Exploring Relations Between Unique Patient Characteristics and Virtual Reality Immersion Level on Anxiety and Pain in Patients Undergoing Venipuncture: Secondary Analysis of a Randomized Control Trial.

BACKGROUND: Virtual reality (VR) is a well-researched digital intervention that has been used for managing acute pain and anxiety in pediatric patients undergoing various medical procedures. This study focuses on investigating the role of unique patient characteristics and VR immersion level on the effectiveness of VR for managing pediatric pain and anxiety during venipuncture. OBJECTIVE: The purpose of this study is to determine how specific patient characteristics and level of immersion during a VR intervention impact anxiety and pain levels for pediatric patients undergoing venipuncture procedures. METHODS: This study is a secondary data analysis of 2 combined, previously published randomized control trials on 252 pediatric patients aged 10-21 years observed at Children's Hospital Los Angeles from April 12, 2017, to July 24, 2019. One randomized clinical trial was conducted in 3 clinical environments examining peripheral intravenous catheter placement (radiology and an infusion center) and blood draw (phlebotomy). Conditional process analysis was used to conduct moderation and mediation analyses to assess the impact of immersion level during the VR intervention. RESULTS: Significant moderation was found between the level of immersion and anxiety sensitivity when predicting postprocedural anxiety (P=.01). Patients exhibiting the highest anxiety sensitivity within the standard of care yielded a 1.9 (95% CI 0.9-2.8; P<.001)-point elevation in postprocedural anxiety relative to individuals with high immersion levels. No other significant factors were found to mediate or moderate the effect of immersion on either postprocedural anxiety or pain. CONCLUSIONS: VR is most effective for patients with higher anxiety sensitivity who report feeling highly immersed. Age, location of the procedure, and gender of the patient were not found to significantly impact VR's success in managing levels of postprocedural pain or anxiety, suggesting that immersive VR may be a beneficial intervention for a broad pediatric population. TRIAL REGISTRATION: ClinicalTrials.gov NCT04268901; https://clinicaltrials.gov/study/NCT04268901.

Child Emotion Regulation Capacity Moderates the Association Between Parent Behaviors and Child Distress During Pediatric Venipuncture.

OBJECTIVES: Medical needle procedures are a common source of pain, distress, and fear for children, which can worsen over time and lead to needle noncompliance and avoidance, if unaddressed. Children's pain experience is multiply determined by external (e.g., parent behaviors) and internal (e.g., cognitive and affective) factors. Some parent behaviors (e.g., reassurance, giving control to child, empathy, apologies, criticism) have related to poor child pain experiences. No research has examined how children's internal emotion regulation, commonly measured via heart rate variability (HRV), may buffer, or strengthen this association. This study is the first to examine child HRV in relation to pain experiences, and as a moderator between a constellation of parent behaviors (reassurance, giving control, empathy) and child pain, fear, and distress. METHODS: Sixty-one children aged 7-12 years undergoing venipuncture and a parent participated. Child HRV was measured before the procedure. After venipuncture, children rated their pain and fear. Parent and child behaviors during venipuncture were coded using the "distress promoting" and "distress" composites of the Child-Adult Medical Procedure Interaction Scale-Revised. RESULTS: Children with lower HRV displayed greater distress. Child HRV moderated the positive association between parent behaviors (reassurance, giving control, empathy) and child distress such that the association was strongest among children with low HRV. CONCLUSIONS: Findings suggest children with lower HRV, indicative of lower emotion regulation capacity, may be at risk of experiencing higher levels of distress and may be more vulnerable to distress when facing parent reassurance, giving control, and empathy verbalizations during venipuncture.

Virtual reality during pediatric vascular access: A pragmatic, prospective randomized, controlled trial.

