The Effect of Music-Moving Toys to Reduce Fear and Anxiety in Preschool Children Undergoing Intravenous Insertion in a Pediatric Emergency Department: A Randomized Clinical Trial

Published:December 03, 2021DOI:



      Intravenous catheter insertion is a highly invasive medical procedure that causes fear and anxiety in children. This study aimed to analyze the effect of a toy (with music and movement) distraction method on fear and anxiety in children aged 4 to 6 years.


      This experimental, randomized clinical trial used parallel trial design guided by the Consolidated Standards of Reporting Trials checklist. Using simple randomization, eligible children (age 4-6; N = 60) were assigned to the intervention group (n = 30), who received the toy distraction method, or to the control group (n = 30), who received standard care. The Children’s Fear Scale was used to evaluate the fear levels, and Children’s State Anxiety Scale was used to evaluate anxiety levels. Physiological parameters (pulse, oxygen saturation) and crying time were monitored by the researcher as indicators of fear and anxiety. The chi-square test, repeated measures analysis of variance, Friedman test, t test, the Mann-Whitney U test, Wilcoxon test, and the intraclass correlation test were used for data analysis.


      There was no statistically significant difference in terms of fear and anxiety scores, physiological parameters, and crying time during the procedure between the children in the intervention and control group.


      We found that this method of toy distraction was not effective in reducing fear or anxiety during the intravenous catheter insertion procedure. Accordingly, we recommend that this distraction method be performed in different age groups and with larger samples in various painful and stressful practices in the future and that comparison be made with various distraction methods.

