Best Practices for Pain Reduction
Associated with Venipuncture in Children
University of Alaska Anchorage
NS 400
Jennifer Crow, Dawn Reishus, Brenda (Cooper) McMillan,
Char Corkery, Rachel Chesser
Searchable Question: What are best nursing practices to reduce the pain of venipuncture in children?
Evidence Synthesis Table
Studies
•
•
Design
Sample
Study Length
Sponsorship
Bias
Finding 1
Finding 2
Cold/Vibration reduces pain
& anxiety during
venipuncture
Randomized
Control Trial (level
2 evidence)
120 children 6-12 years
old
February – March
2010
None
External cold & vibration can reduce pediatric pain and
anxiety during blood specimen collection without IV success.
Vibration devices are inexpensive to
operate per use.
Cold/Vibration on pain &
anxiety during venipuncture
81 children 4-18 year
olds
April – August 2008
None
Cold & vibration decreased venipuncture pain without
affecting procedural success
Vibration devices are inexpensive to
operate per use.
Distracting children during
blood draws: Looking
through Distraction Cards
Randomized
Control Trial (level
2 evidence)
Randomized
Control Trial (level
2 evidence)
123 Children 6-12 years
January 14, 2010 to
February 20, 2010
None
Significant finding?
Children in experimental group had significantly lower pain
levels than the control group
Anxiety level evaluated by parent and
observer report was significantly lower in
experimental group
EMLA and amethocaine for
reduction of children’s pain
associated with needle
insertion
Systematic review
of randomized
control trials (Level
1 evidence)
534 children 3 months –
15 years
Varied
None
Comparison of adverse reactions to
Amethocaine and EMLA favored EMLA
suggesting it resulted in redness less
often than amethocaine
Comparison study of Jetdelivered lidocaine, jetdelivered placebo and no
pretreatment for pain relief
during needle insertion
Comparison of pain reduction
during needle insertion using
topical xylocaine spray to no
intervention
Randomized
control trail (level 2
evidence)
197 children 5-18 years
April 1, 2007 to
August 1, 2008
None
Amethocaine significantly favored over EMLA (the child was
22% less likely to report pain)
Self Report: child was 37% less likely to report pain with
amethocaine versus EMLA
Observational: Difference was not significant
No significant difference between the jet delivered lidocaine
and the jet delivered placebo for pain reduction in needle
insertion
Randomized
control trail (level 2
evidence)
40 neonates under 34
weeks gestation
July – November
2004
None
The intervention group maintained more stable heart rates,
respiratory rates, and oxygen saturation during needle
insertion
Xylocaine spray is fast acting and cost
effective method of reducing pain
Evaluating reduction in pain
of newborns receiving
glucose compared to EMLA
cream prior to venipuncture
Randomized
controlled trial,
double blind
201 newborns
undergoing
venipuncture for clinical
purposes
January 1999 –
October 2000
None
Glucose is effective in reducing pain symptoms from
venipuncture in newborns
Glucose is more effective than local
anesthetic EMLA cream
Comparing non nutritive
sucking to glucose solution
for reduction in pain during
venipuncture
Evaluation of studies looking
at pain reduction of needle
related procedures with
sweet tasting solutions
Randomized
controlled trial,
parallel group
105 neonates at least 32
weeks gestational
June-October 2006
None
NNS can effectively decrease pain during venipunctures
GW can effectively decrease pain during
venipunctures
Systematic review
of randomized
controlled trials
4 studies, 330 children
12 months to 16 years
Varied
None
Infants 0-12months have decreased pain with sweet tasting
solutions
Children 1-16years do not experience a
reduction in pain with sweet tasting
solutions
Background
Venipuncture is found to be a common cause of
pain in children. (Inal & Kelleci, 2012)
Venipuncture pain in children may lead to long
term avoidance of seeking health care,
immunizations, and donations. (Baxter et al., 2011)
•
•
•
•
Databases Searched
CINAHL
Cochrane
Google Scholar
PsychINFO
Results
Critical appraisal of the literature
suggests that some form of pain
control during venipuncture will
be beneficial for children.