BACKGROUND: Vascular access is a minor procedure that is associated with reported pain and fear in pediatric patients, often resulting in procedural incompliance. Virtual reality has been shown to be effective in adult populations for reducing pain and anxiety in various medical settings, although large studies are lacking in pediatrics. AIMS: The primary aim was to determine whether pain would be reduced in pediatric patients using virtual reality undergoing vascular access. The four secondary aims measured patient fear, procedural compliance, satisfaction, and adverse events. METHODS: A prospective, randomized, controlled trial was completed at a pediatric hospital, enrolling children 7-18 years old undergoing vascular access in a variety of clinical settings, randomized to virtual reality or standard of care. Pain scores were measured using a numeric pain faces scale. The secondary outcomes of patient fear, procedural compliance, satisfaction, and adverse events were measured with the Child Fear Scale, modified Induction Compliance Checklist, and satisfaction surveys, respectively. Chi-squared, t tests, and regression models were used to analyze the results. RESULTS: The analysis included 106 patients in the virtual reality group and 114 in the control. There were no significant differences in postprocedure pain (VR group estimated 0.11 points lower, 95% confidence interval: 0.50 points lower to 0.28 points greater, P = .59), postprocedure fear (VR group estimated 0.05 points lower, 95% confidence interval: 0.23 points lower to 0.13 points greater), or compliance (adjusted odds ratio 2.31, 95% confidence interval: 0.96-5.56). Children in the virtual reality group were satisfied with the intervention. There were no adverse events. CONCLUSION: This study demonstrates no reduction in pain while using Virtual reality (VR) across a heterogeneous pediatric inpatient population undergoing vascular access.

Effects of virtual reality on pain, fear and anxiety during blood draw in children aged 5-12 years old: A randomised controlled study.

AIM AND OBJECTIVES: Virtual reality (VR) can be used during painful procedures in children. The aim of this study was to evaluate the effects of two different VR methods on procedure-related pain, fear and anxiety of children aged 5-12 years old during blood draw. METHODS: This randomised controlled study used parallel trial design guided by the CONSORT checklist, see Supporting Information. The sample of children (n = 136) was allocated to the VR-Rollercoaster (n = 45), VR-Ocean Rift (n = 45) and control group (n = 46) using blocked randomisation. The primary outcome was pain scores after the blood draw and fear and anxiety scores before and after the blood draw. Before the blood draw, fear and anxiety scores were assessed using self-report and reports from the parents and the researcher using the Child Fear Scale and Children's Anxiety Meter. After the blood draw, level of pain experienced was assessed using the Wong-Baker Faces Pain Rating Scale and the fear and anxiety levels experienced by the children during the blood draw were re-evaluated. RESULTS: Pain scores were found to be lower in the VR-Rollercoaster group and the VR-Ocean Rift group. A statistical difference was found between groups according to self-, parent- and researcher-reported fear and anxiety scores after blood draw. While being in VR-Rollercoaster and VR-Ocean Rift group reduced children's fear and anxiety, being in the control group increased fear levels by 20% and anxiety levels by 34.1%. CONCLUSIONS: VR is an effective method in reducing procedure-related pain, fear and anxiety in children aged 5-12 years old during blood draw. RELEVANCE TO CLINICAL PRACTICE: Evidence-based guidelines and protocols should be created for nonpharmacological methods such as VR for procedural pain and anxiety in children.

The Effect of Virtual Reality and Kaleidoscope on Pain and Anxiety Levels During Venipuncture in Children.

PURPOSE: The study aimed to determine the effect of two different distractions on pain perceptions and anxiety during venipuncture in children. DESIGN: A randomized controlled study. METHODS: A total of 139 children aged between 4 and 10 years were included in the study: 46 of them in virtual reality goggle group and 43 in the control group. An information form, the Children's Anxiety Scale, Visual Analogue Scale, and Wong-Baker Faces Pain Scale were used in the collection of data. FINDINGS: Pain and anxiety scores were significantly lower in the virtual reality goggle and kaleidoscope group than in the control group (P < .000). CONCLUSIONS: The use of virtual reality goggle and kaleidoscope methods during venipuncture are effective in reducing children's perception of pain and anxiety. The most effective method of reducing perception of pain and anxiety is using the virtual reality goggle.

Young children experience little emotional burden during invasive procedures in asthma research.

