Non-pharmacological analgesia in children and babies beyond the neonatal age
Alfredo Chiurazzi, Andrea Francioni, Neri Demarcus, Carlo V. Bellieni*
Department of Pediatrics, University of Siena, Siena, Italy
Abstract
Introduction: Pain is a major problem in clinical management of children. Pharmacological analgesia is the most commonly used analgesic treatment, but in some cases the use of non-pharmacological analgesic treatments (N-PAT) has been proposed.
Purpose: Our aims were to review the effectiveness and safety of N-PAT for pain relief in children, and to point out which are the most effective.
Material and Methods: We retrieved the clinical trials published in the years 2017-2022 in two databases: PubMed and Index Medicus, analyzing them with the PRISMA method. We used the following key-words: distraction, pain, child. Then we refined our search using in the same databases the key-words “pain” and “child”, matched with the terms that describe the N-PAT: “Virtual reality”, “Robot”, “Audiovisual distraction”, “Audio Distraction”, “Buzzy”, “Videogames”, “Parents verbal interactions”, “Distraction cards”, “Magic glove”, “Ipad”, “Picture book”, “Kaleidoscope”, “Soap bubbles” and “Hand massage”. Exclusion criteria were: reviews, case reports, papers in a language other than English, including patients other than children older than one month of age.
Results: We have screened 126 articles and 66 were excluded from the final pool. The most studied painful stimulation was needle procedures, where the most effective N-PAT was virtual reality, followed by the buzzy system. In the case of other painful procedures, few studies were available; however, in any of these painful stimulations effective analgesia was obtained with the use of virtual reality. Several studies eventually show that the combination of N-PAT with analgesic topic drugs provides more effective analgesia.
Conclusion: Some non-pharmacological treatments appear actually effective. The research in this field should be implemented to get more conclusive data, but our results are in favor of more extended use of N-PAT during potentially painful procedures.
Introduction
Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage1.
Children may be exposed to painful interventions for the purpose of diagnosis, or treatment2. The painful interventions most commonly performed in children include phlebotomy, injection, and vaccination. During these interventions, it is highly important to use methods that have a pain relieving effect3. Pharmacologic and non-pharmacologic analgesic treatments (N-PAT) can be used separately or together to reduce the pain during invasive procedures4. Studies of both pharmacologic and N-PAT in procedural pain relief determined that N-PAT were as effective as pharmacologic methods4,5,6. N-PAT can be preferred in relieving procedural pain, because pharmacologic methods can have side effects7, but also because several studies support the effectiveness of N-PAT in managing the pain associated with invasive procedures in children8,9,10. Moreover, the non-pharmacological approach to pain prevention is important in the vision of a humanized treatment of the young patient, who needs to find a welcoming and non-stressing environment, under the condition that interventions used for optimal pain management should be effective, reliable, child-friendly, and hopefully should not extend the procedure time11.
Several studies have been performed in the neonatal period to evaluate the efficacy of N-PAT12,13,14, but much less in the postnatal period. For this reason, we felt that an updated review of the state of the art on N-PAT (Table 1) in older children was important.
Table 1: The 5 most used non-pharmacological analgesia techniques with definition
VIRTUAL REALITY |
Simulated experience of real or ureal situations lived through an external device (VR glasses, VR headsets) |
BUZZY DEVICE |
Handheld device about the size of a computer mouse that buzzes (vibrates) on the skin |
AUDIOVISUAL DISTRACTION |
Passive distraction like watching television or video with the phone |
VIDEOGAMES |
Active audio-visual distraction like PlayStation |
PARENTAL VERBAL INTERACTION |
Mother/father speaking and cuddling the child during procedures. |
Study Purpose
The purpose of this article is to provide a critical assessment of the evidence-based literature on N-PAT in pediatric age.
