J prev med hyg 2012; 53: 00-00
Pain in children and adolescents with acute and chronic
diseases is a major public health problem that has been
increasing over the last 20 years. Studies confirm that
pain can negatively affect the life of children as well as
that of their parents . Health care practices can have
an impact both on pain onset and its relief. Venepuncture
is one of the invasive procedures most frequently carried
out during the day in chronic patients. Before and during
this procedure most children are fearful and suffer from
pain and anxiety . Anxiety and fear are found to be in-
versely proportional to the age of children. Children cry,
are scared and refuse to collaborate, whereas parents are
often worried and unable to provide any support.
Negative reactions, including phobia linked to previous
procedures, may exacerbate the situation and reduce the
likelihood to successfully carry out venepuncture .
Studies suggest that even painful experiences during
neonatal age can be associated with excessive responses
to pain during childhood and adulthood. Many sources
report that pain relief is both an ethical imperative and a
child’s right requiring an accurate planning focused on
the needs and characteristics of children and their fami-
lies. This requires a multidisciplinary approach that is
simple, safe, effective and inexpensive capable of re-
ducing suffering and improving the outcomes of clinical
procedures in children [4, 5].
It is reported that anxiety in children can increase their
subjective perception of pain, but it can be reduced if
their attention is focused on a pleasant activity. Litera-
ture refers to many coping strategies that can be facili-
tated by means of relaxation and distraction activities.
It is also well known that if parents are properly in-
formed, educated and trained they can improve their
children’s ability to cope with the procedure . How-
ever, the younger the children, the fewer are their cop-
ing resources. Furthermore, it has been demonstrated
that instructions are effective only if associated with ad-
equate parent support. So, apparently reassurance on its
own very often increases anxiety in the child. Parental
training must include information and teaching of useful
behaviours (ex. support in enduring the procedure, dis-
traction techniques). Parents should also be encouraged
to avoid disadvantageous behaviours (i.e. excessive re-
assurance, criticism). Defining the role of the parents
throughout the stages of the procedure is key for them to
minimize their children’s pain and distress. Furthermore,
Distraction Techniques in Children during Venipuncture:
An Italian Experience
Pain and collaboration assessment in children during
A. BAGNASCO, E. PEZZI, F. ROSA, L. FORNONI*, L. SASSO
Health Sciences Department, University of Genoa, Italy; * G. Gaslini Hospital, Genova, Italy
Children • venipuncture • Pain assessment • Distraction techniques
Introduction. Venepuncture in chronically-ill patients is one of
the invasive procedures most frequently repeated during the day.
Most children are frightened and anxious before this procedure,
and during venepuncture they cry, suffer pain and refuse to coop-
erate, whereas parents are often worried and do not know how
Studies suggest that the first experiences of pain in neonatal age
can be associated with altered reactions to pain during childhood
and in adulthood.
Methods. Our sample included 203 patients aged between 2 and
15 years. During venepuncture a video was shown to the patient.
Pain and parent collaboration were measured using validated
Results. Significant differences were observed between the mean
score of pain in patients undergoing venepuncture with audio-
visual distracting technique (2.53 ±1.76) and the mean score
obtained in those undergoing venepuncture without this technique
In the group with audio-video distractors, the mean level of coop-
eration was 0.38 (SD = 0.63) compared to 0.20 (SD = 0.54) in the
control group. In relation to the presence of parents, no significant
differences were found in the mean pain scores (P=0,5>0,05),
whereas the mean scores of cooperation were significantly differ-
Discussion. Audio-visual distraction effectively improved
pain management and favoured children’s cooperation during
venepuncture. This technique is cost-effective, so it can be widely
used for pain management and to promote cooperation with the
child, two aspects that are of key importance in building a rela-
tionship of trustworthiness
A. bAgnAsco et Al.
playing an active role in education/information activities
enable them to reduce their own anxiety and positively
influence the successful outcome of the procedure.
In addition, if the perception of pain does not meet chil-
dren’s expectations they might be unwilling to cooperate
properly in the future and in adult age they could have
distorted memories of the pain suffered.
Furthermore, literature unanimously reports that it is im-
portant to obtain the child’s collaboration and when this is
not possible, literature suggests to postpone the procedure,
possibly after negotiating the new date directly with the
children to ensure their collaboration in the future.