Research in children should strike the right balance between protecting underage study subjects and advancing the medical field. This study gives insight into the emotional burden that common invasive research procedures in asthma research have on young children, both from the child and parent perspective. Puppetry was used to stimulate children (age 5-6 years) to explain their emotional burden prior to and after the research procedures. We operationalised emotional burden as willingness to participate in future research and reluctance towards participation. Parents filled out a questionnaire on this topic. Symptomatic patients as well as healthy controls were analysed. Forty-one children were included. Children's anticipatory fear for future research showed a clear decrease of 0.7 ± 1.6 on a 5-point Likert scale as a consequence of participation (p = 0.02). Sixty percent of all participating children explicitly indicated willingness to undergo identical research procedures again. Children uninformed by their parents about the venipuncture were significantly more reluctant to the venipuncture after the procedure (p < 0.01), compared to children who had been informed (4.0 ± 0.9 resp. 2.8 ± 1.2).Conclusion: This study suggests that the emotional burden of participation in asthma research for underage children can be prevented when they are properly informed and decreases as a consequence of participations. We believe increased emphasis should be placed on informing children and evaluating the emotional impact of research to help caretakers and research ethics committees make informed decisions about participation of children in medical research. What is Known: • Medical professionals and parents are likely to overestimate children's discomfort undergoing (invasive) research procedures. • Two thirds of children (age 6-18 years) participating in medical research indicated that they would participate in the same research study again. What is New: • Pre-school children experience little emotional burden during invasive procedures in asthma research. • Proper communication about (invasive) research procedures in pre-school children helps to reduce the anticipatory fear of these procedures in the future.

Impact of a Child Life and Music Therapy Procedural Support Intervention on Parental Perception of Their Child's Distress During Intravenous Placement.

OBJECTIVES: Child life specialists and music therapists have a unique and integral role in providing psychosocial care to pediatric patients and families. These professionals are trained to provide clinical interventions that support coping and adjustment and reduce the risk of psychological trauma related to hospital visits and health care encounters. The researchers devised a multimodal approach using a combined child life and music therapy intervention to address procedure-related distress in patients receiving intravenous (IV) placement in the pediatric emergency department. The aim of this study was to investigate the efficacy of this collaborative intervention by evaluating parental perception of their child's distress. METHODS: This study was a prospective analysis investigating the impact of a child life and music therapy intervention on children aged 4 to 11 years old receiving an IV placement in the pediatric emergency department. Efficacy was evaluated by comparing scores between a 4-question pretest and subsequent 4-question posttest that asked the child's parent to evaluate how they anticipated their child would respond to the procedure, and then to evaluate how they perceived their child to have responded after the procedure. Qualitative data were collected in the form of open-ended comments, which were accommodated at the end of the posttest. Data were analyzed by the Cochran-Mantel-Haenszel method for testing repeated ordinal responses and the PROC GENMOD procedure in the SAS system software. RESULTS: A total of 41 participants were enrolled in this study. Results of the statistical analysis revealed significant differences between all pre- and posttest scores (P < 0.05), and significant likelihood that the patient would improve relative to the 4 questions, as a result of the child life and music therapy intervention. CONCLUSIONS: Improvement was demonstrated across all 4 questions, suggesting that the child life and music therapy intervention supported healthy, adaptive coping and helped to minimize distress experienced by patients during IV placement. These results underscore the importance and potential clinical impact of child life psychological preparation and psychotherapy-based music therapy interventions in reducing distress in pediatric patients during common medical procedures.

The effect of therapeutic phlebotomy for hemochromatosis on non-suicidal self-injury: A case report.

BACKGROUND: Self-phlebotomy has been described as a form of non-suicidal self-injury. However, a relationship between non-suicidal self-injury and therapeutic phlebotomy for hemochromatosis has not previously been described. Case presentation: We present a case of a 52-year-old man in whom the frequency of his therapeutic phlebotomy and non-suicidal self-injury were inversely linked, leading to adverse outcomes when his phlebotomy was suspended. CONCLUSIONS: This is the first report describing the relationship between non-suicidal self-injury and therapeutic phlebotomy. This case highlights the need for risk assessment and monitoring of self-harm in patients who are undergoing therapeutic phlebotomy in order to prevent adverse outcomes.