Materials and Methods
We retrieved the clinical trials published in the years 2017-2022 in two databases: PubMed and Index Medicus. In the first phase of our search, we used the following key-words: distraction, pain, child. To make our search more complete, in the second phase we searched papers in the same databases using the key-words “pain” and “child”, but matching them with each of the following terms that describe the most used N-PAT: “Virtual reality”, “Robot”, “Audiovisual distraction”, “Audio Distraction”, “Buzzy”, “Videogames”, “Parents verbal interactions”, “Distraction cards”, “Magic glove”, “Ipad”, “Picture book”, “Kaleidoscope”, “Soap bubbles” and “Hand massage”.
Inclusion criteria were: dealing with children with postnatal age ranging 1 month-17 years; use of a validated pain scale to assess pain; availability of raw data of pain reported by the children during the painful procedure; articles in English; fully available statistical data. We screened the whole pool of papers using the PRISMA criterion (Table 2).
Table 2: Studies included in the analysis
First Author, year |
Population |
Setting |
Intervention |
Other intervention |
Primary outcome |
p-value |
|
Intervention |
control |
||||||
15 Shetty V, 2019
|
N= 118 (5-8 year old) |
Group 1 |
VR |
N/A |
SCL: pre 83.45 (12.03) ng/ml intra 68.45 (13.03) ng/ml post 62.55 (13.28) ng/ml
WBFPS mean and median: 2.42 (1.47), 2 (0.52)
|
SCLcontrol: pre 78.35 (14.13) ng/ml, intra 70.72 (13.65) ng/ml, post 62.13 (13.83) ng/ml
WBFPS control: 5.6 (1.22), 6 (4,6)
|
SCL pre-intra: p<0.001 Intra-post: p<0.001 Post-intra: p<0.001
WBFRPS: <0.001
|
43 Gamze Inan, 2019
|
N= 180 (6-10) |
Group 2
|
AVD |
VG PVI |
WBFPS: AVD: 3.02 ± 2.94 VG: 1.42 ± 1.74 PVI: 2.89 ± 3.00
|
WBFPRS control: 5.11 ± 3.78
|
VG vs AVD and PVI: p<0.05
VG/AVD/PVI vs control: p<0.01
AVD vs PVI: ns
|
16 BirguÌl Erdogan, 2021
|
N= 142 (7-12) |
Group 2
|
DC
|
VR B |
WBFPS B: 0.9 ± 0.9 VR: 0.9 ± 0.9 DC: 1.4 ± 1.2
VAS B: 2.2 ± 2.0 VR: 2.7 ± 2.8 DC: 3.4 ± 2.4
|
WBFPS control: 2.5 ± 1.7
VAS control: 5.2 ± 2.8
|
WBFPS DC vs control: p<0.05 VR vs control: p<0.01 B: vs control: p<0.01 DC vs B, VR vs B e VR: DC: ns
VAS: DC vs control: p<0.05 VR vs control: p<0.01 B: vs control: p<0.01 DC vs B, VR vs B e VR: DC: ns
|
50 Volkan Susam 2018
|
N= 64 (3-10) |
Group 2 |
B + DC |
MG |
Integration WBFPS, VAS and NRS:
B+DC: 3.66±2.02
MG: 4.74±2.07
|
N/A
|
p=0.039 |
17 Søren Walther-Larsen 2019
|
N=59 (7-16) |
Group 2
|
VR |
N/A |
VAS: 27 (8 to 33)
|
VAS control (standard of care): 15 (5 to 30)
|
p=0.23 |
45 N.C.A.C. Oliveira, 2017
