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


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 Birgül 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 Gülçin Özalp 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

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

JAPT-22-1133-fig1

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)

 

 

 

 

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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Article Info

  • Journal of Anesthesiology and Pain Therapy
  • Article Type : Review Article
  • View/Download pdf

Article Notes

  • Published on: July 26, 2022

Keywords

  • Pain
  • Analgesia
  • Children
  • Non-pharmacological analgesia

*Correspondence:

Prof. Carlo V. Bellieni,
Department of Pediatrics, University of Siena, Siena, Italy;
Email: bellieni@unisi.it

Copyright: ©2022 Bellieni CV. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License.