Needle-related pain and distress management during needle-related procedures in children with and without intellectual disability.

Children with intellectual disability frequently undergo needle-related procedures for diagnosis or treatment. Nevertheless, only a few studies deal with pain and distress management during the procedure in this population of children. This study aimed to investigate the number of anxiety and pain management techniques performed during needle procedure in children with intellectual disability (cases) compared to a population of children without intellectual disability (controls). This multicenter cohort study was performed from July 2016 to January 2018 in the pediatric ward of four urban hospitals in Italy. Eligible subjects were children with and without intellectual disability, from 4 to 17 years old, who needed venipuncture or intravenous cannulation for diagnosis or treatment. Use of topical anesthesia, distraction techniques, and physical or verbal comfort during procedures were recorded. Pain and anxiety scores were also recorded. Forty-seven cases and 94 controls were recruited. Three pain- and anxiety-relieving techniques were performed during the procedure in 12 (25%) cases and in 10 controls (11%); two techniques were performed in 23 (50%) cases and in 26 (28%) controls; 12 (25%) cases and 52 (55%) controls received only one.Conclusion: In this series, children with intellectual disability received significantly more relieving techniques, but experienced more pain and anxiety when compared to children without intellectual disability. What is Known: • Children with intellectual disability experience more episodes of pain than cognitively healthy ones, and almost 10% of these episodes are due to medical procedures. What is New: • Children with intellectual disability despite receiving more relieving techniques during a needle-related procedure experienced more pain and anxiety when compared to healthy children.

Psychological interventions for needle-related procedural pain and distress in children and adolescents.

