Acessibilidade / Reportar erro

Non-pharmacological interventions in painful needle procedures in children: integrative review

ABSTRACT

BACKGROUND AND OBJECTIVES:

The World Health Organization recommends that pain in children should be treated as a fundamental human right. Children in health services are exposed to numerous painful procedures as part of their treatment, for instance, immunization and blood testing. Painful experiences during such procedures can cause extreme anxiety in future conducts, making children more vulnerable to pain. The present study’s objective was to examine the non-pharmacological interventions most described in the literature for pain management during painful procedures with needles in children above the age of one.

CONTENTS:

Integrative literature review from CINAHL, Embase, Scopus, Web of Science and Pubmed databases. The publications researched were from between 2010 and 2020. The leading question was “Which are the non-pharmacological interventions most described in the literature for pain control in children undergoing needle procedures”? The database search found 252 articles, six were included in the review and distraction was the most observed strategy for non-pharmacological intervention.

CONCLUSION:

The results of this study indicate that the most used strategy for pain relief was distraction, in special the audiovisual distraction.

Keywords:
Child; Pain management; Pain procedural

RESUMO

JUSTIFICATIVA E OBJETIVOS:

A Organização Mundial da Saúde preconiza que a dor na criança seja tratada como um direito humano fundamental. Crianças em serviços de saúde são expostas a diversos procedimentos dolorosos como parte do seu tratamento, a exemplo de imunizações e exames de sangues. Experiências dolorosas durante estes procedimentos podem causar consequências negativas como ansiedade extrema em procedimentos futuros, tornando a criança mais vulnerável à dor. Este estudo teve como objetivo investigar quais são as intervenções não farmacológicas mais descritas na literatura para o controle da dor em procedimentos dolorosos com agulha em crianças acima de um ano.

CONTEÚDO:

Trata-se de uma revisão integrativa, utilizando as bases de dados CINAHL, Embase, Scopus, Web of Science e Pubmed. O recorte das publicações foi entre 2010 e 2020. A questão norteadora foi “Quais são as intervenções não farmacológicas mais descritas na literatura para o controle da dor em crianças sob procedimentos com agulha”? Foram encontrados 252 artigos, incluídos seis artigos para análise e a distração foi a estratégia mais observada para intervenção não farmacológica.

CONCLUSÃO:

Os resultados deste estudo indicam que a estratégia mais utilizada para o alívio da dor foi a distração, sobressaindo a distração audiovisual.

Descritores:
Criança; Dor processual; Manejo da dor

INTRODUCTION

The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage11 Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976-82.,22 DeSantana JM, Perissinotti DMN, Junior JOO, Correia LMF,Oliveira CM, Fonseca PRB. Definição de dor revisada após quatro décadas. BrJP.2020;3(3):197-8.. It is a complex, subjective and multidimensional phenomenon, with sensory, physiological, cognitive, affective, behavioral, and spiritual components33 Koller D, Goldman RD. Distraction techniques for children undergoing procedures: a critical review of pediatric research. J Pediatr Nurs. 2012;27(6):652-81.,44 WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses. Geneva: World Health Organization; 2012. 4, IMPROVING ACCESS TO PAIN RELIEF IN HEALTH SYSTEMS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138355/
https://www.ncbi.nlm.nih.gov/books/NBK13...
.

One of the first phenomena ever experienced in childhood is pain44 WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses. Geneva: World Health Organization; 2012. 4, IMPROVING ACCESS TO PAIN RELIEF IN HEALTH SYSTEMS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138355/
https://www.ncbi.nlm.nih.gov/books/NBK13...
,55 Young KD. Pediatric procedural pain. Ann Emerg Med. 2005;45(2):160-71.. The World Health Organization (WHO) recommends that pain in children should be treated as a fundamental human right33 Koller D, Goldman RD. Distraction techniques for children undergoing procedures: a critical review of pediatric research. J Pediatr Nurs. 2012;27(6):652-81.. In Brazil, the Conselho Nacional dos Direitos da Criança e do Adolescente (CONANDA - National Council for the Rights of Children and Adolescents) guarantees the right to not feel pain when there are means to avoid it66 Conselho Nacional dos Direitos da Criança e do Adolescente (BR). Resolução nº41 de 13 out 1995. Diário Oficial da União, seção 1, 17 out 1995..

Although the progress on pain assessment and treatment in pediatrics is well documented in the literature, there are still some challenges and difficulties, such as lack of understanding on how to conceptualize and quantify a subjective experience and lack of knowledge on pain treatment77 The Assessment and Management of Acute Pain in Infants, Children, and Adolescents. Pediatrics 2001;108(3):793-7. Available from: http://pediatrics.aappublications.org/content/108/3/793.abstract
http://pediatrics.aappublications.org/co...
. In this sense, pain is still undertreated, especially acute pain related to painful procedures88 Birnie KA, Chambers CT, Fernandez CV, Forgeron PA, Latimer MA, McGrath PJ, et al. Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag. 2014;19(4):198-204..

Children in health care services are exposed to several painful procedures as part of their treatment, such as immunizations and blood tests44 WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses. Geneva: World Health Organization; 2012. 4, IMPROVING ACCESS TO PAIN RELIEF IN HEALTH SYSTEMS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138355/
https://www.ncbi.nlm.nih.gov/books/NBK13...
,99 Stevens BJ, Abbott LK, Yamada J, Harrison D, Stinson J, Taddio A, et al. Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ. 2011;183(7):E403-10.. Venipuncture and intravenous cannula insertion have been described as the two most common sources of pain in hospitalized children88 Birnie KA, Chambers CT, Fernandez CV, Forgeron PA, Latimer MA, McGrath PJ, et al. Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag. 2014;19(4):198-204.,1010 Fradet C, McGrath PJ, Kay J, Adams S, Luke B. A prospective survey of reactions to blood tests by children and adolescents. Pain. 1990;40(1):53-60.,1111 Goodenough B, Thomas W, Champion GD, Perrott D, Taplin JE, von Baeyer CL, al. Unravelling age effects and sex differences in needle pain: ratings of sensory intensity and unpleasantness of venipuncture pain by children and their parents. Pain. 1999;80(1-2):179-90.. There is ample evidence in the literature showing that young children, preadolescents, and adolescents submitted to venipuncture had high intensity of pain and distress1212 Humphrey GB, Boon CM, van Linden van den Heuvell GF, van de Wiel HB. The occurrence of high levels of acute behavioral distress in children and adolescents undergoing routine venipunctures. Pediatrics. 1992;90(1 pt 1):87-91.,1313 Van Cleve L, Johnson L, Pothier P. Pain responses of hospitalized infants and children to venipuncture and intravenous cannulation. J Pediatr Nurs. 1996;11(3):161-8..

