Supplemental Information

(1)

SEARCH STRATEGY

Database: ePub Ahead of Print, In- Process and Other Nonindexed Citations, Ovid Daily Medline (R), and Ovid Medline (R) 1946 to Present Date of search: October 12, 2017 Records retrieved: 1093

1 Abdomen, Acute/ (9421) 2 Acute Pain/ (1502)

3 Immunization/ and (anxi* or distract* or distress* or fear* or pain*).mp. (489)

4 exp Injections/ and (anxi* or distract* or distress* or fear* or pain*).mp. (28c510)

5 Needles/ and (anxi* or distract* or distress* or fear* or pain*).mp.

(1767)

6 exp Pain/ and (acute* or sever* or sharp*).tw,kf. (85c764)

7 Pain Management/ (28c205) 8 Pain Perception/ (1923)

9 Phlebotomy/ and (anxi* or distract*

or distress* or fear* or pain*).mp.

(518)

10 Sutures/ and (anxi* or distract* or distress* or fear* or pain*).mp.

(911)

11 Vaccination/ and (anxi* or distract* or distress* or fear* or pain*).mp. (1168)

12 ((acute* or sever* or sharp*) adj2 pain*).tw,kf. (44c387)

13 ((anxi* or distract* or distress* or fear* or perce*) and pain*).tw,kf.

(76c765)

14 ((anxi* or distract* or distress* or

bloodwork* or immunization* or injection* or needle* or

phlebotom* or sutur* or stitch* or vaccinat* or veni puncture* or venipuncture* or

venesection*)).tw,kf. (58c445) 15 (pain* adj2 procedur*).tw,kf.

(4527)

16 or/1–15 [Combined MeSH & text words for acute pain or painful procedures] (259c042)

17 exp Cell Phones/ (10c091) 18 Computers/ (53c339)

19 exp Computers, Handheld/ (4626) 20 Internet/ (65c569)

21 Microcomputers/ (15c040) 22 Mobile Applications/ (2544) 23 Motion Pictures as Topic/ (7807) 24 Multimedia/ (1825)

25 Robotics/ (18c602) 26 exp Television/ (32c112) 27 Therapy, Computer-Assisted/

(6603)

28 Video Games/ (4093)

29 Virtual Reality Exposure Therapy/

(421)

30 (android* or apps or cell* phone or cellphone* or cell* tele-phone*

or cell* telephone* or iPad* or iPhone* or iPod* or smart phone*

or smartphone*).tw,kf. (13c501) 31 ((app* or device* or phone* or

tablet* or technolog* or telephone* or telephone*) adj2 (digital* or electronic* or hand held* or handheld* or mobile or portable or web-based*)).tw,kf.

(33c118)

32 artiﬁcial intelligence*.tw,kf. (2569) 33 computer*.ti,kf. (79c054)

34 computer*.ab. /freq=2 (45c429) 35 (computer* adj2 gam*).tw,kf.

(1789)

36 digital*.ti. (38c139) 37 DVD*.tw,kf. (1680) 38 electronic*.ti. (44c622)

39 (lap top* or laptop*).tw,kf. (1585) 40 (motion picture* or movie*).tw,kf.

(6348)

41 robot*.tw,kf. (32c691) 42 (tele vision* or television* or

TV).tw,kf. (23c857) 43 video*.ti,kf. (27c522) 44 video*.ab. /freq=2 (28c257) 45 (video gam* or videogam*).tw,kf.

(3325)

46 virtual*.ti,kf. (18c782) 47 virtual*.ab. /freq=2 (15c594) 48 virtual reality*.tw,kf. (7192) 49 or/17–48 [Combined MeSH & text

words for digital technologies]

(476c429)

50 Adolescent/ (1c950c009) 51 exp Child/ (1c852c375) 52 exp Infant/ (1c117c651) 53 Minors/ (2539)

54 exp Pediatrics/ (55c304) 55 Young Adult/ (672c052) 56 (adolescen* or boy* or girl* or

minors or teen*).tw,kf. (467c102) 57 (baby* or babies or infant* or

infancy or neonat* or newborn* or postmatur* or prematur* or pre term* or preterm*).tw,kf.

(2)

58 (child* or kid or kids or preschool*

or school age* or schoolchild* or toddler*).tw,kf. (1c337c214) 59 (elementary school* or grade

school* or gradeschool* or high school* or highschool* or kindergar* or nursery school* or primary school* or secondary school*).tw,kf. (60c725) 60 p?ediatric*.tw,jw,kf. (691c539) 61 or/50–60 [Combined MeSH & text

words for children] (4c478c423) 62 and/16,49,61 [Combined concepts

for pain, digital technologies &

children] (1172)

63 remove duplicates from 62 (1093) Database: Ovid Embase 1974 to 2017 October 10

Date of search: October 12, 2017 Records retrieved: 1345

1 acute abdomen/ (11 976) 2 immunization/ and (anxi* or

distract* or distress* or fear* or pain*).mp. (2494)

3 inﬂuenza vaccination/ and (anxi* or distract* or distress* or fear* or pain*).mp. (1296)

4 exp injection/ and (anxi* or distract* or distress* or fear* or pain*).mp. (20 572)

5 measles vaccination/ and (anxi* or distract* or distress* or fear* or pain*).mp. (59)

6 needle/ and (anxi* or distract* or distress* or fear* or pain*).mp.

(7325)

7 exp pain/ and (acute* or sever* or sharp*).tw,kw. (286 564)

8 phlebotomy/ and (anxi* or distract*

or distress* or fear* or pain*).mp.

(932)

9 suture/ and (anxi* or distract* or distress* or fear* or pain*).mp.

(3596)

10 vaccination/ and (anxi* or distract* or distress* or fear* or pain*).mp. (5223)

11 ((acute* or sever* or sharp*) adj2

12 ((anxi* or distress* or fear* or perce*) and pain*).tw,kw.

(110 103)

13 ((anxi* or distract* or distress* or fear* or pain*) and (blood work* or bloodwork* or immunization* or injection* or needle* or

venesection*)).tw,kw. (85 934) 14 (pain* adj2 procedur*).tw,kw.