|
N= 40 (6-11) |
Group 2
|
AVD: G1 T1: 22 G2 T2: 18 |
N/A |
WBFPS G1 T1: 1.91 +/- 1.68 G2 T2: 2.67 +/- 2.74
VAS G1 T1: 1.50 +/- 1.87 G2 T2: 2.33 +/- 2.54
|
WBFPS control: G1 T2: 3.64 +/- 3.06 G2 T1: 6.78 +/- 3.15
VAS control: G1 T2: 3.32 +/- 3.42 G2 T1: 6.28 +/- 2.86
|
AVD vs control: p<0.01 |
18 GuÌlçin OÌzalp Gerçeker 2021
|
N= 42 (6-17) |
Group 2
|
VR |
N/A |
WBFPS: 2.4 ± 1.8
|
WBFPS control: 5.3 ± 1.8
|
p<0,01 |
19 Yen-yu Chen 2020
|
N= 136 (7-12) |
Group 2 |
VR |
N/A |
WBFPS: 3.35±2.38 |
WBFPS control: 4.35±2.95 |
p=0.031 |
70 Zoe Grabinski, 2022
|
N= 40 |
Group 2 |
Distarction |
N/A |
WBFPS 1.4; 95% CI, 0.9-1.9
|
WBFPS 1.3, 95% CI, 0.5-2.1
|
ns |
68 Sherwood Burns-Nader 2017
|
N= 30 (4-12) |
Group 3
|
IPad |
N/A |
WBFPS: 2.53 (1.64)
|
WBFPS control: 3.20 (1.78)
|
p=0.29
|
20 Osama M. Felemban, 2021
|
N=50 (6-12) |
Group 1
|
VR |
AVD |
FLACC: VR: 2.58 ± 1.99 AVD: 2.18 ± 2.29 WBFPS: VR: 2.40 ± 2.82 AVD: 2.72 ± 2.99 |
N/A
|
p=0.497 p=0.707 |
41 Samina Ali, 2021
|
N: 81 (6-11) |
Group 2
|
R |
N/A |
OSBD-R: 0.78 ± 1.32
WBFPRS: 2 (0, 4)
|
OSBD-R control: 1.49 ± 2.36
WBFPS control: 4 (2,6)
|
p<0.05 p<0.13 |
67 Remziye Semerci, 2020
|
N=90 (6-12) |
Group 2
|
DC K |
N/A |
VAS: DC: 2.32 ± 2.55 K: 2.72 ± 3.29
|
VAS control: 6.24 ± 3.93
|
DC vs control: p<0.001 K vs control: p<0.001 DC vs K: p<0.938
|
51 Sevil Inal, 2020
|
N=218 (6-12) |
Group 2
|
DC |
B DC + B |
WBFPS: B: 1.38 ± 1.3 DC: 2.43 ± 1.3 DC+B: 0.53 ± 0.9
|
WBFPS control: 4.46 ± 2.9
|
DC/B/DC+B vs control: p<0.001 |
21 Henry Xiang, 2021
|
N: 90 |
Group 3
|
VR
|
AVD |
VAS: IVR: 24.9 [95% CI, 12.2- 37.6]
|
VAS control: 47.1 [95% CI, 32.1-62.2]
|
IVR vs control: p=0.02
|
44 F. Guinot , 2021
|
N= 68 |
Group 1
|
VG
|
PVR (AVD) |
WBFPS: IVR: 0±0.26
|
WBFPS: PVR: 0.94±1.41
|
p=0.013
|
71 Aylin Arıkan, 2020
|
N=216 (6-12) |
Group 2
|
ID
|
PD |
WBFPS: ID: 2.60 (1.54) PD: 2.60 (1.54)
VAS: ID: 1.50 (0.65) PD: 1.97 (0.81) |
WBFPS control: 7.33 (2.41)
VAS control: 3.79 (1.08)
|
WBFPS: control> PD > ID: p < 0.001
VAS: control>PD>ID: p<0.001
|
22 Fadime Ustuner , 2021 |
N: 77 |
Group 2 |
VR |
N/A |
WBFPS: 3.82 ± 1.20 |
WBFPS: 6.96 ± 2.08
|
p=0.0001 |
52 Cozzi, 2018 |
4-12y (n=200) |
Group 2 |
B |
T |
Faces pain scale-revised (4-7y) Numerical rating scale (8-12y) median (IQR): B: 3 (1-4.8) T: 2 (1-4.8) |
N/A |
B vs. T: p=0.72 |
23 Le May, 2020 |
7-17y (n=20) |
Group 3 |
VR |
N/A |
Numerical rating scale of pain (0-10) mean±SD: 3.8±3.4 |
control: 4.8±3.1 |
p=0.023 |
10 Risaw, 2017 |
4-6y (n=210) |
Group 2 |
DC |
N/A |
FLACC mean±SD: DC: 2.75±0.97 |
control: 3.24±0.85 |
p<0.001 |