Painful experiences during these procedures can cause negative consequences such as extreme anxiety in future procedures and extreme physiological reactions during the actual procedure1414 Taddio A, McMurtry CM, Shah V, Riddell RP, Chambers CT, Noel M, et al., Reducing pain during vaccine injections: clinical practice guideline. CMAJ. 2015;187(13):975-82.. In fact, studies have shown that early experiences with pain have been associated with a number of adverse behavioral and physiological consequences1515 Taddio A, Katz J. The effects of early pain experience in neonates on pain responses in infancy and childhood. Paediatr Drugs 2005;7(4):245-57.,1616 Anand KJ, Barton BA, McIntosh N, Lagercrantz H, Pelausa E, Young TE, et al. Analgesia and sedation in preterm neonates who require ventilatory support: Results from the NOPAIN trial. Arch Pediatr Adolesc Med. 1999;153(4):331-8., and may generate increased pain sensitivity and avoidance of health care in the adult1717 Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract. 1995;41(2):169-75.,1818 Pate JT, Blount RL, Cohen LL, Smith AJ. Childhood medical experience and temperament as predictors of adult functioning in medical situations. Child Health Care. 1996;25(4):281-98..

Painful experiences make the child more vulnerable to pain. Since it’s impossible to completely Eliminate the experience of pain in pediatric patients, the adequate management becomes crucial99 Stevens BJ, Abbott LK, Yamada J, Harrison D, Stinson J, Taddio A, et al. Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ. 2011;183(7):E403-10..

The objective of the present study is to investigate the non-pharmacological interventions most described in the literature for pain control in painful needle procedures in children over one year.

CONTENTS

An integrative review that gathers findings from studies developed using different methodologies, allowing the reviewers to synthesize results without hindering the epistemological affiliation of the included studies1919 Soares CB, Hoga LAK, Peduzzi M, Sangaleti C, Yonekura T, Silva DRAD. Revisão integrativa: conceitos e métodos utilizados na enfermagem. Rev Esc Enferm USP. 2014;48(2):335-45..

The review was developed in five stages: problem formulation, data collection, data assessment, data analysis and interpretation, and data disclosure1919 Soares CB, Hoga LAK, Peduzzi M, Sangaleti C, Yonekura T, Silva DRAD. Revisão integrativa: conceitos e métodos utilizados na enfermagem. Rev Esc Enferm USP. 2014;48(2):335-45.,2020 Mendes KDS, Silveira RCCS, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64..

In the first stage, the formulation of the problem and guiding question was developed using the PICO strategy (Patient - pediatric patient undergoing painful needle procedures; I - non-pharmacological interventions; Control - no comparative; Outcome - pain relief).

As of this, the following guiding question was formulated: “What are the non-pharmacological interventions most described in the literature for pain control in children undergoing needle procedures”?

In the second stage, data collection was performed during the months from September to December 2020. The databases selected were CINAHL (The Cumulative Index to Nursing and Allied Health Literature), Embase, Scopus, Web of Science, and Pubmed, which encompasses Medline.

For the articles search, different strategies were used according to the specificity of each database. Descriptors from the Medical Subject Headings indexing vocabulary (MeSH terms), CINAHL terms, EMTREE terms, and free terms were elected.

The descriptors for CINAHL were “pain, procedural”, “pain management” (MeSH terms), “procedural pain”, “pain relief” and “pain control” combined with the Boolean operator OR, as well as “non-pharmacological intervention”, “non-pharmacological interventions”, “child”, “preeschool”, “adolescent”. Then the Boolean operator AND was used between these.

The search strategy used in PubMed included the MeSH terms “pain procedural,” “pain management,” “child,” “preeschool child,” “adolescent,” and “non-pharmacological interventions,” “non-pharmacological intervention” as free terms. The operators OR and AND were used between the descriptors.

For the Embase, Scopus, and Web of Science databases, the following EMTREE terms and free terms were used: “procedural pain” OR “injection” OR “vein puncture” OR “catheter” OR “phlebotomy” AND “non-pharmacological intervention” OR “non-pharmacological interventions” AND “adolescent” OR “child” OR “preschool” OR “school”.

The following inclusion criteria were defined: studies specifically addressing the research guiding theme, publications from between 2010 and 2020, children aged 1 to 18 years old, articles available for full reading in Portuguese, English, Spanish or French, systematic reviews and meta-analyses, randomized and controlled studies, experimental and quasi-experimental studies.

Exclusion criteria were editorial articles, case reports, narrative reviews, studies that presented pharmacological interventions, and articles with children under one year old. This last criterion was defined for exclusion because there are several studies about non-pharmacological interventions in painful procedures for newborns and infants.

In the third stage, the studies were selected by two reviewers, first by reading the titles and abstracts, and then by reading in full those that met the inclusion criteria. The process of identification, selection, eligibility and inclusion of articles, according to PRISMA2121 Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. recommendations, is shown in Figure 1.

Figure 1
Flowchart of identification, selection, eligibility and inclusion of studies following PRISMA2121 Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. recommendations

In the fourth stage, the articles were read in full and analyzed by two reviewers. A synoptic table containing year, journal, intervention, objective, methods, results, conclusion, and level of evidence was created to organize and synthesize the data from the selected studies (Table 1).

