- Email: [email protected]
Management of injection pain in children
169
Pain, 30 (1987) 169-175
Elsevier PA1 01073
Management of injection pain in children Susan Fowler-Kerry * College of Nursing,
* and Janice Ramsay Lander * *
University of Saskatchewan, Saskatoon S7N 0 WO, and * * Clinical Sciences, University of Alberta, Edmonton T6G 2G3 (Canada)
(Received 8 October 1986, revised received 5 January 1987, accepted 8 January 1987)
Summary
Researchers have come to understand a great deal about pain mechanisms, especially in the past 30 years. This understanding has spawned the development of a number of psychological pain control strategies which have been extensively assessed for use with adults. Less is known about pain control strategies in children. The purpose of this study was to assess the value of 2 cognitive strategies (suggestion and music distraction) in reducing pain in children. Two hundred children, aged 4.5-6.5 years, receiving routine i~u~tion injections were randomly assigned to one of the intervention groups in this factorial study. The groups were designated as: distraction, distraction with suggestion, suggestion and control. Subjects reported their pain using a 4-point pain scale. Distraction was found to significantly decrease pain whereas suggestion did not. Combining suggestion and distraction did not further enhance pain relief compared to use of distraction alone. Age was found to be an important determinant of the success of distraction. Furthermore, age was found to be related to amount of pain reported by children regardless of type of treatment. The results of this study support the use of music distraction in the reduction of injection pain in children. Key wonlr: Pain; Children
There has been an increasing awareness of the deficiencies in research on children’s pain. The point has been made frequently in the literature that children are shortchanged in terms of pain management [6,7,10,12]. In recent years, there have been appeals for researchers to undertake the task of increasing knowledge about children’s pain [9,12,14]. In particular, there is a need for research on the use of cognitive strategies for managing children’s pain. The purpose of the present study is to investigate the value of distraction in reducing pain in children. While the pain literature is not completely lacking research on children, there is a large discrepancy in the proportions of adult- versus child-focused research in the body of literature on pain. The proportions noted a decade ago by Eland and Correspondence to: Susan Fowler-Kerry, M.N., College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan S7N OWO,Canada.
0304-3959/87/$03.50
0 198’7Elsevier Science Publishers B.V. (Biomedical Division)
170
Anderson [5] would likely have increased in recent years but not enough to have satisfied the calls for more research on children’s pain. The systematic examination of pain mechanisms in children (such as placebo responses and thresholds) has never been made as it has with adults. Partly, this seems to be due to ethical considerations about protecting child subjects. The lack of research can also be attributed to concerns about measuring pain in children, a concern which should be diminishing with recent work in the area [see. e.g.. 4,9.13]. Unfortunately, the result of the tendency to avoid using children in research is that we have too little information about basic issues in pain mechanisms in children. For example, a systematic study of age as it relates to children’s pain is lacking. As age is related to level of cognitive development and, in a very general sense, to opportunity for pain experience. it should be carefully considered in research on children’s pain. Indirect support for an age effect comes from a small survey where hospitalized children. 4.5-7 years of age, were found to have less knowledge of pain and cognitive control strategies than children over 7 years [II]. There has been some research on the use of cognitive strategies to reduce pain in children. Many utilize distraction tasks. These include: video ping-pong [2], word association [l], television [15], music [3] and breathing exercises [6]. The pain stimuli of these studies are often related to dental procedures although the pain associated with medical procedures has also served as a stimulus for assessing cognitive strategies [6]. One use for cognitive strategies may be for pain associated with injections. There are several reasons for this logic. One is that a bad early experience with injections may generate anxiety which may make the next injection experience even worse. leading to a vicious circle of increasing anxiety, fear and pain for children. A second reason is that children may not have been prepared for coping with injection pain. It seems that parents actively avoid discussing pain with their children [12] and, as mentioned, young children have little knowledge about pain and cognitive management of pain. Finally, the need to study cognitive strategies is underscored by the report of children opting to suffer moderately severe post-surgical pain rather than receive an injection for the purpose of administering analgesic relief [7]. This study assesses the value of music distraction with and without a positive suggestion for injection pain relief. By using regular DPT immunization injections given in a health clinic setting, some control could be achieved over pain stimulus conditions, the health and age of the children. Children aged 4.5-7 years were considered particularly good candidates for cognitive strategies in view of recent research [ 111. It is hypothesized that music distraction will reduce the pain of DPT immunization injection and that suggestion will potentiate this effect. Method One hundred male and 100 female subjects participated subjects were among those who attended 1 of 3 community
in this study. These health clinics located
171
near a groups group. healthy
large metropolitan area. Subjects were randomly assigned to experimental with the restriction that there be equal numbers of boys and girls in each To control for past experience and level of cognitive development, only children 4.5-7 were permitted to participate.
