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Abstract

Circumcision is a common pediatric operation, and distraction technique can be used as an adjunct analgesic method during the perioperative period. The study aims to explore the effect of distraction techniques on reducing pain, fear, and anxiety in children undergoing circumcision. The PubMed, ClinicalTrials.gov, and Embase databases were searched for articles published from January 1, 2000, to December 31, 2023. Only randomized controlled trials (RCTs) were included. Meta-analysis and forest plots were carried out using Review Manager 5.4.1 software, and outcomes were reviewed by two authors independently. We used the Risk of Bias assessment form (ROB2) developed by the Cochrane Collaboration to assess the quality of included studies. PRISMA 2020 guidelines were used in this article to achieve the quantitative and qualitative synthesis of data. A total of seven RCTs were included. The intervention group consisted of 417 patients, while the control group had 245 patients. The meta-analysis and sensitivity analysis results showed that the distraction technique could significantly relieve pain (MD −1.3, 95% confidence interval [CI]: [−1.61 to −0.99], p < .00001), fear (SMD −1.04, 95%CI −1.68 to −0.4, p = .001), and anxiety (SMD −1.07, 95%CI [−1.64 to −0.51], p = .0002). Similarly, therapeutic play significant could significantly relieve fear (MD −0.4, 95%CI [−0.71 to −0.1], p = .01) and anxiety (SMD -1.31, 95%CI [−2.59 to −0.04], p = .04), virtual reality (VR) could significantly relieve anxiety (SMD −0.67, 95%CI [−0.98 to −0.37], p < .0001). Distraction techniques can alleviate perioperative pain, fear, and anxiety in children undergoing circumcision.

Keywords

circumcision distraction operation pediatrics

Introduction

Male circumcision is one of the most common surgical operations. Its purpose is to remove part or all of the penis foreskin. About 13.3 million children undergo surgery every year. The necessity of circumcision for younger children (including newborns) has been controversial (Blank et al., 2012). In 2012, the American Academy of Pediatrics proposed for the first time that the benefits of neonatal circumcision were higher than its risks, which was considered to reduce the risk of HIV, sexually transmitted diseases, penile cancer, and urinary tract infection, but it was still not recommended as a routine operation for newborns because it was unreasonable to use circumcision as a routine medical procedure in countries with low prevalence of sexually transmitted diseases (Frisch et al., 2013; Kissinger et al., 2010). In some HIV-endemic areas, such as some African countries, the World Health Organization recommends the promotion of male circumcision (Hargreave, 2010; Sánchez et al., 2011). Some regions are affected by religious factors and traditional customs. For example, in Muslim countries represented by Turkey, circumcision is popular among school-age children (Altunkol et al., 2019).

Both general anesthesia and local anesthesia are used for analgesia in circumcision. For children, compared with general anesthesia, local anesthesia reduces the risk of postoperative nausea and vomiting and other complications (Kovac, 2020). No matter what kind of anesthesia, children undergoing operation will inevitably have physiological and psychological stress reactions such as pain, fear, and anxiety during the perioperative period (Fortier et al., 2010; Sancar et al., 2016; Wollin et al., 2004). As an auxiliary or supplementary means of drug analgesia, different types of distraction technology are considered to be able to relieve children’s stress reactions such as pain, fear, and anxiety caused by medical procedures, including video, music, and interactive games (Bascour-Sandoval et al., 2019; Chen et al., 2019; Chow et al., 2016). Circumcision in children is a common pediatric operation. It is necessary to develop an auxiliary analgesic and sedative method that is easy to be accepted by children and different from conventional anesthesia. Therefore, according to different economic, cultural, social, and religious backgrounds, the choice of distraction technology that meets the needs of children in different regions and ages has broad application prospects.

The study aims to explore the effects of different forms of distraction techniques on the pain, fear, and anxiety of children under 18 years old undergoing circumcision during the perioperative period when combined or applied alone.

Method

We predefined the objectives and methods of this systematic review and meta-analysis in a protocol registered at PROSPERO (ID: CRD42023479199) and followed the PRISMA 2020 statement. This study comprehensively evaluates the published studies through meta-analysis to promote the development of scientific knowledge. Therefore, there is no need for individual-level human trials or interventions, so there is no need for ethical review and approval.