Table 1
Distribution of studies included in the synthesis according to authors, year, journal, intervention, objective, methodology, results, conclusion, and level of evidence. São Paulo, SP, Brazil 2020

The articles were categorized into levels of evidence by two reviewers, according to the classification proposed by Melnyk and Fineout-Overholt2222 Bernadette Mazurek Melnyk, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. Vol. 19, The Joanna Briggs Institute. 2013. Available from: http://www.scielo.br/pdf/rbti/v19n4/a12v19n4.pdf%0Ahttp://joannabriggs.org/assets/docs/approach/Levels-of-Evidence-SupportingDocuments-v2.pdf
http://www.scielo.br/pdf/rbti/v19n4/a12v...
. This classification presents seven levels of evidence. At level one, the evidence comes from systematic reviews or meta-analysis of randomized controlled trials or from clinical guidelines based on systematic reviews of randomized controlled trials; at level two, evidence derives from at least one well-designed randomized controlled trial; at level three, from well-designed clinical trials without randomization; at level four, from well-designed cohort and case-control studies; at level five, from systematic review of descriptive and qualitative studies; at level six, from a single descriptive or qualitative study; at level seven, from experts opinion and/or expert committee report obtained.

RESULTS

Initially, 252 articles were found in the chosen databases. After reading the title and identifying duplicates, 227 articles were excluded. Of the 25 articles selected for abstract reading, 9 were selected for the full reading. Three articles were excluded for not being fully available, and six articles were selected for the present review, as shown in table 1.

All selected articles were written in English. The studies were developed in several countries, two of them in India2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.,2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30. and the others in Brazil2323 Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87., Turkey2626 Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32., Italy2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72., and Iran2828 Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in Hugo Point and music on severity of pain during IV insertion in children. Pakistan J Med Heal Sci. 2020;14(2):697-700..

As for the year of publication, two articles dated from 20202525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30.,2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72. and the others were published in the years 201827, 201723 and another two in 20132525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30.,2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72.. Of the six articles, two were published in journals specific to the field of pediatric nursing2626 Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32.,2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72., one was published in European pain-specific journals2222 Bernadette Mazurek Melnyk, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. Vol. 19, The Joanna Briggs Institute. 2013. Available from: http://www.scielo.br/pdf/rbti/v19n4/a12v19n4.pdf%0Ahttp://joannabriggs.org/assets/docs/approach/Levels-of-Evidence-SupportingDocuments-v2.pdf
http://www.scielo.br/pdf/rbti/v19n4/a12v...
and only one was published in a pediatric journal2626 Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32..

The professionals who conducted the research were in their majority nurses2323 Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87.,2626 Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32.,2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72.,2828 Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in Hugo Point and music on severity of pain during IV insertion in children. Pakistan J Med Heal Sci. 2020;14(2):697-700., followed by pediatricians2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.,2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30.. As for the implementation of the interventions, two studies2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30.,2626 Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32. informed they were carried out by nurses, while the others did not specify which professional applied them2323 Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87.,2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.,2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30.,2828 Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in Hugo Point and music on severity of pain during IV insertion in children. Pakistan J Med Heal Sci. 2020;14(2):697-700.. All studies state that the puncture was performed by specific nurses or by nurses with extensive experience in puncturing children.

Regarding the age of the participating children, one study included only infants2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30., while two articles analyzed from infants to preschoolers2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.,2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72. and four articles analyzed only schoolchildren2323 Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87.,2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.,2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72.,2828 Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in Hugo Point and music on severity of pain during IV insertion in children. Pakistan J Med Heal Sci. 2020;14(2):697-700..

As for the scales used, two studies evaluated pain through the Face, Legs, Activity, Cry, Consolability (FLACC) scale2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.,2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30.. In the other studies, the Visual Analog Scale (VAS) and Faces Pain Scale-Revised2323 Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87., Wong-Baker Faces Pain Rating Scale2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72., Ocher’s Pain Score2828 Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in Hugo Point and music on severity of pain during IV insertion in children. Pakistan J Med Heal Sci. 2020;14(2):697-700., and Children’s Anxiety Pain Scale2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30. were used.

The painful needle procedure most performed was the peripheral access insertion (5 of 6 articles)2323 Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87.,2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.,2626 Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32.

27 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72.
-2828 Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in Hugo Point and music on severity of pain during IV insertion in children. Pakistan J Med Heal Sci. 2020;14(2):697-700., followed by vaccination (1 article)2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30..

Of the selected articles, three are quasi-experimental studies2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.,2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30.,2828 Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in Hugo Point and music on severity of pain during IV insertion in children. Pakistan J Med Heal Sci. 2020;14(2):697-700., two are randomized controlled studies2626 Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32.,2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72. and one is a randomized crossover clinical trial2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.. According to the Melnyk & Fineout-Overholt2222 Bernadette Mazurek Melnyk, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. Vol. 19, The Joanna Briggs Institute. 2013. Available from: http://www.scielo.br/pdf/rbti/v19n4/a12v19n4.pdf%0Ahttp://joannabriggs.org/assets/docs/approach/Levels-of-Evidence-SupportingDocuments-v2.pdf
http://www.scielo.br/pdf/rbti/v19n4/a12v...
classification, three articles present level 2 of evidence2323 Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87.,2626 Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32.,2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72. and the others level 32424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.,2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30.,2828 Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in Hugo Point and music on severity of pain during IV insertion in children. Pakistan J Med Heal Sci. 2020;14(2):697-700..

In this review’s studies, three non-pharmacological intervention strategies were used: distraction, chewing gum and cryotherapy combined with vibratory stimulation with Buzzy®. The most frequent strategy was distraction, and the audiovisual distraction stands out as the most used.

All studies showed results in favor of non-pharmacological interventions for pain relief during painful needle procedures in children.

