Painful medical procedures such as phlebotomy and injection may lead children to feel fear and anxiety. American Society for Pain Management Nursing emphasized that coping strategies for pain and anxiety before and during painful procedures in children are important for pain and anxiety control in their adulthood. Therefore, they recommend pharmacological and nonpharmacological approaches for controlling pain (11). Various methods are used to decrease the perception of pain during medical procedures recently and distraction is one of the most commonly used non-pharmacological methods. Distraction methods are used in various forms to divert the attention of the patient from the painful stimulus. (12–16). In our study, a method of letting the patients to play games on a tablet was selected as an active distraction method in one of the groups. Preparing children for upcoming painful procedures is also considered as another intervention method in the recent reports. Strong and consistent evidence indicates that proper preparation before any invasive procedure is very beneficial for children (1) In our study, parents/caregivers in two groups were informed with a form so that they can prepare the children accordingly before the procedure, and children were informed verbally by a special physician as well.
A significant difference was found between the three groups in terms of fear and pain levels of patients; where it was found to be lower in the distracted and informed group than in the other groups according to the evaluations performed by parents/caregivers and an independent observer.
For pediatric acute pain management, many distraction methods such as watching cartoons, blowing balloons, playing with an interactive robot, looking into virtual reality gadgets, reading books, listening to music, and interacting with clowns were evaluated by investigators. In a meta-analysis of 19 pediatric pain management studies evaluating distraction efficiency revealed that distraction has a reasonable effect in decreasing distress behavior. In these studies, distraction was found to be very effective especially in children younger than seven years (8).
Watching cartoons as a passive distraction was found to be more effective than playing with a robot as an active distraction in the study of Maclaren et al (6). In the study of Mason et al (17), reading books to the child by their parents was considered an active distraction, while watching cartoons was considered passive, and stress levels were found to be significantly lower in the reading book group. These miscellaneous results may be associated with the selection of different distraction methods, measurement methods, and design of the studies. However, it was reported in many studies that active or passive distraction reduced fear and pain before and during the procedure (6, 13, 14, 18, 19, 20). In our study, active distraction was used in only one group. No distraction methods were used in the other two groups. In this study, giving information was found significantly more beneficial in the informed and distracted group than the only informed group according to the parents. In the study of Wang et al (5); therapeutic touch, encouragement, and guided imagery methods were utilized during the procedure in the intervention groups, and the pain was found significantly lower in this group than the control group. However; in our study, no significant difference was found in the comparison of the informed and control groups in terms of pain and fear. It was also underlined in the literature that an experienced staff should give information by spending adequate time (12, 17). In the current study, information was given by a physician just before blood was drawn, which may be one of the limitations of this study. Bijttebier et al. (14) reported that children with negative medical experiences displayed higher levels of anxiety before an invasive procedure, also they were more distressed and less cooperative during the procedure. Negative medical experiences in childhood lead to reports of pain and fear in adulthood medical events and result in refraining from medical services (20). Giving information over a longer time by a dedicated staff can be more effective. Since the majority of patients had blood drawing experience previously, that can be considered another limitation in this study (n:130, 92%). In this context, even just giving accurate information may be effective in reducing pain and fear.
Parents’ anxieties of the informed and distracted group were found significantly lower by an independent observer (p = 0.007) in this study. In the study of McCarthy et al (15), the parents of a group were trained on distraction coaching to distract their children and compared to the control group, and it was attained that the children and their parents in the trained group had less stress, which was statistically significant compared to the control group.
McCarthy et al (15) stated that if parents believe in nonpharmacological interventions and are encouraged to use their skills, they may be less stressed during the implementation of invasive procedures on their children and prepare their children better for the procedure. In our study, the stress level was lower in the informed and distracted group, which may be explained by the fact that children were prepared better for the procedure by health care personnel.
In the current study, a significant difference was found between the duration of the procedure in three groups. In a study by Wang et al (5), it was found to be longer in the control group.
In this study, pain and fear scores of children were found lower by both parent and independent observer in the informed and distracted group. Also, parental anxiety was found lower by the independent observer in this group. Some studies have demonstrated that parental anxiety affects the anxiety of the child during invasive procedures. Training parents for coping and distracting was found effective in decreasing the stress levels of children before and during the procedure (8, 11, 19). In our study, parents in informed and distracted group were convinced that distracting and informing has a positive effect on their children in experiencing less anxiety. Jurdi et al. (20) and Wohlheiter et al. (18) stated that electronic video games are very useful in coping with anxiety, stress, and pain; however, they also recommended that more studies should be carried out to confirm benefits and positive outputs. Incompatible with the Jurdi et al. (20) we observed that playing tablet games in pediatric hospital settings seems to increase emotional expressions; and reduce pain, anxiety, and stress. However, there are not many evaluations available on these issues, and more should be carried out to confirm these benefits.
In conclusion, informing, preparing, coping, distracting methods should be used before, during, and after the invasive procedures to reduce children's pain and anxiety. Interventions on this issue should be holistic and psychological support should be provided to children who cannot manage their stress additionally health care professionals should be trained to help the children in mitigating their stress and anxiety.