666

Hua, Y., Qiu, R., Yao, W., Zhang, Q., & Chen, X. (2015). The effect of virtual reality distraction

on pain relief during dressing changes in children with chronic wounds on lower limbs.

Pain Management Nursing, 16(5), 685-691. doi: 10.1016/j.pmn.2015.03.001

Karakaya, A., & Gozen, D. (2016). The effect of distraction on pain level felt by school-

age children during venipuncture procedure – Randomized control trial. Pain

Management Nursing, 17(1), 47-53. doi: 10.1016/j.pmn.2015.08.005