(6661)

15 or/1–14 [Combined Emtree & text words for acute pain or painful procedures] (465 377)

16 computer/ (79 138) 17 computer assisted therapy/

(4296)

18 computer terminal/ (1275) 19 digital computer/ (2599) 20 *Internet/ (30 709) 21 microcomputer/ (14 610) 22 mobile application/ (4863) 23 exp mobile phone/ (16 874) 24 movie/ (656)

25 multimedia/ (3241) 26 personal computer/ (188) 27 personal digital assistant/ (1097) 28 robotics/ (31 731)

29 television/ (14 268) 30 television viewing/ (2289) 31 video game/ (1443) 32 virtual reality/ (12 413)

33 virtual reality exposure therapy/

(400)

or cell* telephone* or iPad* or iPhone* or iPod* or smart phone*

or smartphone*).tw,kw. (17 760) 35 ((app* or device* or phone* or

tablet* or technolog* or telephone* or telephone*) adj2 (digital* or electronic* or hand held* or handheld* or mobile or portable or web- based*)).tw,kw.

(36 587)

36 artiﬁcial intelligence*.tw,kw.

(3342)

37 computer*.ti. (80 453)

38 computer*.ab. /freq=2 (52 981) 39 (computer* adj2 gam*).tw,kw.

(2252)

40 digital*.ti. (39 901) 41 DVD*.tw,kw. (2702) 42 electronic*.ti. (37 633)

43 (lap top* or laptop*).tw,kw. (2300) 44 (motion picture* or movie*).tw,kw.

(6615)

45 robot*.tw,kw. (48 314) 46 (tele vision* or television* or

TV).tw,kw. (29 866) 47 video*.ti,kw. (36 233) 48 video*.ab. /freq=2 (37 251) 49 (video gam* or videogam*).tw,kw.

(3878)

50 virtual*.ti,kw. (25 141) 51 virtual*.ab. /freq=2 (18 475) 52 virtual reality*.tw,kw. (9360) 53 or/16–52 [Combined Emtree &

text words for digital technologies]

(502 462)

54 exp adolescent/ (1 452 380) 55 exp child/ (2 473 744) 56“minor (person)”/ (452) 57 exp pediatrics/ (95 684) 58 young adult/ (204 027) 59 (adolescen* or boy* or girl* or

minors or teen*).tw,kw. (557 126) 60 (baby* or babies or infant* or

infancy or neonat* or newborn* or postmatur* or prematur* or pre term* or preterm*).tw,kw.

(946 204)

61 (child* or kid or kids or preschool*

or school age* or schoolchild* or toddler*).tw,kw. (1 551 587) 62 (elementary school* or grade

school* or gradeschool* or high school* or highschool* or kindergar* or nursery school* or primary school* or secondary school*).tw,kw. (71 160) 63 p?ediatric*.tw,jx,kw. (850 183)

(3)

Database: Wiley Cochrane Library (inception to present)

No. 1 [mh ^”Abdomen, Acute”] 50 No. 2 [mh ^”Acute Pain”] 202 No. 3 [mh ^Immunization] and

(anxi* or distract* or distress* or fear* or pain*):ti,ab,kw 71 No. 4 [mh Injections] and (anxi* or

distract* or distress* or fear* or pain*):ti,ab,kw 6718

No. 5 [mh ^Needles] and (anxi* or distract* or distress* or fear* or pain*):ti,ab,kw 452

No. 6 [mh Pain] and (acute* or sever* or sharp*):ti,ab,kw 10 152 No. 7 [mh ^”Pain

Management”] 2634

No. 8 [mh ^”Pain Perception”] 264 No. 9 [mh ^Phlebotomy] and (anxi*

or distract* or distress* or fear*

or pain*):ti,ab,kw 171

No. 10 [mh ^Sutures] and (anxi* or distract* or distress* or fear* or pain*):ti,ab,kw 213

No. 11 [mh ^Vaccination] and (anxi*

or distract* or distress* or fear*

or pain*):ti,ab,kw 240

No. 12 ((acute* or sever* or sharp*) near/2 pain*):ti,ab,kw 8324 No. 13 ((anxi* or distract* or

distress* or fear* or perce*) and pain*):ti,ab,kw 17 214

No. 14 ((anxi* or distract* or distress* or fear* or pain*) and (“blood work*” or bloodwork* or immunization* or injection* or needle* or phlebotom* or sutur*

or stitch* or vaccinat* or“veni puncture*” or venipuncture* or

Handheld”] 290 No. 20 [mh ^Internet] 3060 No. 21 [mh ^Microcomputers] 238 No. 22 [mh ^”Mobile

Applications”] 169

No. 23 [mh ^”Motion Pictures as Topic”] 124

No. 24 [mh ^Multimedia] 194 No. 25 [mh ^Robotics] 748 No. 26 [mh Television] 1456 No. 27 [mh ^”Therapy, Computer-

Assisted”] 1129

No. 28 [mh ^”Video Games”] 478 No. 29 [mh ^”Virtual Reality

Exposure Therapy”] 115 No. 30 (android* or apps or“cell*

phone” or cellphone* or “cell*

tele-phone*” or “cell*

telephone*” or iPad* or iPhone*

or iPod* or“smart phone*” or smartphone*):ti,ab,kw 1550 No. 31 ((app* or device* or phone*

or tablet* or technolog* or“tele phone*” or telephone*) near/2 (digital* or electronic* or“hand held*” or handheld* or mobile or portable or“web based*”)):

ti,ab,kw 2968

No. 32“artiﬁcial intelligence*”:

ti,ab,kw 184

No. 33 computer*:ti 4157 No. 34 (computer* near/2 gam*):

ti,ab,kw 277 No. 35 digital*:ti 1414 No. 36 DVD*:ti,ab,kw 472 No. 37 electronic*:ti 1477 No. 38 (lap top* or laptop*):

ti,ab,kw 157

No. 39 (“motion picture*” or movie*):ti,ab,kw 337 No. 40 robot*:ti,ab,kw 2335

No. 45“virtual reality”:ti,ab,kw 1350 No. 46 {or #17-#45} 24 111

No. 47 [mh ^Adolescent] 92 001 No. 48 [mh Child] 251

No. 49 [mh Infant] 15 355 No. 50 [mh ^Minors] 9 No. 51 [mh Pediatrics] 671 No. 52 [mh ^”Young Adult”] 296 No. 53 (adolescen* or boy* or girl* or

minors or teen*):ti,ab,kw 121 971

No. 54 (baby* or babies or infant* or infancy or neonat* or newborn*

or postmatur* or prematur* or

“pre term*” or preterm*):ti,ab,kw 63 543

No. 55 (child* or kid or kids or preschool* or“school age*” or schoolchild* or toddler*):ti,ab,kw 105 704

