Evidence Tables, Synthesis of Evidence, and Practice Recommendation

Week 6 Synthesis Project Part II – Evidence Tables, Synthesis of Evidence, and Practice

Recommendation
Introduction

In the US and other parts of the world, access to pain management therapy
(pharmacological and nonpharmacological) is a fundamental human right, and it is
unconstitutional not to deny patients one (McKenzie et al., 2021). Pediatric care from healthcare
facilities in Europe and North America, including the United States, shows that pain is common
but underdiagnosed and undertreated. Needle procedures during routine child care or
immunization are a significant source of pain, distress, and hesitancy. Estimates show that over
25 percent of adults fear needle injections, and most of these phobias develop during childhood.
Studies also show that untreated pain can present long-term ramifications, including needle
hyperalgesia, preprocedural anxiety, phobia, and overall avoidance of healthcare (Grunau et al.,
2009). These factors have been shown to increase mortality and morbidity (like intraventricular
hemorrhage). A 2016 guideline for procedural pain management in newborns by the American
Academy of Pediatrics concluded that neonates, especially premature infants, often experience
unnecessary but preventable pain during vaccination and other routine procedures, resulting in
increased morbidities and mortalities in pediatric facilities. Other studies have also linked
exposure to unnecessary pain in neonates without pain management to poorer motor function and
cognition (Grunau et al., 2009). In cognizance of the long-term effects of pain on aspects like
treatment compliance, this paper synthesizes the literature on the effects of distraction techniques
on pain scores during immunization.

Significance of the Practice Problem

The discovery of vaccines ushered in a new era of disease management, allowing
scientists and clinicians to eliminate previously deadly diseases. Despite immunization
unquestionably improving children’s health and quality of life, concerns have been raised about
vaccines' efficacy, safety, costs, and potential side effects. Additionally, the vaccination
process (injections) has been a significant source of pain and trauma to children – although
compared to its benefits, this has not been a major ethical issue to cancel the routine programs.
Although overlooked for the longest time, researchers are now exploring the potential adverse
effects of vaccination injections on children, their parents, and clinicians (pediatricians)
administering the drugs. Research shows that the pain associated with these injections is a
primary source of 3 trauma and distress for young children, clinicians, and parents. If not
addressed, the distress and pain can result in needle fears, preprocedural anxiety, and
nonadherence to immunization appointments. Evidence shows that approximately 25 percent of
adults fear needles, and most of these fears develop in childhood. Roughly 10 percent of the
population avoids immunization and other needle-related procedures (Taddio et al., 2010).
Researchers are now looking for better ways to reduce pain and improve immunization clinical
experiences and outcomes, including adherence. More positive immunization experiences can
also build and promote trust in clinicians (MacKenzie et al., 2021).

PICO

In young children from birth to young adulthood (P), do distraction techniques during
immunization using toys (I), compared to no intervention (C), result in lower pain scores (O)?

Search Strategy and Results

An online search for “relevant” articles was conducted in several medical databases,
including PubMed, Google Scholar, MEDLINE, CINAHL, EMBASE, and Cochrane. Search
words like “use of toys to reduce pain during child immunization to reduce pain” and “use of

3
distraction techniques to reduce pain scores during child vaccination” were typed and searched
on these databases to identify the most relevant and recent articles. Duplicated articles were first
removed before the rest were screened for eligibility. The following inclusion and exclusion
criteria were followed. For inclusion, articles needed to meet the following criteria: (1) must be
relevant to the topic, that is, focus on how toys and other distraction techniques
(nonpharmacological), compared to no intervention, reduces pain scores in children during
immunization and other injection-related procedures (2) must be primary quantitative research or
a systematic review, (3) must be written in English, (4) published between 2010 onwards, (5) and
focused on the North American population, specifically the US and Canada. The two North
American countries were selected because their healthcare models and policies are similar in
structure, especially vaccination guidelines. Canada was also considered because of a fear of not
getting enough, and recent quantitative studies specifically focused on managing pain in children
during immunization. Exclusion criteria included (1) articles published before 2010, (2) articles
focused on pharmacological (drugs) pain management interventions, (3) articles focused on
populations other than the US and Canada, and (4) articles written in a language other than
English.
Out of the 100 articles identified during the initial search, only 10 met the inclusion
criteria: five for the “primary quantitative” category and five for the “systematic review”
category. The PRISMA figure below illustrates the search results.
Articles identified via database
search (PubMed, etc.) (n=90)

