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Asian Nursing Research

Volume 11, Issue 4, December 2017, Pages 261-267
open access

Research Article

Effectiveness of Cognitive-behavioral Program on Pain and Fear in

School-aged Children Undergoing Intravenous Placement
Yi-Chuan Hsieh RN, MSN 1, Su-Fen Cheng RN, Ph.D. 2, Pei-Kwei Tsay Ph.D. 3, Wen-Jen Su M.D. 4, Yen-Hua Cho RN, BSN
5
, Chi-Wen Chen RN, Ph.D. 6 ☆
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https://doi.org/10.1016/j.anr.2017.10.002 Get rights and content

Open Access funded by Korean Society of Nursing Science
Under a Creative Commons license

Summary

Purpose
This study aimed to evaluate the effects of cognitive-behavioral program on pain and medical
fear in hospitalized school-aged children receiving intravenous (IV) placement.

Methods
This study used an quasi-experimental design. Thirty-five participants were assigned to the
experimental group and 33 to the control group in the acute internal medicine ward of a
children's hospital. The cognitive-behavioral program entailed having the patients read an
educational photo book about IV placement before the procedure and having them watch their
favorite music video during the procedure. The outcome measures were numeric rating scales
for pain intensity and fear during the procedure.

Results
After applying the cognitive-behavioral program, the mean scores on pain and fear decreased in
the experimental group. However, the difference in pain intensity between these two groups
was nonsignificant. The intensity of fear in the experimental group was significantly lower than
that in the control group.

Conclusion
In this study, the cognitive-behavioral program used with school-aged hospitalized children
promoted less fear during IV placement. The results of this study can serve as a reference for
empirical nursing care and as care guidance for clinical IV injections involving children.

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Keywords
children; fear; needle; pain

Introduction

Intravenous (IV) placement is a common procedure for hospitalized children. It is administered

to most hospitalized children from arrival until discharge. While receiving an IV placement,
children experience a moderate level of pain and fear, generating considerable physiological
and psychological distress [1]. A previous systematic review on needle-related procedural pain
and distress in 3,394 children and adolescents reported 5–10% needle phobia and identified
that it would cause more distress when they receive needle procedures with high degree of
needle fear [2]. The negative memories of distressing and painful needle-based procedures in
childhood may result in exaggerated memories of the pain and heighten distress during
subsequent procedures [3]. Unrelieved pain has undesirable physiological and psychological
consequences [4]. A fear of needles, such as a minor medical procedure which creates
significant pain and distress for a child can persist into adulthood 3, 5.

According to Piaget theory of cognitive development, cognitive development in school-aged

children advances from a preoperational stage to a concrete operational stage. At the
preoperational stage, children start reasoning according to their pain experience, thus affecting
their behavioral performance [6]. Therefore, the intensity of the pain that they perceive while
receiving an IV placement is critical to whether they accept or refuse future medical treatments
involving IV placement. The concrete operational stage starts at 7 years of age and is
characterized by children using logical reasoning to solve problems regarding concrete events
or objects. At this stage, children can engage in reversible thinking and connect various events
and objects, but they cannot respond to abstract concepts [6]. Therefore, healthcare providers
must astutely discern children's emotional and informational needs and comfort children by
informing them about their health condition and about coping strategies to alleviate their
distress [7].

Cognitive-behavioral therapy is a psychological intervention aimed at adjusting cognitive

processes to mitigate psychological distress and maladaptation problems. Emotions and
behaviors are products of cognition; therefore, cognitive and behavioral interventions can
induce cognitive, emotional, and behavioral changes [8]. Moreover, multiple resource theory
suggests that attentional resources within the different sensory systems have relatively
independent functions. Highly engaging and interactive distraction activities that involve
multiple sensory systems are likely to be more effective than more passive distractors or
distractors that involve only one or two sensory systems [9].