As regards the characteristics of the nurses and health
professionals performing the procedure, studies empha-
size the importance of acquiring specific skills and expe-
rience in pain management and decision making . It is
clear that parents should stay with their children during
the procedure, but the debate over this issue is still open
Several papers report that distraction (i.e. a nursing in-
tervention aimed at identifying an alternative tool to
distract the patient and divert his/her attention to some-
thing else) can reduce fear, anxiety and pain connected
to painful medical procedures. These tools can include
movies, interactive robot toys, virtual reality goggles,
music, soap bubbles and short stories. Even though lit-
tle is known about the physiological mechanism through
which distraction could lead to a reduction of the per-
ception of pain, distraction supposedly alters nocicep-
tive responses by triggering an internal mechanism of
pain inhibition [8, 9].
Of the non-pharmacological pain relief methods used
during school age, literature cites audio-visual distrac-
tion and psychological interventions (i.e. explanation,
therapeutic touch, encouragement, guided imagery) as
the most effective . It has been demonstrated that
audio-visual distraction – a simple and easily applicable
technique – relieves pain in children during venepunc-
ture procedures as equally and effectively as common
psychological interventions . Theoretically in chil-
dren, the more the distractors are attractive, the greater
the pain relief, but evidence shows that engaging chil-
dren in too many distracting activities during the proce-
dure can be counterproductive. However, some distrac-
tors seem to have no appeal on adolescents undergoing
repeated venepuncture procedures .
The goal of this study was to use validated scales to
observe pain in children during venepuncture made for
clinical aims while showing a DVD. The secondary goal
of the study was to observe children’s collaboration ac-
cording to the “Cooperative Behaviour Scale of Chil-
dren in Venepuncture” (CBSCV).
This observational study was conducted between June
and October 2010 at the “Giannina Gaslini” Institute in
Genoa. After obtaining the approval of the health care
director and of the ethics committee, we enrolled 203
patients aged between 2 and 15 years. These patients un-
derwent venepuncture in the Observation and Emergen-
cy Medicine Unit and in the Day Hospital department of
With regard to the exclusion criteria, patients with men-
tal health disorders, cognitive impairment or a history
of venepuncture in the previous three months were ex-
cluded from the survey.
Detailed information was provided to parents and chil-
dren (according to their cognitive development) and par-
ents were asked to sign an informed consent form. A
movie/cartoon was shown to patients during the whole
duration of the venepuncture. A paediatric nurse with
clinical skills started venepuncture 2-3 minutes after the
beginning of a movie/cartoon, chosen by the child him/
herself according to his personal tastes. At the end the
child was asked to give a score to the intensity of pain
according to validated faces and numerical pain scales
commonly used at the Institute. If patients were unable
to describe their pain with words, they measured it with
the Face, Legs, Activity, Cry, Consolability (FLACC)
scale. The numerical scale was used with children over 7
years, while the faces scale was used with children aged
between 3 and 7 years .
With a view to ensure comfort and minimize pre-proce-
dure anxiety, infants were allowed sit on their parents’
lap. During and after the procedure the researcher fo-
cused on distracting the child and on involving the par-
ent. At the end of the procedure, the child was praised
and in some cases the researcher kept on distracting him/
her with the cartoon/movie depending on the child’s atti-
tude and behaviour, to speed up recovery. Furthermore,
the child’s collaboration was assessed using the Coop-
erative Behaviour Scale of Children in Venepuncture
Also, a chart was designed to map the demographic fea-
tures of patient, pain, cooperation and the presence of
the parents. The statistical analysis required appropri-
ate methods and advice from our Statistics Department.
Since this was an observational study, our findings anal-
ysis was compared with the data of the literature cited in
We found that of the 203 patients undergoing venepunc-
ture while watching a video, 31 (15.3%) said they did
not feel any pain (0), 118 patients (58.1%) reported mild
pain (1-3), 49 (24.1%) moderate pain (4-6), and 5 (2.5%)
severe pain (7-10) (Graph 1).
Data were analysed with the z-test and their statistical
significance was equal to 99%, therefore these findings
can be considered as a casual sample. The average pain
score was 2.53, with a standard deviation of 1.76; the
mean pain score was less than 3 (max level of mild pain)
and statistically significant (P = 0.00007 < 0.01).
It is worth stating that a difference between male and
female patients was evident in terms of venepuncture-
The level of pain in children watching a video was com-
pared to the three age groups commonly used for inter-
nal procedures of our Institute: from 2 to 6 years, from 7
to 11 years and from 12 to 15 years (Graph 2).
Most of the children watching videos aged between 2
and 6 years, approximately 85.1% scored between 2 and
6 in the pain scale, with an overall average 3.4; 92.9%
patients aged between 7 and 11 years scored between 0
and 4, with an overall average score of 2.4; 91.4% of the
patients aged between 12 and 15 years mainly scored
between 0 and 3, with an overall average score of 2.0.
