• Adolescent;
  • Anxiety [*prevention & control; psychology];
  • Cognitive Therapy [*methods];
  • Hypnosis;
  • *Needles;
  • Pain [*prevention & control; psychology];
  • Punctures [*psychology];
  • Randomized Controlled Trials;
  • Adult;
  • Child;
  • Child, Preschool;
  • Humans



Needle-related procedures are a common source of pain and distress for children. Several psychological (cognitive-behavioral) interventions to help manage or reduce pain and distress are available; however, a previous comprehensive systematic review of the efficacy of these interventions has not been conducted.


To assess the efficacy of cognitive-behavioral psychological interventions for needle-related procedural pain and distress in children and adolescents.

Search strategy

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 4, 2005), MEDLINE (1966 to 2005), PsycINFO (1887 to 2005), EMBASE (1974 to 2005), the Cumulative Index to Nursing and Allied Health Literature (1982 to 2005), Web of Science (1980 to 2005), and Dissertation-Abstracts International (1980 to 2005). We also searched citation lists and contacted researchers via various electronic list-servers and via email requests.

Selection criteria

Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only randomized controlled trials (RCTs) with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion.

Data collection and analysis

Two review authors independently extracted data and assessed trial quality. Included studies were coded for quality using the Oxford Quality Scale devised by Jadad and colleagues. Standardized mean differences with 95% confidence intervals were computed for all analyses using RevMan 4.0 software.

Main results

Twenty-eight trials with 1951 participants were included. Together, these studies included 1039 participants in treatment conditions and 951 in control conditions. The most commonly studied needle-procedures were immunizations and injections. The largest effect sizes for treatment improvement over control conditions exist for distraction (self-reported pain: SMD = -0.24, 95% CI = -0.45 to -0.04), hypnosis (self-reported pain: SMD = -1.47, 95% CI = -2.67 to -0.27; self-reported distress: SMD = -2.20, 95% CI = -3.69 to -0.71; and behavioral measures of distress: SMD = -1.07, 95% CI = -1.79 to -0.35), and combined cognitive-behavioral interventions (other-reported distress: SMD = -0.88, 95% CI = -1.65 to -0.12; and behavioral measures of distress: SMD = -0.67, 95% CI = -0.95 to -0.38). Promising but limited evidence exists for the efficacy of numerous other psychological interventions including: information/preparation, nurse coaching plus distraction, parent positioning plus distraction, and distraction plus suggestion.

Authors' conclusions

Overall, there is preliminary evidence that a variety of cognitive-behavioral interventions can be used with children and adolescents to successfully manage or reduce pain and distress associated with needle-related procedures. However, many of the included studies received lower quality scores because they failed to describe the randomization procedure and participant withdrawals or drop-outs from the study. Further RCTs need to be conducted, particularly for the many interventions for which we could not locate any trials.

Plain language summary

Psychological interventions for needle-related procedural pain and distress in children and adolescents

Many psychological interventions are available for managing procedural pain and distress, the majority being cognitive, behavioral, or a combination of the two. Twenty eight trials with 1951 participants were included. There is evidence that certain psychological interventions are effective in reducing needle-related pain and distress in children and adolescents. The largest effect sizes in favor of intervention exist for the efficacy of distraction, combined cognitive-behavioral interventions, and hypnosis, in reducing pain and distress in children. There are insufficient data available to adequately assess the efficacy of several other psychological interventions.