Cognitive-behavioral strategies are aimed at educating parents for alleviating their distress,
which benefits their children [10]. Distraction techniques can reduce the pain of venipuncture in
children that suggested to make these techniques more effective and to apply them by
considering the age and mental and physical conditions of children [11]. Distraction is one of
the cognitive-behavioral management techniques, which is divided into two main categories.
Passive distraction can be used by health care professionals to provide some activities for
children, such as playing with a kaleidoscope [12] or cards 13, 14, 15, or entailing audiovisual
distraction, such as watching videos 16, 17 or listening to music 14, 15, 18. Active distraction is
to encourage the child's participation in the activities during the procedures [19], e.g.,
encouraging children to perform deep-breathing exercises [20], blow pinwheel toys or bubbles
[21], squeeze a soft, inflatable ball 14, 22. Cognitive-behavioral interventions may facilitate
controlling the pain and fear associated with medical procedures. Specifically, music
distraction can be one of the effective cognitive-behavioral strategies for 4–12-year-old
children [11]. Audiovisual distraction used in previous studies has been shown to be effective in
assisting children to manage painful, distressing procedures and other treatments 10, 16. Thus,
the present study investigated audiovisual music distraction, combinations with two different
sensory stimulations, to alleviate school-aged children's pain and fear during IV placement.

However, there is little evidence available supporting the efficacy of combined cognitive-
behavioral program for reducing children's needle-related procedural pain and distress [2]. It is
essential to provide school-aged children with a developmentally appropriate intervention to
help them feel that they are in control of the situation. Thus, this study determined the effect of
using the cognitive-behavioral program of an educational photo book about IV placement
before the IV placement procedure and an audiovisual distraction during the procedure on
children's pain and fear.

This aim of this study investigated the intensity of pain and fear experienced by school-aged
children receiving an IV placement during a hospitalization and the effects of cognitive-
behavioral program on the levels of pain and fear that they experienced.
Hypothesis 1. School-aged children receiving an IV placement using the cognitive-behavioral
program will experience less pain than children not using the cognitive-behavioral program.

Hypothesis 2. School-aged children receiving an IV placement using the cognitive-behavioral

program will experience less fear than children not using the cognitive-behavioral program.

Methods

Study design
This study used an quasi-experimental design. The participant group allocation was
determined by flipping a coin (heads: experimental group, tails: control group).

Setting and sample

The experiment was conducted in an IV placement room in the acute pediatric internal
medicine ward of a private hospital in Northern Taiwan. Two trained researchers recruited the
participants, who were hospitalized school-aged children between 6 and 12 years old.
Participants were excluded if they (1) had physical or mental disability; (2) had a hearing or
visual impairment; (3) had not previously had an IV placement; or (4) had received more than
one IV placement concurrently during the procedure.

Seventy-five hospitalized school-aged children were invited to enroll between June and
November 2014. Among the 75 children, three refused to participate, and four were excluded
because they received more than one IV placement concurrently. The final sample comprised
68 participants, 35 of whom were assigned to the experimental group and 33 of whom were
assigned to the control group. With an acceptable type I error size of .05, a sample size of 68
achieved that power of pain was .54 and power of fear was .86. The participant flow diagram is
presented in Figure 1.
 Download high-res image (339KB) Download full-size image

Figure 1. The flow diagram of participants.

Ethical considerations
Ethical approval of the study was granted by the Chang Gung Medical Foundation institutional
board (Approval no. 103-0827A3), to which one of the researchers is affiliated. The aims and
method of study were explained to the children and their parents. They were also notified that
they could leave the study at any time without having to explain their reasons. Informed
consent was gained from caregivers and assent from children when appropriate. Following
consent, children were allocated into one of the two groups.

Measurements

Measurement of pain and fear

According to Srouji, Ratnapalan [23], Numerical rating scales (NRSs) are an effective means for
assessing pain among school-aged children because they enable a fast, simple, easy-to-use,
reliable, and valid pain measurement. A good validity and reliability was reported for the NRS
24, 25. Moreover, NRSs were used to assess the intensity of pain and fear in children with
diabetes when receiving an injection [26]. NRS is an 11-point NRS ranging from 0 (no pain or
fear) to 10 (severe pain or fear). Previous experiences associated with needle-related pain and
fear were assessed for both groups prior to administering the IV placement, and the intensity of
their pain and fear during the IV placement was then rated using NRS.

