http://doi.org/10.33698/NRF0142 – Jeena James, Sandhya Ghai, K.L.N.Rao, Nitasha Sharma
Abstract : Venipuncture is a minor invasive procedure for pediatric practioners, however for children it is often accompanied by pain, fear and anxiety. Thus the reduction of such pain, fear and anxiety becomes the responsibility of health care professionals to an extent as possible while maintaining patient safety by using various pharmacological and non pharmacological interventions. Hence a quasi – experimental study was undertaken on children of 3 to 6 years age who were undergoing venipuncture to see the effectiveness of “Animated Cartoons” as a distraction strategy to reduce the perception of pain. The study comprised of 50 children selected through purposive sampling method. Children who were seriously ill and were visually and audibly handicapped were excluded from the study. During the first venipuncture children were assessed at pre, during and post venipuncture for perception of pain with routine care only and during the second venipuncture with routine care and animated cartoon.The tools used for the study included a baseline proforma, FLACC (Face, Legs, Activity, Cry and Consolability) behavior pain scale.The results revealed that there is significantly (p <0.001) less pain related behavioural responses with use of animated cartoons as a distraction strategy at pre, during and post venipuncture. The findings also revealed that there is no influence of gender on perception of pain but there was an inverse relation of behaviour pain response with age of the child. Children who had minimal and high rebellious resistance during previous venipuncture had an increased perception of pain during the current venipuncture and the presence of caregiver had no role on the same.It was concluded that animated cartoon is an effective distraction strategy to reduce pain among the children undergoing venipuncture. Thus animated cartoons can be used for effective handling of behavioural responses in children during invasive procedures.
Key words :
Effectiveness, Animated car toon, Distraction,Pain, Venipuncture
Dr. Sandhya Ghai
National Institute of Nursing Education, PGI, Chandigarh
Children often experience unpredictable and severe procedure-related pain in hospitals that can be associated with negative emotional and psychological implications 1. These medical procedures also induce anxiety, fear, and behavioral distress in children and their families, further intensifying their pain and interfering with the procedure. Medical procedures, particularly needle insertions, are among the most feared experiences reported by children.2 Venipuncture is one of the most commonly experienced procedures by children3 and 50% of children experience significant levels of distress during venipuncture4.Venipuncture differs from other needle procedures such as immunization, as venipuncture is longer, involves other medical equipment, such as tourniquets to find an appropriate vein and drawing of blood thereby making it more anxiety provoking for children5.
The pain perception is found to vary with numerous factors including age, sex, cognitive level, temperament, culture, parental support and other situational factors of the child such as previous experience with painful exercise, suppression/alleviation of pain using pharmacologic and non pharmacologic means6. According to McGrath, the behavior of children during invasive procedures is widely individual and dependent on degree of perceived pain6.
In general, younger children (e.g., aged 4-6 years) report higher pain with the same stimulus than older children (aged 7 years or older),7 as well as greater fear and phobia.8 To ensure adequate pain relief, or to make pain more tolerable and to give the children a sense of control over the situation, non- pharmacological methods are widely accepted as strategies that may be used independently or in addition to pharmacological interventions. According to Jacobson9, the use of non-pharmaceutical procedures to cope with pain behavior is less costly and most of these procedures can be administered by a nurse. They have been shown to reduce the perception of pain and make the intervention more bearable. The task of the nurse is to choose an appropriate method and ensure a comfor table environment for the intervention.When used in association with medical procedure, it is advisable to use such distraction strategy intervention before, during, and after the procedure. This gives the child a chance to recover, feel mastery and remember coping10.
Although there are numerous pain reduction methods for children undergoing venipuncture these are not widely used due to the increased time it takes for implementation or their cost and availability in medical offices/hospitals; It is because of these costs and risks that an animated cartoon as a distraction strategy intervention during needle procedures is proposed as a simple alternative to the current methods used.There are very few studies comparing the same children for the perception of pain with routine care and a distraction strategy. And the results of these studies are not consistent.Also the studies focusing on influence of age, sex and other associated factors in pain perception have inconsistent results.In this preview the present study was planned by the researcher.
