Psychological interventions for reducing pain and distress during routine childhood immunizations: A systematic review

Background: Immunizations are a common source of pain and distress for children. Psychological interventions consist of a variety of techniques for relaxing and distracting children during immunization with the goal of reducing pain and distress.Objective: We conducted a systematic review to determine the efficacy of various psychological strategies for reducing pain and distress in children during routine immunizations.Methods: MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials (RCTs) and quasi-RCTs that determined the effect of psychological interventions on pain and distress during injection of vaccines in children 0 to 18 years of age, using validated child self-reported pain or observer-reported assessments of child distress or pain. We examined the efficacy of 7 psychological interventions: (1) breathing exercises; (2) suggestion; (3) child-directed distraction; (4) parent-led distraction; (5) nurse-led distraction; (6) parent coaching; and (7) combined cognitive-behavioral interventions. All meta-analyses were performed using a fixed-effects model.Results: Twenty RCTs involving 1380 infants and children (1 month to 11 years of age) were included in the systematic review. Breathing exercises were effective in reducing children's self-reported pain (standardized mean difference [SMD], −0.43; 95% CI, −0.76 to −0.09; P = 0.01), observer-rated distress (SMD, −0.40; 95% CI, −0.68 to −0.11; P = 0.007), and nurse-reported distress (SMD, −0.57; 95% CI, −0.98 to −0.17; P = 0.005). Self-reported distress ratings appeared to be lower with breathing exercises, but the difference was not statistically significant. No evidence was found to support suggestion as a psychological intervention for reducing pain associated with pediatric immunization. Child-directed distraction was effective in reducing self-reported pain (SMD, −0.28; 95% CI, −0.54 to −0.03; P = 0.03). Parent-led distraction was effective in reducing observer-rated distress (SMD, −0.50; 95% CI, −0.82 to −0.19; P = 0.002), but not other measures of pain or distress. Nurse-led distraction was effective in reducing distress ratings as assessed by the observer (SMD, −0.40; 95% CI, −0.68 to −0.12; P = 0.005), the parent (SMD, −0.37; 95% CI, −0.66 to −0.07; P = 0.01), and the nurse (SMD, −0.42; 95% CI, −0.70 to −0.14; P = 0.004). Parent coaching was effective in reducing observer-rated distress (SMD, −0.71; 95% CI, −1.02 to −0.39; P < 0.001), but not other measures of pain or distress. Combined cognitive-behavioral interventions were effective in reducing children's self-reported pain (SMD, −0.75; 95% CI, −1.03 to −0.48; P < 0.001), observer-rated distress (SMD, −0.53; 95% CI, −0.83 to −0.23; P < 0.001), and parent-rated distress (SMD, −0.97; 95% CI, −1.37 to −0.57; P < 0.001). The methodologic quality of the included trials was generally poor, with 18 (90%) of the 20 studies rated as having a high risk of bias.Conclusions: Evidence suggests that breathing exercises, child-directed distraction, nurse-led distraction, and combined cognitive-behavioral interventions are effective in reducing the pain and distress associated with routine childhood immunizations. Although additional well-designed trials examining psychological interventions are needed, parents and health care professionals should be advised to incorporate psychological interventions to reduce the pain and distress experienced by children during immunization.