53 Redfern, 2018 |
3-18y (n=50) |
Group 2 |
B |
N/A |
WBFS mean±SD: B: 3.56±3.2 |
control: 5.92±3.4 |
p=0.015 |
24 Alshatrat, 2021 |
5-12y (n=54) |
Group 1 |
VR + local anesthesia |
N/A |
FLACC mean (SD): VR+local anesthesia: 2.588±3.001 |
control (local anesthesia): 5.571±3.857 |
p=0.0132 |
25 Custòdio, 2020 |
6-9y (n=44) |
Group 1 |
VR +local anesthesia |
N/A |
Venham Scale mean (SD): AVE+local anesthesia: 0.41 (1.53) |
control (local anesthesia): 1.32 (1.92) |
p=0.07 |
69 Kuo, 2018 |
3-7y (n=276) |
Group 2 |
PB |
iPad |
OSBD-R mean (SD): PB: 27.4 (5.6) Cartoons in iPad: 28.9 (6.3) |
control (routine oral instructions): 38.5 (14.6) |
PB vs. control: p<0.001 iPad vs. control: p<0.001 PB vs. iPad: ns
|
26 Osmanlliu, 2021 |
7-17y (n=62) |
Group 2 |
VR+standard of care |
N/A |
Verbal numerical rating scale (0-10) median (IQR): 3 (1-6) |
control (standard of care): 3 (1-5.5) |
p=0,75 |
46 van der Heijden, 2019 |
3-13y (n=191) |
Group 2 |
AD |
AVD |
AHTPS mean (SD): AD: 2 (2.05) AVD: 2.86 (2.62) |
control (standard of care): 3.10 (2.24) |
AD vs. control: p=0.006 AVD vs. control: p=0.328 |
27 Semerci, 2020 |
7-18y (n=71) |
Group 2 |
VR |
N/A |
WBFS mean±SD: VR: 2.34±3.27 |
control: 5.02±3.35 |
p=0.001 |
28 Liu, 2020 |
7-17y (n=53) |
Group 4 |
VR |
N/A |
WBFS mean±SD: 0.80±1.06 |
control (standard of care): 2.26±2.38 |
p=0.018 |
29 Buyuk, 2021 |
5-10y (78) |
Group 5 |
VR |
N/A |
WBFS mean±SD: VR: 1.35±1.09 |
control: 3.00±1.52 |
p<0.01 |
30 Ran, 2021 |
4-8y (n=120) |
Group 1 |
VR |
N/A |
WBFS mean±SD: VR: 1.62±1.13 |
control (Tell-show-do): 3.59±1.19 |
p<0.001 |
66 Erdogan, 2019 |
1-3y (n=60) |
Group 2 |
PVI |
N/A |
FLACC mean±SD: PVI: 4.76±2.43 |
control: 7.66±3.75 |
p=0.000 |
31 Jeffrey I. Gold,2021 |
10-21 y (n=107) |
Group 2 |
VR |
N/A |
Faces pain scale-revised mean (SD): 1.09 (1.82) |
2.19 (2.21) |
p=0.002 |
32 Tuba Koc Ozkan, 2019 |
4-10 y (n=139) |
Group2 |
VR |
K |
WBFS mean±SD: VR: (1.76+1.4) K: (2.76+1.8) |
6.65+2.2 |
K vs control: p<.000 VRvs control: p<.000 VR vs K: p=0.039 |
47 Fatemeh Cheraghi, 2021 |
6-12 y (n=120) |
Group 3 |
AD |
AVD |
Ocher Pain Scale: mean±SD: AD:3.97 ±12.13 VD: 3.86 ±12.28 |
4.08±12.42 |
AVD vs control: p<0.001 AD vs control: p<0.001 AVD vs AD: p=0.004 |
33 Demet Ä°nangil,2020 |
3-18 y (n=120) |
Group 2 |
VR |
Tablet |
WBFS: mean±SD: VR box: 1.3±2.15 Tablet: 4.55±3.44 |
4.95±3.65 |
p<0.001 |
65 Xiu-Hang Zhang, 2020 |
1-3y (n=120) |
Group 3 |
Medical screen |
VG |
MBPS: mean (SD): Medical screen: 6.78(0.82) VG: 7.775(0.80)
|
8.45(0.51) |
p<0.001 |
72 Xiu-Hang Zhang, 2020 |
1-3y (n=52) |
Group 3 |