DISCUSSION

Pain control includes both pharmacological and nonpharmacological measures. Different non-pharmacological methods can be applied and have been shown to be effective for pain relief in children2929 Hasanpour M, Tootoonchi M, Aein F, Yadegarfar G. The effects of two non-pharmacologic pain management methods for intramuscular injection pain in children. Acute Pain. 2006;8(1):7-12.

30 Gold JI, Kim SH, Kant AJ, Joseph MH, Rizzo A. Effectiveness of virtual reality for pediatric pain distraction during IV placement. Cyberpsychology Behav. 2006;9(2):207-12.
-3131 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.. Non-pharmacological interventions can be grouped in the following categories: behavioral, cognitive, complementary, and physical. The behavioral techniques include coaching and training; the cognitive ones include distraction techniques; the complementary ones include toy therapy techniques and, finally, the physical ones consist of comfort position methods and heat therapy3232 Short S, Pace G, Birnbaum C. Nonpharmacologic techniques to assist in pediatric pain management. Clin Pediatr Emerg Med. 2017;18(4):256-60..

Distraction is a technique that aims to redirect attention from the aspects of health care that are threatening and provoke pain and anxiety to non-threatening and ideally pleasant and engaging objects or situations3333 Blount RL, Piira T, Cohen LL. Management of Pediatric Pain and Distress Due to Medical Procedures. In: Handbook of pediatric psychology, 3 ed. New York, NY, US: The Guilford Press; 2003. p.216-33.. Therefore, changes in the nociceptive response, pain suppression, and the potential to modify cognitive perceptions of pain may be possible to achieve3434 McGrath PA. Intervention and management. In: Bush JP, Harkins SW, editors. Children in pain: clinical and research issues from a developmental perspective. New York (NY): Springer-Verlag; 1991. p. 83-115..

This technique can be classified into active or passive, being the active a method in which the child is engaging in an activity during the procedure, such as video games and virtual reality goggles. Passive distraction, on the other hand, is a method that allows the child to be calm and relaxed during the procedure, making use of music and cartoons (animated films), for example. However, when to start the technique and what types of music and cartoons to use have not been described3535 Inan G, Inal S. The impact of 3 different distraction techniques on the pain and anxiety levels of children during venipuncture: a clinical trial. Clin J Pain. 2019;35(2):140-7..

A systematic review with meta-analysis on psychological interventions for pain relief in needle procedures included 59 trials and 5550 child participants, describing distraction as the most common, present in 32 trials, and although distraction was the most mentioned intervention, the quality of future studies needs to be improved3636 Birnie KA, Noel M, Chambers CT, Uman LS, Parker JA. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;(10):CD005179..

In another meta-analysis that sought to determine the effect of distraction on venipuncture pain in children, distraction techniques were shown to be effective in reducing venipuncture pain3737 Gates M, Hartling L, Shulhan-Kilroy J, MacGregor T, Guitard S, Wingert A, et al. Digital technology distraction for acute pain in children: a meta-analysis. Pediatrics. 2020;145(2):e20191139..

A similar result was identified in a meta-analysis which showed that distraction was a promising intervention for pain in painful procedures3838 Bukola IM, Paula D. The effectiveness of distraction as procedural pain management technique in pediatric oncology patients: a meta-analysis and systematic review. J Pain Symptom Manage. 2017;54(4):589-600.e1..

In the present review, only passive distractions with cartoons, music and acupressure were found. However, a randomized controlled trial compared the effectiveness of passive and active distractions and showed that the type of distraction has no significant influence on the outcome variables related to pain during venipuncture in children3939 Newell A, Keane J, McGuire BE, Heary C, McDarby V, Dudley B, et al. Interactive versus passive distraction and parent psychoeducation as pain management techniques during pediatric venepuncture: a randomized controlled trial. Clin J Pain. 2018;34(11):1008-16..

Audiovisual distraction with cartoons was the most employed type of distraction. In this review’s studies, this technique was compared with not receiving any intervention2323 Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87., with parents holding the child without other interventions2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5., with toys that produce light and sound during vaccination2525 Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30. and with the Buzzy®2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72. device.

The crossover clinical trial2323 Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87. showed that distraction was an effective non-pharmacological intervention for pain relief in hospitalized pediatric patients. The study also suggests that distraction interventions during painful procedures may help children to have more adaptive attitudes in future contexts. This result opposes another study which reveals that the children’s memory of pain influences their next painful experience, so that children who have had positive experiences feel less pain in subsequent experiences4040 Noel M, Chambers CT, McGrath PJ, Klein RM, Stewart SH. The influence of children’s pain memories on subsequent pain experience. Pain. 2012;153(8):1563-72..

During vaccination, audiovisual distraction had a positive effect on pain relief in infants, with a lower average pain score in the group that watched cartoons during and after vaccination compared to the control group2626 Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32.. A clinical trial conducted in Italy with six-year-old children showed lower levels of pain and distress in the group that was distracted with cartoons compared to children who received traditional distraction techniques during immunization4141 Cerne D, Sannino L, Petean M. A randomised controlled trial examining the effectiveness of cartoons as a distraction technique. Nurs Child Young People. 2015;27(3):28-33..

Audiovisual distraction has also been compared with Buzzy®, a bee-shaped device that produces vibrations and cools by means of freezable wings2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72.. The objective of Buzzy® is to block the transmission of pain signals through cold and vibrations, and its effect is based on the Gate Control Theory proposed by Melzack & Wall, in which barriers are capable of controlling the flow of pain information through the activation of nociceptive fibers4242 Susam V, Friedel M, Basile P, Ferri P, Bonetti L. Efficacy of the Buzzy System for pain relief during venipuncture in children: a randomized controlled trial. Acta Biomed. 2018;89(6-S):6-16..