Articles identified using other
online sources (n=10)

Articles after duplicates
were removed (n=35)

Articles Screened for
criteria 1,3, 4, & 5 (n=35)

Full-text articles
screened for criteria 2
(eligibility as
quantitative and
systematic review
(n=20)

Final articles (studies)
included for synthesis
(n=10)

Articles omitted (n=15)

Full-text articles
excluded for not being
a “primary
quantitative” study or
systematic review
(n=5)

4

Synthesis of the Literature and Practice Recommendations
The effect of pain during procedural therapy, including vaccinations, has been positively
associated with adverse child, clinician, and parent experiences, and these childhood experiences
often persist to adulthood (McMurtry et al., 2015). Most of the articles identified in this study
corroborate with past empirical research, mainly showing a positive correlation between
vaccination and higher pain scores. To effectively manage pain in children and improve
clinician, parent, and patient experiences, researchers have proposed a broad range of
nonpharmacological (including distraction using toys) and pharmacological (analgesics)
techniques. All the ten articles examined in this study reveal that nonpharmacological
approaches can significantly lower pain scores and improve patient, parent, and clinician
experiences.
For example, a hospital-wide survey by Friedrichsdorf et al. (2018) showed that
distraction techniques improved patient and parent satisfaction and their experiences with pain
management. It also significantly decreased wait times between baseline and twelve months.
Other pain management strategies like comfort positioning, breastfeeding or sucrose, and topical
anesthetics also positively improved pain scores among children. A randomized controlled trial
(RCT) by Inan & Inan (2019) also showed a statistically significant correlation between the
intervention group (video games, cartoon movies, and parents’ verbal interactions) and lower
pain and anxiety scores (P<0.05). The Wong-Baker Pain Scale and the Children Fear Scale were
used to measure pain and anxiety, respectively.
Similarly, using the FLACC (Face, Leg, Activity, Cry, and Consolability) pain scale,
Gedam et al. (2013) found the mean pain score of the intervention groups (group-2: 3.65 and
group-1: 2.30) to be significantly lower than the control population (group-3: 5.30) during
immunization. Equally, the pain scores for group 1 (4.62) and group 2 (2.79) were substantially
lower than the control group (6.20) after the vaccination (post-procedure). Children in group 1
(n=120) were encouraged to plan and see the sound and light-producing toys during
immunization, while those in group 2 (n=120) were allowed to watch cartoon movies. Those in
group 3 (n=110) were given no distraction. A systematic review of ten RCTs and quasi-RCTs
also found the use of toys to significantly reduce pain scores during and after vaccination for
toddlers (0-3 years) (Riddell et al., 2015). However, other researchers have also found
conflicting outcomes. For example, a 2015 systematic review by Birnie et al. revealed that verbal
distraction (n=46) reduced stress (standard mean deviation of -1.22) but not pain (-0.27). At the
same time, video distraction (n=328) lowered distress (-0.58) and not pain (-0.88). However,
breathing using a toy (n=368) improved pain (-0.27) and not fear (-0.60).
Unmanaged pain during vaccination is also shown to cause needle phobias and treatment
(including immunization) non-compliance in adults and children. For instance, in a cross-
sectional survey by Taddio et al. (2012), 63% and 24% of children and parents reported fearing
needles. Additionally, needle phobias were found to be the primary cause of vaccine non-
compliance for 8% and 7% of children and adults. A study by McLenon & Rogers (2018) also
found that needle fears resulted in avoiding influenza immunization in 16% of adults, 18% of
employees in long-term care facilities, and 27% of hospital workers.
Because of the benefits of distraction techniques and other nonpharmacological
approaches, Henninger et al. (2018) recommend that clinicians show patients (those with
decision-making capacity) or parents (for children below decision-making capacity) “comfort” or
“pain management” alternatives available in their clinics during child immunization, educate