Procedure Before the study, experimenter I introduced subjects to the pain measurement scale to assess their comprehension of the concept of pain and to provide them with experience in use of the scale. They were asked to report anticipated pain from falling in the snow, receiving a mosquito bite and falling on the sidewalk. Pain was measured by self-report using a 4-point visual analogue scale where 0 represented no pain and 3 represented the most pain possible. Subjects were shown a card with 4 equal sized blocks representing the range of pain of the scale. They were asked to point to the block which represented their pain. Following the preparation session, subjects were randomly assigned to groups and the appropriate intervention and the DPT immunization injection were administered. Clinic nurses, parents and children were unaware of group assignment. Experimenter II, who was also blind to the treatment assignment, asked each subject to report injection pain using the 4-point scale. There were 5 groups, each with 20 males and 20 females. Three of the groups received suggestion and/or distraction. Distraction group subjects had headphones placed over their ears and a piece of music suitable for children was played immediately prior to and during the injection. The suggestion group subjects were told that the experimenter was going to help them when they had their injection. The headphones were placed over their ears, but no music was played. The combined suggestion-distraction group received both the music and the suggestion of assistance with pain relief. There were also 2 control groups in this study. Neither control group received distraction or suggestion. One control group wore the headphones and the other did not. These 2 groups permitted a test of the hypothesis that the headphones alone could be a distracting stimulus.
Results The headphone-control and the no-headphone-control groups were compared using analysis of variance. As pain responses were not significantly different, the 2 no-treatment control groups were combined for all further analyses. Characteristics of the sample All parents who were approached volunteered their children for participation in the study. No child refused to participate. No prospective subject had difficulty with the concept of pain as determined by reports of anticipated pain to 3 situations. For the 200 subjects, the mean anticipated pain for the 3 situations was: falling in snow,
172 TABLE I MEAN PAIN RESPONSES BY AGE GROUPS Age group (months)
Mean pain
S.D.
N
54-60 01-67 68-74
2.03 1.63
1.00 1.14 1.12
32 71 91
1.26
0.13; mosquito bite, 0.79; and falling on sidewalk, 2.46. Correlations between each anticipated pain and injection pain experienced during the study were all near zero and non-significant. Ages of subjects ranged from 4 years 6 months to 6 years 2 months. Overall mean age was 5.5 years. Pain responses for males and females were compared and found not to differ significantly. Subjects were grouped on the basis of age, each age class covering a 6 month range (54-60, 61-67, 68-74 months). These 3 groups were compared for pain differences. Analysis of variance determined that pain was significantly related to age (F = 6.44; 2, 197; P = 0.002). Post-hoc comparisons indicated that the youngest group of subjects reported the greatest amount of pain (modified LSD, P = 0.05, Table I). Age was negatively associated with injection pain (Pearson Y= - 0.21. P = 0.001). By contrast, anticipated pains from the falls or mosquito bite were not signific~tly different for the 3 age groups. Pearson correlations between age and anticipated pain from the 3 situations were near zero and non-significant. Effects of distraction and suggestion
Since preliminary analyses indicated an important influence of age on injection pain, age was statistically controlled in the main analysis for the effect of the interventions on pain. A 2 X 2 analysis of covariance compared groups with age used as the covariate. A significant main effect was found for distraction. Pain responses were significantly lower when distraction was used compared to no distraction (Table II: F= 4.20; 3, 195; P = 0.007). Neither the main effect of suggestion nor the suggestion x distraction interaction were significant.
TABLE II EFFECT OF DISTRACTION AND SUGGESTION ON PAIN Group Combined distraction-suggestion Distraction Suggestion Control
Mean pain (adjusted for covariate)
S.D.
