Painful medical procedures for children begin with heel sticks and injections at birth and continue throughout childhood. By the time a child a reaches the age of 6, he or she should have received 36 immunizations via intramuscular injection, with the number of vaccination injections increasing exponentially by the year 2020. In addition to routine well-child visit pain, injuries and illnesses frequently require anxiety-provoking painful procedures.
Numerous modalities exist to decrease procedural pain, from topical anesthetics up to complete deep sedation. The latter requires expertise, forethought, and considerable expense and may not be available in every community. Despite ready availability, however, only 6% of pediatric offices use pain control for shots, and only 2.1% of an estimated 18 million venipunctures are performed each year with pain control. Distraction for minor to moderate procedural pain is free or inexpensive, easy to perform, and an effective method of pain control.
Pain Is More Than Skin Deep
Most toddlers and many school-age children experience high distress during immunization injections. In part due to concern for pain, parents may not complete vaccination series. Parents are not the only ones who cringe with untreated pain: medical personnel are 6 times less likely to administer all vaccinations at a visit if the child is due to receive 3 or more injections.
Research suggests that poor pediatric pain management results in short- and long-term repercussions for the child patient, parent, and staff. Unmanaged pain is associated with elevated child and parent anxiety during the procedure, which can necessitate more personnel resources to restrain the child. Enduring effects of undertreated pain include increased pain with subsequent procedures. Research with human infants and rat pups indicates that early pain impairs physiological development, with persistent neurologic rewiring and altered pain perception.[12,13] Untreated immunization pain might also lead to distorted negative memories of that experience. Ultimately, early pain is linked to poorer healthcare attitudes and elevated fear and avoidance of medical procedures in adulthood.[14-16]
Treatment Approaches Across Medical Procedures
A rich body of literature supports the effectiveness of central and peripheral distraction for acute pediatric pain management across a range of invasive medical events, from shots and needle sticks to burn therapy and oncologic procedures. Although the patient’s experience of pain is a cerebral cortex phenomenon and pain is modulated with both ascending and descending neurochemical mechanisms, for the purpose of this discussion “central” distraction refers to attention or competing mental processes, while “peripheral” refers to nonpharmacologic distraction occurring at the level of the dorsal horn or distal to it.
The most common painful events during infancy and early childhood are immunizations. Most immunization interventions have been single component in nature (testing one intervention at a time), with distraction the most commonly evaluated. A variety of central distraction strategies have been evaluated (eg, party blowers, cartoon movies, music), and outcomes have been assessed on multiple dimensions (eg, parent-report, self-report, observational distress). Despite the variability in approaches, results consistently demonstrate the efficacy of distraction as an intervention for pediatric pain and distress. Notably, those strategies that required an overt response from the child and those that involved multiple sensory modalities were most effective.
Using an elegant cross-over design, Cohen and colleagues evaluated standard care vs a topical anesthetic or watching a movie. Fourth graders receiving a series of 3 hepatitis B shots were allowed to select from Casper, Space Jam, 101 Dalmations, and Mighty Morphin Power Rangers. The movies were started 3 minutes before an immunization, and the nurse was coached to ask relevant questions (eg, “Who’s the bad guy?”) and direct their attention to the film. Child coping and distress were significantly improved in the distraction group vs the other two (P = .000 and P = .012, respectively).
For infant immunizations, Cohen and colleagues found that the use of a movie (eg, Teletubbies™) and age-appropriate toys (eg, rattles) lowered patients’ preinjection and recovery behavioral distress. However, there was no difference during the few seconds of immunization injection itself.[22,23] In another study of infant immunization distress, when controlling for multiple factors including gestational age, previous pain experiences, and temperament, the only factor that significantly improved immunization pain for 4- to 6-month-olds was positive parental coping statements in the 30 seconds preceding immunization. Given that children at this age are preverbal, empathy or parent confidence in the procedure may have conferred the protective effect.
In addition to diverting the patient’s attention, physically distracting the nerves is also effective. Vapocoolant, typically discussed in the context of topical anesthetics, is an ethyl chloride spray that cools as it is released, acting as nerve distracter effective via gate theory. Spray plus distraction was superior to lidocaine/prilocaine eutectic mixture or distraction alone for 62 immunizations in 4- to 6-year-old children. Spray alone worked for adults receiving travel immunizations when compared with placebo; and a recent study found a simple ice cube to be even better than vapocoolant for antibiotic test injections.
Sucrose, a demonstrated effective centrally acting distracter, likely includes endogenous opioid activation. While it is proven effective for immunizations and painful procedures, it is typically considered a pharmacologic agent and as such is outside the scope of this review.[28-30]
Venous access is cited as the most feared and painful part of a child’s hospitalization, but distraction is a well investigated and supported intervention. Early work combined multiple modalities of potential distraction: breathing control, visual and auditory stimulation, and tasks. Manne and colleagues, for example, found that party-blower distraction/paced breathing reinforced with prizes effectively reduced venipuncture distress for both child and parent.