To assess the effectiveness of animated cartoons as a distraction strategy to reduce behaviour response to perception of pain among children of 3-6 years age undergoing venipuncture
There is no significant difference in behavioural response to perception of pain and fear among children of 3 – 6 years age undergoing venipuncture with routine care and using animated cartoons as distraction strategy
Materials & methods
A quasi experimental design was used in the study. The study was conducted at pediatric surgery ward (6th floor, C block) of Advanced Pediatric Centre (APC), PGIMER, Chandigarh. Advanced Pediatric Centre is a 300 bedded multi- specialty facility dedicated exclusively to the care of children. After getting the approval of ethical committee written permission was taken from the Head of the Depar tment and Assistant Nursing Superintendant (ANS) / Sister in Charge of the ward.The data was collected in the month of August – September 2011.
Fifty children undergoing venipuncture were selected according to the inclusion and exclusion criteria using purposive sampling method. Children of 3-6 years age admitted in Pediatric Surgery ward during the data collection period who were undergoing venipuncture were included in the study. Children who were seriously ill and were visually and audibly handicapped were excluded from the study. Written informed consent was taken from the parents/ guardians of the child before including him/ her for the study. The tools used were interview schedule consisting of socio demographic data and information related to the factors that influence the outcome of the procedure such as child’s recent past experience to venipuncture, child’s general reaction towards health personnel (nurses) and relationship of the caregiver who is present during venipuncture procedure. Another tool was a standardized one,FLACC behaviour pain scale which includes five indicators (face, legs, activity, cry, and consolability) with each item ranking on a three point scale (0-2) for severity by behavioral descriptions resulting in a total score between 0-10. According to the behavioral responses to pain children were categorized into four groups Relaxed and comfortable (0), Mild discomfort (1-3), Moderate pain (4-6) and Severe discomfort or pain or both (7-10). The tools for the study were prepared after reviewing various studies and validated by experts in nursing, pediatrics and medical field.
Observation and interviewing were the methods adopted for the study. The parents of the study subjects were interviewed to record interview schedule. In the first venipuncture children were observed for their perception of pain by giving routine care only. In the second venipuncture children were observed for their perception of pain by giving both routine care and showing animated cartoon through observation method. The animated cartoon “Chhota Bheem” was shown to the children at pre, during and post venipuncture while performing their second venipuncture at laptop. The behavioral response to intensity of pain among children was assessed using FLACC behavior pain scale at pre, during and post venipuncture.
The data was analyzed according to the objectives and hypothesis of the study using both descriptive and inferential statistics. Calculation was carried out with the help of Microsoft Excel and Statistical Package for Social Science (SPSS version 16) Program. The various statistical measures used were the frequency distribution, measures of central tendency (mean, mode), measures of dispersion (range, standard deviation), independent t test and ANOVA to find the statistical significance.
Demographic data of study subjects
The demographic data of study subjects is presented in Table1. There were a total of 50 subjects, with age ranging from 3 – 6 years. Among these, 13 (39.4%) were males of 6 yrs of age and 5 (29.4%) were females of 4 and 5 yrs of age. The mean age of the subjects was 4.62± 1.18years.
Table 1: Demographic Data of the study subjects
Factors influencing the outcome of the procedure
The table 2 depicts the factors that influence the outcome of the procedure as reported by parents. Regarding child’s past experience to venipuncture 15 (30%) subjects were rebellious and showed high resistance and only 5 (10%) were calm and quiet. With regard to child’s general reaction towards health personnel (nurses) 28 (56%) demonstrated withdrawal with minimal resistance whereas 16 (32%) had accepted health personnel (nurses) early and only 6 (12%) were totally reluctant to accept them. Majority 36(72%) of the children were accompanied by mother during venipuncture, 10 (20%) were accompanied by father and grandparents accompanied only 4(8%) of children.
Behavioural responses of children to pain
The behavioral responses of the children to pain at pre, during and post venipuncturewith routine care only and with routine care and animated car toon as interventionare depicted in table 3.
At pre venipuncture 27 (54%) children demonstrated moderate pain and none were relaxed & comfortable with routine care whereas 31 (62%) children showed mild discomfort and 12 (24%) children were relaxed and comfortable when animated cartoon was used as distraction strategy.
