Psychological Interventions for Reducing Pain and Distress During Routine Childhood Immunizations: A Systematic Review
Psychological Interventions for Reducing Pain and Distress During Routine Childhood Immunizations: A Systematic Review
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DOI：
10.1016/j.clinthera.2009.07.023
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发表时间：
2009-01-01
影响因子：
3.2
通讯作者：
McMurtry, C. Meghan
中科院分区：
文献类型：
--
作者：
Chambers, Christine T.;Taddio, Anna;McMurtry, C. Meghan
背景：免疫接种是儿童疼痛和痛苦的常见来源。心理干预包括在免疫接种期间放松和分散儿童注意力的各种技术，目的是减少疼痛和痛苦。目的：我们进行了一项系统评价，以确定各种心理策略在常规免疫接种期间减少儿童疼痛和痛苦的有效性。方法：MEDLINE，PsycINFO，EMBASE，CINAHL，和科克伦对照试验中心数据库进行检索，以确定随机对照试验（RCT）和准随机对照试验。随机对照试验确定心理干预对0至18岁儿童注射疫苗期间疼痛和痛苦的影响，使用经验证的儿童自我报告的疼痛或儿童痛苦或疼痛的自我报告评估。我们检查了7种心理干预措施的有效性：（1）呼吸练习;（2）建议;（3）儿童引导的分心;（4）父母引导的分心;（5）护士引导的分心;（6）父母指导;（7）综合认知行为干预。所有的荟萃分析采用固定效应模型进行。结果：20项随机对照试验，涉及1380名婴儿和儿童（1个月至11。年龄）纳入系统评价。呼吸练习在减少儿童自我报告的疼痛方面有效（标准化均值差[SMD]，-0.43; 95% CI，-0.76至-0.09; P = 0.01），（SMD，-0.40; 95% CI，-0.68至-0.11; P = 0.007）和护士报告的痛苦（SMD，-0.57; 95% CI，-0.98至-0.17; P = 0.005）。自我报告的痛苦等级似乎较低的呼吸练习，但差异没有统计学意义。没有发现证据支持暗示作为一种心理干预，以减少与儿童免疫相关的疼痛。儿童导向的分心在减少自我报告的疼痛方面是有效的（SMD，-0.28; 95% CI。-0.54至-0.03; P = 0.03）。父母引导的分心能有效减少儿童的焦虑（SMD，-0.50; 95%CI。-0.82至-0.19; P = 0.002），但没有其他疼痛或痛苦的测量。由观察者（SMD，-0.40; 95% CI，-0.68至-0.12; P = 0.005）、父母（SMD，-0.37; 95% CI，-0.40; 95% CI，-0.68至-0.12; P = 0.005）和父母（SMD，-0.37; 95% CI，-0.40; 95% CI，-0.68至-0.12; P = 0.005）评估，护士引导的分散注意力可有效降低痛苦评分。-0.66至-0.07; P = 0.01）和护士（SMD，-0.42; 95% CI，-0.70至-0.14; P = 0.004）。父母指导在减少儿童的焦虑方面是有效的（SMD，-0.71; 95%CI。-1.02至-0.39; P < 0.001），但没有其他疼痛或痛苦的测量。认知-行为综合干预能有效减少儿童自我报告的疼痛（SMD，-0.75; 95% CI，-1.03至-0.48; P < 0.001），无风险等级的痛苦（SMD，-0.53; 95%CI，-0.83至-0.23; P < 0.001）和父母评定的痛苦（SMD，-0.97; 95%CI，-1.37至-0.57; P < 0.001）。纳入试验的方法学质量普遍较差，20项研究中有18项（90%）被评定为具有较高的偏倚风险。结论：有证据表明，呼吸练习，儿童主导的分心，护士主导的分心，并结合认知行为干预措施，有效地减少与常规儿童免疫接种相关的疼痛和痛苦。虽然需要更多设计良好的试验来检查心理干预，但应建议父母和卫生保健专业人员将心理干预纳入其中，以减少儿童在免疫接种期间经历的疼痛和痛苦。(Clip Ther. 2009; 31 [增刊B]：S77-5103）（C）2009 Excerpta Medica Inc.
Background: Immunizations are a common source of pain and distress for children. Psychological interventions consist of a variety of techniques for relaxing and distracting children during immunization with the goal of reducing pain and distress.Objective: We conducted a systematic review to determine the efficacy of various psychological strategies for reducing pain and distress in children during routine immunizations.Methods: MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials (RCTs) and quasi-RCTs that determined the effect of psychological interventions on pain and distress during injection of vaccines in children 0 to 18 years of age, using validated child self-reported pain or observer-reported assessments of child distress or pain. We examined the efficacy of 7 psychological interventions: (1) breathing exercises; (2) suggestion; (3) child-directed distraction; (4) parentled distraction; (5) nurse-led distraction; (6) parent coaching; and (7) combined cognitive-behavioral interventions. All meta-analyses were performed using a fixed-effects model.Results: Twenty 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 (standardized mean difference [SMD], -0.43; 95% CI, -0.76 to -0.09; P = 0.01), observer-rated distress (SMD, -0.40; 95% CI, -0.68 to -0.11; P = 0.007), and nurse-reported distress (SMD, -0.57; 95% CI, -0.98 to -0.17; 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 (SMD, -0.28; 95% CI. -0.54 to -0.03; P = 0.03). Parent-led distraction was effective in reducing observer-rated distress (SMD, -0.50; 95% CI. -0.82 to -0.19; 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 (SMD,-0.40; 95% CI, -0.68 to -0.12; P = 0.005), the parent (SMD, -0.37; 95% CI. -0.66 to -0.07; P = 0.01), and the nurse (SMD, -0.42; 95% CI, -0.70 to -0.14; P = 0.004). Parent coaching was effective in reducing observer-rated distress (SMD, -0.71; 95% CI. -1.02 to -0.39; P < 0.001), but not other measures of pain or distress. Combined cognitive-behavioral interventions were effective in reducing children's self-reported pain (SMD, -0.75; 95% CI, -1.03 to -0.48; P < 0.001), observer-rated distress (SMD, -0.53; 95% CI, -0.83 to -0.23; P < 0.001), and parent-rated distress (SMD, -0.97; 95% CI, -1.37 to -0.57; 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.Conclusions: 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 well-designed trials examining psychological interventions are needed, parents and health care professionals should be advised to incorporate psychological interventions to reduce the pain and distress experienced by children during immunization. (Clip Ther. 2009; 31 [Suppl B]: S77-5103) (C) 2009 Excerpta Medica Inc.