No. 56 (“elementary school*” or

“grade school*” or gradeschool*

or“high school*” or highschool*

or kindergar* or“nursery school*” or “primary school*” or

“secondary school*”):

ti,ab,kw 4934

No. 57 (pediatric* or pediatric*):

ti,ab,kw 21 103

No. 58 {or #47–#57} 221 732 No. 59 #16 and #46 and #58 271 Results by Database: CDSR: 17; DARE:

2; CENTRAL: 251; Economic Evaluations DB: 1

Database: CINAHL Plus with full text via EBSCOhost (1937 to present) Date of search: October 12, 2017 Records retrieved: 559

(Supplemental Table 6)

Database: Ovid PsycINFO (1806 to October, week 2, 2017)

(4)

Records retrieved: 231 1 Immunization/ and (anxi* or

distract* or distress* or fear* or pain*).mp. (389)

2 exp Injections/ and (anxi* or distract* or distress* or fear* or pain*).mp. (1098)

3 Pain Management/ (8529) 4 Pain Perception/ (10 102)

5 exp Pain/ and (acute* or sever* or sharp*).ti,ab. (14 049)

6 ((acute* or sever* or sharp*) adj2 pain*).ti,ab. (6355)

7 ((anxi* or distract* or distress* or fear* or perce*) and pain*).ti,ab.

(28 063)

8 ((anxi* or distract* or distress* or fear* or pain*) and (blood work* or bloodwork* or immunization* or injection* or needle* or

venesection*)).ti,ab. (8126) 9 (pain* adj2 procedur*).ti,ab. (866) 10 or/1-9 [Combined subject

headings & text words for acute pain or painful procedures]

(57 325)

11 Artiﬁcial Intelligence/ (7113) 12 Audiovisual Communications

Media/ (833)

13 Computer Applications/ (11 001) 14 Computer Assisted Therapy/

(879)

15 exp Computers/ (17 929) 16 Digital Video/ (1483) 17 Films/ (7522) 18 Internet/ (27 045)

19 exp Mobile Devices/ (5134) 20 Multimedia/ (2172) 21 Robotics/ (4815) 22 Television/ (5572) 23 Videotapes/ (2423) 24 Virtual Reality/ (6761)

iPhone* or iPod* or smart phone*

or smartphone*).ti,ab. (5172) 26 ((app* or device* or phone* or

tablet* or technolog* or telephone* or telephone*) adj2 (digital* or electronic* or hand held* or handheld* or mobile or portable or web-based*)).ti,ab.

(10 713)

27 artiﬁcial intelligence*.ti,ab. (3135) 28 computer*.ti. (20 981)

29 computer*.ab. /freq=2 (20 917) 30 (computer* adj2 gam*).ab. (2116) 31 digital*.ti. (5064)

32 DVD*.ti,ab. (1206) 33 electronic*.ti. (4506)

34 (lap top* or laptop*).ti,ab. (864) 35 (motion picture* or movie*).ti,ab.

(7180)

36 robot*.ti,ab. (6372)

37 (tele vision* or television* or TV).ti,ab. (19 441)

38 video*.ti. (9071)

39 video*.ab. /freq=2 (16 446) 40 (video gam* or videogam*).ti,ab.

(4719)

41 virtual*.ti. (7835)

42 virtual*.ab. /freq=2 (7599) 43 virtual reality*.ti,ab. (3865) 44 or/11–43 [Combined subject

headings & text words for digital technologies] (159 009)

45 Pediatrics/ (21 510)

46 (adolescen* or boy* or girl* or minors or teen*).ti,ab. (284 999) 47 (baby* or babies or infant* or

infancy or neonat* or newborn* or postmatur* or prematur* or pre term* or preterm*).ti,ab. (119 301) 48 (child* or kid or kids or preschool*

or school age* or schoolchild* or toddler*).ti,ab. (631 259) 49 (elementary school* or grade

school* or gradeschool* or high school* or highschool* or kindergar* or nursery school* or primary school* or secondary school*).ti,ab. (129 659)

50 p?ediatric*.ti,ab. (31 034) 51 or/45–50 [Combined subject

headings & text words for children]

(930 057)

52 and/10,44,51 [Combined concepts for pain, digital technologies &

children] (231)

53 remove duplicates from 52 (231) Database: IEEE Xplore (inception to present)

Search:

All. pain distraction children (105) Research librarian note: selected 8

conference proceedings; search results were most precise with simpliﬁed strategy

Database: Ei Compendex via Engineering Village (inception to present)

Advanced Search.