5
them about each option, and allow them to select their preferred intervention. In their pilot study
involving 387 respondents, only 20 percent of the parents reported being given a “comfort
menu” during the immunization visit. A guideline established by Taddio et al. (2010) through
systematic reviews and meta-analyses of RCTs recommends mandatory and immediate
implementation of non-pharmacologic pain therapies during immunization because most require
no planning or additional resources like money or supplies. These straightforward and quickly
adopted techniques include toys, video games, and positioning children upright.

Conclusion

Needle procedures during routine child care or immunization are a significant source of
pain, distress, and hesitancy. This review shows that over 25 percent of adults fear needle
injections, and most of these phobias develop during childhood. The review also reveals that
untreated pain can present long-term ramifications, including needle hyperalgesia, preprocedural
anxiety, phobia, and overall avoidance of healthcare. On a positive note, the review has
established that distraction techniques (toys) and other psychological (nonpharmacological
methods) like breastfeeding and video games can also lower distress and pain pre-and post-
injection. Therefore, it is recommended that clinicians integrate pain-relieving psychological
strategies to improve patient experiences.

6

References

Birnie, K. A., Chambers, C. T., Taddio, A., McMurtry, C. M., Noel, M., Riddell, R. P., Shah, V.,
& HELPinKids&Adults Team. (2015). Psychological interventions for vaccine injections
in children and adolescents: Systematic review of randomized and quasi-randomized
controlled trials. Clinical Journal of Pain, 31(10), 72–89. doi:
10.1097/AJP.0000000000000265
Grunau, R. E., Whitfield, M. F., Petrie, J., & Synnes, A. (2009). Neonatal pain, parenting stress
and interaction, in relation to cognitive and motor development at 8 and 18 months in
preterm infants. Pain, 143(1-2). 138–146. doi:10.1016/j.pain.2009.02.014
Gedam, D. S., Verma, M., Patil, U., & Gedam, S. (2013). Effect of distraction technique during
immunization to reduce behavior response score (FLACC) to pain in toddlers. Journal of
Nepal Pediatric Society, 33(1).
Friedrichsdorf, S., Eull, D., Weidner, C., & Postier, A. (2018). A hospital-wide initiative to
eliminate or reduce needle pain in children using lean methodology. Innovations in
Pediatrics Pain Research and Care, 3. doi: 10.1097/PR9.0000000000000671
Henninger, M. L., Kuntz, J. L., Firemark, A. J., Varga, A. M., Bok, K., & Naleway, A. L. (2018).
Feasibility of a pilot intervention to reduce pain and syncope during adolescent
vaccination. Vaccine, 36(27), 3937–3942.
Inan, G., & Inal, S. (2019). The impact of 3 different distraction techniques on the pain and
anxiety levels of children during venipuncture – a clinical trial. Clinical Journal of Pain,
35(2), 140-147.
McKenzie, N. E., et al. (2021). Factors associated with parents’ experiences using a knowledge
translation tool for vaccination pain management: A qualitative study. BMC Health
Services Research, 21(355).
McLenon, J., & Rogers, M. A. (2018). The Fear of needles: A systematic review and meta-
analyses. Journal of Advanced Nursing, 75(1), 30–42.
McMurtry, C. M., et al. (2015). Interventions for individuals with high levels of needle fear
systematic review of randomized controlled trials and quasi-randomized controlled trials.
The Clinical Journal of Pain, 31, 109–123. doi: 10.1097/AJP.0000000000000273
Riddell, R. R., Taddio, A., McMurtry, C. M., & Chambers, C. T. (2015). Psychological
interventions for vaccine injections in young children 0 to 3 years: Systematic review of
randomized controlled trials and quasi-randomized controlled trials. The Clinical Journal
of Pain, 31(10). doi:10.1097/AJP.0000000000000279
Taddio, A., Ipp, M., Thivakaran, S., Jamal, A., Parikh, C., Smart, S., Sovran, J., Stephens, D., &
Katz, J. (2012). Survey of the prevalence of immunization non-compliance due to needle
fears in children and adults. Vaccine, 30(22), 4807-4812.
Taddio, A., Appleton, M., Bortolussi, R., Chambers, C., Dubey, V., Halperin, S., Hanrahan, A.,
Ipp, M., Lockett, D., MacDonald, N., Midmer, D., Mousmanis, P., Palda, V., Pielak, K.,
Riddell, R. P., Rieder, M., Scott, J., & Shah, V. (2010). Reducing the pain of childhood
vaccination: An evidence-based clinical practice guideline. Canadian Medical
Association Journal, 182(18), 843-855.

