It is common for paediatric inpatients to undergo invasive procedures that may be painful during their hospital stay. For this reason, methods are being introduced to provide pain relief and reduce anxiety during such procedures.1 In fact, the Charter of the European Association for Children in Hospital stipulates the right of every child to be protected from unnecessary medical treatment and physical or emotional distress.2

These methods can be divided into pharmacological and nonpharmacological interventions. Nonpharmacological interventions can be further subdivided into support methods (such as viewing videos, reading books and companionship), cognitive methods (such as relaxation or distraction) and physical methods (positioning, massaging and stimulation of the skin by means of vibrations or the application of heat or cold).1,3

As regards the cognitive methods, it has been hypothesised that the “ideal distractor” is one that draws attention to something that involves the use of several senses (vision, touch, hearing) and has an emotional impact, so that it can compete with the unpleasant stimulus. Few articles in the literature have addressed the use of emerging technologies, such as virtual reality (VR), for analgesia in the paediatric population during interventions such as burn care, chemotherapy, dental procedures and other medical procedures.4–9 Neurophysiological studies that used functional magnetic resonance imaging have also found that it achieves a reduction in perceived pain.10,11

When it comes to pharmacological methods, the use of topical anaesthetic drugs avoids systemic effects and reduces adverse events. In clinical practice, a cream consisting of a combination of prilocaine and lidocaine (both at 2.5%) is frequently used and has proven effective as an anaesthetic in minor invasive procedures.12–18

The aim of the study was to assess whether the use of VR, both in isolation or combined with the use of a lidocaine/prilocaine cream, reduced pain and anxiety during invasive procedures in patients hospitalised in the paediatric ward without producing clinically relevant adverse effects.

The findings of our study suggest that the use of adjuvant interventions during invasive procedures can reduce pain and anxiety in patients hospitalised in the paediatric ward, with results similar to those reported in the previous literature with the use of VR in isolation5–9 or combined with topical analgesic creams.12–17

Although most patients in our cohort were previously healthy, a high proportion had needed invasive procedures in the past. Previous studies suggest that the analgesic effect of distraction techniques may be greater in patients with underlying disease,6,9 a population in which it is possible to compare the severity of perceived pain with the pain perceived during previous experiences, but in our study we also found evidence of this effect in previously healthy patients admitted to hospital due to acute disease.24

One of the strengths of our study is that patients were able to choose from several videos that had been previously reviewed, as past evidence suggests that having choices achieves a greater reduction of pain.9

In most of the previous literature, the pain scales were administered only to the patients, unlike in our study, where we also obtained proxy reports from family members and health care staff. We administered the scales individually and in writing to avoid influencing the responses of participants, and we found a very strong correlation between the self-reports of patients and the assessments of the pain experienced by patients made by family members and the health care staff. The assessment of anxiety in children is an area that still needs further development, as there are no validated scales for measuring anxiety in children aged less than 5 years. In this study we used the CFS in children aged more than 4 years and obtained results that were similar to those reported in the previous literature, where this scale was used in children aged more than 5 years.22

The findings of our study are consistent with those of other studies that have demonstrated that VR is a nonpharmacological cognitive method that is quite helpful for relief of pain and anxiety. There are previous studies with very different characteristics that support the use of this technique conducted in healthy adults,25,26 healthy children exposed to pain through the cold pressor test,27 paediatric cancer patients undergoing phlebotomy procedures,6 paediatric cancer patients undergoing lumbar puncture,7 adults and children receiving care for burns,28,29 paediatric outpatients undergoing phlebotomy procecures,5 etc. To our knowledge, ours is the first study conducted in patients hospitalised in a paediatric ward, a subpopulation that has not yet been assessed in the literature that could unquestionably benefit from these modalities of analgesia.

Some authors assert that the use of active distraction, where the patient is immersed in the film, is more effective compared to passive distraction through videos,30 a hypothesis supported by our findings, and the isolation created by the glasses and headphones facilitates detachment from the unpleasant situation to which the patient is exposed.

None of the patients experienced adverse events associated with the use of VR, which may include nausea, dizziness or other motion sickness symptoms described in previous studies.31 This aspect may be associated with the choice of VR device. We ought to highlight the differences between VR glasses used in combination with mobile devices, which are safe to use from age 4 to 5 years if they allow adjustment of the interpupillary distance, and standalone headsets (with a 3D screen) designed for gaming, which are not recommended for children aged less than 12 years since they are the interface that usually produces the aforementioned side effects.

There is controversy in the literature regarding the use of analgesic creams in invasive procedures, although most of the research has assessed their use in isolation.32,33. When it comes to analgesic creams as adjuvant treatment, as was the case in our study, most studies support their use.12–17 Some studies have not found any benefit from their use, which could be due to the simultaneous use of distraction, which may mask the effects of creams.34 Our study found an increase in pain relief when cream was used in combination with VR, although it did not add to the anxiety-reducing effect of VR. Although some authors have reported adverse events associated with the use of topical creams (methaemoglobinaemia, seizures, vasoconstriction and contact dermatitis),18 we had no such case in our sample. This is probably due to the fact that the directions for the use of this drug were always adhered to, in contrast to some of the cases described in the literature in which topical creams were used inappropriately, for instance, by applying them to a large surface or on broken skin.35–37 Some authors have reported that these creams may cause vasoconstriction, which can be counteracted with the application of heat,38 while others state that their application does not interfere with the performance of the procedure.39 Our data support the latter view, as we did not find any differences between the groups in the number of punctures, a variable whose increase may indicate increased difficulty in performing a procedure.

We found a high degree of satisfaction in the patients and their family members in relation to the use of VR, as they considered that in addition to alleviating pain and anxiety, it facilitated the performance of the procedure and also reduced the anxiety of the accompanying person. Most patients and their families requested the use of VR if they happened to need further procedures in the future.

As for the limitations of this study, the chief one is its observational design, as patients were not randomised to different groups, although comparing the baseline characteristics of patients in each group we found that the 2 groups were comparable.

Another limitation is the low number of patients in the sample that underwent other interventions commonly performed during hospitalization, such as lumbar puncture. This is due to the fact that since these interventions are known to be more painful in and of themselves, their performance involved the use of drugs or other analgesic measures that resulted in the exclusion of these patients from the study.

Last of all, it is important to highlight that the main outcome variables in our study were clinical scales that cannot but be somewhat subjective, although the use of other parameters, such as blood pressure and heart rate, complicated their interpretation, as the patients in the study had acute illness and could have fever or breathing difficulties at the time the procedure was performed, which was a potential a source of bias. To minimise the impact of this limitation, we used these instruments to assess the perception of not only the patients, but also the family members and the health care staff.

We expect that future performance of randomised clinical trials in paediatric patient comparing the use of VR and other interventions such as analgesic cream alone or the application of cold, heat or vibration during painful procedures will provide us with more rigorous evidence on these techniques.

The use of VR during invasive procedures in patients hospitalised in the paediatric ward reduced the pain and anxiety perceived by the patient, families and health care staff. We found that pain scores increased as the number of punctures used in a procedure increased and decreased with the use of adjuvant interventions. We did not identify any adverse events associated to the use of VR or analgesic cream or any data suggesting that they interfered with performance of the procedure.

Patients and their families expressed a high level of satisfaction in relation to the use of VR, as they found that in addition to reducing pain and anxiety, it facilitated performance of the procedure and also reduced the anxiety of the accompanying person, and stated they would request the use of VR should they need additional procedures in the future.

The authors have no conflicts of interest to declare