(((immunization* OR injection* OR needle* OR pain* OR vaccinat*) AND (distract* OR manage*)) AND (computer* OR digital* OR electronic* OR robot* OR video* OR

“virtual reality”) AND (adolescen*

OR child* OR p*diatric)) wn KY (91)

Database: Web of Science Core Collection via Clarivate Analytics (inception to present)

(Supplemental Table 7) Health Technology Assessment Database: CADTH (https://www.

cadth.ca)

pain AND distraction (17)

(5)

injection* OR needle* OR pain* OR vaccinat*) AND (distract* OR manage*)) AND (computer* OR digital* OR electronic* OR robot*

OR video* OR“virtual reality”) AND (adolescen* OR child* OR

pediatric* OR pediatric*))– in All Secondary Evidence (45)

Research librarian note: kept 5 Trial registry: clinicaltrials.gov (https://www.clinicaltrials.gov/) Date of search: October 18, 2017 Records retrieved: 4

Condition/Disease: Pain, Acute Age: Child (birth– 17)

Intervention: computer* OR digital*

OR electronic* OR robot* OR video*

OR“virtual reality” (4) Other search method: Google (https://www.google.ca/) Date of search: October 18, 2017 Records retrieved: 6

(((burnsj immunization j injection j needlej pain j vaccination) (distractj manage)) (computer j digitalj electronic j robot j video j

“virtual reality”) (adolescent j child j pediatric)

Reviewedﬁrst 5 pages of results Research librarian note: kept 6 Other search method: Cited Reference Lists

Reviewed and included any studies not already retrieved by the search from the key references below:

(1.) Reference Type: Report Record No.: 3970

Author: Young, C., Spry, C and CADTH

reality-or-gaming-applications- pain-management-or-distraction- clinical-effectiveness-and-0 (3) (2.) Reference Type: Journal Article Record No.: 3965

Author: Shahrbanian, Shahnaz, Ma, Xiaoli, Aghaei, Najaf, Korner- Bitensky, Nicol, Moshiri, Keivan and Simmonds, Maureen J.

Year: 2012

Title: Use of virtual reality

(immersive versus non immersive) for pain management in children and adults: A systematic review of evidence from randomized controlled trials

Research Notes: cited in CADTH rapid review

URL: http://www.imedpub.com/

articles/use-of-virtual-reality- immersive-vs-non-immersive- forpain-management-in-children- and-adults-a-systematic-review-of- evidence-from.pdf (2)

(3.) Reference Type: Report Record No.: 3974

Author: Royal Australian College of General Practitioners

Year: 2016

Title: Pain management strategies for childhood immunization

Series Title: HANDI

URL: https://www.racgp.org.au/

your-practice/guidelines/handi/

interventions/children/pain- management-strategies-for- childhood-immunisation/ (1)

EXCLUDED STUDIES

We excluded studies by population (n

= 78),149–226 intervention or exposure (n = 115),227–339outcome

Any Digital Technology Versus Usual Care

• Self-reported pain

• Funnel plot

• Observer-reported pain

• Funnel plot

• Behavioral measures of pain

• Funnel plot

• Self-reported distress

• Observer-reported distress

• Funnel plot

• Behavioral measures of distress

• Funnel plot

Any Digital Technology Versus Nondigital Distraction

• Funnel plot

• Self-reported distress

• Observer-reported distress

• Behavioral measures of distress Audiovisual Eyeglasses Versus Projected Movie

Video Game Versus Virtual Reality

• Behavioral measures of pain

(6)

SUPPLEMENTAL FIGURE 2

Any digital technology versus usual care: self-reported pain. df, degrees of freedom; IV, inverse variance.

(7)

Any digital technology versus usual care: observer-reported pain. df, degrees of freedom; IV, inverse variance.

(8)

(9)

Any digital technology versus usual care: self-reported distress. df, degrees of freedom; IV, inverse variance.

(10)

Any digital technology versus usual care: observer-reported distress. df, degrees of freedom; IV, inverse variance.

(11)

Any digital technology versus usual care: behavioral measures of distress. df, degrees of freedom; IV, inverse variance.

(12)

Any digital technology versus nondigital distraction: self-reported pain. df, degrees of freedom; IV, inverse variance.

Any digital technology versus nondigital distraction: observer-reported pain. df, degrees of freedom; IV, inverse variance.

(13)

Any digital technology versus nondigital distraction: self-reported distress. df, degrees of freedom; IV, inverse variance.

Any digital technology versus nondigital distraction: observer-reported distress. df, degrees of freedom; IV, inverse variance.

Any digital technology versus nondigital distraction: behavioral measures of distress. df, degrees of freedom; IV, inverse variance.

Audiovisual eyeglasses versus projected movie: self-reported pain. AV, audiovisual; df, degrees of freedom; IV, inverse variance.

Video game versus virtual reality: self-reported pain. df, degrees of freedom; IV, inverse variance.

(14)

Video game versus virtual reality: observer-reported pain. df, degrees of freedom; IV, inverse variance.

Video game versus virtual reality: behavioral measures of pain. df, degrees of freedom; IV, inverse variance.

(15)

“secondary school*”) or AB(“elementary school*” or “grade school*” or gradeschool* or“high school*” or highschool* or kindergar* or “nursery school*” or “primary school*” or “secondary school*”)

S55 TI(child* or kid or kids or preschool* or“school age*” or schoolchild* or toddler*) or AB(child* or kid or kids or preschool* or“school age*” or schoolchild* or toddler*)

347 032

S54 TI(baby* or babies or infant* or infancy or neonat* or newborn* or postmatur*

or prematur* or“pre term*” or preterm*) or AB(baby* or babies or infant*

or infancy or neonat* or newborn* or postmatur* or prematur* or“pre term*” or preterm*)

147 371

S53 TI(adolescen* or boy* or girl* or minors or teen*) or AB(adolescen* or boy* or girl* or minors or teen*)

147 388

S52 (MH“Young Adult”) 158 772

S51 (MH“Pediatrics1”) 15 619

S50 (MH“Minors (Legal)”) 555

S49 (MH“Child1”) 502 425

S48 (MH“Adolescence1”) 394 773

S47 S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 OR S42 OR S43 OR S44 OR S45 OR S46

159 578

S46 TI(“virtual reality*”) or AB(“virtual reality*”) 2180

S45 TI(virtual*) 5741

S44 TI(“video gam*” or videogam*) or AB(“video gam*” or videogam*) 1349

S43 TI(video*) 9525

S42 TI(“tele vision*” or television* or TV) or AB(“tele vision*” or television* or TV) 7705