BACKGROUND: This is the second update of a Cochrane Review (Issue 4, 2006). Pain and distress from needle-related procedures are common during childhood and can be reduced through use of psychological interventions (cognitive or behavioral strategies, or both). Our first review update (Issue 10, 2013) showed efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents. OBJECTIVES: To assess the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents. SEARCH METHODS: We searched six electronic databases for relevant trials: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; PsycINFO; Embase; Web of Science (ISI Web of Knowledge); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). We sent requests for additional studies to pediatric pain and child health electronic listservs. We also searched registries for relevant completed trials: clinicaltrials.gov; and World Health Organization International Clinical Trials Registry Platform (www.who.int.trialsearch). We conducted searches up to September 2017 to identify records published since the last review update in 2013. SELECTION CRITERIA: We included peer-reviewed published randomized controlled trials (RCTs) with at least five participants per study arm, comparing a psychological intervention with a control or comparison group. Trials involved children aged two to 19 years undergoing any needle-related medical procedure. DATA COLLECTION AND ANALYSIS: Two review authors extracted data and assessed risks of bias using the Cochrane 'Risk of bias' tool. We examined pain and distress assessed by child self-report, observer global report, and behavioral measurement (primary outcomes). We also examined any reported physiological outcomes and adverse events (secondary outcomes). We used meta-analysis to assess the efficacy of identified psychological interventions relative to a comparator (i.e. no treatment, other active treatment, treatment as usual, or waitlist) for each outcome separately. We used Review Manager 5 software to compute standardized mean differences (SMDs) with 95% confidence intervals (CIs), and GRADE to assess the quality of the evidence. MAIN RESULTS: We included 59 trials (20 new for this update) with 5550 participants. Needle procedures primarily included venipuncture, intravenous insertion, and vaccine injections. Studies included children aged two to 19 years, with few trials focused on adolescents. The most common psychological interventions were distraction (n = 32), combined cognitive behavioral therapy (CBT; n = 18), and hypnosis (n = 8). Preparation/information (n = 4), breathing (n = 4), suggestion (n = 3), and memory alteration (n = 1) were also included. Control groups were often 'standard care', which varied across studies. Across all studies, 'Risk of bias' scores indicated several domains at high or unclear risk, most notably allocation concealment, blinding of participants and outcome assessment, and selective reporting. We downgraded the quality of evidence largely due to serious study limitations, inconsistency, and imprecision.Very low- to low-quality evidence supported the efficacy of distraction for self-reported pain (n = 30, 2802 participants; SMD -0.56, 95% CI -0.78 to -0.33) and distress (n = 4, 426 participants; SMD -0.82, 95% CI -1.45 to -0.18), observer-reported pain (n = 11, 1512 participants; SMD -0.62, 95% CI -1.00 to -0.23) and distress (n = 5, 1067 participants; SMD -0.72, 95% CI -1.41 to -0.03), and behavioral distress (n = 7, 500 participants; SMD -0.44, 95% CI -0.84 to -0.04). Distraction was not efficacious for behavioral pain (n = 4, 309 participants; SMD -0.33, 95% CI -0.69 to 0.03). Very low-quality evidence indicated hypnosis was efficacious for reducing self-reported pain (n = 5, 176 participants; SMD -1.40, 95% CI -2.32 to -0.48) and distress (n = 5, 176 participants; SMD -2.53, 95% CI -3.93 to -1.12), and behavioral distress (n = 6, 193 participants; SMD -1.15, 95% CI -1.76 to -0.53), but not behavioral pain (n = 2, 69 participants; SMD -0.38, 95% CI -1.57 to 0.81). No studies assessed hypnosis for observer-reported pain and only one study assessed observer-reported distress. Very low- to low-quality evidence supported the efficacy of combined CBT for observer-reported pain (n = 4, 385 participants; SMD -0.52, 95% CI -0.73 to -0.30) and behavioral distress (n = 11, 1105 participants; SMD -0.40, 95% CI -0.67 to -0.14), but not self-reported pain (n = 14, 1359 participants; SMD -0.27, 95% CI -0.58 to 0.03), self-reported distress (n = 6, 234 participants; SMD -0.26, 95% CI -0.56 to 0.04), observer-reported distress (n = 6, 765 participants; SMD 0.08, 95% CI -0.34 to 0.50), or behavioral pain (n = 2, 95 participants; SMD -0.65, 95% CI -2.36 to 1.06). Very low-quality evidence showed efficacy of breathing interventions for self-reported pain (n = 4, 298 participants; SMD -1.04, 95% CI -1.86 to -0.22), but there were too few studies for meta-analysis of other outcomes. Very low-quality evidence revealed no effect for preparation/information (n = 4, 313 participants) or suggestion (n = 3, 218 participants) for any pain or distress outcome. Given only a single trial, we could draw no conclusions about memory alteration. Adverse events of respiratory difficulties were only reported in one breathing intervention. AUTHORS' CONCLUSIONS: We identified evidence supporting the efficacy of distraction, hypnosis, combined CBT, and breathing interventions for reducing children's needle-related pain or distress, or both. Support for the efficacy of combined CBT and breathing interventions is new from our last review update due to the availability of new evidence. The quality of trials and overall evidence remains low to very low, underscoring the need for improved methodological rigor and trial reporting. Despite low-quality evidence, the potential benefits of reduced pain or distress or both support the evidence in favor of using these interventions in clinical practice.

Effect of recorded maternal voice, breast milk odor, and incubator cover on pain and comfort during peripheral cannulation in preterm infants.

PURPOSE: This study was conducted to assess the effect of recorded maternal voice, breast milk odor, and incubator cover on the pain and comfort of preterm infants during peripheral cannulation. METHODS: This study was a randomized controlled trial. The sample of the study included 136 preterm infants who met the case selection criteria. The infants were randomly assigned to different groups. DATA COLLECTION TOOL: In the study, a recorded maternal voice was played to the maternal voice group. The breast milk odor group was exposed to the odor of breast milk. The incubator cover group was covered by using an incubator cover before, during, and after the peripheral cannulation procedure on the infants in the experimental group. RESULT: While no difference was observed between the groups before the peripheral cannulation procedure in terms of the total Premature Infant Pain Profile (PIPP) scores, a significant difference existed between the PIPP scores during and after the procedure. This difference was due to the incubator cover group. CONCLUSION: Breast milk odor, recorded maternal voice, and incubator cover in preterm infants are recommended as simple, safe, and supportive stimuli that facilitate positive effects during painful procedures.