Comparison of jet-delivered lidocaine or
placebo to no pretreatment suggested
that the intervention group showed
superior pain relief to the control group.
Conclusion
Reduction of pain in children during venipuncture will help
prevent increased pain and anxiety in future procedures.
Pain control methods can be achieved through various
inexpensive, non-invasive means.
Further education and training is advised for nursing staff
regarding pain reduction techniques for children.
•
•
•
Summary of Evidence
•
Sweet-tasting solutions significantly reduce pain of venipuncture in infants under 1 year of age (Gradin et al., 2002; Harrison et al.,
2011).
•
•
Amethocaine cream provided significant pain relief of venipuncture compared to EMLA cream in children 3 months - 15 years old
(Lander & Weltman, 2006).
•
•
Xylocaine topical spray significant reduced pain of venipuncture in neonates under 34 weeks gestation in addition to standard care
(Chen et al., 2006).
•
•
Jet delivery of lidocaine or a placebo provided superior pain relief to no pretreatment for children 5-18 years old (Auerbach et al.,
2009).
•
Children 6-12 years old self-reported less pain when distraction by flip-cards was used (Inal & Kelleci, 2011).
•
External cold and vibration significantly reduced pain and anxiety in children ages 4-18 years old versus standard care (Baxter et al.,
2011; Inal & Kelleci, 2012).
Suggestions for Future Research
Additional qualitative studies regarding various
methods of pain reduction for venipuncture in
children.
Additional RCT studies to support use of sweettasting solutions for children over 1 year of age.
Determine whether external cold and vibration
devices could offer pain relief for more invasive
procedures.
Research Question
What are the best nursing
practices to reduce the pain of
venipuncture in children?
Background & Significance
Venipuncture procedures are found
to be a common cause of pain in
children.
(Inal & Kelleci, 2012)
Venipuncture pain in children may lead to
long-term negative effects later in life such
as future avoidance of medical care,
immunizations, and blood donations.
(Baxter et al., 2011)
Topical Xylocaine Spray for Reducing the Pain of
Venipuncture in Neonates
(Chen, et al. 2006)
Design: RCT, Level 2
Population: Newborn infants in the neonatal intensive care units with gestational age of more than 34 weeks (n=40)
Sample: Purposive Sample/ Random Group Assignment
Intervention: Administration of a 10% xylocaine solution pump spray applied topically before venipuncture.
Findings: Infants in the study group had lower heart rate and less changes in oxygen saturations than infants in the
control group.
Weaknesses of the Study
Strengths of the Study
•
Financially feasible intervention
•
Small population
•
RCT
•
Assumes that heart rate, respiratory rate and oxygen
saturation are associated with pain.
A Randomized, Double-blind Controlled Study of Jet Lidocaine
Compared to Jet Placebo for Pain Relief in Children Undergoing
Needle Insertion in the Emergency Department
(Auerbach et al. 2009)
Design: RCT, Double Blind Study, Level 2
Population: Children ages of 5-18 at a pediatric hospital requiring acute needle insertion (venipuncture or peripheral venous
cannulation) (n=197)
Sample: Convenience Sample/ Random Group Assignment
Intervention: Pretreatment with jet delivered lidocaine (n=75) or a with jet-delivered placebo 60 seconds before undergoing
needle insertion. (n=75)
Findings: The mean needle insertion pain score for both the jet lidocaine and the jet placebo groups were lower than the needle
insertion pain scores for the no device group.
Strengths of the Study
•
•
•
•
RCT, Double-blind study
Financially feasible intervention
Large sample size
Patients reported pain levels using a CAS tool
Weaknesses of the Study
•
•
•
•
Pain scores are subjective
Parental presence or lack of was not documented for each
patient
Nonintervention group was smaller than the intervention
groups
Variations in provider’s skills could impact the study.
Pain reduction at venipuncture in newborns:
oral glucose compared with local anesthetic cream
(Gradin et. al, 2002)
Design: Experimental-controlled randomized double blind
Population: 201 Newborns
Interventions: Newborns receiving glucose prior to venipuncture
Findings: Significantly fewer scored as having pain (19.3%) compared to EMLA group (41.7%)
Strengths of the Study
Weaknesses of the Study
•
Decreased wait time
•
Habituation to glucose
•
Easy to use
•
Difficult to measure pain
•
RCT
•
Effectiveness applies to newborns only
•
Large sample size
•
Unknown reason why glucose works best
•
Financially possible.
