Seven psychological interventions were examined: (1) breathing exercises; (2) suggestion; (3) child-directed distraction; (4) parent-led distraction; (5) nurse-led distraction; (6) parent coaching; and (7) combined cognitive-behavioral interventions.
Altogether, 20 RCTs involving 1380 infants and children (1 month to 11 years of age) were included in the systematic review.
Breathing exercises were effective in reducing children's self-reported pain (P = 0.01), observer-rated distress (P = 0.007), and nurse-reported distress (P = 0.005). Self-reported distress ratings appeared to be lower with breathing exercises, but the difference was not statistically significant.
No evidence was found to support suggestion as a psychological intervention for reducing pain associated with pediatric immunization.
Child-directed distraction was effective in reducing self-reported pain (P = 0.03).
Parent-led distraction was effective in reducing observer-rated distress (P = 0.002), but not other measures of pain or distress.
Nurse-led distraction was effective in reducing distress ratings as assessed by the observer (P = 0.005), the parent (; P = 0.01), and the nurse (P = 0.004).
Parent coaching was effective in reducing observer-rated distress (P < 0.001), but not other measures of pain or distress.
Combined cognitive-behavioral interventions were effective in reducing children's self-reported pain (P < 0.001), observer-rated distress (P < 0.001), and parent-rated distress (P < 0.001).
The methodologic quality of the included trials was generally poor, with 18 (90%) of the 20 studies rated as having a high risk of bias.
Evidence suggests that breathing exercises, child-directed distraction, nurse-led distraction, and combined cognitive-behavioral interventions are effective in reducing the pain and distress associated with routine childhood immunizations.
Although additional trials, better designed than most of these, are needed, parents and health care professionals should be advised to incorporate some of these psychological interventions, to reduce the pain and distress experienced by children during immunization.