S41 TI(robot*) or AB(robot*) 7216

S40 TI(“motion picture*” or movie*) or AB(“motion picture*” or movie*) 1438

S39 TI(“lap top*” or laptop*) or AB(“lap top*” or laptop) 557

S38 TI(DVD*) or AB(DVD*) 1020

S37 TI(electronic*) 12 465

S36 TI(DVD*) or AB(DVD*) 1020

S35 TI(digital*) 9211

S34 TI(computer* N2 gam*) or AB(computer* N2 gam*) 580

S33 TI(computer*) 16 279

S32 TI(“artiﬁcial intelligence*”) or AB(“artiﬁcial intelligence*”) 532

S31 TI((app* or device* or phone* or tablet* or technolog* or“tele phone*” or telephone*) N2 (digital* or electronic* or“hand held*” or handheld* or mobile or portable or“web based*”)) or AB((app* or device* or phone* or tablet* or technolog* or“tele phone*” or telephone*) N2 (digital* or electronic* or“hand held*” or handheld* or mobile or portable or “web based*”))

10 501

S30 TI(android* or apps or“cell* phone” or cellphone* or “cell* tele-phone*” or

“cell* telephone*” or iPad* or iPhone* or iPod* or “smart phone*” or smartphone*) or AB(android* or apps or“cell* phone” or cellphone* or

“cell* tele-phone*” or “cell* telephone*” or iPad* or iPhone* or iPod* or

“smart phone*” or smartphone*)

7067

S29 (MH“Video Games1”) 2849

S28 (MH“Virtual Reality Exposure Therapy”) 3

S27 (MH“Therapy, Computer Assisted”) 4665

S26 (MH“Robotics”) 5680

S25 (MH“Videorecording1”) 23 141

S24 (MH“Television”) 8190

S23 (MH“Multimedia”) 1696

S22 (MH“Motion Pictures”) 5018

S21 (MH“Mobile Applications”) 2265

(16)

SUPPLEMENTAL TABLE 6 Continued

No. Query Results

S20 (MH“Microcomputers1”) 6772

S19 (MH“Internet”) 38 073

S18 (MH“Computers and Computerization”) 9191

S17 (MH“Cellular Phone”) 887

S16 (MH“Artiﬁcial Intelligence”) 1772

S15 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14

63 418

S14 TI(pain* N2 procedur*) or AB(pain* N2 procedur*) 2156

S13 TI((anxi* or distract* or distress* or fear* or pain*) and (“blood work*” or bloodwork* or immunization* or injection* or needle* or phlebotom* or sutur* or stitch* or vaccinat* or“veni puncture*” or venipuncture* or venesection*)) or AB((anxi* or distract* or distress* or fear* or pain*) and (“blood work*” or bloodwork* or immunization* or injection* or needle* or phlebotom* or sutur* or stitch* or vaccinat* or“veni puncture*” or venipuncture* or venesection*))

10 918

S12 TI((anxi* or distract* or distress* or fear* or perce*) and pain*) or AB((anxi* or distract* or distress* or fear* or perce*) and pain*)

26 162 S11 TI((acute* or sever* or sharp*) N2 pain*) or AB((acute* or sever* or sharp*) N2

pain*)

15 113 S10 (MH“Sutures”) and (TI(anxi* or distract* or distress* or fear* or pain*) or

AB(anxi* or distract* or distress* or fear* or pain*))

182 S9 (MH“Venipuncture1”) and (TI(anxi* or distract* or distress* or fear* or pain*)

or AB(anxi* or distract* or distress* or fear* or pain*))

339

S8 (MH“Treatment Related Pain”) 1926

S7 (MH“Pain Management”) 527

S6 (MH“Pain1”) and (TI(acute* or sever* or sharp*) or AB(acute* or sever* or sharp*))

23 780 S5 (MH“Needles”) and (TI(anxi* or distract* or distress* or fear* or pain*) or

461 S4 (MH“Injections1”) and (TI(anxi* or distract* or distress* or fear* or pain*) or

4739 S3 (MH“Immunization”) and (TI(anxi* or distract* or distress* or fear* or pain*)

or AB(anxi* or distract* or distress* or fear* or pain*))

464

S2 (MH“Belonephobia”) 11

S1 (MH“Abdomen, Acute”) 721

SUPPLEMENTAL TABLE 7Web of Science Core Collection via Clarivate Analytics (Inception to Present)

No. n Query

4 366 #1 AND #2 AND #3

Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI, CCR-EXPANDED, IC Timespan=All years

3 2 117 900 TS=(adolescen* OR child* OR infan* OR pediatric* OR pediatric*)

2 1 493 685 TS=(computer* OR ((digital* OR electronic*) AND technolog*) OR“mobile app*”

OR multimedia* OR robot* OR television* OR video* OR“virtual reality”) Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI,

CCR-EXPANDED, IC Timespan=All years

1 70 522 TS=((“blood work*” OR bloodwork* OR immunization* OR injection* OR needle*

OR ((acute* OR severe* OR sharp) AND pain*) OR vaccinat*) AND (distract* OR manage*))

(17)

categorizations of the population described within the individual studies

Setting Inpatients, outpatients, and both inpatients and outpatients Populations who were staying in hospital for treatment were considered inpatients; outpatient settings included the ED, day treatment centers, dental clinics, and private physicians’ ofﬁces

Patient population Generally healthy, cancer or major medical diagnosis, general hospital population, and otherwise healthy with burns or wounds

Categorized according to the description provided within individual studies, and we categorized patients with burns or wounds separately from other generally healthy patients because they required repeated procedures; the general hospital population is any sample described by the authors as similar to the population in their hospital

Type of procedure Venipuncture or phlebotomy, dental anesthesia (injection) with or without dental restoration, intravenous cannulation, immunization or intramuscular injection, venous port access, burn dressing change, insertion of a venous catheter, burn hydrotherapy, burn physiotherapy, genital or colposcopic examination, wound dressing change, lumbar puncture, sutures, removal of a foreign body, and voiding cystourethrogram

Whenever possible, we categorized procedures according to the previous categorizations of Stevens et al²to ensure that procedures that differed in the intensity of pain produced would be grouped separately