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Appendices
Appendix A: Table 1. Primary Research Evidence

Citation (in APA 7 th ) Question,
Hypothesis,
or Aims

Research Design, tools, & sample size Key Findings Recommenda
tions

NHNEBP
Level of
Evidence/
Quality

Friedrichsdorf, S., Eull,
D., Weidner, C., &
Postier, A. (2018). A
hospital-wide initiative
to eliminate or reduce
needle pain in children
using lean methodology.
Innovations in Pediatrics
Pain Research and Care,

3. doi:
   10.1097/PR9.000000000
   0000671

To conduct a
hospital-wide
exercise to
reduce pain
associated
with
injections and
vaccinations
in children.

Research design: “Children’s Comfort
Promise” survey
Research tools: QI strategy based on
Toyota’s lean approach
Sample size: 19,949 patients
Data analysis: All analyses were done
using Microsoft Excel

The percentage of
staff providing
bundled services
increased within the
implementation
timeframe,
parent/patient
satisfaction with pain
management
improved based on
Picker/NRC scores,
SLRs dropped, and
nursing time and
patient wait times
reduced.

Clinicians
should use
pain
management
tools to reduce
pain among
children using
distraction
techniques,
positioning,
breastfeeding/
sucrose, and
anesthesia.

Level
III/Good

Henninger, M. L.,
Kuntz, J. L., Firemark,
A. J., Varga, A. M., Bok,
K., & Naleway, A. L.
(2018). Feasibility of a
pilot intervention to
reduce pain and syncope
during adolescent
vaccination. Vaccine,
36(27), 3937–3942.

to evaluate
the
acceptability
and
feasibility of
an
immunization
comfort
intervention
in two Kaiser
Permanente
Northwest
Pediatric
facilities
(clinics).

Research design: Cohort study
Research tools: The pilot survey was
conducted with interviews to collect
data.
Sample size: 378 out of the initial 1136
parents participated in the survey.
Data analysis: Descriptive statistical
methods (percentages) were used to
describe data.

20% of the
participants indicated
being given a pain
comfort menu during
the immunization
visit. About 35% and
38% of the 50% that
selected a comfort
menu reported that
the menu was “very”
or “somewhat”
helpful in improving
their immunization
experience.

Pediatricians
should show
and allow
patients to
select a
“comfort
menu” during
vaccination to
lower their
pain
experiences.
Level
III/Good

Taddio, A., Ipp, M.,
Thivakaran, S., Jamal,
A., Parikh, C., Smart, S.,
Sovran, J., Stephens, D.,
& Katz, J. (2012).
Survey of the prevalence
of immunization non-
compliance due to
needle fears in children
and adults. Vaccine,
30(22), 4807-4812.

To examine
vaccination
non-
compliance
prevalence
because of
needle phobia
(fears) among
children and
adults.

Research design: Cross-sectional study
design
Research tools: Children were asked
questions about vaccination non-
compliance and needle fears.
Sample size: 1907 children and 883
parents were surveyed (convenient
samples)
Data analysis: Descriptive statistical
methods (percentages) were computed.

About 63% and 24%
of children and
parents reported
needle fears. Also,
needle fears were the
main reason for
vaccination non-
compliance for 8%
and 7% of children
and parents,
respectively.