Table 2: Factors influencing outcome of procedure
|Child’s recent past experience to venipuncture|
|Calm & quiet||5 (10)|
|Minimal resistance||30 (60)|
|Rebellious & high resistance||15 (30)|
|Child’s general reaction towards health personnel (nurses)|
|Accept early||16 (32)|
|Withdrawal with minimal resistance||28 (56)|
|Totally reluctant to accept them||6 (12)|
|Caregiver present with the child during venipuncture procedure|
During venipuncture majority of the children i.e. 42 (84%) showed severe discomfort or pain with routine care whereas only 21 (42%) children had shown severe discomfort or pain followed by 25 (50%) children showed moderate pain with animated cartoon.
At post venipuncture 35 (70%) children showed moderate pain and none were relaxed and comfortable with routine care whereas with distraction strategy 3 (6%) children were relaxed and comfortable and 30 (60%) children responded with only mild discomfort which shows that number of children experiencing severe discomfort or pain is much less in animated cartoon group as compared to routine care group.
Comparison of mean pain related behavioural responses scores
Comparison of pain scores in children with and without intervention is shown in table
- The table depicted significantly less pain scores at pre, during and post venipuncture with animated cartoon as distraction strategy as compared to routine care. The mean pain score was significantly less i.e. almost half with animated cartoon (2.26 ± 2.18) as compared to routine care (4.76 ± 2.08) at pre venipuncture. Similarly the mean pain score during venipuncture was significantly less with animated cartoon (6.24 ± 2.09) as compared to routine care (8.06 ± 1.70). During post venipuncture also the mean pain score was significantly less i.e. almost half with animated cartoon (2.94 ± 1.71) as compared to routine care (5.94 ± 1.61). This difference is found to be statistically significant as far independent t test (p<0.001).
Table 3: Comparison of behavioural responses to pain among children undergoing venipuncture with routine care Vs with routine care & animated cartoon
|Routine care||Animated cartoon|
|–||–||–||12 (24)||–||3 (6)|
|Severe discomfort or pain
Table 4: Comparison of pain related behavioral response in children undergoing venipuncture with routine care Vs with routine care & animated cartoon
|Routine care only
(Mean ± SD)
|Routine care + Animated cartoon
Pain score t, df, p value
(Mean ± SD)
|Pre venipuncture||4.76 ± 2.08||2.26 ± 2.18||5.87,98, 0.001**|
|During venipuncture||8.06 ± 1.70||6.24 ± 2.09||4.78,98, 0.001**|
|Post venipuncture||5.94 ± 1.61||2.94 ± 1.71||9.04,98, 0.001**|
Effect of socio demographic data on pain related behavioral response among children undergoing venipuncture with and without intervention
The relation between demographic data and other factors on pain related behavioral response in children at pre, during and post venipuncture is shown in table 5. This table shows that as the age increases the perception of pain decreases suggesting that there is inverse relationship of pain responses with age of the child at pre, during and post venipuncture. However the difference was significant only during venipuncture as per t test (p < 0.05).
The male children have responded with less pain as compared to female children. The children who were calm and quiet during the previous venipuncture had shown less pain scores than those children who had shown minimal and high rebellious resistance and this difference was statistically significant as per ANOVA (p<0.05). The children accompanied by father during the procedure had responded with less pain related behavioural responses as compared to children accompanied by mother or grandparents.