A study observed that the cartoons intervention had superior results for pain relief when compared to Buzzy®2727 Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72.. In a recently published study, Buzzy® was shown to be less effective than lidocaine patches, and most of the children wanted to remove the freezable wings before the end of the procedure because they started to feel uncomfortable with the cold4343 Lescop K, Joret I, Delbos P, Briend-Godet V, Blanchi S, Brechet C, et al. The effectiveness of the Buzzy® device to reduce or prevent pain in children undergoing needle-related procedures: the results from a prospective, open-label, randomised, non-inferiority study. Int J Nurs Stud. 2021;113:103803.. Other studies showed that Buzzy® was not effective in reducing pain in peripheral venous access puncture4444 Semerci R, Kocaaslan EN, Akgün Kostak M, Akın N. Reduction of pain during intravenous cannulation in children: Buzzy application. Agri. 2020;32(4):177-85.,4545 Yılmaz D, Özyazıcıoğlu N, Çıtak Tunç G, Aydın Aİ, Atak M, Duygulu Ş, et al. Efficacy of Buzzy® on pain and anxiety during catheterization in children. Pediatr Int. 2020;62(9):1094-100..

Music and acupressure at the Hugo Point were also passive distraction strategies that had positive results in pain control2424 Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.. The Hugo Point is located on the back of the hand between the first and second metacarpal bones, next to the base of the second metacarpal bone, so that acupressure on this point reduces pain by blocking the transmission of nociceptive impulses4646 Khosravan S, Atayee P, Mazloum Shahri SB, Mojtabavi SJ. Effect of Hugo’s point massage with and without ice on vaccination-related pain in infants. J Hayat. 2018;24(1):7-19.. A randomized clinical trial conducted in Turkey showed that children who received acupressure experienced less pain than children in the control group4747 Aydin D, Sahiner NC. Effects of music therapy and distraction cards on pain relief during phlebotomy in children. Appl Nurs Res. 2017;33:164-8.. Therefore, acupressure can be a simple and affordable non-pharmacological strategy to be employed during needle procedures.

Distraction strategies using high technology are being increasingly applied in health care services. Tablets, video games, and virtual reality3636 Birnie KA, Noel M, Chambers CT, Uman LS, Parker JA. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;(10):CD005179.,4848 Chan E, Hovenden M, Ramage E, Ling N, Pham JH, Rahim A, et al. Virtual reality for pediatric needle procedural pain: two randomized clinical trials. J Pediatr. 2019;209:160-167.e4.,4949 Özalp Gerçeker G, Ayar D, Özdemir EZ, Bektaş M. Effects of virtual reality on pain, fear and anxiety during blood draw in children aged 5-12 years old: a randomised controlled study. J Clin Nurs. 2020;29(7-8):1151-61. have been shown to be effective or moderately effective in reducing pain during painful needle procedures in children3636 Birnie KA, Noel M, Chambers CT, Uman LS, Parker JA. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;(10):CD005179.,5050 Crevatin F, Cozzi G, Braido E, Bertossa G, Rizzitelli P, Lionetti D, et al. Hand-held computers can help to distract children undergoing painful venipuncture procedures. Acta Paediatr Int J Paediatr 2016;105(8):930-4.,5151 Walther-Larsen S, Petersen T, Friis SM, Aagaard G, Drivenes B, Opstrup P. Immersive virtual reality for pediatric procedural pain: a randomized clinical trial. Hosp Pediatr. 2019;9(7):501-7., however, no studies about this technology were observed in this review.

As for the use of chewing gum, it was shown to be less effective in reducing pain, but effective in reducing stress and anxiety. A similar result was found in a randomized clinical trial, in which chewing gum did not reduce pain5252 Lewkowski MD, Barr RG, Sherrard A, Lessard J, Harris AR, Young SN. (2003). Effects of chewing gum on responses to routine painful procedures in children. Physiol Behav. 2003;79(2), 257-65..

The age of the children in this review ranges from newborns to schoolchildren. Newborns, because they are not able to conceptualize pain, benefit from active distraction strategies such as looking at cards, blowing soap bubbles (which was not mentioned in this review). Preschoolers, in turn, can decrease their perception of pain and cope better with the procedure through distraction, which can be audiovisual or in the form of cards. Schoolchildren, on the other hand, have a better understanding of the procedure, of pain, and coping, thus benefiting from distraction strategies such as cartoons, video games, and virtual reality5353 Thrane SE, Wanless, l. Thrane SE, Wanless S, Cohen SM DCTA and N-PT of PPFI to SAT a DLAS of EWRJPN [Internet]. 2016;31(1):e23-32. A from: https://dx., Cohen SM, Danford CA. The Assessment and Non-Pharmacologic Treatment of Procedural Pain From Infancy to School Age Through a Developmental Lens: A Synthesis of Evidence With Recommendations. J Pediatr Nurs. 2016;31(1):e23-32.,5454 Short S, Pace G, Birnbaum C. Nonpharmacologic techniques to assist in pediatric pain management. Clin Pediatr Emerg Med. 2017;18(4):256-60..

Different scales were used to assess pain in this review’s studies. On one hand, it’s coherent since it’s necessary to consider the children’s age. On the other hand, it causes differences in assessment since it makes comparison between studies difficult.

The FLACC scale was applied in two studies with infants and preschoolers; although it is known and commonly used to assess pain in young, noncommunicative children, a recent systematic review of FLACC clinimetry concluded that there is currently insufficient data to accept the scale as reliable and valid for pain assessment during procedures5454 Short S, Pace G, Birnbaum C. Nonpharmacologic techniques to assist in pediatric pain management. Clin Pediatr Emerg Med. 2017;18(4):256-60..

Other scales used were the Faces Pain Scale-Revised, Wong-Baker Faces Pain Rating and Ocher’s Pain Score, which are self-report and easy expression assessment scales, in addition to the VAS, in which the child scores the pain from zero to 10, zero being no pain and 10 being the most intense pain. Because it’s a subjective experience, the self-report in communicative patients is commonly used in evaluations, especially in schoolchildren who can characterize the pain5555 Crellin DJ, Harrison D, Santamaria N, Babl FE. Systematic review of the face, legs, activity, cry and consolability scale for assessing pain in infants and children: is it reliable, valid, and feasible for use? Pain. 2015;156(11):2132-51.. It’s noteworthy that only one study used a specific scale to assess pain in painful procedures, the Children’s Anxiety Pain Scale.