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        • Eldridge C.
        • Kennedy R.
        Nonpharmacologic techniques for distress reduction during emergency medical care: a review.
        Clin Pediatr Emerg Med. 2010; 11: 244-250
        • Koller D.
        • Goldman R.D.
        Distraction techniques for children undergoing procedures: a critical review of pediatric research.
        J Pediatr Nurs. 2012; 27: 652-681
        • Williams A.
        • Ishimine P.
        Non-pharmacologic management of pain and anxiety in the pediatric patient.
        Curr Emerg Hosp Med Rep. 2016; 4: 26-31
        • Monroe R.A.
        Health Promotion of the preschooler and family.
        in: Hockenberry M.J. Wilson D. Wong’s Essentials of Pediatric Nursing. 8th ed. Mosby Elsevier, 2011: 523-542
        • Bice A.A.
        • Wyatt T.H.
        Holistic comfort interventions for pediatric nursing procedures: a systematic review.
        J Holist Nurs. 2017; 35: 280-295
        • Şahiner N.C.
        • Bal M.D.
        The effects of three different distraction methods on pain and anxiety in children.
        J Child Health Care. 2016; 3: 20
        • Tüfekci F.G.
        • Celebioğlu A.
        • Küçükoğlu S.
        Turkish children loved distraction: using kaleidoscope to reduce perceived pain during venipuncture.
        J Clin Nurs. 2009; 18: 2180-2186
        • Lim J.
        • Shin Y.
        Effects of distraction by a cellular phone on pain and fear during venipuncture procedure for hospitalized preschool children.
        Korean J Child Health Nurs. 2007; 13: 506-511
        • Moadad N.
        • Kozman K.
        • Shahine R.
        • Ohanian S.
        • Badr L.K.
        Distraction using the BUZZY for children during an IV insertion.
        J Pediatr Nurs. 2016; 31: 64-72
        • Bekmezci H.
        • Özkan H.
        The effect of games and toys on child health.
        Behcet Uz Cocuk Hast Derg. 2015; 5: 81-87
        • Çalışır H.
        • Karataş P.
        The atraumatic care approach in pediatric nursing: non-pharmacological applications in reducing pain, stress, and anxiety.
        J Educatıon Res Nursıng. 2019; 16: 234-245
        • Koukourikos K.
        • Tzeha L.
        • Pantelidou P.
        • Tsaloglidou A.
        The importance of play durıng hospitalizatıon of children.
        Mater Sociomed. 2015; 27: 438-441
        • Gao X.L.
        • Liu Y.
        • Tian S.
        • Zhang D.
        • Wu Q.
        Effect of interesting games on relief of preoperative anxiety in preschool children.
        Int J Nurs Sci. 2014; 1: 89-92
        • Li W.H.C.
        • Chung J.O.K.
        • Ho K.Y.
        • Kwok B.M.C.
        Play interventions to reduce anxiety and negative emotions in hospitalized children.
        BMC Pediatr. 2016; 16: 36
        • Ullán A.M.
        • Belver M.H.
        • Fernández E.
        • Lorente F.
        • Badía M.
        • Fernández B.
        The effect of a program to promote play to reduce children’s post-surgical pain: with plush toys, it hurts less.
        Pain Manag Nurs. 2014; 15: 273-282
        • Da Silva J.R.S.
        • Pizzoli L.M.L.
        • Amorim A.R.
        Using therapeutic toys to facilitate venipuncture procedure in preschool children.
        Pediatr Nurs. 2016; 42: 61-68
        • Hillgrove-Stuart J.
        • Pillai Riddell R.
        • Horton R.
        • Greenberg S.
        Toy-mediated distraction: clarifying the role of agent of distraction and preneedle distress in toddlers.
        Pain Res Manag. 2013; 18: 197-202
        • Kapkın G.
        • Manav G.
        • Muslu G.K.
        Effect of therapeutic play methods on hospitalized children in Turkey: a systematic review.
        Erciyes Med J. 2020; 42: 127-131
        • McMurtry C.M.
        • Noel M.
        • Chambers C.T.
        • McGrath P.J.
        Children’s fear during procedural pain: preliminary investigation of the children’s fear scale.
        Health Psychol. 2011; 30: 780-788
        • Özalp Gerçekker G.
        • Ayar D.
        • Özdemir Z.
        • et al.
        Gaining of children’s state anxiety and children’s fear scale.
        Dokuz Eylul Univ J Nurs Fac. 2018; 11: 9-13
        • Ersig A.L.
        • Kleiber C.
        • McCarthy A.M.
        • Hanrahan K.
        Validation of a clinically useful measure of children’s state anxiety before medical procedures.
        J Spec Pediatr Nurs. 2013; 18: 311-319
        • Karagöz Y.
        The power and effectiveness of nonparametric techniques.
        Electron J Soc Sci. 2010; 9: 18-40
        • Akgül E.A.
        • Karahan Y.
        • Başoğlu F.
        • et al.
        Effects of watching cartoons on pain scores in children undergoing venepuncture. Nurs Child Young People. Published online December 13, 2018.
        • Ibrahim H.
        • Elsayed Yousef Y.
        • Elrigal E.E.
        • Ayed M.M.A.
        Effect of using non pharmacological methods on relief of pain and fear among children undergoing venipuncture.
        Egypt J Health Care. 2017; 8: 244-252
        • Kuo H.C.
        • Pan H.H.
        • Creedy D.K.
        • Tsao Y.
        Distraction-based ınterventions for children undergoing venipuncture procedures: a randomized controlled study.
        Clin Nurs Res. 2018; 27: 467-482
        • Lilik Lestari M.P.
        • Wanda D.
        • Hayati H.
        The effectiveness of distraction (cartoon-patterned clothes and bubble-blowing) on pain and anxiety in preschool children during venipuncture in the emergency department.