N
1.07 1.34 1.59 1.78
1.02 1.14 1.13 1.14
40 40 40 80
173 TABLE
III
RELATIONSHIP
BETWEEN
AGE AND
PAIN,
DISTRACTION
GROUPS
ONLY
Age group (months)
Mean pain
S.D.
N
54-60 61-67 68-74
1.85 1.12 1.07
1.14 1.07 1.03
13 26 41
(N = 80)
All subjects who received distraction (distraction group, N = 40 and combined suggestion-distraction group, N = 40) were analyzed separately to determine whether age predicted success of distraction. Lower pain responses (0 or 1 on the pain scale) would indicate a successful intervention. Subjects were categorized into 3 age classes which were compared for pain differences (F = 2.77; 2, 77; P = 0.07; Table III). The youngest group of subjects reported the greatest mean pain (Pearson r = - 0.22, P = 0.03, N = 80).
Discussion The purpose of the present study was to evaluate the effectiveness of music distraction and suggestion as strategies to reduce short-term injection pain in children. The results support the use of music distraction. The value of suggestion, as assessed in this study, is not as clear. Use of distraction, particularly music distraction, is a simple, safe and yet effective cognitive strategy which could have considerable potential for clinical settings. This relatively low-cost strategy, requiring minimal training of staff, could reduce the pain and misery of the dreaded ‘needle’ for children. However, it should be noted that distraction is differentially effective depending on the age of the child. Older children in this study benefitted more from distraction than did younger ones. Our distraction consisted of novel music and lyrics to capture the attention of children but this may be a stimulus which is less commanding for younger children compared to older ones. Perhaps cognitive strategies which assure more active participation of children would reduce the age effect noted in this study. This matter deserves further study. Another important age effect is noted in the finding that across groups younger children report more pain from injections than older children. This is interesting for several reasons. Firstly, the age range of subjects in this study was quite restricted (less than 2 year range). A study of the relationship between age and pain with a wider age range, particularly with even younger subjects, is needed. Secondly, the age effect observed in this study was apparent only for actual pain. There was no relationship between age and anticipated pain as assessed in the preparatory session. Lastly, the finding of a negative age-pain relationship should combat the myth that the younger the child the less the ability to perceive and recall pain experiences.
Suggestion appears not to be effective in reducing children’s injection pain. This was a surprise considering that the combination of the suggestion and headphones being placed over the ears could be expected to enhance a child’s assumption that some event would occur. The anticipation could have been distracting but if so it apparently was not sufficiently distracting to reduce pain. Suggestion in this study acted as a placebo treatment. Therefore, the placebo response was not demonstrated here. The failure of suggestion may be attributed to an ineffective suggestion statement. (The children reported hearing the suggestion but apparently were not swayed by it.) Mean pain responses in Table II do indicate some benefits obtained by adding suggestion to distraction (X = 1.07 for suggestion with distraction compared to X = 1.34 for distraction only). Further, the mean pain response of the suggestion group is lower than that of the control group but greater than that of the distraction group. Perhaps more attention to the strength of the suggestion would produce a significant effect. In summary, the results of this study suggest several directions for future research on children’s pain. One is a careful consideration of age effects on pain in children. Younger and older children than were studied here should be included in future research on age effects. Age effects on the success of various pain control strategies should also be considered. Another direction for future research is a further exploration of the effects of suggestion on children. From a clinical perspective, music distraction can be recommended as a strategy to be adapted for a variety of short-term painful stimuli to which children are exposed. Suggested music for use in distraction strategies are offbeat and captivating pieces of music, especially those with children singing.
Acknowledgements This study was supported by a grant from the Alberta Association of Registered Nurses. We are indebted to the staff and clients of three community health clinics for the support they provided, and to Carl von Baeyer and Myles Genest for their helpful criticisms of an earlier draft of this paper.
References 1 Barber, T.X. and Cooper, B.J., Effects on pain of experimentally induced and spontaneous distraction, Psychol. Rep., 31 (1972) 647-651. 2 Corah, N.. Gale, E. and Illig, S., Psychological stress reduction during dental procedures. J. dent. Res., 58 (1979) 1347-1351. 3 Corah, N.L., Gale, E.N., Pace, L.F. and Seyrek, S.K., Relaxation and musical programming as a means of reducing psychological stress during dental procedures, J. Amer. dent. Ass.. 103 (1981) 232-234. 4 Craig, K., McMahon, R., Morrison, J. and Zaskow, C., Developmental changes in infant pain expression during immunization injections, Sot. Sci. Med., 19 (1984) 1331-1338.