Type of distraction Audiovisual aid (watching a movie, cartoon, or television program), audiovisual eyeglasses (watching a movie, cartoon, or scene), virtual reality, computer tablet with game apps, playing a video game, humanoid robot, live video of the procedure, handheld digital game (unspeciﬁed)

We grouped distractors as they were reported in the individual studies; for a system to be considered virtual reality, children needed to be able to interact with the space (ie,

three-dimensional movies were not considered virtual reality even if they were described as such within individual studies) Active or passive

distraction

Active and passive distraction We used Koller and Goldman’s²⁷deﬁnition of active versus passive distraction; active distraction techniques require the child’s engagement in the activity (eg, virtual reality), whereas passive does not require overt participation (eg, watching a movie)

Use of cointerventions Cointerventions used no cointerventions used We categorized studies according to the use of cointerventions as reported in the individual studies; cointerventions could include analgesics and/or anesthetics

Measurement scale Varied (multiple) We categorized studies according to the scales reported to be used to measure pain and distress outcomes

(18)

SUPPLEMENTAL TABLE 9Detailed Characteristics of the Included Studies Study, Country, Sources

of Support

n (%

Male Sex)

Age, y^a Setting Painful Procedure Intervention(s) and

Comparator(s)

Additional Interventions Provided

to All Groups

Pain and Distress Outcomes Reported

RCTs and quasi RCTs (n = 78)

Agarwal et al³⁰India, funding NR

120 (50)

8.8 (estimated

SD 2.8)

Outpatient dental clinic Injection (dental anesthetic)

EMLA plus laptop (movie) (P);

benzocaine gel plus laptop (movie) (P);

EMLA with no distraction;

benzocaine gel with no distraction

Topical anesthetic (EMLA or benzocaine gel)

Self-reported pain (VAS)

Al-Halabi et al,³¹ Syria, academic funding

60 (59)

Mean: 7.4;

eligibility range: 6–10

Outpatient dental clinic Injection (dental anesthetic) and dental restoration

AV eyeglasses (P); tablet computer (cartoon) (P); usual care

Topical anesthetic (20% benzocaine gel)

Self-reported pain (Wong-Baker Faces Scale), behavioral measure of pain (FLACC) Al-Khotani et al,³²

Saudi Arabia, no external funding

56 (39)

8.2 (0.8) Outpatient dental clinic Injection (dental anesthetic) and dental restoration

AV eyeglasses (cartoon) (P); usual care

Local anesthesia injection

Self-reported anxiety (FIS)

Aminabadi et al 2012,³³Iran, academic funding

120 (54)

AV eyeglasses (i-Glasses 920 HR, cartoons) (P);

usual care

Topical anesthetic and local anesthetic injection

Self-reported pain (Wong-Baker Faces Scale); self-reported anxiety (Faces version of MCDAS) Asvanund et al,³⁴

Thailand, academic funding

53 (45)

AV eyeglasses (cartoon) (P); conventional behavioral management and distraction techniques

Topical anesthetics (benzocaine); local anesthetic injection

Self-reported pain (FPS), behavioral measure of pain (FLACC)

Attar and Baghdadi,³⁵ Canada, funding NR

39 (51)

6.3 (1.2) Outpatient dental clinic Injection (dental anesthetic)1 dental restoration

Tablet computer (games) (A); AV eyeglasses (P)

Topical (benzocaine gel) and local anesthetic (lidocaine) injection

Self-reported pain (Wong-Baker Faces Scale); observed anxiety (MDAS)

Atzori et al,³⁷Italy, foundation funding

7 (64) 10.64 (2.58) Outpatient oncology- hematology unit

Venipuncture VR helmet (SnowWorld three-dimensional software) (A); usual care

None reported Self-reported pain (GRS)

Atzori et al,³⁷Italy, foundation funding

12 (50)

11.34 (2.58) Outpatient nephrology unit

Venipuncture VR helmet (SnowWorld three-dimensional software) (A); usual care

None reported Self-reported pain (GRS)

Atzori et al,³⁶Italy, government and foundation funding

3 (60) 13.2 (2.39) Outpatient dental clinic Dental extraction or restoration

VR goggles (SnowWorld game) (A); usual care

NR Self-reported pain (GRS)

Bagattoni et al,³⁸Italy, foundation funding

48 (46)

7.3 (1.5) Outpatient dental clinic Injection (dental anesthetic) plus dental restoration

AV eyeglasses (Unidexx, cartoons) (P); usual care behavioral management techniques

Topical (lidocaine spray) and local (mepivacaine plus epinephrine) anesthetic injection

Self-reported pain (FPS-R); behavioral pain (r-FLACC)

Bellieni et al,⁴¹Italy, funding NR

69 (48)

Range: 7–12 Outpatient clinic Phlebotomy Television (cartoons) (P);

mother’s interaction;

usual care

None reported Self-reported pain (Oucher), observed pain (Oucher) Beran et al,^42,135

Canada, no external funding

57 (53)

6.9 (1.3) Outpatient clinic Immunization Humanoid robot (A);

usual care with minimal nondigital distraction

None reported Self-reported pain (FPS-R), observed pain (FPS-R), behavioral measure of distress (BAADS) Berenson et al,⁴³

United States, funding NR

89 (0) 6.2 (0.9) Outpatient well-child clinic

Genital examination AV eyeglasses (movie) (P); active play (eg, singing, blowing bubbles); passive play (were read a fairy tale)

None reported Behavioral measure of distress (OSBD)

60 8.9 (2.1) Outpatient clinic Venipuncture or AV aid (cartoon) (P); None reported Self-reported pain

(19)

distress (CEMS) Burns-Nader et al,⁴⁵

United States, no external funding

41 (56)

6.6 (2.6) Outpatient pediatric clinic Venipuncture Computer tablet with games and CLS coach (A); usual care

None reported Self-reported pain (Wong-Baker Faces Scale), behavioral measures of pain (FLACC) and anxiety (CEMS)

Burns-Nader et al,⁴⁶ United States, no external funding

30 (63)