Interventions
focused on
supporting
training/educat
ion about
access and use
of analgesic
therapies
during
vaccination
injections
during
childhood are
recommended.
Level
III/Good

Inan, G., & Inal, S.
(2019). The impact of 3
different distraction
techniques on the pain

To assess the
impact of
three
different

Research design: Randomized
controlled trial (RCT)
Research tools: The Wong-Baker Faces
Pain Scale (W-BFS) and the Children’s

Pain and anxiety
levels were
significantly higher
in the intervention

Clinicians
should
implement
distraction

Level
III/Good

8

and anxiety levels of
children during
venipuncture – a clinical
trial. Clinical Journal of
Pain, 35(2), 140-147.

distraction
techniques
(video
games,
cartoon
movies, and
parents’
verbal
interactions)
on the
anxiety and
pain levels of
children
during
venipuncture.

Fear Scale (CFS) were used to measure
pain and stress levels, respectively.
Seven open-ended and sixteen closed-
ended questions were used to determine
factors affecting anxiety and pain levels.
Sample size: 180 children were
surveyed
Data analysis: The NCSS (Number
Cruncher Statistical System) software
was used for inferential statistical
analysis, in addition to descriptive
methods (percentages, frequency,
median, SD, means, and max and min
values).

group (venipuncture)
than in the control
group (P<0.05).

techniques to
lower pain
scores in
children
during
immunization.

Gedam, D. S., Verma,
M., Patil, U., & Gedam,
S. (2013). Effect of
distraction technique
during immunization
reduces behavior
response score (FLACC)
to pain in toddlers.
Journal of Nepal
Pediatric Society, 33(1).

To examine
the impact of
distraction
techniques
during
vaccination
on pain
scores for
toddlers.

Research design: Quasi-experimental
Research tools: Pain scores were
measured using the Reduce Behavior
Response Score (FLACC) scale.
Sample size: A total of 350 participants
(children), including group-1 (n=120),
group-2 (n=120), and group-3 (n=110).
Group 1 was encouraged to play with
sound and light-producing toys during
immunization, group 2 was encouraged
to watch cartoon movies, and group 3
had no intervention (distraction).
Data Analysis: Crying durations were
measured and scored in seconds, while
pain scores were measured on a scale of
0-10. ANOVA test was used to evaluate
the statistical significance between pre-
and post-procedure. An unpaired t-test
was also used to measure the statistical
significance of the means of the
distraction techniques between the three
groups.

During the
procedure, the mean
pain score of the
intervention groups
(group-2: 3.65 and
group-1: 2.30) was
significantly lower
than the control
population (group-3:
5.30). Equally, the
scores for the group-
1 (4.62) and group-2
(2.79) were
substantially lower
than the control
group (6.20).

Sound and
light-
producing toys
and cartoon
films (with
auditory/visual
elements)
should be used
to distract
children
during
vaccination to
lower pain
scores.

Level
III/Good

9

Appendix B: Table 2. Systematic Reviews
Citation Question Search Strategy Inclusion &
Exclusion
Criteria

Data Extraction
and Analysis

Key Findings Recommendat
ion &
Implications

JHNEB
P Level
of
Evidenc
e

Taddio, A., et al.
(2010). Reducing
the pain of
childhood
vaccination: An
evidence-based
clinical practice
guideline.
Canadian Medical
Association
Journal, 182(18),
843-855.

Build a
clinical
practice
guideline to
help
providers
or
clinicians
manage the
distress and
pain of
children
undergoing
procedural
vaccination
.

An evidence
search was
conducted on
three main
domains
(psychological,
physical, and
pharmacologic)
interventions. The
selected panel
only searched for
RCTs and quasi-
experimental
studies. A
Cochrane Risk of
Bias Tool was
used to determine
the studies’
quality.

Articles
included
focused on
three areas:
psychological,
physical, and
pharmacologi
c
interventions.
Also, only
RCTs and
quasi-
experimental
articles were
included.