Medical screen |
N/A |
MBPS: mean (SD): Medical screen: 6.77 (1.42) |
8.50 (0.51) |
p<0.001 |
54 Seyda Binay, 2018 |
3-6y (n=96) |
Group 2 |
B |
SB |
WBFS mean±SD: ECV: 3.12±0.38 BSB: 2.15±0.35 |
7.37±0.38 |
B vs SB: p=0,387 B/SB versus control: p<.000 |
48 J.-S. Song, 2020 |
3-7y (n=48) |
Group 3 |
AVD |
N/A |
WBFS mean (SD): 6 (22.43) |
0 (15.66) |
p<0,001 |
49 Muhammet Bulut, 2020 |
7-11 y (n=140)
|
Group 5 |
AD |
K HM |
WBFS mean (SD): AD: 1.68 (1.13) K: 1.08 (0.98) HM: 1.31 (1.10) |
2.45 (0.95) |
p=0,000 |
34 Jordan S. Taylor |
6-17 y (n=70) |
Group 5 |
VR |
N/A |
Verbal Pain Scale mean±SD: VR: 0.4 ±1.1 |
0.03± 0.2 |
p=0.073 |
35 A. Garrocho-Rangel |
5-8 y
|
Group 1 |
VR |
N/A |
FLACC mean (SD): VEES 1.03 (2.21) |
0.64 (1.31) |
p=0.7 |
56 Yilmaz, 2020 |
8-16y (n=60) |
Group 2 |
B |
N/A |
FACES mean (SD): B: 1.36 (1.12) |
control: 1.33 (1.15) |
p=0.829 |
57 Bourdier, 2021 |
18m-6y (n=607) |
Group 2 |
B |
N/A |
Children's Hospital of Eastern Ontario Pain Scale mean (SD): B: 8.5 (2.6) |
EMLA patch: 7.2 (2.4) |
EMLA patch vs B: p<0.01 |
58 Bilgen, 2019 |
7-12y (n=150) |
Group 2 |
B |
ShotBlocker |
FACES mean (SD): B: 3.64 (3.10) ShotBlocker: 6.24 (3.20) |
control: 7.36 (3.09) |
B vs control: p<0.01 B vs ShotBlocker: p<0.01 |
59 Sahiner, 2018 |
6-12y (n=60) |
Group 2 |
B |
ShotBlocker |
FACES mean (SD): B: 1.26 (1.36) ShotBlocker: 0.9 (1.20) |
control: 3.2 (2.78) |
p=0.008 |
60 Alemdar, 2019 |
5-10y (n=195) |
Group 2 |
B |
SB Aromatherapy |
Oucher pain scale mean (SD): B: 3.51 (3.49) SB: 4.53 (3.25) Aromatherapy: 5.46 (2.75) |
control: 5.87 (2.87) |
B vs control: p<0.05 |
61 Ueki, 2020 |
0-6y (n=118) |
Group 2 |
B |
N/A |
FLACC mean (SD): BD: 6.98 (3.28) |
control: 7.63 (2.79) |
p=0.25 |
42 Lee-Krueger, 2021 |
4-12y (n=137) |
Group 2 |
R |
N/A |
Faces Pain Scale-Revised mean±SD: MEDi Robot: 2.74 (2.96) |
control: 2.76 (2.97) |
p=0.98 |
55 Yilmaz, 2019 |
5-10y (n=120) |
Group 2 |
B |
ShotBlocker SB |
Oucher pain scale mean (SD): B: 3.87 (1.79) ShotBlocker: 4.14 (2.12) SB: 4.75 (1.74) |
control: 6.72 (2.16) |
ShotBlocker vs Control: p<0.05 B vs Control: p<0.05 SB vs Control: p<0.05 |
62 Sapci, 2021 |
3-18y (n=90) |
Group 2 |
B |
N/A |
FACES mean (SD): B: 2.44 (1.85) |
control: 5.77 (2.14) |
p<0.05 |
36 Gerceker 2018 |
7-12 y (n = 121) |
Group 2 |
VR |
B |
WBFPS mean (SD): VR: 1.5 (0.2) B: 2 (0.2) |
control: 5.1 (0.4) |
VR vs control: p<0.05 B vs control: p<0.05 |
63 Alanazi 2018 |
6-7 y (n = 60) |
Group 1 |
B + Analgesia |
Analgesia |
WBFPS mean rank (sum of ranks) B + analgesia: 17.50 (1759.00) Analgesia: 3.50 (10.50) |