Brief Clinical Report: A Systematic Review and Meta-analysis of Pain Memory-reframing Interventions for Children's Needle Procedures.

OBJECTIVE: Children's pain memories play a powerful role in shaping future pain experiences. Interventions aiming to reframe children's memories of painful medical procedures hold promise for altering pain memories and improving subsequent pain experience; however, this evidence has not been synthesized. This brief clinical report includes a systematic review and meta-analysis of existing memory-reframing interventions for needle procedures in children and adolescents to stimulate future research. METHODS: Database searches identified relevant randomized and quasi-randomized controlled trials. Data were extracted and pooled using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) and Cochrane methodologies. Critically important outcomes included fear during a subsequent needle procedure; important outcomes included memory of fear and pain following the needle procedure and pain and distress during a subsequent needle procedure. RESULTS: Three studies including 158 children 3 to 18 years of age were identified. The quality of evidence was low to very low. There was no benefit for the critically important outcome of anticipatory fear; however, the test for overall effect trended toward significance (P = 0.07). Memory-reframing interventions were efficacious in altering children's memories of needle procedures to be less distressing. No benefit was found for acute fear or anticipatory, acute, or overall distress. CONCLUSIONS: There are limited data suggesting that interventions that reframe children's memories of needle procedures hold promise for altering pain memories and potentially reducing anticipatory fear. High-quality intervention development work is needed to determine how these interventions can be adapted to the developing child in order to lead to lasting reductions in pain, fear, and distress at future needle procedures.

Blood pressure and heart rate during stress in children born small for gestational age.

BACKGROUND: Increased sympathetic nervous system activity has been proposed as a potential mechanism for the blood pressure (BP) elevation seen in individuals born small for gestational age (SGA). This study was carried out to detect the changes in BP and heart rate (HR) in children born SGA during exposure to stress and to assess for changes in urinary catecholamine excretion. METHODS: Nineteen children aged 6-14 years born SGA and 17 age- and gender-matched healthy controls were included in the study. The stress test included a mathematical test and venipuncture. BP and HR were monitored during the test. Spot urine samples were collected at baseline and after the stress test to determine dopamine, epinephrine and norepinephrine levels. RESULTS: At baseline, there was no difference in BP and HR between the SGA and control groups, but mean urinary norepinephrine levels were slightly higher in the SGA group (55.7 ± 16.1 vs. 43.4 ± 3.8 mcg/gCr; P = 0.10). Compared to the control group, mean maximal HR increase was higher in the SGA group (31.3 ± 3.1 vs. 19.2 ± 3.8%; P = 0.008), and mean duration of maximal HR to baseline HR was longer (186 ± 23 vs. 97 ± 13 s, respectively; P = 0.003). There was a significant negative correlation between birth weight and maximal HR increase (r = -0.497, P = 0.003). CONCLUSION: Children born SGA showed significantly greater increases in HR and significantly longer periods of tachycardia during exposure to stress than did healthy controls. The rise in HR was inversely correlated with birth weight. These findings suggest that children born SGA have a greater increase in sympathetic response when exposed to stress than do healthy individuals.

Effects of a new device to guide venous puncture in elderly critically ill patients: results of a pilot randomized study.

BACKGROUND: Novel devices based on the emission of near-infrared electromagnetic radiation (NIR) have been developed to minimize venous puncture failures. These instruments produce an "augmented reality" image, in which subcutaneous veins are depicted on a LCD display. We compared the new technique with standard venipuncture in a population of elderly patients. METHODS: Patients admitted in Intensive Care Unit were randomized to standard or to NIR assisted procedure. RESULTS: In the 103 enrolled patients (age 74 ± 12 years; standard venipuncture-N = 56; NIR-N = 47), no differences were found in procedure length, number of attempts, and referred pain. With NIR there was a lower incidence of hematomas and fewer anxiety and depressive symptoms. CONCLUSIONS: The use of the novel NIR-based device is safer and more psychologically tolerable, and it is not associated to an increase of procedure length or number of attempts.