The Cochrane Risk
of Bias instrument
was leveraged to
establish the articles’
quality. Evidenced
was critically
appraised, and
recommendations
were developed
using approaches and
criteria established
by the Canadian
Task Force on
Preventive
Healthcare. The final
guideline was
circulated to relevant
authorities and
professionals for
review.

Pain relief is
integral in
improving
child
experiences
with vaccines
and injections.
Assessing and
documenting
pain during
immunization
are critical
components of
ensuring
quality care.

The guideline
recommends
implementing
pain
management to
reduce
iatrogenic pain
and distress
during
immunization
and other
injection-
related
procedures.

Level
I/Good

Riddell, R. R.,
Taddio, A.,
McMurtry, C. M.,
& Chambers, C. T.
(2015).
Psychological
interventions for
vaccine injections
in young children 0
to 3 years:
Systematic review
of randomized
controlled trials
and quasi-
randomized
controlled trials.
The Clinical
Journal of Pain,
31(10).

Examine
the
effectivene
ss of
distraction
techniques
for
lowering
infant (ages
0-3 years)
pain and
distress
during
immunizati
on.

A database search
was conducted to
establish relevant
RCTs and quasi-
RCTs on five
databases:
ProQuest
Dissertations,
CINAHL,
PsychINFO,
Medline, and
EMBASE.

Only studies
on pain-
relieving
psychological
techniques
during
vaccination
were included
in the study.

The researchers used
the Cochrane Risk of
Bias tool to establish
the articles’
methodological
limitations, while the
RevMan program
(software) was used
to pool the collected
data. The findings
were summarized,
and the GRADE
program software
generated evidence
profiles.

A total of ten
studies (RCTs
& quasi-
RCTs) were
included in the
study. The
results found
that directed
video
distraction
significantly
lowered in the
treatment
group for both
acute plus
recovery and
preprocedural
phases. The
use of toys
also
significantly
reduced pain
levels for the
acute phase.

Clinicians are
recommended
to use toy
distraction
techniques to
alleviate
vaccine pain
for infants aged
0-3 years.

Level
I/Good

Birnie, K. A.,
Chambers, C. T.,
Taddio, A.,
McMurtry, C. M.,

Appraise
the
effectivene
ss of

Articles were
searched in four
databases:
CIHAHL,

The review
centered on
RCTs and
quasi-RCTs of

The meta-analytic
and systematic
review approaches
were informed by

Twenty-two
articles were
included in the
review. Verbal

Psychological
interventions
should be used
to minimize

Level
I/Good

10

Noel, M., Riddell,
R. P., Shah, V., &
HELPinKids&Adu
lts Team. (2015).
Psychological
interventions for
vaccine injections
in children and
adolescents:
Systematic review
of randomized and
quasi-randomized
controlled trials.
Clinical Journal of
Pain, 31(10),
72–89.

psychother
apeutic
solutions
for
lowering
immunizati
on pain and
other
outcomes
in
adolescents
and
children.

PsychINFO,
Medline, and
EMBASE.

psychological
interventions
for children
aged 3-12
years, those
undergoing
immunization
in any clinical
setting.

Cochrane
collaboration and
GRADE.

distraction
(n=46)
reduced stress
(standard
mean
deviation of –
1.22) but not
pain (-0.27).
At the same
time, video
distraction
(n=328)
lowered
distress (-0.58)
and not pain (-
0.88).
However,
breathing
using a toy
(n=368)
improves pain
(-0.27) and not
fear (-0.60).

pain in children
and
adolescents.

McLenon, J., &
Rogers, M. A.
(2018). The Fear of
needles: A
systematic review
and meta-analyses.
Journal of
Advanced Nursing,
75(1), 30–42.

Assess the
prevalence
of needle
phobias/fea
rs among
children,
adolescents
, and young
adults.

Articles were
searched in four
databases:
CINAHL,
PsychINFO,
Embase, and
Medline.

Articles
published
between 1947
and 2017
focused on
needle fears in
children,
adolescents,
and young
adults.