7.5 (2.5) Inpatient burn center Hydrotherapy for burns

Computer tablet with games engaged by CLS (A); usual care

Intravenous analgesia (morphine plus Versed)

Self-reported pain (Wong-Baker Faces Scale), observed pain (VAS), behavioral measure of anxiety (CEMS) Cassidy et al,⁴⁷

Canada, foundation and industry funding

62 (45)

All were 5 y Outpatient pediatric practice

Immunization Television (cartoons) (P);

usual care (no distraction)

None reported Self-reported pain (FPS), behavioral measures of pain (CHEOPS and CFCS)

Cerne et al,⁴⁸Italy, funding NR

45 (47)

4.5 (1.4) Inpatient surgical unit Venipuncture Computer tablet (cartoons) (P);

blowing soap bubbles; usual care (verbal distraction by nursing staff)

None reported Self-reported pain (Wong-Baker Faces Scale), behavioral measures of distress (OSBD-R, Italian version) Chan et al,⁵⁰Taiwan,

academic funding

8 (88) 6.5 (2.3) Inpatient burn unit Burn dressing change VR eyeglasses (A); usual care

Oral Tylenol analgesia Self-reported pain (FPS)

Cohen et al,⁵³United States, funding NR

39 (41)

9.9 (0.5) School health clinic Immunization Television (movie) with nurse coaching (P);

EMLA cream; usual care (“likely includes distraction in addition to other behaviors”)

None reported Self-reported pain (VAS), observed pain (VAS), self-reported distress (VAS), observed distress (VAS), behavioral measure of distress (CAMPIS-R) Cohen et al,⁵⁵United

States, funding NR 136 (40)

0.6 (0.4) Outpatient clinics Immunization Portable DVD (movie) (P); usual care, no movie or toy distraction

None reported Observed distress (VAS), behavioral measure of distress (MAISD)

Cohen et al,⁵⁶United States, government funding

90 (49)

4.8 (9.7) Outpatient pediatric practice

Immunization DVD player (movies) (P);

parent training plus DVD player (movies) (P); usual care (parents and nurses

“probably” used idiosyncratic distraction)

None reported Self-reported pain (CAPS), observed pain (VAS), behavioral measure of distress (author developed)

Crevatin et al,⁵⁷Italy, no external funding

200 (49)

Range: 4–13 Outpatient phlebotomy center

Phlebotomy Computer tablet (game app) (A); nurse-led distraction (singing, bubbles, reading, puppet show)

None reported Self-reported pain (FPS-R or VAS)

Dahlquist et al,^58,136 United States, government funding

29 (76)

3.5 (0.8) Outpatient

hematology-oncology clinic

Venous port access or intramuscular injection plus chemotherapy

“Touch and Discover”

electronic toy (A);

usual care

None reported Observed anxiety (7-point scale), behavioral measure of distress (OSBD) Das et al,⁵⁹Australia,

funding NR

9 (67) 10.0 (3.6) Hospital ward Burn dressing change Head-mounted VR (eMagin Z800 Three-dimensional Visor, games) (A);

usual care

Routine pharmacologic analgesia

Self-reported pain (10-point faces scale)

Downey and Zun,⁶¹ United States,

100 (62)

8.6 (NR); 33%

(3–5); 64%

–18)

ED 5% sutures, 39%

intravenous

Television (cartoon) (P);

usual care

Those receiving sutures were given

Self-reported pain (PCT or faces scale)

(20)

SUPPLEMENTAL TABLE 9 Continued Study, Country, Sources

of Support

n (%

Male Sex)

Age, y^a Setting Painful Procedure Intervention(s) and

Comparator(s)

Additional Interventions Provided

to All Groups

Pain and Distress Outcomes Reported

phlebotomy, 4%

other procedure

local anesthesia injection El-Sharkawi et al,⁶²

Egypt, funding NR 42 (48)

Range: 5–7 Outpatient dental clinic Injection (dental anesthetic)

AV eyeglasses (cartoon) (P); usual care

Topical anesthetic (benzocaine gel)

Self-reported pain (FPS), behavioral measure of pain (FLACC) Fakhruddin et al,⁶³

United Arab Emirates, no external funding

60 (52)

AV eyeglasses (Vuzix Wrap 310XL, movie) (P); movie projected on ceiling (P)

Local anesthetic injection, topical anesthetic as needed

Self-reported pain (Wong-Baker Faces Scale), self-reported anxiety (MCDAS) Fakhruddin et al,⁶⁴

United Arab Emirates, no external funding

15 (47)

AV eyeglasses (Vuzix Wrap 310XL) (cartoon) (P);

cartoon projected on ceiling (P)

Local anesthetic injection, topical anesthetic drops as needed

Self-reported pain (Wong-Baker Faces Scale)

Garrocho-Rangel et al,⁶⁵Mexico, funding NR

20 (56)

6.2 (1.3) Outpatient dentistry clinic Injection (dental anesthetic) plus dental restoration

AV eyeglasses (P); usual care

Local anesthesic injection

Behavioral measure of pain (FLACC)

Gerçeker et al,⁶⁷ Turkey, academic funding

61 (50)

9.43 (1.51) Outpatient unit Phlebotomy AV eyeglasses (P); Buzzy cryotherapy plus vibration device;

usual care

None reported Self-reported pain (Wong-Baker Faces Scale), observed pain (Wong-Baker Faces Scale)

Gershon et al,^68,137 United States, foundation funding

59 (51)

12.7 (NR) Outpatient oncology clinic Venous port access (for chemotherapy)

Head-mounted VR (games) (A);

computer game (A);

usual care

Topical anesthetic (EMLA)

Self-reported pain (VAS), observed pain (VAS), behavioral measure of pain (CHEOPS), self-reported anxiety (VAS), observed anxiety (VAS) Ghadimi et al,⁶⁹Iran,

no external funding

15 (54)

4.5 (NR) Outpatient dental clinic Injection (dental anesthetic) plus dental restoration

AV aid (cartoon) (P);

usual care

Local anesthesic injection

Self-reported anxiety (VPT)

Gold et al,⁷⁰United States, funding NR

20 (60)