Subsequent work isolated pharmacologic and specific distraction interventions. Arts and colleagues tried “upbeat contemporary music” vs lidocaine/prilocaine for children aged 4 years and up but found a difference only in the youngest children, and then lidocaine/prilocaine was superior. In contrast, MacLaren and Cohen found a cartoon movie decreased venipuncture distress more than an interactive toy. The authors suggested that children’s anticipatory anxiety may have interfered with their ability to play with the interactive toy. However, children in the study by MacLaren and Cohen were allowed to choose between movies. The contribution of patient control and choice has been demonstrated to be helpful, but its contribution in combination with other factors has not been quantified.
Cold spray was shown in a recent study to help venipuncture pain in children as young as 6 years old, but other studies have either found no improvement or improvement only for children older than 12 years old. Vibration stimulates large motor receptor fibers, which can override sharp pain, much as rubbing a bumped elbow makes it feel better. The technique of wiggling lip skin, often used for dental injections, was replicated using commercial therapeutic massagers to anecdotally decrease the pain of dermatology shots. A new device, Buzzy® (MMJ Labs LLC, Atlanta, Georgia), combining vibration, cold, and distraction, significantly decreased the pain of cannulation in adults, with pediatric trials pending.
Pain from burn injuries is exacerbated by aggressive treatments such as debridement and physical therapy. Passive movie watching was not sufficient to reduce pain for children with 5% to 10% body surface area burns. Increasing distraction to the level of hypnosis, however, has been used successfully in treatment of debridement pain. More recently, virtual reality distraction — perhaps neurochemically an equivalent of instant hypnosis without training — has been used to great effect for burns. Initial work by Hoffman and colleagues established the efficacy of a multisensory, multidimensional computer-generated game called “Snow World” to decrease pain reports. Pain relief with virtual reality seems to be independent of age or amount of burn, but children may be more likely to “disappear” into the world than adults. Other research with virtual reality distractions supports the argument that this intensive distraction is helpful for patients’ burn pain relief.[43,44] Child life therapists often mimic the restricted visual stimulation of virtual reality using low-tech “Viewmaster” toys.
Cancer treatments include venipuncture, port access procedures, and bone marrow aspirations and lumbar punctures, all associated with high anxiety and pain. Distraction for children’s oncologic procedural pain is well established and is commonly used as an adjuvant to standard pharmacologic pain control.
Echoing previously detailed work, distraction with a simple electronic toy was better than nothing for port access in 2- to 5-year-olds. For older children, being allowed to self-select a distraction (bubbles, I Spy: Super Challenger book, music table, virtual reality glasses, or handheld video games) significantly decreased fear and pain with port access, reinforcing that providing children options is recommended.
Virtual reality distraction has not been studied as extensively as for burn pain but is a likely new modality for children’s cancer procedural pain. Although a 2002-era pair of virtual reality glasses showing skiing were not statistically helpful to adolescents undergoing lumbar punctures, a 2004 study found virtual reality helped children undergoing port access procedures.[49,50]
Patient Characteristic Considerations
In general, younger children (eg, aged 4-6 years) report higher pain with the same stimulus than older children (aged 7 years or older), as well as greater fear and phobia. Data suggest that distraction might be effective for patients as young as several months old. Studies by Cohen and colleagues suggest that age-appropriate televised movies along with adult coaching (eg, prompting the patient to watch a Sesame Street movie) and using age-appropriate distraction (eg, rattles, stuffed animals) results in lower behavioral pain in infants and toddlers. Whereas research typically targets patients of preschool age, there is support for the efficacy of distraction in older children.
Distraction persists as a method until adulthood. In a crossover design, patients who performed a moderate intensity “fake cough” had decreased pain during venipuncture compared with when they didn’t. In general, it is critical that age-appropriate distraction stimuli are selected.
Although pain threshold research has suggested differing sensitivities and reactions to pain, regarding sex differences, there are no data to suggest that boys or girls are more responsive to the benefits of distraction.
Tailoring distraction stimuli to the preferences and coping style of the patient helps. For example, children who prefer to avoid stressors might prefer to watch a movie, whereas children who seek out information might want to watch part of the procedure. Further, distraction stimuli that function to divert multiple senses (ie, sight, hearing, touch, taste, smell) are likely to be more effective than those that only function on one modality. Distractors that elicit positive emotional states (eg, humorous stimuli) are especially potent; it is difficult to laugh and cry at the same time. Finally, providing choices and several options of distraction stimuli is a good idea to avoid boredom or satiation. Selecting a mix of items that are familiar and provide comfort (teddy bear brought from home, bubbles) as well as those that are novel and diverting is advised (new movie, virtual reality).
Regarding who is best suited to assist or coach the child, research supports using any number of different people. Parent coaches free the medical staff to focus on the procedure and provide a coaching role for the parents, which can reduce their own anxiety. Timing is also important. In order to best minimize anticipatory anxiety and speed emotional recovery following the event, distraction should begin as soon as the child enters the medical treatment room and continue for several minutes following the procedure.
