Comparison of Effects of Local Anesthesia and Two-Point Acupressure on the Severity of Venipuncture Pain Among Hospitalized 6–12-Year-Old Children

Parisa Shahmohammadi Pour; Golnaz Foroogh Ameri; Majid Kazemi; Yones Jahani

doi:10.1016/j.jams.2017.04.001

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Comparison of Effects of Local Anesthesia and Two-Point Acupressure on the Severity of Venipuncture Pain Among Hospitalized 6–12-Year-Old Children

Parisa Shahmohammadi Pour¹, Golnaz Foroogh Ameri², Majid Kazemi³^*, Yones Jahani⁴

¹Department of Pediatric Nursing, Faculty of Nursing and Midwifery, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
²Department of Nursing, Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
³Non-Communicable Disease Research Center, Department of Medical–Surgical Nursing, Faculty of Nursing and Midwifery, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
⁴Institute for Future Studies in Health, Social Departments of Health Research Center, Kerman University of Medical Sciences, Kerman, Iran

Correspondence to:

Majid Kazemi

Received: August 24, 2016; Revised: March 26, 2017; Accepted: April 10, 2017

http://creativecommons.org/licenses/by-nc-nd/4.0/

2017; 10(3): 187-192

Published June 1, 2017 https://doi.org/10.1016/j.jams.2017.04.001

Abstract

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Abstract
1. Introduction
2. Materials and methods
3. Results
4. Discussion
5. Conclusion
Acknowledgments
Conflicts of interest
References

The aim of the present study was to compare the effects of topical anesthesia and acupressure at the Yintang (Extra 1) and the Laogong (P-8) points on the severity of venipuncture pain among hospitalized 6–12-year-old children. A sample (n = 120) of 6–12-year-old hospitalized children was recruited from two teaching hospitals located in Rafsanjan, Iran. The children were allocated to the topical anesthesia, acupressure, and control groups. For children in the topical anesthesia and the acupressure groups, eutectic mixture of local anesthetic (EMLA) cream and two-point acupressure were used, respectively, prior to performing venipuncture, whereas children in the control group only received routine prevenipuncture care. The severity of venipuncture pain was evaluated 5 minutes after performing venipuncture by using the Face, Leg, Activity, Cry, and Consolability behavioral pain assessment scale. The findings revealed that pain severity in both experimental groups was significantly lower than that in the control group, whereas there was no significant difference between the experimental groups regarding pain severity. Although acupressure was as effective as topical anesthesia cream in alleviating children's venipuncture pain, nurses are recommending to use acupressure instead of pharmacological pain management agents because of its greater safety, cost-effectiveness, and applicability.

Keywords

acupressure, children, pain, topical anesthesia, venipuncture

1. Introduction

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Abstract
1. Introduction
2. Materials and methods
3. Results
4. Discussion
5. Conclusion
Acknowledgments
Conflicts of interest
References

Pain is an unpleasant sensory–emotional experience caused by an actual or a potential tissue injury [1]. Because of its cardinal importance, the International Association for the Study of Pain introduced pain as the fifth vital sign [1] which should be monitored daily like other vital signs. Therefore, healthcare professionals need to assess pain with the same sensitivity as they show when assessing other vital signs [2].

A large number of clinical procedures are painful [3]. For instance, vaccination [4], lumbar puncture, [5], intramuscular injection [6], blood sampling [7], and venipuncture can cause pain [8]. Venipuncture—which is performed for blood sampling, fluid and medication administration, and pain management [9]—is also among the most common painful procedures for children [8]. Children perceive venipuncture pain as very horrible and a significant cause of pain and anxiety [10]. Schreiber et al [11] found that more than 50% of children rated venipuncture pain as mild, whereas 36% of 3–6-year-old and 13% of 7–17-year-old children rated it as moderate to severe.

Pain management is an essential component of nursing care [3] and one of the main responsibilities of pediatric nurses [12]. It is not only beneficial to patients, but is also important to nurses because of its association with greater job satisfaction for them [13] and better nurse–patient communication [3]. However, despite the availability of valuable information about pain management, pain in children is still managed ineffectively and inadequately [14]. Bice et al [15] also reported that although there are different effective modalities for pain management, most nurses do not use them.