175 5 Eland, J.M. and Anderson, J.E., The experience of pain in children. In: A. Jacox (Ed.), Pain: a Source Book for Nurses and Other Health Professionals, Little, Brown and Co., Boston, MA, 1977. 6 Jay, S., Elliott, C., Ozolins, M., Olson, R. and Pruitt, S., Behavioral management of children’s distress during painful medication procedures, Behav. Res. Ther., 23 (1985) 513-520. 7 Mather, L. and Ma&e, J., The incidence of postoperative pain in children, Pain, 15 (1983) 271-282. 8 Owens, M., Pain in infancy: conceptual and methodological issues, Pain, 20 (1984) 213-220. 9 Owens, M. and Tedt, E., Pain in infancy: neonatal reaction to heel lance, Pain, 20 (1984) 77-86. 10 Perry, S. and Heidrich, G., Management of pain during debridement: a survey of U.S. bum units, Pain, 13 (1982) 267-280. 11 Reissland, N., Cognitive maturity and the experience of fear and pain in hospital, Sot. Sci. Med., 17 (1983) 1389-1395. 12 Ross, D. and Ross, S., Childhood pain: the school-aged child’s viewpoint, Pain, 20 (1984) 179-191. 13 Scott, R., It hurts red: a preliminary study of children’s perception of pain, Percept. Mot. Skills, 47 (1978) 787-791. 14 Szyfelbein, S., Osgood, P. and Carr, D., The assessment of pain and plasma p-endorphin immunoactivity in burned children, Pain, 22 (1985) 173-182. 15 Venham, L.L., Goldstein, M., Gualin-Kremen, E., Peteros, K., Cohan, J. and Fairbanks, J.. Effectiveness of a distraction technique in managing young dental patients, Pediat. Dent., 3 (1981) 7-11.
Pain, 30 (1987) 169-175
Elsevier PA1 01073
Management of injection pain in children Susan Fowler-Kerry * College of Nursing,
* and Janice Ramsay Lander * *
University of Saskatchewan, Saskatoon S7N 0 WO, and * * Clinical Sciences, University of Alberta, Edmonton T6G 2G3 (Canada)
(Received 8 October 1986, revised received 5 January 1987, accepted 8 January 1987)
Summary
Researchers have come to understand a great deal about pain mechanisms, especially in the past 30 years. This understanding has spawned the development of a number of psychological pain control strategies which have been extensively assessed for use with adults. Less is known about pain control strategies in children. The purpose of this study was to assess the value of 2 cognitive strategies (suggestion and music distraction) in reducing pain in children. Two hundred children, aged 4.5-6.5 years, receiving routine i~u~tion injections were randomly assigned to one of the intervention groups in this factorial study. The groups were designated as: distraction, distraction with suggestion, suggestion and control. Subjects reported their pain using a 4-point pain scale. Distraction was found to significantly decrease pain whereas suggestion did not. Combining suggestion and distraction did not further enhance pain relief compared to use of distraction alone. Age was found to be an important determinant of the success of distraction. Furthermore, age was found to be related to amount of pain reported by children regardless of type of treatment. The results of this study support the use of music distraction in the reduction of injection pain in children. Key wonlr: Pain; Children
There has been an increasing awareness of the deficiencies in research on children’s pain. The point has been made frequently in the literature that children are shortchanged in terms of pain management [6,7,10,12]. In recent years, there have been appeals for researchers to undertake the task of increasing knowledge about children’s pain [9,12,14]. In particular, there is a need for research on the use of cognitive strategies for managing children’s pain. The purpose of the present study is to investigate the value of distraction in reducing pain in children. While the pain literature is not completely lacking research on children, there is a large discrepancy in the proportions of adult- versus child-focused research in the body of literature on pain. The proportions noted a decade ago by Eland and Correspondence to: Susan Fowler-Kerry, M.N., College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan S7N OWO,Canada.
