1 of Table 3
Practice Area: Cognitive/Behavioral Techniques for Needlesticks/Procedures
Topic
Ulman, LS,
Chambers,
Ct,
McGrath,
PJ and
Kisely S
Citation
Cochrane Review
Psychological interventions for needle-related procedural pain and distress in children and adolescents.
Assessed as up – to –date 2006
Sample
28 trials 1951 participants immunizations and injections were most commonly studied
Behavioral approache s-over view
Distraction
Cohen LL
Behavioral Approaches to Anxiety and Pain Management for Pediatric
Venous Access
Pediatrics2008 122 S134-139
Klieber C, Craft-Rosenberg, M &
Harper DC
Parents As Distraction Coaches
During IV Insertion: A Randomized
Study
Journal Pain Symptom
Management 2001: 22:851-861.
Article
44 children with chronic illness
4-7 yrs old
Dyads randomized to groups
RCT
Key Findings
Review of
Distraction , Memory Alteration
CBT, Nurse Coaching, Parent
Coaching, Video tape modeling
Suggestion, Blowing out air
The largest effect for treatment over control exits for distraction, hypnosis, and combined CBT
Preparation
Positioning
Adults should encourage coping
Engage child in distraction
Infants: swaddling skin-to –skin contact, breast feeding, and sucrose.
2 groups: standard vs. distraction education for parents
No difference between groups in observed behavior scores, pain scores
Educated Parents displayed more distraction
Experimental group displayed less distress over the time of the IV start
Comments
Research in behavioral approaches provide recommendations for minimizing anxiety and pain.
86 references
Excellent article
Small n-power low to evaluate child’s pain response
Some parents did well – other were not effective
**5 key points for coach
Focus attention away from procedure
Use activities to keep attention
Try to get attention back
Using distraction takes effort
Praise child at the end

2 of Table 3
Distraction
Distraction
Dahlquiest, LM, Busby, SM, Slifer, KJ,
Tucker, CL et al.
Distraction for Children of
Different Ages Who Undergo
Repeated Needle Sticks
Journal of Pediatric Oncology
Nursing 2002: 19:22-34
Cohen, LL, Blount, RL & Panopoulos
G.
Nurse Coaching and Cartoon
Distraction: An Effective and
Practical Interventions to Reduce
Child, Parent and Nurse Distress
During Immunizations
Journal of Pediatric Psychology
22(3): 355-370
6 children longitudinal study
2-8 years
92 children
4-6yrs
4 th graders- completed 3 immunization, exposed to 3 conditions
Standard
Nurse coach
Nurse coach + parent child education
Videotaped
Nurse not blinded
RCT
5 of 6 children showed a decrease in distress, Parent and staff reported less anxiety and better cooperation from the child.
Young children had trouble staying distracted during traumatic procedure
Distraction is a simple, practical and relatively inexpensive pain management strategy that may have the potential to remain effective over repeated invasive procedures.
Tailor activities to developmental level of child
Distraction had greater decreases in distress and increased coping than EMLA
Less distress reported over time
More nurse coaching with distraction intervention
Less parent distress
Distraction helps build coping skills, Less effect of EMLA on older children
Simple instruction by nurse help parents be coaches
Parent participation as a coach may decrease feelings of stress and helplessness. Decrease in nurse stress may be related to having a protocol, focusing on procedure while child is distracted and having child/parent less stressed.

3 of Table 3
Distraction
Distraction- touch and
Cohen LL
Can’t find it
Sparks, L
Taking the” Ouch” Out of
Injections for Children: Using
Rural health care cents
92 children and parents
More coping behaviors with
No difference in vital signs and pain measure, but difference in total scores of distress behaviors over the procedure
Parents have less stress when they are coaching.
Parents model nurses behaviors.
Best words . Distress promoting behaviors increases child’s distress: reassurance, empathy, apologies, criticism and giving child control over beginning of the procedure.
? if younger patients do not find music as effective of a distraction as older children
Distraction
Distraction
& positioning
Megel, M E, Houser, CW, Gleaves,
LS.
Children’s Response to
Immunizations: Lullabies as a
Distraction
Issues in Comprehensive Pediatric
Nursing 21:3 129-145
Cavender, K, Goff, MD, Hollon, ED and Guzzetta, CE
Parent’s Positioning and Distracting
Children During Venipuncture:
Effects on Children’s Pain, Fear, and Distress
99 children in pediatric clinic
3-6yrs
RCT
43 children
Chronic illness
ED
4-11years
RCT
105 children public health clinic
Standard care included preparation and education- treatment group received instruction by CLS on how to position and distract
Pain scores- lower in exp group but not significant
Both distraction methods reduced pain perception
Touch group had the lowest pain
Good reference list for studies related to behavioral response
Fear and pain scores were related
Behavioral distress dropped over time ( recovery was quicker)
Good article for ED
Two components of injection pain: needle through skin and solution

4 of Table 3 bubble blowing
Distraction
Cough
Trick
Distraction to Decrease Pain
MCN 26(2): 72-78
Wallace, DP, Allen KD, Lacroix, AE and Pitner, SL
The “Cough Trick”, A Brief
Strategy to Manage Pediatric Pain
From Immunization Injections
Pediatric 2010 125: e 367-373
4-6 yrs
3 groups;
Standard, touch or bubble blowing
DTP vaccine
Oucher scale
RCT
Immunization clinics
4-5 yr and
11=13yr
68 participated
(many refused due to perceived time to complete papers)
RCT score.
Bubble blowers would stop blowing bubbles when immunization started.
Assessed nurse satisfaction
Pain scores were lower but not significantly different
Participants identified as black did not find trick as helpful
Infants- sucrose and positioning
Reis, EC, Roth EK, Syphan, JL,
Tarbell, SE, Holoubkov, R
Effective pain reductions for multiple immunizations injections in young infants
Arch pediatr Adolesc Med , 2003 157:
1115-
Heel stick -
Infants
Gray, L, Watt, L & Blass, EM
Skin-to-skin contact is analgesic in healthy newborns
Pediatrics 20002, 105(1)
116 infants
7-11 weeks
2 month injections ( 4 shots)
RCT
30 newborns
Held by mother ( skin contact) or swaddled in crib
RCT
Sucrose and pacifier, held by parent less crying for infant
Parent preference for holding and sucrose
Crying and grimacing were reduced by 82% and 65% respectively. Heart rate was also reduced. in tissue.
Touch: light stroking of the skin around the injection site prior to and during injection
Fear is a factor in pain
Cough Trick: single warm-up cough of moderate force followed by a second cough that coincides with needle puncture- first tested in adults
Some children delayed cough when they learned the injection would occur with the cough
Cross cradle position- upper body close to mother’s chest,
held in that position for 6 minutes
Injection site cleaned 2 minutes after sucrose was given