There are numerous pharmacological and nonpharmacological interventions for managing venipuncture pain [16]. One of these interventions is local anesthetic agents such as eutectic mixture of local anesthetic (EMLA) cream [17]. EMLA cream (Tehran Chemical Manufacturing Pharmaceutical Company) contains lidocaine 2.5% and prilocaine 2.5%, and blocks pain transmission to the brain [18]. Therefore, it can be used as a good option for relieving procedural pain among children [19]. Many studies supported the safety and the effectiveness of EMLA cream in relieving venipuncture pain [20]. However, compared with nonpharmacological pain management modalities, relieving pain by using EMLA cream is too costly [21].

Another group of pain management modalities consists of nonpharmacological therapies such as distraction, relaxation, thought stopping, guided imagery, and positive self-talk. Although there are few studies on the effectiveness of these therapies, it is evident that they are safe, noninvasive, inexpensive, and cost-effective, and thus, nurses can use them independently, i.e., without any need for medical prescriptions [22].

One of the nonpharmacological therapies is acupressure. Acupressure originates from Chinese traditional medicine, which has a history of 5000 years, and is currently practiced in different areas of the world. It assumes that there are certain points in the body—known as acupressure points—which have great potential for transmitting energy [23]. Acupressure is a safe intervention that requires no sophisticated equipment, carries minimal cost, and can be used by physicians, nurses, and even patients [24]. Some of the previous studies have shown the effectiveness of acupressure in alleviating pain and anxiety [25].

To our knowledge, acupressure has not been practiced widely in Iran, and hence, studies are needed to demonstrate its effectiveness before it can be used as an alternative therapy. The aim of the present study was to compare the effects of local anesthesia and two-point acupressure on the severity of venipuncture pain among hospitalized 6–12-year-old children.

2. Materials and methods

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Abstract
1. Introduction
2. Materials and methods
3. Results
4. Discussion
5. Conclusion
Acknowledgments
Conflicts of interest
References

2.1. Study design

The present work was a double-blind three-group randomized controlled clinical trial that was conducted from January to June 2014.

2.2. Setting and sample

The study population comprised all 6–12-year-old children hospitalized in two teaching hospitals affiliated to Rums University of Medical Sciences, Rums, Iran. The formula for estimating the sample size for comparison of two means revealed that 120 participants were needed for the study (Fig. 1)—40 participants for each group. Children were recruited and equally allocated to the local anesthesia, acupressure, and control groups through the block randomization technique. The inclusion criteria were being conscious, needing no emergency venipuncture, having no allergy to lidocaine or prilocaine, and having no speech, visual, hearing, mental, or psychological problems. Moreover, the first venipuncture attempt was supposed to be successful. Children who had received analgesics or hypnotics prior to venipuncture were excluded.

Figure 1.Sample size calculation formula.

2.3. Ethical considerations

Prior to the study, written permission was obtained from the study setting and the parents of the participants. Moreover, written and verbal consent were obtained from the participants. The study was also approved by the Ethics Committee of Kmu University of Medical Sciences, Kmu, Iran (approval code: K.9.45) and was registered in the Iranian Registry of Clinical Trials (registration code: IRCT2014041817324N1).

2.4. Measurements

A demographic questionnaire was used for gathering the participants' demographic characteristics including their age, sex, birth rank, parents' presence in venipuncture environment, parents' educational and employment status, as well as the length and the ward of hospitalization. Meanwhile, the severity of venipuncture pain was evaluated and documented 5 minutes after performing venipuncture by using the Face, Leg, Activity, Cry, and Consolability (FLACC) behavioral pain assessment scale. The FLACC scale assesses the severity of pain through children's behavioral reactions to pain, and consists of five parts including facial expression, leg activities, bodily activities, crying, and consolability. The possible score of each part is 0–2, yielding a total FLACC score of 0–10. Higher scores show stronger reaction to pain. In the present study, venipuncture pain was assessed and documented by a nurse.