N/A |
WBFPS p <0.001
|
64 Bilisin 2019 |
n = 60 |
Group 1 |
B + Analgesia |
Analgesia |
WBFPS mean (SD) B + analgesia: 0.867 (1.136) Analgesia: 3.333 (1.917) |
N/A |
p<0.01 |
37 Eijlers R.
|
4-12 y (n=200) |
Group 5 |
VR |
N/A |
FPS-r: VR: 2.0 [0.0 to 4.0]
|
2.0 [0.0 to 2.5]
|
p=0.699
|
117 Özalp Gerçeker G
|
5-12 y (136) |
Group 2 |
VR-Rollercoaster
|
VR-Ocean Rift
|
WBFS mean ± (SD) (min-max): VR-Rollercoaster=1.2 ± 2.2 (0-10) VR-Ocean Rift= 1.0 ± 1.5 (0-6)
|
4.1 ± 3.5 (0-10)
|
p=0.000
|
38 Aydın Aİ
|
(n=120) |
Group 2 |
VR |
N/A |
WBFS mean ± (SD) VR: 1.68 ± 1.51
|
2.02±1.96
|
p=0.006
|
39 Tennant M
|
7-19 y (n=90) |
Group 6 |
VR
|
IPad |
VAS mean (SD): VR 10.97 (11.23) IPad 12.82 (11.34) |
N/A |
p=0.475
|
40 Arman N |
6-18 (n=62) |
Group 6 |
VR |
TOAT |
NRS mean (SD): VR: 0.64 (1.31) TOAT: 1.04 (1.62) |
N/A |
p=0.000 |
Legend: R: Robot, VR: virtual reality, AVD: audio-visual distraction, AD: audio distraction, B: Buzzy system, DC: Distraction Cards, K: Kaleidoscopic, T: tablets, VG: videogames, PVI: parents verbal interaction, SB: soap bubbles, MG: Magic Glove, HM: hand massage, WBFPS: wong baker faces pain rating scale, SCL: salivary cortisol levels, VAS visual analogue scale, NRS numeric rating scale, Others (ID: interactive distraction, PD: passive distraction, TOET, medical screen), OSBD-R: Observed Scale of Behavioral Distress-Revised; CFS: Children's Fear Scale MBPS: modified behavioural pain scale, FLACC: Face Legs Activity Cry Consolability, AHTPS: Alder Hey Triage Pain Score, ns: not significant, CI: confidence intervals
Group 1: Dental treatment, Group 2: Needle related procedures, Group 3: Medical procedures in children with burns, Group 4: Endoscopic procedures, Group 5: Surgery procedures, Group 6: Oncology and rheumatology disease therapy
Results
We found in total 197 articles of which 83 were found during the first search on databases and 114 during the second part; 71 were removed during the second search, because they were duplicates of the first research. Out of these 126 articles, 65 were excluded for reporting data on pain in newborn and adult (n=6), data not on pain (n=27), incomplete statistical data (n=11), non-English written articles (n=3), pilot studies (n=8), too small sample of babies (n=1), inability to retrieve the full text of the paper (n=10). A total of 61 articles were included in this review75-116 (Table 2).