The variance analysis showed a significant difference
between the average pain scores in the three age groups
(P = 0.0001 < 0.05).
Significant differences were found in literature  (P =
0.047 < 0.05) between the average pain score in patients
undergoing venepuncture with the support of audio-
visual distraction (4.55 ± 2.26) and the average score
observed in patients undergoing the procedure without
audio-visual distraction (5.22 ± 2.53). In the group re-
ceiving audio-visual distraction we obtained an average
pain score of 2.53 (Standard Deviation = 1.76).
We used the z-test, with a 99% statistical significance,
to check the difference between the average pain scores
observed in our study and those reported in literature.
In particular, the comparison focused on the average
pain score observed in our study (μ1) and the average
observed in the experimental group (μ2) as reported in
literature . The hypothesis system we defined was:
H0: μ1 - μ2 = 0 (null hypothesis) H1: μ1 — μ2 < 0 (al-
The statistics test = -7.85 is smaller than = -2.33, H0
is refused: μ1 = μ2 at level α = 0.01. In conclusion, a
significant difference was observed between the average
pain score observed in our study and the findings report-
ed in literature on patients undergoing venepuncture us-
ing audio-visual distraction techniques (P = .000) .
As a consequence, also the average score of our research
and the average score of the control group, as in litera-
ture, were significantly different (P = .000).
With regard to the level of collaboration, 142 (70%) and
45 (22%) patients presented a level of collaboration of 0
and 1 respectively; 16 patients (8%) were of level 2 (=
No significant differences were observed between the
average level of collaboration in the experimental group
(0.38 ± 0.63) versus the control group, taken from the
literature  (0.20 ± 0.54). The z-test was applied with
a 95% statistic significance, to check the difference be-
tween the levels of collaboration observed in the group
undergoing the procedure with visual distraction tech-
niques and data reported in literature. Firstly, we com-
pared the average value of our research data (μ1) with
the average value of the data drawn from the literature
relating to the experimental group (μ2).
Since the statistics test = 0.39 was < than = 1.65, we
accept the H0: μ1 = μ2. In conclusion, no significant dif-
ference exists between the average level of cooperation
observed in our study and the data reported in literature
on patients undergoing venepuncture with audio-visual
distraction techniques (P = 0.35 > 0.05).
The average level of our study was compared with the
average level of the control group as reported in litera-
ture. The z-test was applied and produced a statistical
relevance of 95%.
Since the test statistics = -1.56 was > than = -1.65, H0:
μ1 = μ2 is accepted. In conclusion, no significant dif-
ference exists between the average level of cooperation
observed in children watching the video and the aver-
age level of cooperation observed in patients undergoing
venepuncture without distraction techniques (P = 0.06 >
Parental presence during venepuncture
Most of the children undergoing venepuncture with vis-
ual distraction techniques (video/films) were with their
mothers (n = 122, equal to 60.1%) or their fathers 17.7%
(n = 36). Both parents were present in 20.2% of the cases
(n = 41) and, finally, none of the parents were present in
2% of the cases (n = 4).
Pain levels were observed and compared during
venepuncture in relation to the parent present; in par-
ticular, children were evaluated separately, according
to whether they were with their mother, father or both
Most (91.7%) of the children accompanied by their fa-
thers obtained the equally distributed pain scores be-
tween 0 and 4, with a total average of 2.4; pain scores
in children accompanied by their mothers were mostly
(in 52.5%) between 2 and 3, with a total average of 2.5;
finally, the pain score in children accompanied by both
parents was mainly (in 70.7%) between 2 and 4, with a
total average of 2.8.
The variance analysis (ANOVA) produced a level of
significance α = 0.05 to compare the average levels of
pain declared by the three groups and no significant dif-
ference was found (P = 0.5 > 0.05).
Conversely, with regard to the level of cooperation,
based on the parent present, the variance analysis (ANO-
VA) showed a significant difference (P = 0.0076 < 0.05)
between the average pain scores reported by children
The main purpose of this study was to measure pain using
validated scales pain in children undergoing venepunc-
ture, while they were distracted watching a cartoon/film.
The secondary aim was to observe the child’s level of
cooperation using the validated Cooperative Behaviour
Scale of Children in Venepuncture (CBSCV).