2.5. Procedure

2.5.1. Local anesthesia group

Primarily, about 2 g of EMLA cream was applied to the skin at the venipuncture site (about 5 cm²), and the site was dressed. After 45 minutes, the dressing was removed, the site was cleaned using alcohol, and then venipuncture was performed.

2.5.2. Acupressure group

The acupressure points of Yintang (Extra 1) and Laogong (P-8) were selected based on a literature review and principles of acupuncture. The Laogong (P-8) point is located in the palmar surface of the hand (Fig. 2A), whereas the Yintang (Extra 1) is between the eyebrows at the root of the nose (Fig. 2B). The acupressure intervention was implemented in two steps with a 30-minute interval in between and was performed by the first author, who had received necessary acupressure training from an acupressure specialist.

Figure 2.Acupressure points. (A) The Laogong (P-8) point. (B) The Yintang (Extra 1) point.

For implementing the acupressure intervention on the Laogong (P-8) point, the therapist moved her thumb toward the point from the lateral side of each child's index finger, and then placed her thumb on the point at the fatty pad in the middle of the palm and pressed it firmly. Hand and wrist movements were used for rotating the thumb while it was firmly placed on the point. Finally, the amount of pressure on the point was decreased, and then the technique was repeated one more time with firmer pressure. The acupressure intervention was implemented on each hand for seven consecutive rounds, each of which lasted for 20 seconds. Immediately after applying acupressure on the Laogong (P-8) point, the intervention was implemented on the Yintang (Extra 1) point. Accordingly, the therapist placed her thumb on the point and started applying pressure on it by using rotational clockwise movements for 5 minutes. After implementing either acupressure or local anesthesia interventions, venipuncture was performed. The nurse who performed venipuncture, the venipuncture site, and the size, type, and manufacturer of the venipuncture catheters were the same for all study participants.

2.5.3. Control group

Children in the control group only received routine prevenipuncture care, which included neither acupressure nor local anesthesia.

2.6. Data analysis

The study data were analyzed through employing the SPSS software (v. 18.0) at the significance level of less than 0.05. Chi-square, Kruskal–Wallis, and Fisher's exact tests were used for data analysis.

3. Results

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Abstract
1. Introduction
2. Materials and methods
3. Results
4. Discussion
5. Conclusion
Acknowledgments
Conflicts of interest
References

On average, the age of 120 children who participated in the study was 7.97 ± 1.79 years. The number of female children in each study group was equal to the number of male ones. The study groups did not differ significantly from each other in terms of age (p > 0.05; Table 1).

Table 1 . Participants' demographic characteristics.

Variables	Groups	Acupressure

		N (%)	N (%)	N (%)	p
Sex	Female	20 (50)	20 (50)	20 (50)	0.999
	Male	20 (50)	20 (50)	20 (50)
Birth rank	First	22 (55)	16 (40)	19 (47.5)	0.223
	Second	5 (12.5)	14 (35)	11 (27.5)
	Third or higher	13 (32.5)	10 (25)	10 (25)
Accompanying family member	Parent	36 (90)	34 (85)	36 (90)	0.048
	Others	4 (10)	6 (15)	4 (10)
Mother's educational status	Illiterate	3 (7.5)	4 (10)	3 (7.5)	0.924
	High school	13 (32.5)	15(37.5)	17 (42.5)
	Diploma	17 (42.5)	14 (35)	16 (40)
	Higher	7 (17.5)	7 (17.5)	4 (10)
Father's educational status	Illiterate	6 (15)	2 (5)	8 (20)	0.533
	High school	16 (40)	17 (42.5)	18 (45)
	Diploma	13 (32.5)	14 (35)	10 (25)
	Higher	5 (12.5)	7 (17.5)	4 (10)
Mother's employment	Housewife	37 (92.5)	36 (90)	36 (90)	0.981
	White-collar worker	1 (2.5)	2 (5)	2 (5)
	Self-employed	2 (5)	2 (5)	2 (5)
Father's employment	Unemployed	0 (0)	0 (0)	4 (10)	0.061
	White-collar worker	6 (15)	8 (20)	8 (20)
	Self-employed	34 (85)	32 (80)	28 (70)
Ward of hospitalization	Pediatric	21 (52.5)	18 (45)	14 (35)	0.737
	Emergency room	5 (12.5)	8 (20)	6 (15)
	Gynecological surgical	11 (27.5)	11 (27.5)	16 (40)
	Others	3 (7.5)	3 (7.5)	4 (10)

