Article Text


Review: distraction, hypnosis, and combined cognitive-behavioural interventions reduce needle related pain and distress in children and adolescents
  1. Jeanette Robertson, RN, MSc
  1. Princess Margaret Hospital for Children,
 Perth, Western Australia, Australia

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 Q In children and adolescents, do cognitive-behavioural psychological interventions reduce pain and distress associated with needle related procedures?


    Embedded ImageData sources:

    Medline, EMBASE/Excerpta Medica, CINAHL, PsycINFO, Web of Science, and Dissertation Abstracts International (all up to 2005); Cochrane Library (Issue 4, 2005); bibliographies of relevant studies; and researchers.

    Embedded ImageStudy selection and assessment:

    randomised controlled trials (RCTs) that had ⩾5 participants per group and compared cognitive and behavioural psychological interventions with a control or comparison condition in children or adolescents 2–19 years of age who were healthy (or had chronic or transitory illnesses) and were receiving needle related medical procedures. Studies of dental or other surgeries, body piercings or tattoos, or of patients with known needle phobias were excluded. 28 studies (n = 1951) met the selection criteria. Quality scores of individual studies ranged from 0–3 on the 5 point Oxford Quality Scale; 16 RCTs had scores of 0.

    Embedded ImageOutcomes:

    pain and distress (self or observer reported, physiological, or behavioural measures).


    Meta-analyses showed that hypnosis and distraction alone reduced self reported pain; hypnosis, distraction with nurse coaching, and combined cognitive-behavioural therapy (CBT) reduced distress more than usual care or no intervention (table). Individual studies showed that distraction with suggestion reduced self reported pain, preparation and information reduced observer reported pain, and distraction with parent positioning reduced observer reported distress (table). Preparation and information and memory alteration improved pulse rate and diastolic blood pressure, respectively (table). Suggestion, blowing out air, memory alteration, and distraction with parent coaching did not differ from control for pain and distress.

    Cognitive and behavioural interventions v usual care or no intervention for needle related procedures in children and adolescents


    Distraction, hypnosis, and combined cognitive-behavioural interventions reduce needle related pain and distress in children and adolescents.


    The use of distraction to reduce pain and discomfort associated with needle related procedures in children should not come as a surprise to parents or paediatric nurses. Thus, the value of the systematic review by Uman et al lies in the suggestion that there are additional benefits when cognitive and/or behavioural interventions are used in conjunction with simple distraction.

    The strengths of the review are the detailed description of the interventions evaluated in individual studies and the comprehensive search strategy used to identify studies. In all, 43 search terms encompassing participants’ age, nature of procedure, and intervention type, were used either alone or in combination to select studies for further quality assessment. Although 188 papers were identified from the search, only 28 were regarded as rigorous enough to include in the review. It should be noted, however, that 57% (n = 16) of included studies reached minimum quality standards. The high rejection rate resulted from the standards required for randomisation procedures, which are necessary because studies of psychological interventions often cannot be blinded. Nevertheless, the review was able to reach clear conclusions about the effects of distraction, hypnosis, and combined CBT.

    There are challenges in providing some of these interventions in clinical practice. Interventions can require at least some expertise outside of usual nursing practice (eg, hypnosis); some are not suitable for young children, and most, with the possible exception of distraction, require additional dedicated time for the procedure. The review provides evidence to support selection of the most effective interventions where resources are available, although widespread implementation may require extending the skills of nurses in paediatric settings.

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    • For correspondence: MsL Uman, Dalhousie University, Halifax, Nova Scotia, Canada. luman{at}

    • Sources of funding: National Science and Engineering Research Council Canada, Nova Scotia Health Research Foundation, and Pain in Child Health.

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