Intervention program

Educational photo book on IV placement

The main content of the photo book entailed the aim of intravenous placement, sensory and
procedural information, and care considerations. We held face-to-face consultations with two
teachers in a nursing program, two directors of hospital nursing, and one deputy director of
nursing to assess the validity of the photo book's content. The efficacy score for the content of
each page was determined according to the relevance, accuracy, and language appropriateness
of the information. A 5-point rating scale was adopted, and a content validity index (CVI) of 0.9
was obtained. Although no content was deleted, some of the wording was changed, thus
completing the preliminary version of the educational photo book on IV placement entitled
Detective Conan: The Truth about Needles. Finally, to assess the content validity of the photo
book, six elementary school students aged 6–12 years were recruited. We explained the photo
book's content to the children individually and answered their questions to clarify any
misconceptions before asking them to score the validity of the educational photo book on IV
placement according to a set of items: the purpose of IV drips, the IV drip process, IV drip self-
care, and the symptoms and treatments of vascular inflammation. The children rated the items
as 1 (do not understand), 2 (understand partially), 3 (understand), or 4 (understand completely).
The questionnaire employed in the present study attained a CVI of 0.8. Moreover, because the
students, who were 6–8 years old, did not understand the concepts of electrolytes and calories
in the book, the content was modified, thus completing the final version of Detective Conan: The
Truth about Needles.

Music videos
Allowing the children to watch or listen to their favorite music videos (MV) was an intervention
measure used to divert their attention during the IV placement procedure, thereby mitigating
their pain and fear. Before the IV placements were administered, the researchers discussed
with the participants regarding their favorite songs, inviting their primary care providers to
participate in the discussion. According to the children's selections, their preferred MVs were
played from YouTube during the intervention. Immediately before the procedure, the children
started to listen to the MVs that they had selected (total time: 5–10 minutes); the volume was
controlled within a range of 40–60 dB.

Procedures
Before conducting the experiment, we referred our experimental plan to the hospital ethics
committee for its approval. Because we assisted the participants in the experimental group
and their parents in completing the child and parent demographic questionnaire, we obtained
the self-reported data prior to administering the IV placements. The collected data indicated
how the participants perceived the pain and fear in their prior and most recent IV placement
experiences. The control group received routine care; specifically, before the IV placements
were administered, the participants were verbally informed regarding the placement aims and
procedure, and, after the placement, they were educated about care procedures. By contrast, in
addition to receiving routine care, the experimental group received the cognitive intervention
before the placement procedure. The preplacement intervention measures included providing
the proposed educational photo book on IV placement (i.e., Detective Conan) and explaining the
contents of each page in the photo book within 10–15 minutes, thereby guiding the
participants in comprehending the aims and procedure of IV placements.

School-aged children who are in the stage of industry versus inferiority may act to meet the
expectations of others [6]. Thereafter, the participants watched their self-selected MVs while
receiving the IV placement. In consideration of their privacy and other interference factors, self-
reported data were then acquired within 30 minutes of administering the IV placement.

The collected data included the scores for the intensity of pain and fear that the participants
perceived during the current IV placements. The children in both groups received their favorite
stationery as a gift of appreciation after the data were collected.

Data analysis
The data were analyzed using SPSS version 22.0 for Windows (IBM, Armonk, NY, USA). Data
analysis included descriptive and inferential analysis. Descriptive analyses were used to
describe the sample characteristics, and inferential statistics were used to assess the outcome
variables. Paired and independent t tests were used to assess the levels of pain and fear before
and after the cognitive-behavioral program in the two groups receiving IV placement. All tests
were two-sided, and the level of significance was set at p < .05. Index of pain and fear
calculated by the statistical power analyses using the G*Power analysis version 3.1.3
(Universitat Kiel, Kiel, Germany) is .54 and .86, respectively.

