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Psychological Interventions for Vaccine Injections in Young Children 0 to 3 Years: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials

Pillai Riddell, Rebecca PhD*,†,‡; Taddio, Anna BScPhm, MSc, PhD†,§,∥; McMurtry, C. Meghan PhD¶,#,**; Chambers, Christine PhD, R Psych††; Shah, Vibhuti MD, MSc‡‡,§§,∥∥; Noel, Melanie PhD¶¶HELPinKIDS Team

doi: 10.1097/AJP.0000000000000279
Psychological Interventions 0-3 Years

Background: This systematic review evaluated the effectiveness of distraction for reducing infant distress during vaccinations in young children aged 0 to 3 years.

Design/Methods: Database searches identified relevant randomized and quasi-randomized controlled trials. Three separate clinical questions related to variants of the psychological strategy of distraction (directed video; directed toy; nondirected toy) were pursued. Distress was identified as the critical outcome to assess the benefits of distraction and extracted from relevant trials. Distress was analyzed by phase of procedure (distress preprocedure; distress acute; distress recovery; idiosyncratic phases based on some or all of the 3 aforementioned phases).

Results: Ten studies were included in the review. Significant results are presented herein. For directed video distraction, moderate quality evidence suggested that distress was lowered in the treatment group standardized mean difference (SMD −0.68 lower [95% confidence interval (CI), −1.04 to −0.32]) for the acute+recovery phase as well as the preprocedure phase (SMD −0.49 lower [95% CI, −7.6 to −0.22]). For directed toy distraction, the analysis of low-quality evidence for a combined preprocedure+acute+recovery phase of distress (analysis n=81), suggested that distress was lowered in the treatment group (SMD −0.47 lower [95% CI, −0.91 to −0.02]). An effect for nondirected toy distraction was also seen, analyzing very–low-quality evidence, for the acute distress phase (n=290; SMD −0.93 lower [95% CI, −1.86 to 0.00]).

Conclusion: Generally low-quality to very–low-quality evidence suggests that there may be an effect of directed (toy and video) and nondirected toy distraction for children aged 0 to 3 years, for certain phases of the vaccination.

Supplemental Digital Content is available in the text.

*Department of Psychology, York University

Department of Psychiatry, The Hospital for Sick Children

§Child Health and Evaluative Sciences

∥∥Department of Neonatology

Department of Psychiatry

Leslie Dan Faculty of Pharmacy

§§Faculty of Medicine, University of Toronto

‡‡Mount Sinai Hospital, Toronto, ON

Department of Psychology, University of Guelph, Guelph

#Children’s Health Research Institute, Children’s Hospital

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

††Department of Pediatrics and Psychology, Centre for Pediatric Pain Research, IWK Health Centre, Dalhousie University, Halifax, NS, Canada

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

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

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

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. T., declares a grant from Pfizer, and study supplies from Natus and Ferndale. C.T. C., declares consultation fees from Abbvie. E. L. is a member of the GRADE working group and declares consultation fees from the International Liaison Committee on Resuscitation (ILCOR).L. B., declares a relationship with government agencies and grants from Merck, GSK, Novartis, Sanofi, and Pfizer. S.A. H., declares grants from GSK, Sanofi, Novartis, Pfizer, Merck, PREVENT, ImmunoVaccine, NovaVax, Janssen, and Folia.

Reprints: Rebecca Pillai Riddell, PhD, Department of Psychology, York University, 4700 Keele Street, Toronto, ON, Canada M3H 4C4 (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 13, 2015

Accepted June 29, 2015

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