.
Using non-nutritive sucking and oral glucose solution
with neonates to relieve pain: A randomized controlled
trial
(Liu et. al, 2010)
Design: Randomized, parallel group controlled trial
Population: 105 neonates at least 32 weeks gestational
Interventions: Newborns receiving glucose prior to venipuncture
Findings: Glucose group and non nutritive sucking group had significantly lower pain scores than
control group
Weaknesses of the Study
Strengths of the Study
•
Use of NIPS
•
Limited generalizability
•
RCT
•
No use of double blind
•
Relevance to Clinical Practice
Sweet tasting solutions for reduction of needle-related
procedural pain in children aged one to 16 years.
(Harrison et al., 2011)
Design: Systematic Review of RCTs, Level I Evidence
Population: 4 studies and 330 children 12 months to 16 years of age
Intervention: The use of sweet tasting solutions in children over one year of age during venipuncture.
Findings: Sweet tasting solutions did not show a reduction in pain with needle related proceedures in
children 12 months to 16 years of age.
f
Strengths of the Study
•
High Level Cochrane Review
Weaknesses of the Study
•
Conflicting Studies
•
Requires more well-conducted RCTs with
larger sample sizes
Distracting children during blood draw: Looking
through distraction cards
(Inal & Kelleci, 2012)
Design: RCT, Level II
Population: Children 6 – 12 years (n=123)
Sample: Convenience Sample, Random Group Assignment
Intervention: Flippits® Distraction Cards during blood draw procedures
Findings: Children receiving intervention self-reported and were observed to have less pain and
anxiety
Weaknesses of the Study
Strengths of the Study
•
•
Not suitable for children with neurologic, visual,
RCT, large sample
or auditory deficits
•
Financially feasible
•
Effectiveness after multiple uses with one child are
unclear
EMLA and Amethocaine for reduction of children’s
pain associated with needle insertion (Review)
(Lander, Weltman, & So, 2010)
Design: Systematic Review of RCT, Level I
Population: 6 trials of 534 children 3 months to 15 years of age
Intervention: Compared EMLA to Amethocaine in reduction of pain associated with venipuncture
Findings: Amethocaine significantly reduced risk of pain when compared with EMLA
Strengths of the Study
Weaknesses of the Study
•
High-level Cochrane review
•
•
Exhaustive database search and handsearch of reference lists and journals
Some of the trials used scales that had
not been properly analyzed
An Integration of Vibration and Cold Relieves
Venipuncture Pain in a Pediatric Emergency Department
(Baxter et al., 2011)
Design: RCT, Level II
Population: Children 4-18 years (n=81)
Sample: Convenience Sample/Random Group Assignment
Intervention: The use of both cold & vibration during venipuncture
Findings: Children in the device group had significantly lower pain by parent report and the
observational scale than children in the standard care group
Strengths of the Study
Weaknesses of the Study
•
RCT
•
Small Sample
•
Quick-acting option vs. topical analgesics
•
Subjects & coders not blinded to intervention groups
•
Low cost ($0.09 per attempt)
•
No control for placebo effects
Relief of Pain During Blood Specimen Collection in
Pediatric Patients
(Inal & Kelleci, 2012)
Design: RCT, Level II
Population: Children 6-12 years (n=120)
Sample: Convenience Sample/Random Group Assignment
Intervention: using the “Buzzy” or cold & vibration applied to the site of insertion during venipuncture
Findings: Children in the device group had significantly lower pain (p<0.001) and anxiety (p<0.001)
Strengths of the Study
Weaknesses of the Study
• RCT
• Not double-blind
• Quick-acting option vs. topical analgesics
• No control for placebo effects
• Large sample size
• Nurses not randomly selected
• Pain & anxiety levels not assess by researcher to limit bias
Stake Holders
 Nurses
 Certified Nursing Assistants
 Phlebotomists
 Intravenous Access Team
 Facility Administration/Accounting
Future Research
Additional qualitative studies regarding
various methods of pain reduction for
venipuncture in children.