Results

Demographics
A valid sample size of 68 was used for the statistical analysis, and the experimental and
control groups comprised 35 and 33 children, respectively. The average age was 8.26 years in
the experimental group and 7.84 years in the control group. According to the children's previous
pain perception, the mean scores on the 11-point NRS were 5.34 for the experimental group
and 4.48 for the control group. The mean score of the children's previous fear perception was
5.34. However, the mean score of the control group was 4.70. The results of the Chi-square and
independent t tests showed no significant difference in any of the demographic variables
between the two groups (p > .05), indicating that the two groups were similar in composition
(Table 1).
 Table 1. Demographics (N = 68).

Demographics Experimental group (n = 35) Control group (n = 33) χ2 or t p

M ± SD or n (%) M ± SD or n (%)

Participants’ characteristics

 Age (yr) 8.26 ± 1.64 7.84 ± 1.53 1.93 .278

 6–7.9 15 (42.9) 21 (63.6) 2.94 .229

 8–9.9 15 (42.9) 9 (27.3)

 10–12.9 5 (13.6) 3 (9.1)

 Gender

 Male 15 (42.9) 21 (63.6) 2.94 .086

 Female 20 (57.1) 12 (36.4)

 Education

 1st–2nd grade 16 (45.7) 19 (57.6) 1.64 .441

 3rd–4th grade 14 (40.0) 12 (36.4)

 5th–6th grade 5 (14.3) 2 (6.1)

 Past injection frequency in the past year

 ≤1 20 (57.1) 13 (39.4) 2.26 .323

 2–5 12 (34.3) 15 (45.5)

 >6 3 (8.6) 5 (15.2)

 Past injection pain level 5.34 ± 3.40 4.48 ± 3.32 1.05 .296

 0–3 9 (25.7) 12 (36.4) 0.90 .637

 4–6 16 (45.7) 13 (39.4)

 7–10 10 (28.6) 8 (24.2)

 Past injection fear level 5.34 ± 3.47 4.70 ± 3.67 0.75 .463

 0–3 12 (34.3) 13 (39.4) 0.23 .894

 4–6 11 (31.4) 9 (27.3)

 7–10 12 (34.3) 11 (33.3)

Primary caregivers’ characteristics

 Primary caregivers

 Father 8 (22.9) 8 (24.2) 2.28 .321

 Mother 26 (74.3) 21 (63.6)

 Other 1 (2.9) 4 (12.1)

 Gender

 Male 8 (22.9) 9 (27.3) 0.18 .674

 Female 27 (77.1) 24 (72.7)

 Age (yr) 38.97 ± 4.66 40.85 ± 9.77 −1.02 .311

 29–39 17 (48.6) 18 (54.5) 4.46 .108

 40–49 17 (48.6) 10 (30.3)

 ≥50 1 (2.9) 5 (15.2)

 Education

 Less than high school degree 6 (17.1) 4 (12.1) 4.89 .087

 High school degree/some college 8 (22.9) 16 (48.5)

 Bachelor s degree or more 21 (60.0) 13 (39.4)

Injection situations

 Family accompanies

 Yes 34 (97.1) 33 (100.0) 0.96 .328

 No 1 (2.9) 0 (0)

 Pediatric nursing experience (yr) 6.97 ± 5.28 5.67 ± 3.46 1.20 .236

 ≤2 7 (20.0) 8 (24.2)

 3–5 14 (40.0) 13 (39.4) 0.20 .905

 >6 14 (40.0) 12 (36.4)

 Nurse injection education

 Associate degree 12 (34.3) 11 (33.3) 0.01 .934

 Bachelor's degree 23 (65.7) 22 (66.7)

Note. M = mean; SD = standard deviation.

