Distraction methods for pain relief of cancer children submitted to
               painful procedures: systematic review

Ferreira, Elaine Barros; Cruz, Flávia Oliveira de Almeida Marques da; Silveira, Renata Cristina de Campos Pereira; Reis, Paula Elaine Diniz dos

doi:10.5935/1806-0013.20150028

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REVIEW ARTICLES • Rev. dor 16 (2) • Jan-Mar 2015 • https://doi.org/10.5935/1806-0013.20150028 copy

Distraction methods for pain relief of cancer children submitted to painful procedures: systematic review^* * Received from University of Brasília, School of Health Sciences, Nursing Department, Brasília, DF, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND AND OBJECTIVES:

Pain is one of the most persistent cancer symptoms. Non-pharmacological therapies are potential sources for cancer children care and should be considered alternatives for handling cancer signs and symptoms. This study aimed at identifying effective distraction interventions for pain relief and control of cancer children submitted to invasive procedures.

This is a systematic review carried out in electronic databases LILACS, CINAHL, CENTRAL Cochrane Library and Pubmed, using the combination of controlled and uncontrolled keywords: child, pain, cancer and distraction. Ten studies were identified addressing distraction as intervention for venous, muscle and subcutaneous punctures, and procedures related to bone marrow aspiration and lumbar puncture.

CONCLUSION:

Among identified interventions, there are virtual reality, practices such as blowing soap bubbles, use of warm pillows, party blower, electronic toys, among other selfselected interventions (music, games, books). Most interventions are easy to implement considering their low cost and are useful for health professionals looking at enhancing pediatric patients’ assistance with regard to pain management.

