Pediatric Coping During Venipuncture With Virtual Reality: Pilot Randomized Controlled Trial

Abstract

Background Virtual reality (VR) has shown promise in reducing children’s pain and anxiety during venipuncture, but studies on VR lack objective observations of pediatric coping. Notably, the process of capturing objective behavioral coping data can be labor- and personnel-intensive. Objective The primary aims of this pilot trial were to assess the feasibility of conducting a trial of VR in a pediatric emergency department and the feasibility of documenting observed coping behaviors during pediatric procedures. Secondarily, this study examined whether VR affects child and caregiver coping and distress during venipuncture in the pediatric emergency department. Methods This stratified, randomized, controlled pilot trial compared coping and distress between child life–supported VR engagement and child life specialist support without VR during painful procedures in children aged 7-22 years in the pediatric emergency department. An external control (reference group) received no standardized support. Primary feasibility outcomes included rates of recruitment, rates of withdrawal from VR, and rates of completed Child Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) observations. Secondary clinical outcomes were applied to venipuncture procedures and included CAMPIS-SF coping and distress (range 0-1.0), pain and anxiety on a visual analog scale (range 0-10), and cybersickness symptoms. Results Overall recruitment was 93% (66/71), VR withdrawal rate was 27% (4/15), and of the completed procedures, 100% (63/63) CAMPIS-SF observations were completed. A total of 55 patients undergoing venipuncture in the pediatric emergency department were included in the analyses of clinical outcomes: 15 patients (15 caregivers) randomized to VR, 20 patients (15 caregivers) randomized to child life specialist support, and 20 patients (17 caregivers) in the reference group. Patient coping differed across groups with higher coping in the VR group and child life specialist group than in the reference group (P=.046). There were no significant differences in the distress and pain ratings for patients and caregivers between the groups. Caregivers rated the lowest perceived anxiety in the child life specialist group (P=.03). There was no apparent change in cybersickness symptoms before and after VR use (P=.37). Conclusions Real-time documentation of observed behaviors in patients and caregivers was feasible during medical procedures in which VR was utilized, particularly with the availability of research staff. VR and child life specialists improved coping in children during venipuncture procedures. Given the high participation rate, future studies to evaluate the efficacy of VR are recommended to determine whether an off-the-shelf VR headset can be a low-cost and low-risk tool to improve children’s coping during venipuncture or other related procedures. Trial Registration ClinicalTrials.gov NCT03686176; https://clinicaltrials.gov/ct2/show/NCT03686176

Use of virtual reality in managing paediatric procedural pain and anxiety: An integrative literature review

“…SnowWorld was the first immersive VR game designed for pain reduction in patients undergoing burn wound care (Hoffman et al, 2008). In other studies ( n = 20), children experienced a VR adventure during their medical procedure, such as going on a rollercoaster ride, swimming underwater, travelling around the world or enjoying nature (Althumairi et al, 2021; Aydın & Özyazıcıoğlu, 2019; Canares et al, 2021; Chad et al, 2018; Chan et al, 2019; Chau et al, 2018; Chen et al, 2020; Clerc et al, 2021; Erdogan & Aytekin Ozdemir, 2021; Gerçeker et al, 2020; Gerçeker et al, 2021; Goldman & Behboudi, 2021; Knight et al, 2019; Litwin et al, 2021; Ran et al, 2021; Sander Wint et al, 2002; Scapin et al, 2017; Semerci et al, 2021; Ustuner Top and Kuzlu Ayyıldız, 2021; Xiang et al, 2021). Finally, some children selected a cartoon or movie to watch in their VR headset during their dental or needle‐related procedure ( n = 15) (Ali et al, 2021; Alshatrat et al, 2021; Asl Aminabadi et al, 2012; Felemban et al, 2021; Gerçeker et al, 2018; Koticha et al, 2019; Lee et al, 2021; Mbazzi et al, 2021; Mohanasundari et al, 2021; Niharika et al, 2018; Nunna et al, 2019; Rao et al, 2019; Shetty et al, 2019; Toledo Del Castillo et al, 2019; Wong et al, 2020).…”

“…Twelve studies found no statistically significant difference between VR distraction and standard of care procedures (Canares et al, 2021; Caruso et al, 2020; Dumoulin et al, 2019; Dunn et al, 2019; G. Gerçeker et al, 2020; Goldman & Behboudi, 2021; Lee et al, 2021; Litwin et al, 2021; Nilsson et al, 2009; Osmanlliu et al, 2021; Sander Wint et al, 2002; Schlechter et al, 2021; Walther‐Larsen et al, 2019). Erdogan and Aytekin Ozdemir (2021) found that children using Buzzy during venipuncture experienced the least pain, followed by VR, distraction cards and standard of care.…”

“…3.9.2 | Virtual reality helps manage anxiety associated with needle-related procedures Some studies also investigated the use of VR in managing anxietyrelated outcomes, including procedural anxiety, stress, distress and fear. Eleven studies reported that VR distraction significantly reduced procedural anxiety compared to standard of care procedures (Althumairi et al, 2021;Gerçeker et al, 2020Gerçeker et al, , 2021Gershon et al, 2004;Gold & Mahrer, 2018;Gold et al, 2021;Mohanasundari et al, 2021;Osmanlliu et al, 2021;Toledo Del Castillo et al, 2019;Wolitzky et al, 2005;Wong et al, 2020), while five other studies found no such differences (Canares et al, 2021;Dunn et al, 2019;Litwin et al, 2021;Schlechter et al, 2021). Two studies reported significantly less stress in children undergoing a VR intervention compared to standard of care procedures (Piskorz & Czub, 2018;Piskorz et al, 2020).…”

“…SnowWorld was the first immersive VR game designed for pain reduction in patients undergoing burn wound care (Hoffman et al, 2008). In other studies (n = 20), children experienced a VR adventure during their medical procedure, such as going on a rollercoaster ride, swimming underwater, travelling around the world or enjoying nature (Althumairi et al, 2021;Aydın & Özyazıcıoğlu, 2019;Canares et al, 2021;Chad et al, 2018;Chan et al, 2019;Chau et al, 2018;Chen et al, 2020;Clerc et al, 2021;Erdogan & Aytekin Ozdemir, 2021;Gerçeker et al, 2020;Gerçeker et al, 2021;Knight et al, 2019;Litwin et al, 2021;Ran et al, 2021;Sander Wint et al, 2002;Scapin et al, 2017;Semerci et al, 2021;Ustuner Top and Kuzlu Ayyıldız, 2021;Xiang et al, 2021).…”

“…reported a significant difference in pain scores between the VR and Flippit group, only when self-reported by children but not when assessed by the researcher. WhileLitwin et al (2021) did not find a statistically significant difference in pain ratings during VR and video distraction, there was a clinically significant decrease in pain in the VR group.Twelve studies found no statistically significant difference between VR distraction and standard of care procedures(Canares et al, 2021;Caruso et al, 2020;Dumoulin et al, 2019;Dunn et al, 2019;G. Gerçeker et al, 2020;Lee et al, 2021;Litwin et al, 2021;Nilsson et al, 2009; were lower following the VR intervention compared to standard of care; however, no significant difference was obtained between VR distraction and external cold vibrations.…”