Effect of Distraction Technique During Immunization to Reduce Behaviour Response Score (FLACC) to Pain in Toddlers

1Dr. D Sharad Gedam, MBBS, MD, Associate Professor of Paediatrics, 2Ms. Mamta Verma, Principle and Professor of Nursing, LN Nursing College, 3Dr. Umesh Patil, MBBS, MD, Assistant Professor of Paediatrics. All from L. N. Medical Colllege, Sarvadharam C sector, Kolar Road, Bhopal, M.P. India and 4Dr. Sanjay Gedam, MBBS. (Resident in Pharmacology) RD Gardi Medical College, Ujjain, MP, India. Abstract


Introduction
U nfortunately, pain is a natural and unavoidable part of childhood.While most pain is the result of minor scrapes and bruises, there is a very different kind of pain that is associated with the delivery of healthcare.Painful medical procedure is a fact of life.Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage¹.For paediatric patients medical procedure are often painful, unexpected and heightened by situational stress and anxiety leading to an overall unpleasant experience.In spite of its frequency, pain in infant, children and adolescent is often under estimated.
The routine vaccine injections are some of the most common and most painful procedures during childhood especially when they are administered without adopting any pain management practice² , ³. Uncontrolled pain experience in early period of life has a negative and long lasting effect such as distress 4,5 and can negatively affect the development of central nervous system [6][7][8] .Moreover fear and avoidance of medical care during adulthood are partially related to experiences of many painful procedures and fears experienced during childhood.With the continued introduction of new vaccines, children may now receive up to 20 injections by their second birthday 9 .Unfortunately, despite an increased focus on pain assessment and management, infant injection related pain remains largely untreated.
Various simple methods effectively reduce the pain response of newborns undergoing routine procedures, such as heel lancing.Swaddling, holding, and providing the oral tactile stimulation of sucking on a pacifi er are effective non-pharmacologic approaches¹º - sucrose is an effective pharmacologic analgesic that acts via endogenous opioid pathways [15][16][17][18][19][20][21][22] .The analgesic effect of oral sucrose alone²³ or combined only with parent holding 24 has been reported to be limited in infants beyond the newborn period.
Numerous studies have focused on the effi cacy of various methods of distracting attention to minimize acute pain in a paediatric population, specially toddler and preschool children such as movies 25 , party blowers 26 , nonprocedural talk 27 , interactive robots 28 , virtual reality goggles 29 , kaleidoscopes³º, bubbleblowing³¹, short stories³² and music³³ None of these options totally abolishes the pain from injections, but distraction, in general, helps moderately in preschool age and older children 34 .
Regardless of the medical procedure, reducing pain and stress may help children cooperate during the treatment and develop a positive attitude that will benefi t both the patient and healthcare provider during future medical experiences.The young patient will have a more positive memory related to the procedure by reducing or alleviating the pain, which will reduce the stress and anxiety.By relieving pain and stress, the healthcare provider faces a less anxious and more cooperative child, resulting in a better medical outcome.

Study design:
The study used a quasi experimental three group pre-test post test design.

Setting and Samples:
The research was conducted in Out Patient setting of Department of Paediatrics at Tertiary care teaching Institute in Central India from 1 st April to 30 th September 2012.It is a tertiary care teaching Hospital in Central India having visit of more than 100 patients in Out Patient Department every day.Orientation about the study topic and procedure was given to staff member including nurse, vaccination clerk and parents.Written consent was obtained from parents to participate in study.The child along with caregiver was taken to immunization room.During the vaccination procedure, the parents of infants in both groups were allowed to calm their babies by touching and talking to them, but not to feed and do anything that would distract the infant's attention (giving toys, showing a dummy, clapping, etc.).Toddler who comes fi rst to the healthcare centre for vaccination were assigned to the test group -1, who came in second place to the centre were assigned to test group -2 and third one to the control group-3.It was lasted in this way.For all the three groups, the injections were administered by same staff nurse.Group-1 (120 Patient) was encouraged to see and play with light and sound producing toy.Group-2 (120 Patient) children were encouraged to see cartoon movie and children of control group-3 (110 patient) were immunized without any distraction technique.

Exclusion criteria:
1. Presence of any neurological or chronic disorders.
2. No treatment of any kind received at a healthcare institution before the study.
3. No analgesic medicine taken in the last three hours before the vaccination procedure.
5.Not being accompanied by a parent.
5.Not crying before vaccination procedure.

Subcutaneous vaccination i.e. MMR, Chickenpox
Question Form: This form, prepared by the researchers, based on relevant literature, comprised questions to collect participants' demographic data, such as, gender, age, and weight.Information was collected from parents of the children, who had volunteered to participate in the study.