Table 5: Influence of demographic data on pain related behavioral response in children
undergoing venipuncture with routine care N=50
|Variables Pain related behavioural response scores Pre venipuncture During venipuncture Post venipuncture (mean ± SD) (mean ± SD) (mean ± SD)|
|Age of the child|
|3yrs 4.08 ± 2.83||8.21 ± 2.23||5.21 ± 2.23|
|4yrs 4.14 ± 2.77||7.68 ± 2.08||4.50 ± 2.09|
|5yrs 3.27 ± 1.75||7.00 ± 1.83||4.50 ± 2.18|
|6yrs 2.80 ± 2.27||6.09 ± 2.04||3.78 ± 2.28|
|F, p value 1.88, 0.14||6.00, 0.001**||1.94, 0.13|
|Sex of the child|
|Male 4.55 ± 1.89||7.97 ± 1.86||5.94 ± 1.71|
|Female 5.18 ± 2.40||8.24 ± 1.35||5.94 ± 1.44|
|t, df, P value -1.02, 98, 0.31||-0.52, 98, 0.61||-0.01, 98, 0.99|
|Past experience to venipuncture|
|Calm & quiet 2.60 ± 1.14||6.20 ± 1.30||4.60 ± 1.67|
|Minimal resistance 4.53 ± 1.66||8.07 ± 1.34||5.83 ± 1.37|
|Rebellious & high|
|resistance 5.93 ± 2.40||8.67 ± 2.06||6.60 ± 1.81|
|F, p value 6.46, 0.003**||4.55, 0.016*||3.36, 0,04*|
|Presence of caregiver|
|Father 3.60 ± 1.58||6.90 ± 2.13||5.00 ± 1.40|
|Mother 5.08 ± 2.03||8.36 ± 1.49||6.14 ± 1.55|
|Grandparents 4.75 ± 2.99||8.25 ± 1.26||6.50 ± 1.92|
|F, p value 2.08, 0.135||3.19, 0.05*||2.35, 0.11|
Interventions aimed at improving the health and well being of children unintentionally become the cause for pain and anxiety in them.11 While most medical procedures provoke anxiety and distress, needle insertion continues to be the most frightening and bothersome medical procedure for children.1 Nonetheless, venipuncture is routinely practiced in pediatric centers without taking much measures to reduce pain and distress.
Pain-management interventions for children undergoing acute painful procedures include pharmacological and non- pharmacological methods.Among these, distraction technique, a non pharmacological method can become an effective way of handling children’s behavioral response since it is easy, economical and needs limited training.Depending on the age group of the subjects undergoing the intervention, the effectiveness of the distraction technique may vary11. For example, interactive distraction intervention may be appropriate for older children and passive distractions, such as cartoon movies, may be appropriate for children of all ages. These inferences made animated cartoon, the preferred distraction strategy for the present study to assess its effects on reducing pain induced behavioral response in children undergoing venipuncture.
The distraction strategy used in a study should be according to the child’s choice and culture. In Indian social culture children are more accessible only to the television cartoons. As per Ormax Media 2011 report, ‘Chhota Bheem’ is leading the list of kids’ favourite TV characters with 21% market share in India. And the survey done by the researcher before the study, among viable subjects, also reflected the same. Thus, the animated cartoon ‘Chhota Bheem’ was chosen as the distraction and was shown on the laptop to the subjects during venipuncture.
The age group of the children, selected as the subjects for the present study (3-6 yrs), was chosen based on the data available from various studies that shows, younger children (e.g., 4 -6 years) report higher pain with the same stimulus than older children (aged 7 years or older)7 as well as greater phobia.
Given the fact that the subjects under study are a pediatric population, even though the distraction strategy seems to be concrete and simple, there are complexities in measuring constructs like pain. A large number of tools, like Oucher scale12 Wong – Becker faces pain scale13, , FLACC behaviour pain scale14, 15CHEOPS scale16 have been used to assess pain. In the present study pain is assessed by FLACC behaviour pain scale which is an observational scale that can be used from 2 months to 7 years of age. Children experience anxiety both before and during the procedure.16Therefore any intervention aiming to prevent or reduce distress should focus on the entire experience of the procedure including waiting, actual preparation, the procedure itself and conclusion. This is suppor ted by a randomized prospective study conducted by Caprilli etal in 2007 with interactive music as a distraction method, for reducing pain and stress in children during venipuncture. They assessed the pain and stress before, during and after the blood test and found out that distress and pain intensity was significantly lower (p< .001; p< .05) in the music group compared with the control group.17 In the present study also perception of pain was assessed at pre, during and post venipuncture with animated car toon as a distraction strategy.