In addition to pain relief, half of the studies in this review also evaluate psychological aspects, such as distress, fear and anxiety. Because pain is a multidimensional experience, it’s necessary to take into account the affective dimension of pain and the suffering caused in the child5656 Mehack R, Torgerson WS. On the language of pain. Anesthesiology: J Am Soc Anesthesiol. 1971;34(1):50-9..

A study sought to know the representations of pain in schoolchildren who had undergone venipuncture and found that pain is often considered a triggering factor of suffering, often exteriorized through crying and associated with fear of being hospitalized5757 Guerreiro M, Curado M. PICAR ... FAZ DOER! Representações de dor na criança, em idade escolar, submetida a punção venosa. Enferm Glob Rev Electrónica Trimest Enferm. 2012;25:75-91..

Negative experiences can generate needle phobia, anxiety, and exacerbated reactions in future procedures1515 Taddio A, Katz J. The effects of early pain experience in neonates on pain responses in infancy and childhood. Paediatr Drugs 2005;7(4):245-57.,1717 Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract. 1995;41(2):169-75.,1818 Pate JT, Blount RL, Cohen LL, Smith AJ. Childhood medical experience and temperament as predictors of adult functioning in medical situations. Child Health Care. 1996;25(4):281-98.,4040 Noel M, Chambers CT, McGrath PJ, Klein RM, Stewart SH. The influence of children’s pain memories on subsequent pain experience. Pain. 2012;153(8):1563-72.. Therefore, by managing children’s pain during painful procedures with needles, their emotional health is taken care of, allowing them to create coping strategies for future experiences4040 Noel M, Chambers CT, McGrath PJ, Klein RM, Stewart SH. The influence of children’s pain memories on subsequent pain experience. Pain. 2012;153(8):1563-72..

Furthermore, only one intervention other than distraction was identified, although other strategies such as using clowns, soap bubbles, cards, and therapy with dogs5858 Kristensen HN, Lundbye-Christensen S, Haslund-Thomsen H, Graven-Nielsen T, Elgaard Sørensen E. Acute procedural pain in children: intervention with the hospital clown. Clin J Pain. 2018;34(11):1032-8.,5959 Lilik Lestari MP, Wanda D, Hayati H. The effectiveness of distraction (Cartoon-Patterned Clothes and Bubble-Blowing) on pain and anxiety in preschool children during venipuncture in the emergency department. Compr Child Adolesc Nurs. 2017;40(1):22-8.,5959 Lilik Lestari MP, Wanda D, Hayati H. The effectiveness of distraction (Cartoon-Patterned Clothes and Bubble-Blowing) on pain and anxiety in preschool children during venipuncture in the emergency department. Compr Child Adolesc Nurs. 2017;40(1):22-8.

60 Yilmaz G, Alemdar DK. Using Buzzy, Shotblocker, and Bubble Blowing in a pediatric emergency department to reduce the pain and fear caused by intramuscular injection: a randomized controlled trial. J Emerg Nurs. 2019;45(5):502-11.

61 Risaw L, Narang K, Thakur JS, Ghai S, Kaur S, Bharti B. Efficacy of flippits to reduce pain in children during venipuncture - a randomized controlled trial. Indian J Pediatr. 2017;84(8):597-600.
-6262 Vagnoli L, Caprilli S, Vernucci C, Zagni S, Mugnai F, Messeri A. Can presence of a dog reduce pain and distress in children during venipuncture? Pain Manag Nurs. 2015;16(2):89-95. exist in the literature.

This study’s limitations comprise a small sample of articles, the low level of methodological evidence of the articles, methodological differences between articles, and the use of different scales to assess pain.

CONCLUSION

The results indicate that the most commonly used strategy for pain relief was distraction, and audiovisual distraction stands out.