0304-3959/87/$03.50
0 198’7Elsevier Science Publishers B.V. (Biomedical Division)
170
Anderson [5] would likely have increased in recent years but not enough to have satisfied the calls for more research on children’s pain. The systematic examination of pain mechanisms in children (such as placebo responses and thresholds) has never been made as it has with adults. Partly, this seems to be due to ethical considerations about protecting child subjects. The lack of research can also be attributed to concerns about measuring pain in children, a concern which should be diminishing with recent work in the area [see. e.g.. 4,9.13]. Unfortunately, the result of the tendency to avoid using children in research is that we have too little information about basic issues in pain mechanisms in children. For example, a systematic study of age as it relates to children’s pain is lacking. As age is related to level of cognitive development and, in a very general sense, to opportunity for pain experience. it should be carefully considered in research on children’s pain. Indirect support for an age effect comes from a small survey where hospitalized children. 4.5-7 years of age, were found to have less knowledge of pain and cognitive control strategies than children over 7 years [II]. There has been some research on the use of cognitive strategies to reduce pain in children. Many utilize distraction tasks. These include: video ping-pong [2], word association [l], television [15], music [3] and breathing exercises [6]. The pain stimuli of these studies are often related to dental procedures although the pain associated with medical procedures has also served as a stimulus for assessing cognitive strategies [6]. One use for cognitive strategies may be for pain associated with injections. There are several reasons for this logic. One is that a bad early experience with injections may generate anxiety which may make the next injection experience even worse. leading to a vicious circle of increasing anxiety, fear and pain for children. A second reason is that children may not have been prepared for coping with injection pain. It seems that parents actively avoid discussing pain with their children [12] and, as mentioned, young children have little knowledge about pain and cognitive management of pain. Finally, the need to study cognitive strategies is underscored by the report of children opting to suffer moderately severe post-surgical pain rather than receive an injection for the purpose of administering analgesic relief [7]. This study assesses the value of music distraction with and without a positive suggestion for injection pain relief. By using regular DPT immunization injections given in a health clinic setting, some control could be achieved over pain stimulus conditions, the health and age of the children. Children aged 4.5-7 years were considered particularly good candidates for cognitive strategies in view of recent research [ 111. It is hypothesized that music distraction will reduce the pain of DPT immunization injection and that suggestion will potentiate this effect. Method One hundred male and 100 female subjects participated subjects were among those who attended 1 of 3 community
in this study. These health clinics located
171
near a groups group. healthy
large metropolitan area. Subjects were randomly assigned to experimental with the restriction that there be equal numbers of boys and girls in each To control for past experience and level of cognitive development, only children 4.5-7 were permitted to participate.
Procedure Before the study, experimenter I introduced subjects to the pain measurement scale to assess their comprehension of the concept of pain and to provide them with experience in use of the scale. They were asked to report anticipated pain from falling in the snow, receiving a mosquito bite and falling on the sidewalk. Pain was measured by self-report using a 4-point visual analogue scale where 0 represented no pain and 3 represented the most pain possible. Subjects were shown a card with 4 equal sized blocks representing the range of pain of the scale. They were asked to point to the block which represented their pain. Following the preparation session, subjects were randomly assigned to groups and the appropriate intervention and the DPT immunization injection were administered. Clinic nurses, parents and children were unaware of group assignment. Experimenter II, who was also blind to the treatment assignment, asked each subject to report injection pain using the 4-point scale. There were 5 groups, each with 20 males and 20 females. Three of the groups received suggestion and/or distraction. Distraction group subjects had headphones placed over their ears and a piece of music suitable for children was played immediately prior to and during the injection. The suggestion group subjects were told that the experimenter was going to help them when they had their injection. The headphones were placed over their ears, but no music was played. The combined suggestion-distraction group received both the music and the suggestion of assistance with pain relief. There were also 2 control groups in this study. Neither control group received distraction or suggestion. One control group wore the headphones and the other did not. These 2 groups permitted a test of the hypothesis that the headphones alone could be a distracting stimulus.