The present study showed that children, who underwent venipuncture with animated cartoon, had less pain score as compared to routine care at pre, during and post venipuncture. This is supported by the results of the study conducted to investigate the effectiveness of a distraction technique in reducing a child’s perceived pain and behavioral distress during an acute pain experience confirmed that the experimental group perceived less pain and demonstrated less behavioral distress than the control group.18Another study by Pringle etal examined the effectiveness of an intervention for reducing behavioral distress in children during needle sticks. The distress management intervention included instruction for children to engage in a distraction activity during needle sticks and parent training in coaching their children. Results indicated that the child distress was significantly and negatively related to use of the experimental distracter.19
Craig states that the intensity of pain behavior during invasive procedures decreases with the age of the child20 i.e., younger children responds to painful procedures with more distress than older children.20 The present study also suggested the same i.e. as the age increases the perception of pain and fear decreases. Gender has always been believed to be a mediator in pain experiences. Pain threshold research has suggested differing sensitivities and reactions to pain, based on sex differences22. However, researchers have shown that gender has no effect on pain intensity responses and behavioral responses to venipunctureand males were significantly more likely to underestimate pain and females were significantly more likely to overestimate pain..23-26 It was found out that from approximately 8 years of age, children (especially girls) gave significantly higher ratings of unpleasantness than sensory intensity of needle pain. Prior to the age of 8 years, children tended to give equivalent ratings of intensity and unpleasantness, with no evidence of a sex difference 5 The present study showed no impact of sex on pain perception. But some studies repor t differences in expressions of pain during invasive procedures between girls and boys.27-28
Several researchers have reported that children’s exposure to past painful procedures is inversely related to their behavioral responses to a venipuncture. A cycle of increased anxiety, fear, and pain can result from negative experiences with injections, which in turn can exacerbate future injection experiences.26 If past experiences of medical- procedure pain have been negative, even the smell of the alcohol swab can condition a child to become anxious and worry about the pain even before the needle is inserted. Children with a history of negative medical experiences showed higher levels of anxiety before a venipuncture procedure, and were more distressed and less cooperative during the procedure.29,30The present study also showed that those children who had minimal and high resistance during previous venipuncture had increased sign of perception of pain at pre, during and post procedure. However, in another study, this relationship did not reach statistical significance.28
Instructing the parents had positive results on the behavior of children during the procedure in the research of Broome.2 But parental anxiety can also influence the child’s anxiety and the consequent pain experience.
The present study showed that perception of pain in children was significantly less when father was present with the child as compared to mother or grandparents. This may be due to the increased anxiety or stress in the mother and grandparents compared to the father, which influenced the child. The findings of the study revealed that use of animated cartoon as a distraction strategy has a significant effect on reducing the perception of pain among children undergoing venipuncture at pre, during and post venipuncture. Thus the null hypothesis was rejected (p<0.001). It recommends that pediatric settings should implement television with cartoons as a distraction strategy to reduce the perception of pain on hospitalization and invasive procedures.
- Cummings EA, Reid GJ, Finley GA, McGrath PJ, Ritchie JA. Prevalence and source of pain in pediatric inpatients. Pain 1996; 68: 25-31.
- Broome ME, Bates TA, Lillis PP, McGahee Children’s medical fears, coping behaviors, and pain perceptions during a lumbar puncture. Oncology Nursing Forum 1990; 17: 361-7.
- Gupta D, Agarwal A, Dhiraaj S, Tandon M, Kumar M, Singh PK, et An evaluation of efficacy of balloon inflation on venous cannulation pain in children: A prospective, randomized, controlled study. Anesthesia and Analgesia 2006; 102: 1372-5.
- Fradet C, McGrath PJ, Kay J, Adams S, Luke A prospective survey of reactions to blood tests by children and adolescents. Pain 1990; 40(1):53-60.
- Goodenough B, Thomas W, Champion GD, Perrot D, Taplin ET, von Baeyer CL, et al. Unraveling age effects and sex differences in needle pain: Ratings of sensory intensity and unpleasantness of venipuncture pain by children and their Pain 1999; 80 (1-2):179-90.
- McGrath Pain in children: nature, assessment, and treatment. New York: Guilford Press, 1990.
- Costello M, Ramundo M, Christopher NC, Powell Ethyl vinyl chloride vapocoolant spray fails to decrease pain associated with intravenous cannulation in children. Clin Pediatr (Phila) 2006;45:628-32
- Merskey Pain terms: A list with definitions and notes on usage. Pain 1979; 6: 249-52.