Considering the short and long term effects of procedure-
related pain, research has recently focused on the factors
involved in the increase of pain and on the improvement
A. bAgnAsco et Al.
of pain management procedures . Unfortunately,
most of these studies have not been made widely avail-
able to the primary health care services yet. Although lit-
erature supports the efficacy of behavioural techniques
for the relief of acute pain in children, data recommend-
ing specific actions for a specific patient undergoing a
specific procedure are often vague . Several stud-
ies have specifically focused on audio-visual distraction
techniques. The application of these techniques by nurs-
es and parents could reduce the time required to perform
the procedure and the number of staff involved .
The findings of our research showed that during
venepuncture with audio-visual distraction most patients
(73.4%) reported either mild pain or no pain at all (from
0 to 3), with a total average of 2.53 (standard deviation
Cooperation was 0 and 1 in 92% of cases (a good and
fairly good level of cooperation respectively), with an
average of 0.38 (standard deviation = 0.63).
The comparison of the data of this study with the val-
ues observed in the control group  showed different
results for both pain and collaboration. Significant dif-
ferences emerged between the average pain score in
our study and the average score obtained by the control
group (P= .000). Compared to older children, infants re-
ported a higher degree of pain and were less collabora-
tive (respectively P = .0001 and P = .000). This finding
could be linked to the children’s young age. In fact, chil-
dren aged between 2 and 3 (non-collaborative in 70.6%
of the cases and fairly collaborative in 29.4% of the cas-
es) accounted for 17.1% of the patients undergoing the
procedure with both parents present, whereas those only
with their mothers were 5.7% and those only with their
fathers were 8.3%.
Furthermore, the skills of the nurse professionals per-
forming venepuncture in all the children included in
our study proved to be of key importance. In fact, many
studies show that the nurses’ competences as well as
their lack of confidence play an important role in pain
relief actions versus other factors such as the environ-
ment or the personal characteristics of the child and/or
Limits of the study
Our study was limited by a potential bias associated with
the use of self-evaluation pain scales and by the fact that
it was not designed as a case-control study. Objective
physical measurements such as heart rate, blood pres-
sure, body temperature or neurohormonal mediators
were not made. In addition, our research considered the
efficacy of the audio-visual distraction technique only in
patients undergoing venepuncture. In the future, it could
be interesting to explore the efficacy of this technique
in patients undergoing other medical procedures, such
as wound cleansing, sutures and injections. Moreover,
future studies could focus on associating distraction
techniques with drug treatments, such as applying an
anaesthetic cream, to see if such techniques optimise
the analgesic efficacy of the cream and therefore better
achieve the main goal, that is pain relief.
In agreement with the data reported in literature, our
study highlighted the effectiveness of audio-visual dis-
traction techniques (showing films or cartoons) in man-
aging pain and promoting the cooperation in children
undergoing venepuncture. This distracting technique is
recommended because it is effective, easy to carry out
and inexpensive. Pain relief is an ethical imperative,
especially in children. All health professionals ought to
be more sensitive and caring about preventing and man-
aging pain in children. In this regard, it is imperative
to have a properly trained multidisciplinary team, with
a major understanding of the role family-centred care
and empowerment in reducing the onset and perception
of pain, and at the same time know how to successful-
ly deal with children and their families when they are
frightened, anxious and stressed.
Promoting the child’s collaboration was found to be
equally important, especially during hospitalization,
when the children and their families very often feel
uneasy and stressed, because parents are very worried
about their child’s health conditions and at the same time
find themselves in an unfamiliar or totally unknown set-
ting. As a matter of fact, when you are surrounded by
unknown people in a totally unfamiliar environment, it
is much easier to end up feeling overwhelmed by anxi-
ety and fear. This is why it is important to ensure that
both parents and children are properly informed, using a
language that is appropriate to the child’s age and mental
Effective pain management blended with the collabo-
ration of the patients and their families during the care
process facilitated and improved the experience of all
the family members in the hospital. These two aspects
allowed to develop a trustworthy relationship with the
health care team, which is fundamental in paediatric
We encourage further research on reducing distress and
pain in children and adolescents during venepuncture.
Moreover, the findings of our study suggest: 1) to search
for any differences between acute and chronic patients;
2) to see if there are other distractors that may prove to
be even more effective; 3) to gain more knowledge on
parents experience. So, the ultimate goal is to improve
the standard of care provided to paediatric patients and
their families placed at the centre of a caring relation-
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n? Received on xx xx, 2012. Accepted on xx xx, 2012.
n? Correspondence: Annamaria Bagnasco, Health Sciences Depart-
ment, University of Genoa, via Pastore 1, 16132 Genova, Italy
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