Search for Included Studies

The PubMed, ClinicalTrials.gov, and Embase databases were searched for articles published from January 1, 2000 to December 31, 2023. We performed a systematic search using key words: “Circumcision,” “Pain,” “Anxiety,” and “Fear.” The search formula was “(Circumcision) AND (Pain OR Anxiety OR Fear).” Two authors reviewed independently; disagreements were resolved by discussion.

Selection of Included Studies

The inclusion criteria were randomized controlled trials (RCT). The scope of the study included the effects of interventions (such as video, music, interactive games, etc.) that can play a distracting role on physiological or psychological stress responses such as pain, anxiety, and fear in children under 18 years old undergoing circumcision during the perioperative period. The exclusion criteria were first non-English articles and duplicate articles. Other excluded articles included: meta-analysis, systematic review, intervention studies unrelated to circumcision, studies including other combination therapies (such as narcotic drugs), single-arm studies, conference abstracts, animal experiments, editorial responses, and unfinished clinical studies.

Data Extraction

The data were independently extracted by two authors. Basic information: author, publication date, journal name, article title. Randomized controlled trial information: blind method, inclusion and exclusion criteria, demographic data of participants, number of participants in each group, and follow-up time. Methodological information: experimental group intervention methods, control group intervention methods, intervention frequency, pain assessment methods, anxiety assessment methods, fear assessment methods, first assessment time, last assessment time, total assessment times, evaluators. Result information: Changes in pain scores, anxiety scores, and fear scores.

Data Synthesis and Analysis

The two authors independently used the ROB2 tool of the Cochrane Collaboration Network to assess the risk of bias. Review Manager 5.4.1 software (the Cochrane Collaboration, Copenhagen, Denmark) was used for statistical analysis. The outcomes were the changes in pain, anxiety, and fear scores of children undergoing circumcision before and after distraction technology intervention. The changes in outcomes after the intervention of different types of distraction techniques in the study were combined and analyzed to obtain the overall effect value of distraction techniques. Subgroup analysis was conducted according to the types of distraction techniques, and the effects of different types of distraction techniques were analyzed in detail. We analyzed continuous data. The random effects model was used to describe the outcome score of continuous variables on the same scale with mean difference (MD), and the standardized mean difference (SMD) described the outcome score of continuous outcome variables on different scales. Under the guidance of Cochran Handbook of evidence-based medicine, the inverse variance method was used to evaluate the mean difference or standardized mean difference of continuous variables. All results were presented as 95% confidence intervals (CI). Significance was set at a p value < .05. Missing data were transformed to complement using statistical formulas. Heterogeneity was tested by I² test. If I² > 50%, the heterogeneity of the results was considered high. The sensitivity analysis of the meta-analysis results was carried out by using the method of one-by-one elimination.

Results

Literature Search

We obtained 2,604 articles by searching PubMed, ClinicalTrials.gov and Embase databases, from which seven RCTs with high quality were selected for full-text review (Ayan & Şahin, 2023; Bulut et al., 2020; Buyuk et al., 2021; Luo et al., 2023; Pazarcikci & Efe, 2023; Tuncay & Tüfekci, 2023; Yeniay et al., 2023). Other studies that did not meet the requirements of evidence-based medicine were excluded, and the flow diagram is presented in Figure 1.

Figure 1.

PRISMA Data Flow Diagram for Systemic Search of Databases.

Study Characteristics

The baseline characteristics and some of the results of the included studies are presented in Tables 1 and 2, we summarized the methodological characteristics of the included studies. Using the Risk of Bias assessment form (ROB2) by Cochrane Collaboration for assessment, the 7 included studies had a low risk of bias. The independent and aggregated bias risk assessment results of the included studies are presented in Figure 2A, B. Only seven studies were included, and no funnel plot was used to assess the risk of publication bias. None of the included studies had a conflict of interest.

Table 1.

Summary of the Methodologies of the Included Studies.