Theoretical suppositions a decade ago of how distraction alters acute pain have been recently illuminated with functional magnetic resonance imaging and sophisticated animal model studies. Several mechanisms are likely at work. Focused attention increases electrical activity in the cingulo-frontal cortex, particularly the anterior cingulate gyrus, with a concomitant decrease in firing in pain receptor areas.
A key underlying rationale for describing peripheral distraction is the gate control theory of pain. Cutaneous receptors transmit sharp pain (nociception) via fast myelinated A-delta fibers, temperature sensations via fat unmyelinated C fibers, and movement and position sense moves along myelinated A-beta fibers. These nerve impulses are modulated in the dorsal horn of the spinal cord before they reach the cerebral cortex, where pain is perceived. The theory proposes that external stimulation (eg, movement, rubbing, vibration) can prioritize other sensations by inhibiting pain, “shutting the gate” to block sharp pain.
In addition to physiologic explanations, pain inhibition through inattention can be described and measured as a cognitive construct. Two widely regarded cognitive theories are the limited attentional capacity theory (LCT) and multiple attentional resource theory (MRT), which both suggest that there exists only a finite amount of attentional capacity. Thus, if an activity occupies all of a person’s attentional resources, then pain stimuli will not be perceived. However, focused attention is rarely complete; thus, there are situations in which distraction is more or less effective. In reaction to the assumption of LCT that there is a single domain of attention resources, MRT proposes that there exist separate “pools” or dimensions of information-processing capacity. In support of these theories, studies have found an inverse linear relation between pain and quantity of distraction.[34,59]
In addition to being physiologic and cognitive, attention can be a behavioral phenomenon. For example, attention can be characterized as an orienting response to external stimuli. These responses can be visual orientation to the stimulus (eg, turn of head or eyes) or auditory orientation (eg, pricking of ears). One behavioral theory to explain the mechanism of distraction in pain management is Mowrer’s 2-factor learning theory.[61,62] This theory incorporates classical and instrumental conditioning. For example, in acute painful pediatric procedures, the stimuli associated with the setting of the procedure (eg, medical staff, hospital) could become conditioned stimuli. The unconditioned stimuli are the pain (eg, needle insertion, vaccine’s irritation), and the unconditioned response is the pulling away from this stimulus. Instrumental responding in an attempt to avoid the conditioned stimuli and the unconditioned stimuli could include a wide range of child behaviors that function as conditioned responses as well as to avoid the conditioned stimuli and unconditioned stimuli.
Cohen proposes that distraction functions to reduce the conditioned response and the unconditioned response associated with painful pediatric procedures by diverting attention from the unconditioned pain-eliciting stimulus and the conditioned stimuli paired with pain. The aspect of distraction that sets the occasion for nonpain-related behaviors to occur prevents the development of a conditioned fear response, or it reduces or eliminates fear by facilitating exposure to the conditioned stimuli in the absence of the unconditioned stimuli. In addition, distraction may elicit the process of reciprocal conditioning via conditioning incompatible responses (eg, relaxation, laughter) to the stimulus that previously evoked a fear or avoidance response.
In summary, there is a strong body of evidence supporting the efficacy of distraction for acute pediatric procedure pain. Although a number of theories have been proposed to explain the pain management mechanism of distraction, none have been recognized as the accepted explanation. Regardless, distraction minimizes children’s behavioral reactions to acute pain procedures across a range of medical events including burn treatment, immunizations, cancer care, and venous access. Further, the literature is sufficiently mature to detail recommendations regarding qualities of the distraction stimuli, who might perform the distraction, and when it is best to be conducted. Given the low cost of distraction, lack of side effects, and proven benefits, it should be considered for any potentially painful or distressing pediatric medical procedure.
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Authors and Disclosures
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Lindsey L. Cohen, PhD
Associate Professor of Psychology, Georgia State University, Atlanta
Disclosure: Lindsey L. Cohen, PhD, has disclosed no relevant financial relationships.
Amy L Baxter, MD
Staff Physician, Department of Emergency Medicine, Scottish Rite Hospital, Atlanta, Georgia
Disclosure: Amy L. Baxter, MD, has disclosed that she is a member of MMJ Labs LLC, a company that holds patents to medical devices.
Laurie E. Scudder, MS, NP-C
Nurse Planner, Medscape; Adjunct Assistant Professor, School of Health Sciences, George Washington University, Washington, DC; Curriculum Coordinator, Nurse Practitioner Alternatives, Inc., Ellicott City; Nurse Practitioner, Baltimore City School-Based Health Centers, Baltimore, Maryland
Disclosure: Laurie E. Scudder, MS, NP-C, has disclosed that she has no relevant financial relationships.
Editorial Director, Medscape Pediatrics and Business of Medicine
Disclosure: Mindy Hung has disclosed no relevant financial relationships.