Comparison of Children's Venipuncture Fear and Pain: Randomized Controlled Trial of EMLA® and J-Tip Needleless Injection System®.

PURPOSE: Needle procedures, like venipuncture and intravenous (IV) catheter insertion, are recognized as a common cause of pain and fear for children in hospitals and emergency departments. The purpose of this study was to compare children's self-reported pain and fear related to IV insertion with administration of either the topical local anesthetic EMLA® or 1% buffered lidocaine delivered with the J-Tip Needleless Injection System® (J-Tip®). DESIGN AND METHODS: In this prospective, randomized trial, 150 consecutive pediatric patients 8 to 18years of age undergoing IV insertion were randomly assigned 1:1 to treatment group. Participants self-reported procedural pain using a Visual Analog Scale, and procedural fear using the Children's Fear Scale. RESULTS: Procedural pain scores were significantly lower in the EMLA® group (mean score 1.63+1.659) vs. the J-Tip® group (2.99±2.586; p<0.001). Post-procedure fear scores were significantly lower than pre-procedure fear scores in both treatment groups (p<0.002), but there was no difference in fear scores between the two treatment groups (p=0.314). CONCLUSION: EMLA® provided superior pain relief for IV insertion compared to J-Tip®. PRACTICE IMPLICATIONS: Although EMLA® use resulted in lower self-reported pain scores compared to J-Tip®, pain scores for both treatments were low and fear scores did not differ. When IV insertion can be delayed for 60-90min, EMLA® should be used. When a delay is contraindicated, J-Tip® may be a reasonable alternative to minimize procedural pain of IV insertion.

Developing a medical picture book for reducing venipuncture distress in preschool-aged children.

AIM: Distress associated with needle-related procedures is a major concern in preschool-aged children nursing. This study developed a medical picture book for supporting preschool-aged children facing a venipuncture and determined the effectiveness of such a book intervention in decreasing behavioural distress. METHODS: The picture book was designed in 3 stages: developing stories on medical situations, penning the text, and drafting the book. We conducted a quasiexperimental study to examine the effectiveness of the book. The behavioural distress of the control and picture book groups were assessed before, during, and after the intervention by using the Observational Scale of Behavioral Distress-Revised (OSBD-R). RESULTS: We created a 12-page picture book, Sick Rui-Rui Bear, in which cartoon characters were depicted undergoing venipunctures, as a guide for vein injection and for facilitating positive venipuncture outcomes in preschool-aged children. Over time, the OSBD-R scores of the picture book group were significantly lower than those of the control group (P < .001). CONCLUSION: We recommend the picture book be routinely read and used during venipunctures to decrease procedural distress in preschool-aged children.

Fear of blood draw and total draw time combine to predict vasovagal reactions among whole blood donors.

BACKGROUND: Fear of blood draws is a predictor of vasovagal reaction risk among whole blood donors, and this relationship is particularly evident among less experienced donors. This study examines the combined effect of donor fear and total blood draw time on vasovagal reactions. STUDY DESIGN AND METHODS: After successfully completing the blood donor health screening, 2730 whole blood donors attending high school drives were asked about their fear of having blood drawn. Donor reports of fear versus no fear were combined with total blood draw time to predict phlebotomist ratings of donor vasovagal reactions. RESULTS: Both fear and draw time were significant predictors of vasovagal reactions, with observed reaction rates of 31.2% for fearful donors whose blood draw lasted 10 minutes or more versus 5.0% for nonfearful donors whose draw lasted less than 6 minutes. Binomial regression analyses revealed that fear remained a significant predictor of reaction rates across all blood draw intervals examined (odds ratio, 2.8-4.1; all p < 0.001) and that these effects were maintained after controlling for donor sex, weight, estimated blood volume, pulse rate, and donation status. CONCLUSION: This report shows that both fear and blood draw time increase vasovagal reaction rates, and the two are additive. These findings suggest that fearful donors should be the focus of special attention to reduce their distress before donation as well as careful observation throughout the draw.