10.2 (estimated

SD 1.0)

Outpatient radiology clinic Intravenous cannulation

VR (game) (A); usual care

80% received topical anesthetic cream or spray

Self-reported pain (Wong-Baker Faces Scale, FPS-R) Gold and Mahrer,⁷¹

United States, industry funding

149 (48)

15.4 (3.1) Outpatient phlebotomy clinic

Phlebotomy VR eyeglasses (game) (A); usual care (television in the room played at low volume)

None reported Self-reported pain (FPS-R, VAS [0–10], CAS), observed pain (FPS-R, VAS, CAS), self-reported anxiety (VAS), observed anxiety (VAS and FAS) Hoge et al,⁷⁴United

States, government funding

128 (30)

AV eyeglasses (movie) (P); usual care

Local anesthetic injection

Self-reported pain (FPS-R), behavioral measure of pain (%

pain behavior) Hua et al,⁷⁵China,

funding NR

65 (48)

8.7 (3.4) Inpatient pediatric ward Wound dressing change

Head-mounted VR (eMagin Z800 Three-dimensional Visor, games) (A);

usual care (toys, television, books)

None reported Self-reported pain (Wong-Baker Faces Scale), observed pain (VAS), behavioral measure of pain (FLACC) Inan and Inal,⁷⁷

Turkey, funding NR 89 (49)

7.78 (1.27) Outpatient clinic Phlebotomy Computer tablet (cartoon) (P);

computer tablet (game) (A); parental support; usual care

None reported Self-reported pain, observed pain (Wong-Baker Faces Scale), self-reported distress, observer distress (CFS) Ingersoll et al,⁷⁸

United States, government funding

45 (64)

6.5 (estimated

SD 1.4)

Outpatient dental clinic Injection (dental anesthetic) plus dental restoration

Cartoons projected on ceiling: cartoons projected only if child cooperated; usual care

None reported (local anesthetic injection assumed)

Self-reported fear (CFS) and anxiety (VPT)

Jeffs et al,⁸⁰United States, research institute and

30 (68)

13.5 (2.3) Outpatient burn clinic Burn dressing change Desk- or head-mounted VR (SnowWorld game) (A); television

75% received opioid analgesics (acetaminophen

Self-reported pain (APPT), self-reported anxiety (5-point

(21)

funding humanoid robot (mediport;

distraction) (P)

before self-reported

distress (CFS), observed distress (NRS), behavioral measure of distress (BAADS) Kaheni et al,⁸³Iran,

funding NR

80 (54)

4.0 (1.1) Inpatient pediatric unit Venipuncture Sega video game (Sonic) (A); usual care (no distraction)

None reported Behavioral measure of pain (FLACC)

Kaheni et al,⁸⁴Iran, funding NR

80 (56)

3.9 (0.9) Inpatient burn unit Burn dressing change Sega video game (Sonic) (A); usual care

None reported Behavioral measure of pain (FLACC) Khandelwal et al,⁸⁷

India, no external funding

221 (55)

Range: 5–8 Outpatient dental clinic Injection (dental anesthetic) plus dental restoration

Tell-show-do; laptop with cartoons (P); both 1 and 2; usual care

None Self-reported anxiety

(FIS and VPT)

Kipping et al,⁸⁸ Australia, industry funding

41 (28)

13.1 (1.6) Inpatient burn unit Burn dressing change Head-mounted VR (Chicken Little or Need for Speed) (A);

usual care including television, music, caregiver, or no distraction

78% received opioids, 12% received opioids plus another medication (Paracetamol, Entonox), 2%

received Paracetamol plus Entonox

Self-reported pain (VAS), observed pain (VAS), behavioral measure of pain (FLACC)

Kuo et al,⁹¹China, no external funding

136 (49)

4.52 (NR) Outpatient pediatric unit Intravenous cannulation

Storybook; computer tablet (movie) (P);

usual care

None reported Observer-reported distress (OBSD-R)

Landolt et al,⁹² Switzerland, funding NR

13 (92)

7.9 (2.6) Inpatient pediatric burn unit

Burn dressing change Television (cartoons), attention drawn as needed (P); usual care

Codeine phosphate analgesic

Behavioral measure of distress (OSBD)

Lim et al 2013,⁹⁴ Singapore, funding NR

60 (85)

9.1 (1.9 Operating theater Intravenous cannulation

AV eyeglasses (Headplay system, movie) (P);

conventional distraction (eg, verbal, bubbles, choosing stickers)

Topical anesthetic (EMLA)

Self-reported pain and anxiety (Wong-Baker Faces Scale), observed anxiety (5-point scale), behavioral measure of anxiety (MYPAS) Luthy et al,⁹⁵United

States, academic funding

68 (47)

5.2 (3.4) Outpatient pediatric ofﬁce Immunization Portable DVD (movie) (P); vapocoolant spray without distraction; usual care

None reported Observed pain (Wong-Baker Faces Scale), observed anxiety (6-point Likert scale) Ma et al,⁹⁶Canada,

academic funding 45 (53)

Median 8 (IQR 7–10)

Pediatric ED Intravenous

cannulation

Computer tablet (games or movies) (A or P);

usual care

Topical anesthetic cream (4%

lidocaine;

Malxilene)

Self-reported pain (Faces revised), behavioral measure of distress (OBSD-R) MacLaren and

Cohen,⁹⁷United States, academic funding

88 (59)

4.3 (1.8) Outpatient surgery clinic Venipuncture Interactive robot (younger children) or laptop (games, older children) with nurse or caregiver coaching (A); portable DVD (movie) with nurse or caregiver coaching (P); usual care with no or minimal distraction

None reported Self-reported distress (scale with 5 faces), observed distress (VAS), behavioral measures of distress (OSBD)

Mason et al,⁹⁹New Zealand, academic funding

7 (43) 3.5 (0.5) Inpatient and outpatient pediatric units

Venous port access Television (cartoon) (P);

musical storybook read with parent;

usual care

None reported Observed distress (VAS), behavioral measure of distress (OSBD-R)