Results The headphone-control and the no-headphone-control groups were compared using analysis of variance. As pain responses were not significantly different, the 2 no-treatment control groups were combined for all further analyses. Characteristics of the sample All parents who were approached volunteered their children for participation in the study. No child refused to participate. No prospective subject had difficulty with the concept of pain as determined by reports of anticipated pain to 3 situations. For the 200 subjects, the mean anticipated pain for the 3 situations was: falling in snow,
172 TABLE I MEAN PAIN RESPONSES BY AGE GROUPS Age group (months)
Mean pain
S.D.
N
54-60 01-67 68-74
2.03 1.63
1.00 1.14 1.12
32 71 91
1.26
0.13; mosquito bite, 0.79; and falling on sidewalk, 2.46. Correlations between each anticipated pain and injection pain experienced during the study were all near zero and non-significant. Ages of subjects ranged from 4 years 6 months to 6 years 2 months. Overall mean age was 5.5 years. Pain responses for males and females were compared and found not to differ significantly. Subjects were grouped on the basis of age, each age class covering a 6 month range (54-60, 61-67, 68-74 months). These 3 groups were compared for pain differences. Analysis of variance determined that pain was significantly related to age (F = 6.44; 2, 197; P = 0.002). Post-hoc comparisons indicated that the youngest group of subjects reported the greatest amount of pain (modified LSD, P = 0.05, Table I). Age was negatively associated with injection pain (Pearson Y= - 0.21. P = 0.001). By contrast, anticipated pains from the falls or mosquito bite were not signific~tly different for the 3 age groups. Pearson correlations between age and anticipated pain from the 3 situations were near zero and non-significant. Effects of distraction and suggestion
Since preliminary analyses indicated an important influence of age on injection pain, age was statistically controlled in the main analysis for the effect of the interventions on pain. A 2 X 2 analysis of covariance compared groups with age used as the covariate. A significant main effect was found for distraction. Pain responses were significantly lower when distraction was used compared to no distraction (Table II: F= 4.20; 3, 195; P = 0.007). Neither the main effect of suggestion nor the suggestion x distraction interaction were significant.
TABLE II EFFECT OF DISTRACTION AND SUGGESTION ON PAIN Group Combined distraction-suggestion Distraction Suggestion Control
Mean pain (adjusted for covariate)
S.D.
N
1.07 1.34 1.59 1.78
1.02 1.14 1.13 1.14
40 40 40 80
173 TABLE
III
RELATIONSHIP
BETWEEN
AGE AND
PAIN,
DISTRACTION
GROUPS
ONLY
Age group (months)
Mean pain
S.D.
N
54-60 61-67 68-74
1.85 1.12 1.07
1.14 1.07 1.03
13 26 41
(N = 80)
All subjects who received distraction (distraction group, N = 40 and combined suggestion-distraction group, N = 40) were analyzed separately to determine whether age predicted success of distraction. Lower pain responses (0 or 1 on the pain scale) would indicate a successful intervention. Subjects were categorized into 3 age classes which were compared for pain differences (F = 2.77; 2, 77; P = 0.07; Table III). The youngest group of subjects reported the greatest mean pain (Pearson r = - 0.22, P = 0.03, N = 80).
Discussion The purpose of the present study was to evaluate the effectiveness of music distraction and suggestion as strategies to reduce short-term injection pain in children. The results support the use of music distraction. The value of suggestion, as assessed in this study, is not as clear. Use of distraction, particularly music distraction, is a simple, safe and yet effective cognitive strategy which could have considerable potential for clinical settings. This relatively low-cost strategy, requiring minimal training of staff, could reduce the pain and misery of the dreaded ‘needle’ for children. However, it should be noted that distraction is differentially effective depending on the age of the child. Older children in this study benefitted more from distraction than did younger ones. Our distraction consisted of novel music and lyrics to capture the attention of children but this may be a stimulus which is less commanding for younger children compared to older ones. Perhaps cognitive strategies which assure more active participation of children would reduce the age effect noted in this study. This matter deserves further study. Another important age effect is noted in the finding that across groups younger children report more pain from injections than older children. This is interesting for several reasons. Firstly, the age range of subjects in this study was quite restricted (less than 2 year range). A study of the relationship between age and pain with a wider age range, particularly with even younger subjects, is needed. Secondly, the age effect observed in this study was apparent only for actual pain. There was no relationship between age and anticipated pain as assessed in the preparatory session. Lastly, the finding of a negative age-pain relationship should combat the myth that the younger the child the less the ability to perceive and recall pain experiences.