The included articles described the following non-pharmacological analgesia techniques: Virtual reality (n=27)15-40, Robot (n=2)41,42, Audio visual distraction (n=8)21,43-48, Audio distraction (n=3)46,47,49, Buzzy (n=17)16,36,50-64, Videogames (n=3)43,44,65, Parents verbal interactions (n=2)43,66, Distraction cards (n=5)10,16,50,51,67, Magic glove (n=1)50, IPad (n=5)33,39,52,68,69, Picture book (n=1)69, Kaleidoscope (n=3)32,49,67, Soap bubbles (n=1)54, Hand massage (n=1)49 (Table 3). The data on how many times the method used was significant in a given setting can be found in Table 4. Out of the 61 selected studies15-74, 40 concern needle related procedures16-19,22,26,27,31,32,36,38,41-43,45,46,50-62,66,67,69,71,117, 8 dental treatment15,20,24,25,30,35,44,64, 6 medical procedures in children with burns21,23,47,65,68,72, 4 surgery procedures29,34,37,49, 1 endoscopic procedures28 and 2 oncology and rheumatology disease39,40.
Table 3: Studies screened from PubMed database
Table 4: Comparisons of non-pharmacological methods vs Standard of care
Technique vs Control |
Needle related procedures |
Dental treatment |
Medical procedures in children with burns |
Surgery procedures |
Endoscopic procedures |
Oncology and rheumatology disease |
Virtual reality |
S=12 (vs Control) NS=2 (vs Control) |
S=4 (vs Control) NS=1 (vs Control) |
S=2 (vs Control) |
S=2 (vs Control) NS=1 (vs Control) |
S=1 (vs Control) |
|
Robot |
NS=2 (vs Control) |
|
|
|
|
|
Audio visual distraction |
S=2 (vs Control) NS= 2 (vs Control)* |
|
S=2 (vs Control) NS=1 (vs Control) |
|
|
|
Buzzy |
S=10 (vs Control) NS=2 (vs Control) |
S=2 (vs Control)
|
|
|
|
|
Videogames |
S=1 (vs Control) |
|
S=1 (vs Control) |
|
|
|
Parents verbal interactions |
S=2 (vs Control) |
|
|
|
|
|
Distraction cards |
S=4 (vs Control) |
|
|
|
|
|
Magic glove |
|
|
|
|
|
|
IPad |
S=2 (vs Control) |
|
NS=1 (vs Control) |
|
|
|
Picture book |
S=1 (vs Control) |
|
|
|
|
|
Kaleidoscope |
S=2 (vs Control) |
|
|
S=1 (vs Control) |
|
|
Soap bubbles |
S=2 (vs Control) NS=1 (vs Control) |
|
|
|
|
|
Hand massage |
|
|
|
S=1 (vs Control) |
|
|
Audio distraction |
S=1 (vs Control) |
|
S=1 (vs Control)
|
S=1 (vs Control)
|
|
|
Others |
S= 3 (vs Control) NS=1 (vs Control) |
|
S= 2 (vs Control)
|
|
|
|
S: Treatment group is significantly better than control; NS: No significant difference
Here we report the results for each painful procedure.
Needle related procedures: The most effective N-PAT were the virtual reality in 12 studies16,18,19,22,27,31,32,36,38,117, in 2 studies it was the audiovisual distraction43,45, in 10 the buzzy system16,36,53-55,57-60,62, in 4 the distraction cards10,16,51,67, in 1 the picture books69, in 2 the kaleidoscope32,67, in 2 the soap bubbles54,55, in 1 the videogames43, in 2 the parental verbal interactions43,66, in 1 the combination of distraction cards with the buzzy system50, in 1 the audio distraction46 and in 1 the iPad68,69. In no study the robots, magic glove and hand massage were effective.
Dental treatment: The most effective N-PAT was the virtual reality in 4 study15,24,25,30, in 2 studies it was the buzzy system63,64 and in no study the robots, audiovisual distraction, videogames, parents verbal interactions, distraction cards, magic glove, iPad, picture book, kaleidoscope, soap bubbles, hand massage and the combination of distraction cards with buzzy system.