Analysis of pain intensity

Regarding the variable of prior needle-related pain intensity, the mean scores of the
experimental and control groups were 4.43 and 4.97, respectively. In addition, 45.7% (n = 16) of
the children in the experimental group scored 0–3, and 48.5% (n = 16) in the control group
scored 4–6. However, the proportion of the 0–3 score in the experimental group was increased
from 25.7% to 45.7%, an increase of 20.0%. Using the scores for prior needle-related pain
intensity as a baseline for comparison with the pain intensity measured in this study showed a
decrease of 0.91 in the mean score of the experimental group and an increase of 0.48 in that of
the control group (Table 2).

Table 2. Comparison of the Degree of Injection Pain in Experimental Group with Control Group (N = 68).

Pain score Past pain level After intervention pain level Change from baseline t pa
(P1) (P2) (P1–P2)

M ± SD or n (%) M ± SD or n (%) M ± SD

Experimental group 5.34 ± 3.40 4.43 ± 3.21 −0.91 ± 2.77 −1.95 .059

(n = 35)

 0–3 9 (25.7) 16 (45.7)

 4–6 16 (45.7) 9 (25.7)

 7–10 10 (28.6) 10 (28.6)

Control group (n = 33) 4.48 ± 3.32 4.97 ± 3.58 0.48 ± 3.21 0.87 .392

 0–3 12 (36.4) 10 (30.3)

 4–6 13 (39.4) 16 (48.5)

 7–10 8 (24.2) 7 (21.2)

 t 1.05 −0.66 −1.93

 pb .302 .514 .058

Note. M = mean; SD = standard deviation.

a
Paired-samples t test.

b
Independent samples t test.
The results of a paired t test conducted to analyze the efficacy of the cognitive-behavioral
program in reducing the pain that the children experienced while receiving an IV placement
indicated that the pain perceived by the experimental group children differed nonsignificantly
(t = −1.95, p = .059). According to the results of the independent t test, the change in the
intensity of the pain experienced by both groups differed nonsignificantly (t = −1.93, p = .058),
indicating that interventions entailing cognitive-behavioral program contributed nonsignificantly
to reduce the pain intensity in either group (Table 2).

Analysis of fear intensity

The experimental and control groups attained mean scores of 3.37 and 5.03, respectively;
60.0% (n = 21) of the children in the experimental group scored 0–3, and 36.4% (n = 12) in the
control group scored 4–6. By comparing the fear intensity with the prior needle-related fear
intensity (baseline), we found that the mean score for fear intensity decreased by 1.97 in the
experimental group and increased by 0.33 in the control group (Table 3).

Table 3. Comparison of the Degree of Injection Fear in Experimental Group with Control Group (N = 68).

Fear score Past fear level After intervention fear Change from baseline t pa
(P1) level (P2) (P1–P2)

M ± SD or n (%) M ± SD or n (%) M ± SD

Experimental group score 5.34 ± 3.47 3.37 ± 3.16 −1.97 ± 3.79 −3.08 .004

(n = 35)

 0–3 12 (34.3) 21 (60.0)

 4–6 11 (31.4) 9 (25.7)

 7–10 12 (34.3) 5 (14.3)

Control group score 4.70 ± 3.67 5.03 ± 3.10 0.33 ± 2.99 0.64 .526

(n = 33)

 0–3 13 (39.4) 11 (33.3)

 4–6 9 (27.3) 12 (36.4)

 7–10 11 (33.3) 10 (30.3)

 t 0.75 −2.19 −2.78

 pb .460 .032 .007

Note. M = mean; SD = standard deviation.

a
 Paired-samples t test.

b
Independent samples t test.

The results of the paired t test, which was performed to analyze the efficacy of the cognitive-
behavioral program in reducing the fear experienced by the children during IV placement,
indicated that the fear perceived by the experimental group children differed significantly
(t = −3.08, p = .004). The results of an independent t test showed that the change in the fear
intensity perceived by both groups differed significantly (t = −2.78, p = .007). In addition, the
intensity of fear decreased more in the experimental group than in the control group because
the cognitive-behavioral program was used. For this study population, the use of cognitive-
behavioral program significantly reduced the fear perceived by school-aged children receiving
IV placement during a hospitalization (Table 3).