REFERENCES

  • 1
    Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976-82.
  • 2
    DeSantana JM, Perissinotti DMN, Junior JOO, Correia LMF,Oliveira CM, Fonseca PRB. Definição de dor revisada após quatro décadas. BrJP.2020;3(3):197-8.
  • 3
    Koller D, Goldman RD. Distraction techniques for children undergoing procedures: a critical review of pediatric research. J Pediatr Nurs. 2012;27(6):652-81.
  • 4
    WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses. Geneva: World Health Organization; 2012. 4, IMPROVING ACCESS TO PAIN RELIEF IN HEALTH SYSTEMS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138355/
    » https://www.ncbi.nlm.nih.gov/books/NBK138355/
  • 5
    Young KD. Pediatric procedural pain. Ann Emerg Med. 2005;45(2):160-71.
  • 6
    Conselho Nacional dos Direitos da Criança e do Adolescente (BR). Resolução nº41 de 13 out 1995. Diário Oficial da União, seção 1, 17 out 1995.
  • 7
    The Assessment and Management of Acute Pain in Infants, Children, and Adolescents. Pediatrics 2001;108(3):793-7. Available from: http://pediatrics.aappublications.org/content/108/3/793.abstract
    » http://pediatrics.aappublications.org/content/108/3/793.abstract
  • 8
    Birnie KA, Chambers CT, Fernandez CV, Forgeron PA, Latimer MA, McGrath PJ, et al. Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag. 2014;19(4):198-204.
  • 9
    Stevens BJ, Abbott LK, Yamada J, Harrison D, Stinson J, Taddio A, et al. Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ. 2011;183(7):E403-10.
  • 10
    Fradet C, McGrath PJ, Kay J, Adams S, Luke B. A prospective survey of reactions to blood tests by children and adolescents. Pain. 1990;40(1):53-60.
  • 11
    Goodenough B, Thomas W, Champion GD, Perrott D, Taplin JE, von Baeyer CL, al. Unravelling age effects and sex differences in needle pain: ratings of sensory intensity and unpleasantness of venipuncture pain by children and their parents. Pain. 1999;80(1-2):179-90.
  • 12
    Humphrey GB, Boon CM, van Linden van den Heuvell GF, van de Wiel HB. The occurrence of high levels of acute behavioral distress in children and adolescents undergoing routine venipunctures. Pediatrics. 1992;90(1 pt 1):87-91.
  • 13
    Van Cleve L, Johnson L, Pothier P. Pain responses of hospitalized infants and children to venipuncture and intravenous cannulation. J Pediatr Nurs. 1996;11(3):161-8.
  • 14
    Taddio A, McMurtry CM, Shah V, Riddell RP, Chambers CT, Noel M, et al., Reducing pain during vaccine injections: clinical practice guideline. CMAJ. 2015;187(13):975-82.
  • 15
    Taddio A, Katz J. The effects of early pain experience in neonates on pain responses in infancy and childhood. Paediatr Drugs 2005;7(4):245-57.
  • 16
    Anand KJ, Barton BA, McIntosh N, Lagercrantz H, Pelausa E, Young TE, et al. Analgesia and sedation in preterm neonates who require ventilatory support: Results from the NOPAIN trial. Arch Pediatr Adolesc Med. 1999;153(4):331-8.
  • 17
    Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract. 1995;41(2):169-75.
  • 18
    Pate JT, Blount RL, Cohen LL, Smith AJ. Childhood medical experience and temperament as predictors of adult functioning in medical situations. Child Health Care. 1996;25(4):281-98.
  • 19
    Soares CB, Hoga LAK, Peduzzi M, Sangaleti C, Yonekura T, Silva DRAD. Revisão integrativa: conceitos e métodos utilizados na enfermagem. Rev Esc Enferm USP. 2014;48(2):335-45.
  • 20
    Mendes KDS, Silveira RCCS, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64.
  • 21
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.
  • 22
    Bernadette Mazurek Melnyk, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. Vol. 19, The Joanna Briggs Institute. 2013. Available from: http://www.scielo.br/pdf/rbti/v19n4/a12v19n4.pdf%0Ahttp://joannabriggs.org/assets/docs/approach/Levels-of-Evidence-SupportingDocuments-v2.pdf
    » http://www.scielo.br/pdf/rbti/v19n4/a12v19n4.pdf%0Ahttp://joannabriggs.org/assets/docs/approach/Levels-of-Evidence-SupportingDocuments-v2.pdf
  • 23
    Oliveira NC, Santos JL, Linhares MB. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21(1):178-87.
  • 24
    Gupta HV, Gupta VV, Kaur A, Singla R, Chitkara N, Bajaj KV, et al. Comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: A quasi-experimental study. J Clin Diagnostic Res. 2014;8(8):1-5.
  • 25
    Gedam DS, Verma M, Patil U, Gedam S. Effect of distraction technique during immunization to reduce behaviour response score (FLACC) to pain in Toddlers. J Nepal Paediatr Soc. 2013;33(1):25-30.
  • 26
    Yildizeli Topcu S, Akgun Kostak M, Semerci R, Guray O. Effect of gum chewing on pain and anxiety in turkish children during intravenous cannulation: a randomized controlled study. J Pediatr Nurs. 2020;52:e26-32.
  • 27
    Bergomi P, Scudeller L, Pintaldi S, Dal Molin A. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-72.
  • 28
    Momenabadi A, Radmehr M, Sadeghi N. Effect of two methods of acupressure in Hugo Point and music on severity of pain during IV insertion in children. Pakistan J Med Heal Sci. 2020;14(2):697-700.
  • 29
    Hasanpour M, Tootoonchi M, Aein F, Yadegarfar G. The effects of two non-pharmacologic pain management methods for intramuscular injection pain in children. Acute Pain. 2006;8(1):7-12.
  • 30
    Gold JI, Kim SH, Kant AJ, Joseph MH, Rizzo A. Effectiveness of virtual reality for pediatric pain distraction during IV placement. Cyberpsychology Behav. 2006;9(2):207-12.
  • 31
    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.
  • 32
    Short S, Pace G, Birnbaum C. Nonpharmacologic techniques to assist in pediatric pain management. Clin Pediatr Emerg Med. 2017;18(4):256-60.
  • 33
    Blount RL, Piira T, Cohen LL. Management of Pediatric Pain and Distress Due to Medical Procedures. In: Handbook of pediatric psychology, 3 ed. New York, NY, US: The Guilford Press; 2003. p.216-33.
  • 34
    McGrath PA. Intervention and management. In: Bush JP, Harkins SW, editors. Children in pain: clinical and research issues from a developmental perspective. New York (NY): Springer-Verlag; 1991. p. 83-115.
  • 35