Suggestion appears not to be effective in reducing children’s injection pain. This was a surprise considering that the combination of the suggestion and headphones being placed over the ears could be expected to enhance a child’s assumption that some event would occur. The anticipation could have been distracting but if so it apparently was not sufficiently distracting to reduce pain. Suggestion in this study acted as a placebo treatment. Therefore, the placebo response was not demonstrated here. The failure of suggestion may be attributed to an ineffective suggestion statement. (The children reported hearing the suggestion but apparently were not swayed by it.) Mean pain responses in Table II do indicate some benefits obtained by adding suggestion to distraction (X = 1.07 for suggestion with distraction compared to X = 1.34 for distraction only). Further, the mean pain response of the suggestion group is lower than that of the control group but greater than that of the distraction group. Perhaps more attention to the strength of the suggestion would produce a significant effect. In summary, the results of this study suggest several directions for future research on children’s pain. One is a careful consideration of age effects on pain in children. Younger and older children than were studied here should be included in future research on age effects. Age effects on the success of various pain control strategies should also be considered. Another direction for future research is a further exploration of the effects of suggestion on children. From a clinical perspective, music distraction can be recommended as a strategy to be adapted for a variety of short-term painful stimuli to which children are exposed. Suggested music for use in distraction strategies are offbeat and captivating pieces of music, especially those with children singing.
Acknowledgements This study was supported by a grant from the Alberta Association of Registered Nurses. We are indebted to the staff and clients of three community health clinics for the support they provided, and to Carl von Baeyer and Myles Genest for their helpful criticisms of an earlier draft of this paper.
References 1 Barber, T.X. and Cooper, B.J., Effects on pain of experimentally induced and spontaneous distraction, Psychol. Rep., 31 (1972) 647-651. 2 Corah, N.. Gale, E. and Illig, S., Psychological stress reduction during dental procedures. J. dent. Res., 58 (1979) 1347-1351. 3 Corah, N.L., Gale, E.N., Pace, L.F. and Seyrek, S.K., Relaxation and musical programming as a means of reducing psychological stress during dental procedures, J. Amer. dent. Ass.. 103 (1981) 232-234. 4 Craig, K., McMahon, R., Morrison, J. and Zaskow, C., Developmental changes in infant pain expression during immunization injections, Sot. Sci. Med., 19 (1984) 1331-1338.
175 5 Eland, J.M. and Anderson, J.E., The experience of pain in children. In: A. Jacox (Ed.), Pain: a Source Book for Nurses and Other Health Professionals, Little, Brown and Co., Boston, MA, 1977. 6 Jay, S., Elliott, C., Ozolins, M., Olson, R. and Pruitt, S., Behavioral management of children’s distress during painful medication procedures, Behav. Res. Ther., 23 (1985) 513-520. 7 Mather, L. and Ma&e, J., The incidence of postoperative pain in children, Pain, 15 (1983) 271-282. 8 Owens, M., Pain in infancy: conceptual and methodological issues, Pain, 20 (1984) 213-220. 9 Owens, M. and Tedt, E., Pain in infancy: neonatal reaction to heel lance, Pain, 20 (1984) 77-86. 10 Perry, S. and Heidrich, G., Management of pain during debridement: a survey of U.S. bum units, Pain, 13 (1982) 267-280. 11 Reissland, N., Cognitive maturity and the experience of fear and pain in hospital, Sot. Sci. Med., 17 (1983) 1389-1395. 12 Ross, D. and Ross, S., Childhood pain: the school-aged child’s viewpoint, Pain, 20 (1984) 179-191. 13 Scott, R., It hurts red: a preliminary study of children’s perception of pain, Percept. Mot. Skills, 47 (1978) 787-791. 14 Szyfelbein, S., Osgood, P. and Carr, D., The assessment of pain and plasma p-endorphin immunoactivity in burned children, Pain, 22 (1985) 173-182. 15 Venham, L.L., Goldstein, M., Gualin-Kremen, E., Peteros, K., Cohan, J. and Fairbanks, J.. Effectiveness of a distraction technique in managing young dental patients, Pediat. Dent., 3 (1981) 7-11.