1. In a single-center randomized control study, young children in the pediatric emergency department who participated in a virtual reality (VR) experience had lower standardized pain scores during intravenous catheter (IV) placement.
2. The subgroup analysis suggested that the effect of the VR experience on reducing apparent stress and perceived pain was greater in female patients.
Evidence Rating Level: 2 (good)
Course of study: The infliction of procedural complaints in children poses a significant challenge for providers and caregivers in pediatric practice. Researchers at Seoul National University built on the growing evidence of the use of virtual reality as an effective tool for pain relief by using a high-resolution VR simulation created that placed pediatric patients in the middle of a forest exploration with four animal friends and projected this simulation onto a vaulted ceiling in a treatment room. Eighty-eight children aged 6 months to 4 years undergoing intravenous placement were randomly assigned to either standard distraction techniques or distraction with the VR experience. The children’s responses to IV placement were videotaped, with pain intensity ratings assigned by two protocol-blind physicians using the FLACC (Face, Legs, Activity, Cry, and Consolability) scale. The caregivers received a questionnaire asking their satisfaction with the procedure and their assessment of their child’s pain. Overall, the VR intervention resulted in a significantly reduced likelihood of having higher FLACC scores. Furthermore, caregivers rated their child’s pain and distress significantly lower when assigned to the VR experimental group, although there was no difference in their satisfaction with the overall procedure. While this supports the growing interest in virtual reality as a method for psychological pain relief, the study suffers from technical and design limitations. Despite the overall reduction in FLACC scores throughout the procedure in the VR group, loading at critical points of the procedure (i.e. tourniquet placement, needle insertion) did not differ significantly between the control and experimental groups. Interestingly, a subgroup analysis stratified by sex showed a significant decrease in FLACC scores for girls randomized to undergo the VR experience but not for boys in the same experimental group, with the authors postulating that social expectations and/or the content of the VR -Experience could contribute to this gender difference.
Click here to read the study in JAMA Pediatrics
Relevant reading: The effectiveness of virtual reality distraction for pain relief: a systematic review.
Detailed [randomized controlled trial]: This two-group, single-center, parallel, randomized, controlled study identified 88 children aged 4 months to 6 years who required non-urgent intravenous placement in the pediatric emergency department. Subjects were randomized into two groups: the control group received standard IV placement procedures, while the second group participated in a novel virtual reality experience consisting of an imaginary forest exploration with four friendly animals. Primary endpoints were FLACC-standardized pain ratings at five time points (T0=baseline, T1=immediately after the infant was placed on the bed, T2=tourniquet application, T3=alcohol swab, T4=venipuncture) performed by two independent protocol-blinded physicians who watch a video recording of the procedure. Secondary outcomes included parent/carer satisfaction with the procedure and their subjective ratings of their children’s pain and anxiety on a 0-10 visual analogue scale. Children assigned to the VR experience had a significantly lower likelihood of having higher FLACC scores (IQR 1.1–5.4 vs. IQR 1.8–6.9, OR 0.53, p=0.049), although there was no significant difference in individual time points were compared across groups. Repeated measures analysis of variance for subgroups revealed that this effect persisted when only girls were assessed across both the experimental group and the time point of the procedure (F = 6.56, P = 0.1, and F = 14.31, respectively , P < 0.001), but did not occur when only boys were included in the analysis. Caregivers reported a significantly lower pain perception of their child (5.0 [3.0-8.0] versus 7.0 [5.0-10.0]P=0.08) and anxiety (5.0 [3.0-7.0] versus 8.0 [6.5-10.0]P < 0.001) when they were in the experimental VR group, but no significant differences in overall satisfaction with the procedure.
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