Additional RCT studies to support use of
sweet-tasting solutions for children over 1
year of age.
Determine whether external cold and
vibration devices could offer pain relief for
more invasive procedures.
Summary of Evidence
Xylocaine topical spray significantly
reduced the pain of venipuncture in
neonates under 34 weeks gestation in
addition to standard care.
(Chen et al., 2006)
Sweet-tasting solutions
significantly reduce the pain of
venipuncture in infants under one
year of age.
(Gradin et al., 2002; Harrison et al., 2011).
Summary of Evidence
Children 6-12 years old self-reported
less pain when distraction by flipcards was used
(Inal & Kelleci, 2011).
External cold and vibration significantly
reduced pain and anxiety in children ages 4-18
years old versus standard care
(Baxter et al., 2011; Inal & Kelleci, 2012).
Summary of Evidence
Amethocaine cream provided significant
pain relief of venipuncture compared to
EMLA cream in children 3 months - 15
years old.
(Lander & Weltman, 2006)
Jet delivery of lidocaine or a placebo
provided superior pain relief to no
pretreatment for children 5-18 years old.
(Auerbach et al., 2009)
Results
Critical appraisal of the literature
suggests that some form of pain
control during venipuncture will be
beneficial for children.
Implementation
Create EBP quality intervention teams
Provide training for staff regarding pain
relief methods
Implement protocol for venipuncture pain
relief
Evaluation
Assess pain using hospital approved
pain scales
Document pain response to used
intervention
Periodic review of documentation
regarding response to intervention
Conclusion
Reduction of pain in children during venipuncture will
help prevent increased pain and anxiety in future
procedures.
Pain control methods can be achieved
through various inexpensive, noninvasive means.
Further education and training is advised for nursing
staff regarding pain reduction techniques for children.
References
Auerbach, M., Tunik, M., & Mojica, M. (2009). A randomized, double-blind controlled study of jet lidocaine compared
to jet placebo for pain relief in children undergoing needle insertion in the emergency department.
Academic Emergency Medicine, 16(5), 388-393. doi:10.1111/j.1553-2712.2009.00401.x
Baxter, A., Cohen, L., McElvery, H., Lawson, M., & von Baeyer, C. (2011). An integration of vibration and cold
relieves venipuncture pain in a pediatric emergency department. Pediatric Emergency Care, 27(12),
1151-1156.
Chen, H., Tzeng, C., Liu, W., Huang, Y., & Chen, Y. (2006). Topical xylocaine spray for reducing the pain of
venipuncture in neonates. Clinical Neonatology, 13(2), 38-41.
Gradin, M., Eriksson, M., Holmqvist, G., Holstein, Å., & Schollin, J. (2002). Pain reduction at venipuncture in
newborns: oral glucose compared with local anesthetic cream. Pediatrics, 110(6 part 1), 1053-1057.
Harrison D., Yamada J., Adam-Webber T., Ohlsson A., Beyene J., & Stevens B. Sweet tasting solutions for reduction of
needle-related procedual pain in children aged one to 16 years. cochrane review 2011, Issue 10
References
Inal, S., & Kelleci, M. (2012). Distracting children during blood draw: Looking through distraction cards is effective in
pain relief of children during blood draw. International Journal Of Nursing Practice, 18(2), 210-219.
doi:10.1111/j.1440-172X.2012.02016.x
İnal, S., & Kelleci, M. (2012). Relief of Pain During Blood Specimen Collection in Pediatric Patients. MCN: The
American Journal Of Maternal Child Nursing, 37(5), 339-345. doi:10.1097/NMC.0b013e31825a8aa
Lander JA, Weltman BJ, So SS. EMLA and Amethocaine for reduction of children's pain associated with needle
insertion. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004236. DOI:
10.1002/14651858.CD004236.pub2.
Liu, M., Lin, K., Chou, Y., & Lee, T. (2010). Using non-nutritive sucking and oral glucose solution with neonates to
relieve pain: A randomized controlled trial. Journal Of Clinical Nursing, 19(11-12), 1604-1611.