Face, Legs, Activity, Cry, Consolability Pain Scale (FLACC):
The FLACC is used to assess the behavioural reactions to pain by infants and children (two months to seven years), who cannot express their own pain and with whom oral communication cannot be established 35 .The FLACC pain scale access fi ve behavioural areas (facial expression of the child, the position of the legs, activity, crying, and consolability) with scores ranging from 0 to 2 for each item.
Using the FLACC Pain Scale, the toddler's behavioural reaction to the pain during and after the vaccination was determined in the control and test groups.These responses were coded separately by the researcher and a registered nurse, who was blind to the subject group.

Data analysis:
In the evaluation of the data, the crying durations of the infants were recorded and scored in seconds, and the pain reaction during and after procedure were scored between 0 and 10, according to the FLACC Pain Scale.For the data analysis, Statistical Package for the Social Sciences (SPSS 11.0) computer program was used.Statistical signifi cance was considered at a p value less than 0.05.
ANNOVA test is to assess the signifi cance of difference of pre procedure observation between experimental group-1, experimental group-2 and control group-3.Unpaired t-test was used to determine the signifi cance differences of means of distraction technique between the three groups.

Results
There were 162 female babies (46.29%) and 188 male babies (53.71%) (Table1).Most number of patients came to hospital for DPT booster dose (79.4%) (Table 2).It may be because of age group we have selected for study (1-3 Years).As per the data of table 2 most of children came for DPT booster dose.
There is signifi cant difference in the behavioural score of group-1 and group-3 (t=18.29,p<0.05).It indicates that distraction technique i.e. light and sound producing toys are effective to reduce pain in toddler during immunization (Table 3).
There is signifi cant difference in the behavioural score of group-2 and group-3 (t=9.93,p<0.05).It indicates that distraction technique i.e. cartoon movie is effective to reduce pain in toddler during immunization (Table 4).
There is signifi cant difference in the behavioural score of group-1 and group-2 (t=7.759,p<0.05).It indicates that distraction technique i.e. light and sound producing toys are more effective than cartoon movie to reduce pain in toddler during immunization (Table 5).
There is signifi cant difference in the behavioural score of group-1 and group-3 (t=11.29,p<0.05) after immunization.It indicates that distraction technique i.e. sound and light producing toys are effective to reduce pain in toddler even after immunization (Table 6).
There is signifi cant difference in the behavioural score of group-2 and group-3 (t=22.73,p<0.05) after immunization.It indicates that distraction technique i.e. cartoon movie is effective to reduce pain in toddler even after immunization (Table 7).
There is signifi cant difference in the behavioural score of group-1 and group-2 (t=13.35,p<0.05) after immunization.It indicates that distraction technique i.e. cartoon movie is more effective than light and sound producing toys to reduce pain in toddler after immunization (Table 8).

Discussion
Immunization becomes a part of children's life.As it protects children from many diseases but it can become stressful for both parents and children.Distraction techniques are effective, easy, and economical and needs no special training.
Previous studies addressing non pharmacological methods, such as parental holding, sucrose, and breastfeeding, confi rmed pain reduction in infants when they were subjected to painful procedures.Pain reduction was also reported in previous studies when using various distraction methods in American children during vaccination 38,39 and during other injection procedures³² as well as in American infants during vaccination 40,41 .Finding of our study indicates that distraction technique i.e. light and sound producing toys and cartoon movies are effective in reducing pain during and after immunization.Results are comparable with other studies 40,41 .It has been reported that distraction strategies that use two senses (visual with audio) appears to be more effective in reducing pain than the use of either one alone; and content, intensity, and combinations of multisensory stimuli are important elements of distraction interventions 42 .

Conclusion
In conclusion, light and sound producing toys and cartoon movies with both visual and auditory elements is a validated and reliable observational measure and a practical way of distracting infants from vaccination pain.It can be regularly used to reduce pain during the vaccination procedure.
Limitations of this study; First, variables such as pain score and crying durations were subjective and based on observational measures.Physiological indices (e.g., heart rate, blood pressure and oxygen saturation) could have been assessed to more accurately determine this factor.Secondly there is diffi culty in managing behaviour of parents during vaccination .Parents of control groups are more comfortable during study which may be contributory factor for toddler's anxiety and pain 43 .
¹ 4 .Oral How to cite this article ?Gedam DS, Verma M, Patil U, Gedam S. Eff ect of Distraction Technique During Immunization to Reduce Behaviour Response Score (FLACC) to Pain in Toddlers.J Nepal Paediatr Soc 2013;33(1):25-30.Effect of Distraction Technique During Immunization to Reduce Behaviour Response Score (FLACC) to Pain in Toddlers

Table 3 :
Comparison of Behavioural Response scores in group I & III during immunization Group I: 120 and Group III: 110

Table 5 :
Comparison of behavioural response (FLACC) in Group I and II during immunization.Group I: 120 and Group II: 120

Table 6 :
Comparison of behavioural Score (FLACC) in Group I and III after immunization.

Table 7 :
Comparison of Behavioural Response (FLACC) in Group II & III after immunization

Table 8 :
Comparison of Behavioural response (FLACC) in Group I and II after immunization.