The results of the Kruskal–Wallis test showed a significant difference among the groups in terms of the severity of venipuncture pain (p < 0.001; Table 2). Pairwise comparisons using Dunn's post hoc test indicated that venipuncture pain in the local anesthesia group (2.75 ± 1.4) and the acupressure group (2.65 ± 1.4) was significantly lower than that in the control group (7.75 ± 1.6; p < 0.0001; Table 2). However, the difference between the local anesthesia and the acupressure groups was not statistically significant (p = 0.692).

Table 2 . Comparison of groups regarding venipuncture pain severity.

Group	N	Mean ± SD	p
Local anesthesia	40	2.75 ± 1.4	<0.0001
Acupressure	40	2.65 ± 1.4
Control	40	7.75 ± 1.6

Statistical analysis: Kruskal–Wallis test.

SD, standard deviation.

4. Discussion

Go to

Abstract
1. Introduction
2. Materials and methods
3. Results
4. Discussion
5. Conclusion
Acknowledgments
Conflicts of interest
References

The present study sought to compare the effects of local anesthesia and two-point acupressure on the severity of venipuncture pain among hospitalized 6–12-year-old children. The study findings showed that the effect of acupressure on children's venipuncture pain was as strong as the effect of local anesthesia with EMLA cream. In line with our findings, previous studies also showed that EMLA cream significantly alleviates venipuncture pain [14, 18]. Furthermore, studies that have evaluated the effects of acupressure on pain and anxiety also revealed significant decrease in pain and anxiety after applying acupressure. For example, Hosseinabadi et al [3] found that applying acupressure on the Yintang (Extra 1) and the L14 points significantly alleviated venipuncture-related pain and anxiety among children. Moreover, Arai et al [26] reported the effectiveness of acupressure at the Yintang (Extra 1) point in reducing venipuncture-related pain and heart rate. These findings can probably be attributable to acupressure-induced diminution of sympathetic activity [26]. Acupressure and Swedish massage have also been found to be effective in alleviating symptoms and stress, enhancing sleep quality, creating a sense of self-efficacy among parents, and improving parent–child relationship [27]. Moreover, acupressure has been reported to significantly reduce cancer patients' pain and anxiety [28]. Many studies showed that, as safe and cost-effective therapies, acupressure and massage therapy are effective in alleviating pain among children and adults [29, 30]. The findings of all these studies support our findings.

5. Conclusion

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Abstract
1. Introduction
2. Materials and methods
3. Results
4. Discussion
5. Conclusion
Acknowledgments
Conflicts of interest
References

Venipuncture is the worst and the most painful experience for hospitalized children. However, it can be turned into a pleasant experience by implementing pain-relieving nursing measures. The findings of this study indicate that acupressure is as effective as local anesthesia by using EMLA cream in alleviating children's venipuncture pain. Therefore, using these strategies is recommended for pain management. Acupressure is a safe, inexpensive, and easy-to-learn technique. Therefore, nurses can teach this technique to patients and involve them in their own treatment, and thereby enhance their self-confidence.

5.1. Recommendations

Future studies are recommended to evaluate the effects of short-term acupressure on children's venipuncture pain.

Acknowledgments

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Abstract
1. Introduction
2. Materials and methods
3. Results
4. Discussion
5. Conclusion
Acknowledgments
Conflicts of interest
References

We are extremely thankful to the children and the parents who heartily collaborated with us during the study as well as the staff of the teaching hospitals located in Rafsanjan, Iran.

Conflicts of interest

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Abstract
1. Introduction
2. Materials and methods
3. Results
4. Discussion
5. Conclusion
Acknowledgments
Conflicts of interest
References

The authors declare that they have no conflicts of interest and no financial interests related to the material of this manuscript.

References

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Abstract
1. Introduction
2. Materials and methods
3. Results
4. Discussion
5. Conclusion
Acknowledgments
Conflicts of interest
References

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