Procedures in children with burns: The most effective N-PAT was the virtual reality21,23in 2 studies, in 2 studies the audiovisual distraction21,47, in 2 studies others techniques (medical screen)65,67, in 1 study videogames65, in 1 study audio distraction47 and in no study the robots, buzzy system, , parents verbal interactions, distraction cards, magic glove, iPad, picture book, kaleidoscope, soap bubbles, hand massage and the combination of distraction cards with buzzy system.
Surgical procedures (circumcision, hormone implant placement): The most effective N-PAT was the virtual reality in 2 studies29,34, in 1 study it was the audiovisual distraction49, in 1 study the kaleidoscope49, in 1 study the hand massage49 and in no study the robots, buzzy system, videogames, parents verbal interactions, distraction cards, magic glove, iPad, picture book, soap bubbles and the combination of distraction cards with buzzy system.
Endoscopic procedures: The most effective N-PAT was the virtual reality in 1 study28 and in no study the robots, audiovisual distraction, buzzy system, videogames, parents verbal interactions, distraction cards, magic glove, IPad, picture book, kaleidoscope, soap bubbles, hand massage and the combination of distraction cards with buzzy system.
Procedures correlated to oncology and rheumatology diseases: The most effective N-PAT were the videogames40 in 1 study and in no study the virtual reality, robots, audiovisual distraction, buzzy system, parents verbal interactions, distractions cards, magic glove, iPad, picture book, kaleidoscope, soap bubbles, hand massage and the combination of distraction cards with buzzy system.
When comparing N-PAT with pharmacological analgesia techniques, one study57 showed the superiority of the EMLA gel over the use of the buzzy device. Two studies63,64 showed the superiority of the combined use of buzzy device and analgesia with lidocaine compared to the use of only lidocaine. Two studies24,25 showed the superiority of the combined use of virtual reality and local analgesia compared to the use of only local analgesics.
As for the effectiveness of NPATs based on the age of children, it seems that virtual reality is more effective in children between the ages of 7 and 12 (average age 10.8 years)15-40. While with regard to buzzy devices, the age at which these systems are most effective is between 7 and 10 years (average age 8.9 years)16,36,50-64,117-121. Unfortunately, the few published studies regarding the other techniques used do not allow to detect an evident efficacy on a certain age range of the tested children.
Discussion
This review analyzed the clinical trials conducted between 2017 and 2022 and examined which are the most effective non-pharmacological analgesic techniques in the treatment of pediatric pain. The articles analyzed compared specific N-PAT with controls.
Our search showed that virtual reality was the most often used N-PAT, moreover it appears to be the most effective compared vs control in particular in the field of venipuncture. The buzzy device system was the second most used technique. Scarce studies were developed in this period using other N-PAT (Robot, Audio visual distraction, Video Games, Parents verbal interactions, Distraction cards, Magic glove, IPad, Picture book, Kaleidoscope, Soap bubbles, Hand massage).
The use of N-PAT is important to avoid pain in children2. Stress and pain are factors that can alter a child's homeostasis, causing fear, increased blood pressure and tachycardia122. They can also cause the child's lack of compliance with the pediatrician and nurse, as well as make him lose confidence in them during future visits. The relationship with the healthcare environment must avoid being traumatic123.
Unfortunately, children and their families still feel uncomfortable when going to a medical visit: for an ancient equation between visit and pain, saying “no pain no gain” seems always true, and analgesia during procedural pain is still scarcely used, though today we have valid tools to avoid pain as this review has shown. Pain management in pediatrics is still defined as “suboptimal”124, and this has become a “major public health problem”125.
Procedural pain is less painful than surgical or physically traumatic pain, but it cannot be ignored: we know that repeated stress and suffering even has a negative epigenetic effect on the expression of corticosteroid receptor genes or for the brain growth factor; repeated pain causes growth retardation of the cerebral cortex126. This is especially true for hospitalized patients who receive numerous painful events; the physical and psychological risks associated with pain are not absent even when pain is experienced after the first month of life12,14.
In conclusion, despite the need for further studies, this review shows the effectiveness of several N-PAT. There is enough evidence to recommend the use of these methods, particularly in the context of skin punctures. Further studies must be conducted comparing the various N-PAT and their use in combination with drug analgesia.
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