- Jacobson Intradermal normal saline solution, self-selected music, and insertion difficulty effects on intravenous insertion pain. Heart Lung 1999; 28:114- 22.
- Ball JW, Bindler Paediatric nursing. 2nd ed. St. Louis: Mosby Publication; 1998.
- Klassen JA, Liang Y, Tjosvold L, Klassen TP, Harling Music for pain and anxiety in children undergoing medical procedures: a systematic review of randomized controlled trials.Ambulatory Pediatrics 2008 Mar-Apr;8(2):117-128.
- Kleiber C, Harper Effects of distraction on children’s pain and distress during medical procedures: A meta- analysis. Nursing Research Journal 1994 Feb; 48:401-81.
- Wong DL, Baker Pain in children: comparison of assessment scales. Okla Nurse 1988; 33:8.
- Noguchi The effect of music versus non music on behavioral signs of distress and self-report of pain in pediatric injection patients. J Music Ther. 2006; 43(1): 16-38.
- l SI, Voepel-Lewis T, Shayevitz JR, Malviya The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatric Nursing. 1997; 23(3):293-297.
- Merkel S, Voepel-Lewis T, Malviya
- Pain assessment in infants and young children: the FLACC scale. American Journal of Nursing 2002; 102(10):55-68.
- Caprilli S, Anastasi F, Grotto RP, Abeti MS, Messeri A. Interactive music as a treatment for pain and stress in children during venepuncture: a randomized prospective J Dev Behav Pediatr. 2007; 28(5):399-403.
- Vessey AJ, Carlson LK, McGill J. Use of distraction with children during an acute pain experience. Nursing Research 1994 Nov-Dec; 43(6):369.
- Pringle B, Hilley L, Gelfand K, Dahlquist LM, Switkin M, Diver T Decreasing Child Distress During Needle Sticks and Maintaining Treatment Gains Over Time. Journal of clinical psychology in medical settings. 2003; 8 (2): 119-30
- Craig Pain in infants and children: Socio developmental variations on the theme. An Updated Review. Refresher Course Syllabus. World Congress on Pain, San Diego, CA. Seattle.10th ed. IASP Press, 2002;305-14.
- Bantick SJ, Wise RG, Ploghaus A, Clare S, Smith S, Tracey Imaging how attention modulates pain in humans using functional MRI. Brain 2002; 125: 310-319.
- Frankenstein UN, Richter W, McIntyre MC, & Remy Distraction modulates anterior cingulate gyrus activations during cold pressor test. Neuroimage 2001; 14: 827-836.
- Humphrey GB, Boon CMJ, van Linden van den Heuvell GEFC, van de Wiel The occurrence of high levels of acute behavioral distress in children and adolescents undergoing routine venipuncture. Pediatrics. 1992 Jul; 90(1 Pt 1):87-91
- Petrovic P, Petersson KM, Ghatan PH, Stone-Elander S, Ingvar M. Pain related cerebral activation is altered by a distracting cognitive Pain 2000; 85: 19-30.
- Cohen LL, Bernard RS, Greco LR, McClellan A child-focused intervention for coping with procedural pain: Are parent and nurse coaches necessary? Journal of Pediatric Psychology 2002; 27: 749-757.
- owler-Kerry S, Lander Management of injection pain in children. Pain 1987 Aug; 30(2):169-75.
- Cohen LL, Blount RL, Cohen RJ, Schaen ER, Zaff Comparative study of distraction versus topical anesthesia for pediatric pain management during immunizations. Health Psychol. 1999; 18: 591-98.
- Manne SL, Redd WH, Jacobsen PB, Gorfinkle K, Schorr O, Rapkin Behavioral intervention to reduce child and parent distress during venipuncture. J Consult Clin Psychol. 1990; 58: 565-72.
- Fitzgerald M, Beggs The neurobiology of pain: Developmental aspects. Neuroscientist 2001; 7:246-57.
- Bijttebier P, Vertommen The Impact of previous experience onchildren’s reactions to venepuncture. J Health Psychol 1998; 3:39-46.