Discussion
This study found that school-aged children receiving IV placement typically experience a
moderate level of pain. This result agrees with certain related studies 12, 20. By applying
cognitive-behavioral strategies to the experimental group, we observed nonsignificant
differences in the pain intensity, although it followed a reduction in experimental when
compared with the control group, as hypothesized. This phenomenon was also observed in the
previous study involving a large sample of 136 hospitalized children receiving venipuncture
[17]. In the present study, the results of pain were not statistically significant. However, the
proportion of the 0–3 score in the experimental group was shown to increase by 20.0%. Those
whose scores increased by 20.0% were more likely to be men (71.4%), all attended from the
grade 3 to 6 and reported moderate (71.4%) to high (28.6%) pain level in their past injection
experience. The findings could further serve as a target group for the future study.

According to that study, providing procedure-related information to the children and allowing
them to watch MVs while using headphones are ineffective in distracting them from the pain.
Other similar studies 12, 13, 20 have explored the effectiveness of using distraction techniques
(e.g., performing deep-breathing exercises and playing with a kaleidoscope or cards) for
diverting school-aged children's attention during IV injection or venipuncture and have
produced findings that conflict with our study. This difference might be attributable to the
participants in those studies 13, 20 having had chronic diseases and requiring routine
treatments involving injections; therefore, the basic characteristics of research participants
may affect the research results. Moreover, Tüfekci et al [12] discussed using distraction
measures to reduce the pain of outpatient children during venipuncture, in which the treatment
setting differed from that in our study.
As shown in similar studies, using distraction techniques can effectively alleviate anxiety and
distress in children during IV placement. The reported distraction techniques include providing
short, educational picture books about injections before administering one, delivering visual
and sensory information regarding the procedure [27], spending 15 minutes teaching parents
strategies for distracting children's attention (e.g., educational materials, videos, and
discussion). In addition, parents and children are encouraged to select the activity that most
effectively distracts the child's attention, such as reading books, playing with toys or computer
games 10, 19, blowing bubbles or pinwheels, preparing for the IV placement, and having
parents participate in the procedure [19]. In addition, Aydin and Sahiner [15] used distraction
cards, music, and distraction cards with music combined during phlebotomy could reduce pain
and anxiety levels, but the results were not significantly different. It is still worthy to note that
scenario and complexity for treatment may cause the difference in results. Therefore, the
characteristics of the research participants, the situations under which the medical treatments
are administered, and the type of distraction measure can affect the efficacy of interventions.
These findings are in accordance with Rezai et al's [11] study that has reported to reduce the
pain of venipuncture in children more effectively, it is better to use these techniques according
to age as well as mental and physical conditions of children.

The present study had the children in the experimental group read an educational photo book
on IV placement entitled Detective Conan: The Truth about Needles and asked them whether
they knew why they were receiving an IV placement. Most of the younger children responded
“because I am sick,” but did not know the purpose of the IV placement. Moreover, when school-
aged children anticipate an IV placement, they choose to verbally express their feelings (e.g., “I
am scared” or “I am afraid of pain”).

A large time gap between the most recent IV placement experience and the one in the present
study might have caused the children to forget the IV placement procedure that they
underwent. However, assuming that children remember the previous procedure, clinical nurses
may refer to it only briefly and may choose not to offer any further explanation regarding the
procedure, thereby neglecting the children's feelings and informational needs. Furthermore,
hospitalized children at the concrete operational stage of development can easily generate an
illusion of fear regarding medical treatments. By using the Detective Conan book, which
featured pictures demonstrating real IV placement procedures, the children were informed
about each step of the procedure and any possible sensations that they might perceive. This
strategy was found effective in reducing children's perceived fear in this study population. As
suggested by Coyne [7], children who perceive intense injection fear require more assistance in
understanding the injection procedure.