        Compr Child Adolesc Nurs. 2017; 40: 22-28
        • Özalp Gerçeker G.
        • Ayar D.
        • Özdemir Z.
        • et al.
        Effects of virtual reality on pain, fear and anxiety during blood draw in children aged 5–12 years old: a randomised controlled study.
        J Clin Nurs. 2020; 29: 1151-1161
        • Potasz M.
        • Varela J.V.
        • Carvalho L.C.
        • Do Prado L.F.
        • Do Prado G.F.
        Effect of play activities on hospitalized children’s stress: a randomized clinical trial.
        Scand J Occup Ther. 2013; 20: 71-79
        • Sönmez D.
        • Bozkurt G.
        • Ulupınar G.
        • Uysal G.
        • Uçar S.
        • Uysalol M.
        The effect of a cartoon and an information video about intravenous insertion on pain and fear in children aged 6 to 12 years in the pediatric emergency unit: a randomized controlled trial.
        J Emerg Nurs. 2021; 47: 76-87
        • Carlson K.L.
        • Broome M.
        • Vessey J.A.
        Using distraction to reduce reported pain, fear and behavioral distress in children and adolescents: a multisite study.
        J Soc Pediatr Nurs. 2000; 5: 75-85
        • Cassidy K.L.
        • Reid G.J.
        • McGrath P.J.
        • et al.
        Watch needle, watch tv: audiovisual distraction in preschool immunization.
        Pain Med. 2002; 3: 108-118
        • MacLaren J.E.
        • Cohen L.
        A Comparison of distraction strategies for venipuncture distress in children.
        J Pediatr Psychol. 2005; 30: 387-396
        • García-Aracil N.
        • Ramos-Pichardo J.D.
        • Castejón-de la Encina M.E.
        • José-Alcaide L.
        • Juliá-Sanchís R.
        • Sanjuan-Quiles Á.
        Effectiveness of non-pharmacological measures for reducing pain and fear in children during venipuncture in the emergency department: a vibrating cold devices versus distraction.
        Emergencias. 2018; 30: 182-185
        • Burns-Nader S.
        • Atencio S.
        • Chavez M.
        Computer tablet distraction in children receiving an ınjection.
        Pain Med. 2016; 17: 590-595
        • Spagrud L.J.
        • von Baeyer C.L.
        • Ali K.
        • et al.
        Pain, distress, and adult-child interaction during venipuncture in pediatric oncology: an examination of three types of venous access.
        J Pain Symptom Manage. 2008; 36: 173-184
        • Khandelwal D.
        • Kalra N.
        • Tyagi R.
        • Khatri A.
        • Gupta K.
        Control of anxiety in pediatric patients using “tell show do” method and audiovisual distraction.
        J Contemp Dent Pract. 2018; 19: 1058-1064
        • Wong C.
        • Lui M.M.W.
        • Choil K.C.
        Effects of immersive virtual reality intervention on pain and anxiety among pediatric patients undergoing venipuncture: a study protocol for a randomized controlled trial.
        Trials. 2019; 20: 369
        • Heijden M.J.E.
        • Mevius H.
        • Heijde N.
        • et al.
        Children listening to music or watching cartoons during ER procedures: a RCT.
        J Pediatr Psychol. 2019; 44: 1151-1162
        • Shaker N.
        • Taha A.
        Effectiveness of distraction therapy on children’s pain perceptions during peripheral venous cannulation at pediatric teaching hospital in Erbil City.
        Erbil J Nurs Midwifery. 2018; 1: 75-84
        • Aitken J.C.
        • Wilson S.
        • Coury D.
        • Moursi A.M.
        The effect of music distraction on pain, anxiety and behavior in pediatric dental patients.
        Pediatr Dent. 2002; 24: 114-118
        • Miller K.
        • Rodger S.
        • Bucolo S.
        • Greer R.
        • Kimble R.M.
        Multi-modal distraction. Using technology to combat pain in young children with burn injuries.
        Burns. 2010; 36: 647-658
        • Tuncay S.
        • Günay U.
        The effects of playing digital games on the pain levels and mobility states of children post-angiography: a randomized controlled trial.
        Ann Res. 2019; 26 ( 1731-1736
        • Meiri N.
        • Ankri A.
        • Hamad-Saied M.
        • Konopnicki M.
        • Pillar G.
        The effect of medical clowning on reducing pain, crying, and anxiety in children aged 2-10 years old undergoing venous blood drawing-a randomized controlled study.
        Eur J Pediatr. 2016; 175: 373-379
        • Pontes J.E.
        • Tabet E.
        • Folkmann M.Á.
        • Cunha M.L.
        • Fde A.
        • Almeida
        Therapeutic play: preparing the child for the vaccine.
        Einstein (SaoPaulo). 2015; 13: 238-242
        • Tsao Y.
        • Kuo H.C.
        • Lee H.C.
        • Yiin S.J.
        Developing a medical picture book for reducing venipuncture distress in preschool aged children.
        Int J Nurs Pract. 2017; 23: e12569
        • ENA Clinical Practice Guideline Committee
        • ENA Board of Directors Liaisons
        • Methodologist
        • Staff Liaisons
        • Administrative Staff
        Clinical practice guideline: needle-related or minor procedural pain in pediatric patients: clinical practice guideline.
        J Emerg Nurs. 2019; 45: 437.e1-437.e32


      Tugba Nur Karaca is a Nurse, Tokat State Hospital, Tokat, Turkey. ORCID identifier:


      Umran Cevik Guner is an Assistant Professor, Pediatric Nursing Department, Faculty of Health Sciences, Tokat Gaziosmanpasa University, Tokat, Turkey. ORCID identifier: