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Randomised controlled trial
A multifaceted distraction intervention may reduce pain and discomfort in children 4–6 years of age receiving immunisation
  1. Lindsey L Cohen
  1. Lindsey L Cohen
    Department of Psychology, Georgia State University, Atlanta, GA 30302-5010, USA; llcohen{at}

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Children experience frequent pain with regular healthcare (eg, immunisations), and evidence suggests that there are a host of negative repercussions for untreated pain. Berberich and Landman evaluated an innovative intervention to minimise children’s pain. They combined ethyl chloride, a plastic “multipronged gripper” similar to the ShotBlocker (Bionix, Toledo, Ohio, USA), vibration and a game with the child guessing when the vibrating instrument reached the elbow. The authors refer to this as a “multifaceted distraction” (p. e203) and compared it with routine care for preschoolers’ immunisation injections. Twenty children were randomised to the intervention group and 21 to the control group. Patient self-report, parent report and observational behavioural coding indicated that the intervention resulted in lower paediatric patient distress than in the control group (p < 0.001).

In general, this is an elegant study and provides convincing data to support the intervention. The integration of distinct interventions is particularly novel in the field. Too often researchers evaluate single-modality interventions (eg, ethyl chloride or distraction) within circumscribed professional fields (eg, paediatric medicine or psychology) rather than combining proven approaches. Although it is important to isolate effective treatment components, it is likely that packages that integrate approaches will be the most successful. The authors describe their treatment as a “combination of several distinct distraction interventions” (p. e204); however, distraction is only one component. In addition to data supporting distraction for paediatric pain,1 studies have validated the other components, including ethyl chloride,2 multiprong arm grippers3 and vibration.4 (As a side note, there are studies that do not support ethyl chloride spray5 or the ShotBlocker.6) Rather than simply a “distraction method” (p. e207), Berberich and Landman weave together multiple successful pain relief approaches, which should be highlighted as a direction for future inquiry. In fact, the integration of cold, vibration and distraction for reducing children’s medical pain was evaluated in a recent study.7

In terms of the methodology, the study is largely sound. The use of validated measures from many perspectives and the focus on a specific age group increase internal validity. Furthermore, given the small sample size, the findings are particularly impressive and suggest strong effects for the intervention. However, there are caveats to keep in mind when considering the results. The observational coding was conducted by the co-author, who was privy to hypotheses, likely invested in study outcomes and thus potentially biased. In addition, relying on only one coder precludes evaluations of whether the instrument was used in a valid or reliable fashion. Similarly, it would have been preferable to have had impartial researchers collect data (eg, videotaping, questionnaire assistance) to minimise potential influence. It is also unfortunate that the authors did not incorporate a placebo condition, which might have helped identify active ingredients of the intervention. In general, if the CONSORT guidelines8 had been followed, the findings from this randomised trial would be more convincing.

The authors choose to frame the results with data regarding children’s “trance states” and “hypnotic suggestion”. Given that this describes only a portion of the intervention, a more holistic theoretical rationale that integrates multiple modalities might be in order for this package. For example, the gate control theory or neuromatrix theory9 can account for the influences of sensory, affective and cognitive stimuli on pain experience.

Regarding clinical practice, the results suggest that a combination of intervention modalities might be an excellent way to minimise paediatric acute pain. That said, single-component interventions (eg, distraction alone) would be a more practical approach if research were able to demonstrate that they were as effective. That is an empirical question that deserves further attention. In making decisions around pain management, unfortunately, cost, time and effort are factors to consider. For example, with this approach, the cost and availability of ethyl chloride might be a factor to take into account.

Although Berberich and Landman’s results are promising, children’s injection pain was not eliminated, which should be kept in mind as a goal in this line of inquiry. Researchers should continue to incorporate effective interventions while balancing practical considerations (eg, cost, time requirements), especially in busy clinical settings. Future work should also attempt to determine whether individual characteristics (eg, coping style, temperament) might be best suited for particular interventions. Ideally, brief assessments should guide the selection or modification of practical interventions, which should result in optimum paediatric pain relief. Although Berberich and Landman have shown that an innovative intervention is generally helpful to distressed children, this should be viewed as one step and not the end in our goal of identifying and disseminating evidence-based paediatric pain management approaches.

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  • Competing interests None.

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