    Inan G, Inal S. The impact of 3 different distraction techniques on the pain and anxiety levels of children during venipuncture: a clinical trial. Clin J Pain. 2019;35(2):140-7.
  • 36
    Birnie KA, Noel M, Chambers CT, Uman LS, Parker JA. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;(10):CD005179.
  • 37
    Gates M, Hartling L, Shulhan-Kilroy J, MacGregor T, Guitard S, Wingert A, et al. Digital technology distraction for acute pain in children: a meta-analysis. Pediatrics. 2020;145(2):e20191139.
  • 38
    Bukola IM, Paula D. The effectiveness of distraction as procedural pain management technique in pediatric oncology patients: a meta-analysis and systematic review. J Pain Symptom Manage. 2017;54(4):589-600.e1.
  • 39
    Newell A, Keane J, McGuire BE, Heary C, McDarby V, Dudley B, et al. Interactive versus passive distraction and parent psychoeducation as pain management techniques during pediatric venepuncture: a randomized controlled trial. Clin J Pain. 2018;34(11):1008-16.
  • 40
    Noel M, Chambers CT, McGrath PJ, Klein RM, Stewart SH. The influence of children’s pain memories on subsequent pain experience. Pain. 2012;153(8):1563-72.
  • 41
    Cerne D, Sannino L, Petean M. A randomised controlled trial examining the effectiveness of cartoons as a distraction technique. Nurs Child Young People. 2015;27(3):28-33.
  • 42
    Susam V, Friedel M, Basile P, Ferri P, Bonetti L. Efficacy of the Buzzy System for pain relief during venipuncture in children: a randomized controlled trial. Acta Biomed. 2018;89(6-S):6-16.
  • 43
    Lescop K, Joret I, Delbos P, Briend-Godet V, Blanchi S, Brechet C, et al. The effectiveness of the Buzzy® device to reduce or prevent pain in children undergoing needle-related procedures: the results from a prospective, open-label, randomised, non-inferiority study. Int J Nurs Stud. 2021;113:103803.
  • 44
    Semerci R, Kocaaslan EN, Akgün Kostak M, Akın N. Reduction of pain during intravenous cannulation in children: Buzzy application. Agri. 2020;32(4):177-85.
  • 45
    Yılmaz D, Özyazıcıoğlu N, Çıtak Tunç G, Aydın Aİ, Atak M, Duygulu Ş, et al. Efficacy of Buzzy® on pain and anxiety during catheterization in children. Pediatr Int. 2020;62(9):1094-100.
  • 46
    Khosravan S, Atayee P, Mazloum Shahri SB, Mojtabavi SJ. Effect of Hugo’s point massage with and without ice on vaccination-related pain in infants. J Hayat. 2018;24(1):7-19.
  • 47
    Aydin D, Sahiner NC. Effects of music therapy and distraction cards on pain relief during phlebotomy in children. Appl Nurs Res. 2017;33:164-8.
  • 48
    Chan E, Hovenden M, Ramage E, Ling N, Pham JH, Rahim A, et al. Virtual reality for pediatric needle procedural pain: two randomized clinical trials. J Pediatr. 2019;209:160-167.e4.
  • 49
    Özalp Gerçeker G, Ayar D, Özdemir EZ, Bektaş M. Effects of virtual reality on pain, fear and anxiety during blood draw in children aged 5-12 years old: a randomised controlled study. J Clin Nurs. 2020;29(7-8):1151-61.
  • 50
    Crevatin F, Cozzi G, Braido E, Bertossa G, Rizzitelli P, Lionetti D, et al. Hand-held computers can help to distract children undergoing painful venipuncture procedures. Acta Paediatr Int J Paediatr 2016;105(8):930-4.
  • 51
    Walther-Larsen S, Petersen T, Friis SM, Aagaard G, Drivenes B, Opstrup P. Immersive virtual reality for pediatric procedural pain: a randomized clinical trial. Hosp Pediatr. 2019;9(7):501-7.
  • 52
    Lewkowski MD, Barr RG, Sherrard A, Lessard J, Harris AR, Young SN. (2003). Effects of chewing gum on responses to routine painful procedures in children. Physiol Behav. 2003;79(2), 257-65.
  • 53
    Thrane SE, Wanless, l. Thrane SE, Wanless S, Cohen SM DCTA and N-PT of PPFI to SAT a DLAS of EWRJPN [Internet]. 2016;31(1):e23-32. A from: https://dx., Cohen SM, Danford CA. The Assessment and Non-Pharmacologic Treatment of Procedural Pain From Infancy to School Age Through a Developmental Lens: A Synthesis of Evidence With Recommendations. J Pediatr Nurs. 2016;31(1):e23-32.
  • 54
    Short S, Pace G, Birnbaum C. Nonpharmacologic techniques to assist in pediatric pain management. Clin Pediatr Emerg Med. 2017;18(4):256-60.
  • 55
    Crellin DJ, Harrison D, Santamaria N, Babl FE. Systematic review of the face, legs, activity, cry and consolability scale for assessing pain in infants and children: is it reliable, valid, and feasible for use? Pain. 2015;156(11):2132-51.
  • 56
    Mehack R, Torgerson WS. On the language of pain. Anesthesiology: J Am Soc Anesthesiol. 1971;34(1):50-9.
  • 57
    Guerreiro M, Curado M. PICAR ... FAZ DOER! Representações de dor na criança, em idade escolar, submetida a punção venosa. Enferm Glob Rev Electrónica Trimest Enferm. 2012;25:75-91.
  • 58
    Kristensen HN, Lundbye-Christensen S, Haslund-Thomsen H, Graven-Nielsen T, Elgaard Sørensen E. Acute procedural pain in children: intervention with the hospital clown. Clin J Pain. 2018;34(11):1032-8.
  • 59
    Lilik Lestari MP, Wanda D, Hayati H. The effectiveness of distraction (Cartoon-Patterned Clothes and Bubble-Blowing) on pain and anxiety in preschool children during venipuncture in the emergency department. Compr Child Adolesc Nurs. 2017;40(1):22-8.
  • 60
    Yilmaz G, Alemdar DK. Using Buzzy, Shotblocker, and Bubble Blowing in a pediatric emergency department to reduce the pain and fear caused by intramuscular injection: a randomized controlled trial. J Emerg Nurs. 2019;45(5):502-11.
  • 61
    Risaw L, Narang K, Thakur JS, Ghai S, Kaur S, Bharti B. Efficacy of flippits to reduce pain in children during venipuncture - a randomized controlled trial. Indian J Pediatr. 2017;84(8):597-600.
  • 62
    Vagnoli L, Caprilli S, Vernucci C, Zagni S, Mugnai F, Messeri A. Can presence of a dog reduce pain and distress in children during venipuncture? Pain Manag Nurs. 2015;16(2):89-95.

Publication Dates

  • Publication in this collection
    16 Feb 2022
  • Date of issue
    Jan-Mar 2022

History

  • Received
    20 Jan 2021
  • Accepted
    06 Jan 2022
Sociedade Brasileira para o Estudo da Dor Av. Conselheiro Rodrigues Alves, 937 Cj2 - Vila Mariana, CEP: 04014-012, São Paulo, SP - Brasil, Telefones: , (55) 11 5904-2881/3959 - São Paulo - SP - Brazil
E-mail: dor@dor.org.br