Restricted max
likelihood random
effect tools (models)
were used to
calculate needle fear
prevalence rates.

A majority of
children (over
70%)
exhibited
needle fears.
About 20-50%
of adolescents
and 20-30% of
young adults
also showed
needle
phobias.
Avoidance of
influenza
immunization
due to needle
phobia in 16%
of adults, 18%
of employees
in long-term
care facilities,
and 27% of
hospital
workers.

Pain
management
should be
integrated into
vaccinations
and other
needle-related
exercises to
avoid treatment
avoidance.

Level
I/Good.

McMurtry, C. M.,
et al. (2015).
Interventions for
individuals with
high levels of
needle fear
systematic review
of randomized
controlled trials

To appraise
interventio
ns for
people with
high needle
phobia
levels.

Relevant articles
were searched on
ProQuest
Dissertations,
CINAHL,
PsycINFO,
Medline, and
EMBASE.

Inclusion
criteria were
as follows: (1)
an RCT or
quasi-RCT
with at least
five
participants,
(2)

GRADE quality
exam tool/software
was used to measure
the quality of studies,
and a Cochrane
methodology was
used to assess the
risk.

Eleven articles
were included
in the review.
Exposure-
based
psychological
therapies
reduced needle
phobia in adult

Clinicians are
advised to
incorporate
exposure-based
psychological
approaches to
lower needle
phobias.

Level
I/Good

11

and quasi-
randomized
controlled trials.
The Clinical
Journal of Pain, 31,
109–123.

participants
included
persons
exhibiting a
high level of
needle
phobias, and
(3) reports
were
published.

and pediatric
populations.

12

Appendix C: Table 3. Synthesis Matrix

Main Idea Friedrichsdorf, S., Eull, D.,
Weidner, C., & Postier, A.
(2018). A hospital-wide
initiative to eliminate or
reduce needle pain in
children using lean
methodology. Innovations
in Pediatrics Pain
Research and Care, 3.

Henninger, M. L.,
Kuntz, J. L.,
Firemark, A. J.,
Varga, A. M., Bok,
K., & Naleway, A.
L. (2018).
Feasibility of a
pilot intervention
to reduce pain and
syncope during
adolescent
vaccination.
Vaccine, 36(27),
3937–3942.

Taddio, A., Ipp, M.,
Thivakaran, S.,
Jamal, A., Parikh,
C., Smart, S.,
Sovran, J.,
Stephens, D., &
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Survey of the
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Inan, G., & Inal, S.
(2019). The impact of
3 different distraction
techniques on the pain
and anxiety levels of
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140-147.

Gedam, D. S.,
Verma, M., Patil, U.,
& Gedam, S. (2013).
Effect of distraction
technique during
immunization to
reduce behavior
response score
(FLACC) to pain in
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Use of toys to
lower pain
levels

Clinicians should use
distraction techniques like
toys and video games to
improve child pain
experiences.

Sound and light-
producing toys and
cartoon films (with
auditory/visual
elements) should be
used to distract
children during
vaccination to lower
pain scores.

Use of other
nonpharmacolo
gical techniques
for pain
management

Clinicians are advised to
use alternative methods
like comfort positioning,
breastfeeding/sucrose, or
topical anesthetics to
control pain in children
during vaccination.

Distraction techniques
(video games, cartoon
movies, and parents’
verbal interactions)
can be used to
alleviate pain and
anxiety during
vaccination.

Use of
pharmacologica
l techniques to
manage pain

Analgesics should
be used to reduce
needle fears and
improve non-
compliance

Barriers to
implementing
distraction
techniques

Lack of
convenience and
time and brevity of
the pilot duration.

Need to offer
patients
“comfort”
interventions
during
immunization

Healthcare
providers should
show and allow
patients to select a
“comfort menu”
during vaccination.

Need to
consider other
pain
confounding
factors

Examining
physiological
variables (oxygen
saturation, blood
pressure, and heart
rate) can assist in

13
accurately measuring
crying durations and
pain scores.