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Systematic Review and Meta-analysis of Virtual Reality in Pediatrics

Effects on Pain and Anxiety

Eijlers, Robin MSc*; Utens, Elisabeth M. W. J. PhD*,†,‡; Staals, Lonneke M. MD, PhD§; de Nijs, Pieter F. A. MD, PhD*; Berghmans, Johan M. MD*,‖; Wijnen, René M. H. MD, PhD; Hillegers, Manon H. J. MD, PhD*; Dierckx, Bram MD, PhD*; Legerstee, Jeroen S. PhD*

doi: 10.1213/ANE.0000000000004165
Pediatric Anesthesiology: PDF Only

BACKGROUND: Medical procedures often evoke pain and anxiety in pediatric patients. Virtual reality (VR) is a relatively new intervention that can be used to provide distraction during, or to prepare patients for, medical procedures. This meta-analysis is the first to collate evidence on the effectiveness of VR on reducing pain and anxiety in pediatric patients undergoing medical procedures.

METHODS: On April 25, 2018, we searched EMBASE, MEDLINE, CENTRAL, PubMed, Web of Science, and PsycINFO with the keywords “VR”, “children,” and “gadolescents”. Studies that applied VR in a somatic setting with participants ≤21 years of age were included. VR was defined as a fully immersive 3-dimensional environment displayed in surround stereoscopic vision on a head-mounted display (HMD). We evaluated pain and anxiety outcomes during medical procedures in VR and standard care conditions.

RESULTS: We identified 2889 citations, of which 17 met our inclusion criteria. VR was applied as distraction (n = 16) during venous access, dental, burn, or oncological care or as exposure (n = 1) before elective surgery under general anesthesia. The effect of VR was mostly studied in patients receiving burn care (n = 6). The overall weighted standardized mean difference (SMD) for VR was 1.30 (95% CI, 0.68–1.91) on patient-reported pain (based on 14 studies) and 1.32 (95% CI, 0.21–2.44) on patient-reported anxiety (based on 7 studies). The effect of VR on pediatric pain was also significant when observed by caregivers (SMD = 2.08; 95% CI, 0.55–3.61) or professionals (SMD = 3.02; 95% CI, 0.79–2.25). For anxiety, limited observer data were available.

CONCLUSIONS: VR research in pediatrics has mainly focused on distraction. Large effect sizes indicate that VR is an effective distraction intervention to reduce pain and anxiety in pediatric patients undergoing a wide variety of medical procedures. However, further research on the effect of VR exposure as a preparation tool for medical procedures is needed because of the paucity of research into this field.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

From the *Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center-Sophia Children’s Hospital, Rotterdam, the Netherlands

Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, the Netherlands

Academic Center for Child Psychiatry, The Bascule/Department of Child and Adolescent Psychiatry, Academic Medical Center, Amsterdam, the Netherlands

§Department of Anesthesiology, Erasmus Medical Center-Sophia Children’s Hospital, Rotterdam, the Netherlands

Department of Anesthesia, ZNA Middelheim, Queen Paola Children’s Hospital, Antwerp, Belgium

Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children’s Hospital, Rotterdam, the Netherlands.

Accepted for publication February 27, 2019.

Funding: This research is funded by the Zilveren Kruis foundation (project No. 2015233) and the Coolsingel foundation (project No. 401).

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Elisabeth M. W. J. Utens, PhD, Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center–Sophia Children’s Hospital, KP-2865, Wytemaweg 8, 3015 CN, Rotterdam, the Netherlands. Address e-mail to

© 2019 International Anesthesia Research Society