Limitations
This study found that children who had experienced intense injection pain and fear were less
likely to be distracted from the pain. In similar situations, nurses must cautiously divert the
attention of their patients. Secondly, recall bias may occur when children reported their
previous experiences associated with needle-related pain and fear in this study. Thirdly, a large
sample with stronger power could be employed to verify the efficacy of such interventions in
mitigating injection pain. Lastly, these results can be applied only to school-aged children who
are hospitalized in an acute internal medicine department and receiving IV injections. Thus, the
results cannot be generalized to children in other age groups, to those with surgical diseases or
chronic diseases, or to those receiving medical treatments other than IV placement.

Conclusion
This study showed the efficacy of cognitive-behavioral program in reducing the fear
experienced by school-aged children receiving an IV placement during a hospitalization. The
participants enrolled in this study were able to reason logically and analyze their prior
placement experiences. Although school-aged children at this stage understand the need for
invasive medical treatments during a hospitalization, they cannot comprehend abstract objects
and events. In contrast with younger children overreacting to fear, the moderate responses of
school-aged children often mislead their parents and clinical nurses into assuming that they
can endure the pain and fear of an IV placement, causing their true feelings to be neglected or
underestimated. Most of the school-aged children in the present study had experienced
moderately intense pain and fear during the previous placement. After being provided with
easy-to-understand picture-based instructions to enable visualizing the IV placement
procedure, these children were less fearful of IV placement. In addition, during the procedure,
their fear of IV placement decreased significantly as their attention was diverted by watching
their favorite MV. However, such programs can be used to effectively mitigate the intensity of
children's fear and assist them in coping with short-term medical treatments, thus minimizing
the possibility of psychological trauma in children. Consequently, imparting a supportive
injection experience can facilitate subsequent medical care and foster a positive nurse–patient
relationship.

Conflict of interest

No conflict of interest has been declared by the authors.

Acknowledgments
The authors would like to thank all the study participants for their participation.

Recommended articles Citing articles (0)

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12 F.G. Tüfekci, A. Celebioğlu, S. Küçükoğlu

Turkish children loved distraction: using kaleidoscope to reduce perceived pain during venipuncture
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13 S. Inal, M. Kelleci
Distracting children during blood draw: looking through distraction cards is effective in pain relief of
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14 N.C. Sahiner, M.D. Bal

The effects of three different distraction methods on pain and anxiety in children
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15 D. Aydin, N.C. Sahiner

Effects of music therapy and distraction cards on pain relief during phlebotomy in children
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16 Y.O. Ha, H.S. Kim

The effects of audiovisual distraction on children's pain during laceration repair
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17 J. Tak, W. Van Bon

Pain-and distress-reducing interventions for venepuncture in children
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18 Ó. Kristjánsdóttir, G. Kristjánsdóttir
Randomized clinical trial of musical distraction with and without headphones for adolescents'
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19 D. Koller, R.D. Goldman

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Analgesic effect of regular breathing exercises with the aim of distraction during venipuncture in school-
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21 W.B. Schiff, K.D. Holtz, N. Peterson, T. Rakusan

Effect of an intervention to reduce procedural pain and distress for children with HIV infection
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22 T. Sadeghi, N. Mohammadi, M. Shamshiri, R. Bagherzadeh, N. Hossinkhani

Effect of distraction on children's pain during intravenous catheter insertion
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23 R. Srouji, S. Ratnapalan, S. Schneeweiss

Pain in children: assessment and nonpharmacological management
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24 L.L. Chuang, K.C. Lin, A.L. Hsu, C.Y. Wu, K.C. Chang, Y.C. Li, et al.
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25 G.A. Hawker, S. Mian, T. Kendzerska, M. French

Measures of adult pain: visual analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain),
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26 T. Vervoort, L. Goubert, H. Vandenbossche, S. Van Aken, D. Matthys, G. Crombez

Child's and parent's catastrophizing about pain is associated with procedural fear in children: a study in
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27 A. Kolk, R. Van Hoof, M. Dop

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