Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review.
BACKGROUND
Immunizations are a common source of pain and distress for children. Psychological interventions consist of a variety of techniques for relaxing and distracting children during immunization with the goal of reducing pain and distress.


OBJECTIVE
We conducted a systematic review to determine the efficacy of various psychological strategies for reducing pain and distress in children during routine immunizations.


METHODS
MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials (RCTs) and quasi-RCTs that determined the effect of psychological interventions on pain and distress during injection of vaccines in children 0 to 18 years of age, using validated child self-reported pain or observer-reported assessments of child distress or pain. We examined the efficacy of 7 psychological interventions: (1) breathing exercises; (2) suggestion; (3) child-directed distraction; (4) parent-led distraction; (5) nurse-led distraction; (6) parent coaching; and (7) combined cognitive-behavioral interventions. All meta-analyses were performed using a fixed-effects model.


RESULTS
Twenty RCTs involving 1380 infants and children (1 month to 11 years of age) were included in the systematic review. Breathing exercises were effective in reducing children's self-reported pain (standardized mean difference [SMD], -0.43; 95% CI, -0.76 to -0.09; P = 0.01), observer-rated distress (SMD, -0.40; 95% CI, -0.68 to -0.11; P = 0.007), and nurse-reported distress (SMD, -0.57; 95% CI, -0.98 to -0.17; P = 0.005). Self-reported distress ratings appeared to be lower with breathing exercises, but the difference was not statistically significant. No evidence was found to support suggestion as a psychological intervention for reducing pain associated with pediatric immunization. Child-directed distraction was effective in reducing self-reported pain (SMD, -0.28; 95% CI, -0.54 to -0.03; P = 0.03). Parent-led distraction was effective in reducing observer-rated distress (SMD, -0.50; 95% CI, -0.82 to -0.19; P = 0.002), but not other measures of pain or distress. Nurse-led distraction was effective in reducing distress ratings as assessed by the observer (SMD, -0.40; 95% CI, -0.68 to -0.12; P = 0.005), the parent (SMD, -0.37; 95% CI, -0.66 to -0.07; P = 0.01), and the nurse (SMD, -0.42; 95% CI, -0.70 to -0.14; P = 0.004). Parent coaching was effective in reducing observer-rated distress (SMD, -0.71; 95% CI, -1.02 to -0.39; P < 0.001), but not other measures of pain or distress. Combined cognitive-behavioral interventions were effective in reducing children's self-reported pain (SMD, -0.75; 95% CI, -1.03 to -0.48; P < 0.001), observer-rated distress (SMD, -0.53; 95% CI, -0.83 to -0.23; P < 0.001), and parent-rated distress (SMD, -0.97; 95% CI, -1.37 to -0.57; P < 0.001). The methodologic quality of the included trials was generally poor, with 18 (90%) of the 20 studies rated as having a high risk of bias.


CONCLUSIONS
Evidence suggests that breathing exercises, child-directed distraction, nurse-led distraction, and combined cognitive-behavioral interventions are effective in reducing the pain and distress associated with routine childhood immunizations. Although additional well-designed trials examining psychological interventions are needed, parents and health care professionals should be advised to incorporate psychological interventions to reduce the pain and distress experienced by children during immunization.
Departments of Pediatrics and Psychology, Dalhousie University, Halifax, Nova Scotia, Canada. christine.chambers@dal.ca
Christine T
CT
Chambers
Anna
A
Taddio
Lindsay S
LS
Uman
C Meghan
CM
McMurtry
D001945:Breathing Exercises; D002648:Child; D002675:Child, Preschool; D015928:Cognitive Behavioral Therapy; D003627:Data Interpretation, Statistical; D016206:Databases, Bibliographic; D006801:Humans; D007114:Immunization / Q000009:adverse effects*; D007223:Infant; D009726:Nurses; D010146:Pain / Q000209:etiology / Q000517:prevention & control* / Q000523:psychology; D010147:Pain Measurement; D010290:Parents; D016032:Randomized Controlled Trials as Topic; D015203:Reproducibility of Results; D013315:Stress, Psychological / Q000209:etiology / Q000517:prevention & control* / Q000523:psychology; D013404:Suggestion; D016896:Treatment Outcome