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Psychological Interventions for Vaccine Injections in Children and Adolescents: Systematic Review of Randomized and Quasi-Randomized Controlled Trials

Birnie, Kathryn A. BA(Hons)*,†; Chambers, Christine T. PhD, R Psych*,†,‡; Taddio, Anna BScPhm, MSc, PhD§,∥; McMurtry, C. Meghan PhD, C Psych¶,#,**; Noel, Melanie PhD††; Pillai Riddell, Rebecca PhD, C Psych∥,‡‡; Shah, Vibhuti MD, MSc§§,∥∥HELPinKids&Adults Team

doi: 10.1097/AJP.0000000000000265
Child Psychological Interventions

Background: This systematic review evaluated the effectiveness of psychological interventions for reducing vaccination pain and related outcomes in children and adolescents.

Design/Methods: Database searches identified relevant randomized and quasi-randomized controlled trials. Data were extracted and pooled using established methods. Pain, fear, and distress were considered critically important outcomes.

Results: Twenty-two studies were included; 2 included adolescents. Findings showed no benefit of false suggestion (n=240) for pain (standardized mean difference [SMD] −0.21 [−0.47, 0.05]) or distress (SMD −0.28 [−0.59, 0.11]), or for use of repeated reassurance (n=82) for pain (SMD −0.18 [−0.92, 0.56]), fear (SMD −0.18 [−0.71, 0.36]), or distress (SMD 0.10 [−0.33, 0.54]). Verbal distraction (n=46) showed reduced distress (SMD −1.22 [−1.87, −0.58]), but not reduced pain (SMD −0.27 [−1.02, 0.47]). Similarly, video distraction (n=328) showed reduced distress (SMD −0.58 [−0.82, −0.34]), but not reduced pain (SMD −0.88 [−1.78, 0.02]) or fear (SMD 0.08 [−0.25, 0.41]). Music distraction demonstrated reduced pain when used with children (n=417) (SMD −0.45 [−0.71, −0.18]), but not with adolescents (n=118) (SMD −0.04 [−0.42, 0.34]). Breathing with a toy (n=368) showed benefit for pain (SMD −0.49 [−0.85, −0.13]), but not fear (SMD −0.60 [−1.22, 0.02]); whereas breathing without a toy (n=136) showed no benefit for pain (SMD −0.27 [−0.61, 0.07]) or fear (SMD −0.36 [−0.86, 0.15]). There was no benefit for a breathing intervention (cough) in children and adolescents (n=136) for pain (SMD −0.17 [−0.41, 0.07]).

Conclusions: Psychological interventions with some evidence of benefit in children include: verbal distraction, video distraction, music distraction, and breathing with a toy.

Supplemental Digital Content is available in the text.

Departments of *Psychology and Neuroscience

Pediatrics, Dalhousie University

Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS

§Leslie Dan Faculty of Pharmacy, University of Toronto

The Hospital for Sick Children

‡‡York University

§§Mount Sinai Hospital

∥∥Faculty of Medicine, University of Toronto, Toronto

Department of Psychology, University of Guelph, Guelph

#Children’s Health Research Institute

**Department of Paediatrics, Western University, London, ON

††Department of Psychology, University of Calgary, AB, Canada

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HELPinKids&Adults (Help ELiminate Pain in Kids and Adults) Team: N.E. MacDonald, J. Rogers, L. Bucci, E. Lang, P. Mousmanis, S.A. Halperin, S. Bowles, C. Halpert, M. Ipp, M. Rieder, K. Robson, G.J.G. Asmundson, E. Uleryk, M. Antony, D. Alexander, M. Appleton, V. Dubey, A. Hanrahan, D. Lockett, J. Scott, E. Votta Bleeker.

Supported by the Canadian Institutes of Health Research (CIHR), Ottawa, ON, Canada (KRS 132031). Open access funding was provided by the Mayday Fund in the United States. A. Taddio declares a grant from Pfizer, and study supplies from Natus and Ferndale. C.T. Chambers declares consultation fees from Abbvie. E. Lang is a member of the GRADE working group and declares consultation fees from the International Liaison Committee on Resuscitation (ILCOR). L. Bucci declares a relationship with government agencies and grants from Merck, GSK, Novartis, Sanofi, and Pfizer. S.A. Halperin declares grants from GSK, Sanofi, Novartis, Pfizer, Merck, PREVENT, ImmunoVaccine, NovaVax, Janssen, and Folia. The remaining authors declare no conflict of interest.

Reprints: Christine Chambers, PhD, RPsych, Professor, Centre for Pediatric Pain Research (West), K8536, IWK Health Centre, 5850/5980 University Avenue, Halifax, NS B3K 6R8 (e-mail:

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.

Received April 10, 2015

Accepted June 3, 2015

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