Keywords:
Child; Children care; Pain; Pediatrics; Tumors

Authors	JADAD	Sample size	Age group	Invasive procedure	Distraction intervention	Evaluation scales	Objective
Heden, Von Essen, & Ljungman¹²12 Hedén L, Von Essen L, Ljungman G. Randomized interventions for needle procedures in children with cancer. Eur J Cancer Care. 2009;18(4):358-63.	3 Study not described as double-blind	n=28 n=14 Intervention group blowing soap bubbles n=14 Intervention group warm pad	2 to 7 years	S u b c u t a - neous puncture for TI- -CVC acess	blowing soap bubbles Warm pad	VAS	To evaluate whether children had less fear, distress and pain at routine puncture when submitted to some interventions: blowing soap bubbles our warm pad, as compared to usual established care.
W i n d i c h --Biermeier, Sj o b e rg, Dale, et al.¹³13 Windich-Biermeier A, Sjoberg I, Dale JC, Eshelman D, Guzzetta CE. Effects of distraction on pain, fear, and distress during venous port access and venipuncture in children and adolescents with cancer. J Pediatr Oncol Nurs. 2007;24(1):8-19.	2 Study not described as double-blind. No description of removal and waiver of the sample.	n=50 n=28 Control group n=22 Intervention group	5 to 1 8 years	S u b c u t a-neous puncture for TI--CVC access and venous puncture	Self-selected interventions, among them: bubbles, chal-l e n g i n g book, virtual reality glasses or portable games	CAS Glasses Fear Scale OSBD	To evaluate the effect of self-selected distractions on pain, fear and distress in cancer children and adolescents submitted to procedures such as venous access, via subcutaneous puncture, to TI-CVC or venous punctures.
Wol itzky, Fivush, Zi-mand, et al.¹⁴14 Wolitzky K, Fivush R, Zimand E, Hodges L, Rothbaum BO. Effectiveness of virtual reality distraction during a painful medical procedure in pediatric oncology patients. Psychol Health. 2005;20(6):817-24.	2 Study not described as double-blind. No description of randomization method.	n=20 n=10 Experimental group -Virtual reality n=10 Control group	7 to 1 4 years	S u b c u t a-neous puncture for TI--CVC access	Virtual reality	VAS H o w-1 - Feel Questionnaire Heart rate CHEOPS	To evaluate the effectiveness of virtual reality as behavioral intervention to decrease distress during TI-CVC access procedure.
G e rs h o n , Z i m a n d , Pickering,et al.¹⁵15 Gershon J, Zimand E, Pickering M, Rothbaum BO, Hodges L. A pilot and feasibility study of virtual reality as a distraction for children with cancer. J Am Acad Child Adolesc Psychiatry. 2004;43(10):1243-9.	2 Study not described as double-blind. No description of removal and waiver of the sample.	n=59 n=22 Virtual reality distraction n=22 Control group w/o distraction n=15 distraction w/o virtual reality	7 to 1 9 years	S u b c u t a-neous puncture for TI--CVC access	Virtual reality	VAS Heart rate CHEOPS	To observe the feasibility of a new technology to decrease anxiety and pain associated to invasive procedures in cancer children.
Authors	JADAD	Sample size	Age group	Invasive procedure	Distraction intervention	Evaluation scales	Objective
Dahlquist, P e n dley, Landthrip,et al.¹⁶16 Dahlquist LM, Pendley JS, Landthrip DS, Jones CL, Steuber CP. Distraction intervention for preschoolers undergoing intramuscular injections and subcutaneous port access. Health Psychol. 2002;21(1):94-9.	2 Study not described as double-blind. No description of randomization method.	n=29 No description of sample of each group.	2 to 5 years	Su bcuta-neous puncture for TI--CVC access and muscle injections	Electronic toy	OSBD	To evaluate a distraction intervention developed to decrease distress of pre-school children submitted to repeated chemotherapy injections.
Broome, Rehwaldt & Fogg¹⁷17 Broome ME, Rehwaldt M, Fogg L. Relationships between cognitive behavioral techniques, temperament, observed distress, and pain reports in children and adolescents during lumbar puncture. J Pediatr Nurs. 1998;13(1):48-54.	3 Study not described as double-blind.	n=19 No description of sample of each group.	4 to 18 years	Lumbar puncture	Relaxation, distraction and imagination	Oucher Scale OSBD	To examine how specific individual differences and contextual variables influence children/adolescents response to painful procedures during cancer treatment and how do such variables influence the effectiveness of relaxation, distraction and imagination.
M a n n e , Bakeman, Jacobsen, et al.¹⁸18 Manne SL, Bakeman R, Jacobsen PB, Gorfinkle K, Redd WH. An analysis of a behavioral intervention for children undergoing venipuncture. Health Psychol. 1994;13(6):556-66.	1 Study not described as double-blind. No description of randomization method. No description of removal and waiver of the sample.	n=35 n=17 Group with training nurse n=18 Group w/o training nurse	36 to Venous 1 0 7 puncture months		Intervention has i ncorpo-rated both distraction (party blower used by children) and parents’ training during procedure.	Own scale	To analyze a behavioral intervention developed to decrease stress in children submitted to venous puncture for cancer treatment.
M a n n e , Redd, Jacobsen, et al.¹⁹19 Manne SL, Redd WH, Jacobsen PB, Gorfinkle K, Schorr O. Behavioral intervention to reduce child and parent distress during venipuncture. J Consult Clin Psychol. 1990;58(5):565-72.	1 Study not described as double-blind. No description of randomization method.	n=23 n=13 Experimental group n=10 Control group	3 to 9 years	Venous puncture	Use of party blower by means of parent training and positive reinforcement	VAS	To investigate a behavioral intervention incorporating parents training, attention distraction and positive reinforcement to control children’s affliction/distress during invasive cancer treatment.
Smith, Ackerson & Blotcky²⁰20 Smith KE, Ackerson JD, Blotcky AD. Reducing distress during invasive medical procedures: relating behavioral interventions to preferred coping style in pediatric cancer patients. J Pediatr Psychol. 1989;14(3):405-19.	2 Study not described as double-blind. No description of randomization method.	n=28 No description of sample of each group.	6 to 18 years	Bone marrow aspiration and/ or lumbar puncture	Verbal distraction and sensory information	OSBD Self-reported fear and pain measures Physiological anxiety measure	To combine two behavioral interventions with two coping styles and to evaluate its effectiveness to minimize fear and pain in pediatric cancer patients who have experienced several invasive procedures.
Kuttner, Bowman e, Te- asdale²¹21 Kuttner L, Bowman M, Teasdale M. Psychological treatment of distress, pain, and anxiety for young children with cancer. J Dev Behav Pediatr. 1988;9(6):374-81.	2 Study not described as double-blind. No description of randomization method.	n=48 No description of sample of each group.	3 to 6 years and 7 to 1 0 years	Bone marrow aspiration	Hypnosis, “imaginative event”, behavioral distraction	PBRS-R Observational scale for pain and anxiety Self-report scale developed and validated for the study	To compare the effectiveness of hypnosis, “imaginative involvement”, behavioral distraction and standard medical practice to decrease pain, distress and anxiety in leukemia children during bone marrow aspiration.