The Effect of Distraction on Pain Level Felt by School-age Children During Venipuncture Procedure--Randomized Controlled Trial.

The experimental study that follows was planned to determine the effectiveness of distraction on the pain level in school-age children as they underwent venipuncture. The study sample consisted of children between the ages of 7 and 12 years who underwent venipuncture at the Training and Research Hospital in Istanbul, Turkey between February and May 2012. A total of 144 children were conveniently sampled and evenly randomized into two groups of 72 children each. The primary instrument used to test children's pain level was the Faces Pain Scale-Revised (FPS-R). During the blood draw, the experimental group was given a kaleidoscope and told to look through it and describe what they saw, then rate their pain level on the FPS-R. Results showed that during venipuncture, the pain level of the control group was significantly higher (FPS-R = 3.27 ± 2.87) than the experimental group (FPS-R = 1.80 ± 1.84; p = .001) suggesting that distraction with a kaleidoscope is effective in reducing the pain children experience during venipuncture.

Comparison of the effectiveness of three different methods in decreasing pain during venipuncture in children: ball squeezing, balloon inflating and distraction cards.

AIMS AND OBJECTIVES: This study aimed to investigate three different distraction methods (squeezing a soft ball, balloon inflation and distraction cards) on pain and anxiety relief in children during phlebotomy. BACKGROUND: Needle-requiring medical procedures such as venipuncture, phlebotomy and intramuscular injections are common and significant sources of pain for children, and these cause anxiety, distress and fear. DESIGN: This study was a prospective, randomised controlled trial. METHODS: The sample consisted of children (n = 120) who required blood tests. Data were obtained through face-to-face interviews with the children, their parents and the observer before and after the procedure. The children's pain levels were assessed and reported by the parents and observers, and the children themselves who self-reported using Wong-Baker FACES. The children's anxiety levels were also assessed using the Children's Fear Scale. RESULTS: One hundred and twenty children (mean age: 9·64 ± 2·07 years) were included. No difference was found between the groups in the self-, parent- and observer-reported procedural pain levels (p = 0·446, p = 0·467, p = 0·318 respectively). Furthermore, no significant differences were observed between the groups in procedural child anxiety levels according to the parents and observer (p = 0·323, p = 0·144 respectively). CONCLUSION: Pain and anxiety relief was seen in the three methods used during phlebotomy; however, no statistically significant difference was observed. RELEVANCE TO CLINICAL PRACTICE: This study contributes to the literature on nonpharmacologic pain relief methods during phlebotomy in children.

A skin disease, a blood disease or something in between? An exploratory focus group study of patients' experiences with porphyria cutanea tarda.

BACKGROUND: Porphyria cutanea tarda (PCT) is characterized by fragile skin with blistering on sun-exposed areas. Symptoms typically develop in late adulthood and can be triggered by iron overload, alcohol intake, oestrogens and various liver diseases. Treatment consists of phlebotomy to reduce iron, or increasing urinary porphyrin excretion by administering chlorochin. To optimize patient care, health personnel need to understand the subjective experiences of PCT. OBJECTIVES: To explore the experiences of persons with PCT with regard to symptoms, treatment, follow-up and prevention of the disease. METHODS: Interpretive description was used as a qualitative approach. Twenty-one participants attended three focus groups. All participants had experienced PCT symptoms during the last 5 years. RESULTS: Participants' experiences varied from trivializing symptoms and fragile skin to what was described as a desperate situation, with huge blisters, skin falling off and feeling as if one was in a 'horror movie'. For some, itching was very troublesome, preventing sleep and delaying skin healing. In managing PCT a shift in focus from skin to blood was described. PCT was perceived as a chronic and systemic disease causing a range of health problems. Strategies for preventing symptoms ranged from doing nothing to frequent controls and check-ups. CONCLUSIONS: Participants had a systemic perception of PCT, and a tendency to attribute a range of health problems to the condition. This study adds insight into the experiences patients have with PCT.