Virtual Reality in Pediatric Pain Management
Virtual Reality for Acute Procedural Pain: Reflections and Challenges
By Paul Leong, MBBS, MPH & TM, CCPU, FRACP, PhD
School of Clinical Sciences, Monash University
Clayton, Victoria, Australia
In 2016, my coworkers and I were confronted by the familiar, sad story of severe needle phobia. An adolescent with a chronic medical condition, and severe needle phobia required intravenous antibiotics. His needle phobia was so severe that he was in tears just thinking about the cannula and he continually requested nitrous oxide every three days for the intravenous cannula changes. He had, of course, experienced repeated adverse needle experiences in early childhood with a subsequent, severe conditioned response.
This is the classic story and unfortunately predictable outcome of poorly managed pediatric pain – a human right(1) which continues to be sub-optimally managed in children(2) despite multiple strident calls to action(3–5), and the widespread recognition of major lifelong consequences if poorly managed(6).
We needed a tool that would allow us to manage needle pain and we turned to Virtual Reality (VR) as a technology that was diminishing in cost and increasing in availability. VR, a head-mounted computer-generated system, could support patients in what is a frequently confronting real-world experience.
We conducted a systematic review and meta-analysis(7) to see if VR could be used in our own practice, applying the medical standards we would typically use to assess interventions. We found that there was a preliminary signal that VR could help for needles. The quality of evidence was low – no studies at that stage reported in sufficient detail for us to be able to assess their Cochrane risk of bias, and studies were generally small. There was therefore no commercially available VR solution to solve our clinical need.
As a result, we created a VR visualization in response to this clinical need. It embeds multiple techniques including relaxation breathing, light hypnosis, neutral language, and a low-stimulation environment. But most importantly, it also includes a new technique which we have termed reframing, in which threatening external stimuli (e.g. needle) are represented as less threatening stimuli (e.g. fish nibbling).
Based on the systematic review, we tested this VR visualization in two large randomized studies, recruiting children aged 4-11 years undergoing clinically indicated peripheral venous access procedures(8). We examined the efficacy/safety of this VR in two settings – the emergency room, and outpatient phlebotomy. We deliberately chose to compare VR to the ‘standard of care’ for pediatric pain. This was usual tertiary hospital care consisting of analgesia, topical anesthetic at clinician discretion, and distraction therapy. These choices were driven by our desire to address the shortcomings in the literature – to maximize internal and external validity. Put another way, we aimed to address the fundamental question of whether we could confidently apply VR in our patients, and whether VR was superior to tertiary standard of care.
These studies recruited the largest sample size of patients in the VR procedural literature. They showed consistent, beneficial effects for our VR when compared to tertiary standard of care, with clinically and statistically important reductions in child-assessed maximal pain, anxiety, parent-rated distress and the need to restrain children(8). As a result, the Infusion Nurses Society 2021 Infusion Therapy Standards of Practice(9) now recommends VR as a pain management technique during vascular access procedures, citing our work. Following our publication, we have focused on implementation so that research benefits reach clinical populations. There have been three key reflections.
First, although pain and its consequences are a critical priority to children and caregivers, it is our experience that some clinicians view pediatric pain as a secondary consequence of a therapeutic goal (e.g. securing an intravenous cannula), and somehow of less importance. The Children’s Comfort Promise(3) and other major initiatives(10) are crucial in heightening clinician awareness and ensuring that ameliorating pediatric pain is a worthwhile and essential goal. Clinician leadership is key.
Second, the practical aspects of VR implementation require careful consideration. Many promising healthcare interventions fail at the implementation stage. To be accepted, VR needs to work with, or for, clinicians, and seamlessly blend into clinical workflows. In the coronavirus era, infection-control awareness is high and VR hardware needs to be healthcare adherent.
Third, standards of care should begin to incorporate VR. As the evidence base for VR evolves, indications and contraindications, optimum patient identification and so on will become clearer. Standards of care, or guidelines for, can facilitate evidence dissemination, and provide clinicians with frameworks for providing effective interventions, and as an effective intervention, VR clearly warrants mention. In this regard, the Infusion Nurses Society are to be commended.
It is our sincere ambition that no child will have to endure what our index patient endured. Providing adequate pain relief in childhood is a critical ethical and clinical priority, and VR can be part of the solution.
- Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain. 2004 Nov;112(1):1–4.
- Friedrichsdorf SJ, Postier A, Eull D, Weidner C, Foster L, Gilbert M, et al. Pain Outcomes in a US Children’s Hospital: A Prospective Cross-Sectional Survey. Hosp Pediatr. 2015 Jan;5(1):18–26.
- Friedrichsdorf SJ, Eull D, Weidner C. A Children’s Comfort Promise: how can we do everything possible to prevent and treat pain in children using quality improvement strategies? Paediatr Pain Lett. 2016;18(3):5.
- Krauss BS, Calligaris L, Green SM, Barbi E. Current concepts in management of pain in children in the emergency department. The Lancet. 2016 Jan;387(10013):83–92.
- Eccleston C, Fisher E, Howard RF, Slater R, Forgeron P, Palermo TM, et al. Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission. Lancet Child Adolesc Health. 2021 Jan 1;5(1):47–87.
- McMurtry CM, Pillai Riddell R, Taddio A, Racine N, Asmundson GJG, Noel M, et al. Far From “Just a Poke”: Common Painful Needle Procedures and the Development of Needle Fear. Clin J Pain. 2015 Oct;31:S3–11.
- Chan E, Foster S, Sambell R, Leong P. Clinical efficacy of virtual reality for acute procedural pain management: A systematic review and meta-analysis. PLOS ONE. 2018 Jul 27;13(7):e0200987.
- Chan E, Hovenden M, Ramage E, Ling N, Pham JH, Rahim A, et al. Virtual Reality for Pediatric Needle Procedural Pain: Two Randomized Clinical Trials. J Pediatr. 2019 Apr 29;209:160–7.
- Gorski LA, Hadaway L, Hagle ME, Broadhurst D, Clare S, Kleidon T, et al. Infusion Therapy Standards of Practice, 8th Edition. J Infus Nurs. 2021 Jan;44(1S):S1–224.
- Madhok M, Scribner-O’Pray M, Teele M. No needless pain: managing pediatric pain in minor injuries. Contemporary Pediatrics. 2011 Jun;28(6):24+.