Authors	Results and Conclusions
Heden, Von Essen e Ljungman¹²12 Hedén L, Von Essen L, Ljungman G. Randomized interventions for needle procedures in children with cancer. Eur J Cancer Care. 2009;18(4):358-63.	According to parents’ reports, children had less fear with submitted to proposed intervention as compared to standard treatment (p<0.001). Children had less fear (p<0.05) and distress (p<0.05) when submitted to standard treatment associated to the activity of blowing soap bubbles as compared to standard treatment alone (n=14), and less fear when submitted to standard treatment associated to warm pillow as compared to standard treatment alone (p<0.05).
	Pain and fear reported by children were significantly correlated (p=0.01) in treatment groups, but not significantly different among groups. Intervention group participants have shown significantly less fear (p<0.001) and distress (p=0.03), as evaluated by the nurse, and less fear (p=0.07), as evaluated by parents. All intervention group parents have stated that puncture was better tolerated due to distraction.
Wolitzky, Fivush, Zimand, et al.¹⁴14 Wolitzky K, Fivush R, Zimand E, Hodges L, Rothbaum BO. Effectiveness of virtual reality distraction during a painful medical procedure in pediatric oncology patients. Psychol Health. 2005;20(6):817-24.	Children of both groups were not different in levels of anxiety and distress, or heart rate values before the procedure. During the procedure, groups were different in pain and heart rate measures, indicating that children under virtual reality have not suffered so much pain and anxiety and tend to be slightly less afflicted as compared to controls.
Gershon, Zimand, Pickering, et al.¹⁵15 Gershon J, Zimand E, Pickering M, Rothbaum BO, Hodges L. A pilot and feasibility study of virtual reality as a distraction for children with cancer. J Am Acad Child Adolesc Psychiatry. 2004;43(10):1243-9.	Children of the distraction group with virtual reality had significantly lower heart rates as compared to control group children (p<0.05). Non-verbal distress indices indicated that control group individuals had more muscle tension as compared to those in the distraction group with virtual reality. Even more tension was identified on the leg both in the group with virtual reality and the group without virtual reality (p<0.05).
Dahlquist, Pendley, Landthrip, et al.¹⁶16 Dahlquist LM, Pendley JS, Landthrip DS, Jones CL, Steuber CP. Distraction intervention for preschoolers undergoing intramuscular injections and subcutaneous port access. Health Psychol. 2002;21(1):94-9.	Children receiving distraction intervention had decreased distress behavior and lower levels of anxiety as compared to control group children, according to parents and nurses evaluation. Results suggest that adequately developed activity - varied, multi-sensory distraction, requiring active cognitive processing and active motor responses might be a feasible and low-cost alternative for preschoolers.
Broome, Rehwaldt & Fogg¹⁷17 Broome ME, Rehwaldt M, Fogg L. Relationships between cognitive behavioral techniques, temperament, observed distress, and pain reports in children and adolescents during lumbar puncture. J Pediatr Nurs. 1998;13(1):48-54.	There has been pain improvement during the period of five months, but distress behavior has not changed. At baseline visit, temperament, decreased activities, less persistence and distraction parameters were related to higher pain intensity reports, but not to distress behavior. However, after five months, only good mood parameter was related to better pain reports. Time spent by parents and children performing techniques, comfort of their performance and their efficacy were also correlated to good mood.
Manne, Bakeman, Jacobsen, et al.¹⁸18 Manne SL, Bakeman R, Jacobsen PB, Gorfinkle K, Redd WH. An analysis of a behavioral intervention for children undergoing venipuncture. Health Psychol. 1994;13(6):556-66.	Distraction technique was associated with less crying. Health professional encouragement and early procedure intervention have not indicated improvement on intervention effectiveness. Older children and those less distressed during initial procedure stage were less prone to reject the intervention.
Manne, Redd, Jacobsen, et al.¹⁹19 Manne SL, Redd WH, Jacobsen PB, Gorfinkle K, Schorr O. Behavioral intervention to reduce child and parent distress during venipuncture. J Consult Clin Psychol. 1990;58(5):565-72.	Results indicate that distress classifications observed by children, children’s affliction according to parents’ evaluation and self-evaluation of parents distress were decreased after behavioral intervention and were maintained along three intervention attempts. Physical contention to manage children’s behavior was also decreased. Pain reported by children, and nursing evaluation of distress were not affected. There were no differences between groups in fear or pain self-report. Children receiving information had higher heart rates as compared to those using distraction, regardless of coping style. The level of previous experience with invasive procedures may be an important factor for the preferred coping style when managing these patients’ pain.
Kuttner, Bowman & Teasdale²¹21 Kuttner L, Bowman M, Teasdale M. Psychological treatment of distress, pain, and anxiety for young children with cancer. J Dev Behav Pediatr. 1988;9(6):374-81.	In the first intervention session, observational evaluations of distress have shown reductions for the younger group under hypnotic treatment, while the group of older children had reductions in both treatment conditions for pain and anxiety. In the second intervention session, all groups had reductions and control group was seemingly contaminated. The hypnotic method with its internal focus had an everything-or-nothing effect, and distraction has required coping skills to be learned throughout one or more sessions.

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[1] Correspondence to: Elaine Barros Ferreira, Departamento de Enfermagem, Faculdade de Ciências da Saúde da Universidade de Brasília, Campus Darcy Ribeiro. Asa Norte, 70910-900 Brasília, DF, Brasil. E-mail: elaine.barrosf@gmail.com

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Distraction methods for pain relief of cancer children submitted to painful procedures: systematic review* * Received from University of Brasília, School of Health Sciences, Nursing Department, Brasília, DF, Brazil.

ABSTRACT

BACKGROUND AND OBJECTIVES:

CONTENTS:

CONCLUSION:

Distraction methods for pain relief of cancer children submitted to painful procedures: systematic review^* * Received from University of Brasília, School of Health Sciences, Nursing Department, Brasília, DF, Brazil.