Methodology & Author	Bulut et al. (2020)	Buyuk et al. (2021)	Luo et al. (2023)	Pazarcikci & Efe (2023)	Ayan & Şahin (2023)	Yeniay et al. (2023)	Tuncay & Tüfekci (2023)
Design	RCT	RCT	RCT	RCT	Quasi-experimental study	RCT	RCT
Blinding	Single blind	Single blind	Single blind	Double blind	Single blind	Single blind	NM
Inclusion criteria	Inclusion criteria included agreement to participate in the study and giving written and oral consent (the children and their parents), the ability to speak Turkish and literacy in Turkish, 7 to 11 years of age, an adequate level of mental development to answer questions (the children), suitability for circumcision under general anesthesia, no congenital urologic anomaly, no history of previous postoperative nausea and vomiting, a score of 0 on the Wong-Baker Pain Rating Scale before surgery, and exposure to no previous postoperative analgesics.	The inclusion criteria for the study were an agreement to participate in the study, age between 4 and 10 years, no vision or hearing problems, no history of surgical intervention, and no chronic and mental health problems.	Consecutive children aged 7 to 18 years undergoing circumcision surgery between January 2022 and September 2022, pathological phimosis, recurrent balanitis of the foreskin, and balanitis xerotica obliterans.	Aged 4 to 7 years and undergoing general anesthesia for circumcision with the open surgical technique (sleeve resection); and volunteered to participate in the research, and parents provided written consent for male children to be included in the research.	Agreeing to participate in the study, being able to speak and write in Turkish, having a mental development level to understand the training program, and having a planned circumcision under general anesthesia.	Boys who were scheduled to have circumcision surgery under sedation and analgesia at Giresun Gynecology and Pediatrics Training and Research Hospital boys aged 5 to 10 years of age, who possessed enough mental development level to answer the questions, who agreed to participate in the study, and whose legal guardians had given written and verbal consent.	Boys between the ages of 4 and 6. Children circumcised at the request of their parents (religious and cultural reasons).
Exclusion criteria	NM	NM	Severe developmental or cognitive delays, inability of parents to read or write Chinese, epilepsy, visual impairment, blindness, symptoms of vertigo, an American Society of Anaesthesiologists (ASA) physical status at least III, need for pre-operative anxiolytic medication, and head/face skin ulcers or other infectious skin conditions.	Those with previous surgical intervention experience; those with chronic disease; and children with disability, developmental limitations, and special circumstances involving difficulty with comprehension and perception. Children who stated they wished to leave the study; did not communicate by telephone after discharge; and did not attend check-ups after discharge were removed from the study.	NM	Those with congenital urological anomalies, a history of postoperative nausea and vomiting, and allergy to anesthetic drugs.	Children with chronic diseases. Children with genital medical problems. Children and parents with mental and communication disabilities
Number of intervention group	107	40	70	60	30	62	60
Number of control group	37	38	36	60	30	31	30
Drop out	4	0	0	22	0	3	0
Interventions of intervention group	Music (The Art of The Fugue of Bach)/Hand massage (Classical massage techniques/kaleidoscope (A toy within a variety of shapes and colors that can be observed monocularly when turning this single binocularshaped cylinder).	Virtual reality (VR BOX 3.000 with VR glasses).	Virtual reality (VR): Biophilic-VR (BVR) and Indoor-VR(IVR) / VR glasses (weigh 350g, Unity3D 2018.3.10f1, Shu Rui Medical).	Comfort-oriented nursing care based on the comfort theory.	Therapeutic play-based training program.	Music (classical music piece)/Video (informative cartoon about the operation).	Puppet play/video animation.
Interventions of control group	Routine care	Clinical routine care	Patients who did not wear VR glasses throughout the procedure.	Routine nursing care	NM	Routine care	Routine procedures
Implementation period of intervention	Postoperative	Preoperative	Preoperative	Preoperative	2 hours before operation	Preoperative	Preoperative
Intervention frequency	Music (once every 20 minutes, lasting for 20 minutes)/Hand massage (for a total of 20 minutes, 10 minutes per hand)/Kaleidoscope (with an interval of 20 minutes, lasting for 1 hour).	Once	During the whole operation	During the whole hospitalization	Once	Music: once (lasting for 20 minutes)/Video: once.	Music: once (lasting for 10 minutes)/Video: once (lasting for 4 minutes)
Measure of pain	Wong-Baker Faces Pain Rating Scale (WBS)	Wong-Baker Faces Pain Rating Scale (WBS)	The faces pain scale-revised (FPS-R)/Pain index (Pi)	NM	NM	Wong-Baker Faces Pain Rating Scale (WBS)	Wong-Baker Faces Pain Rating Scale (WBS)
Measure of fear	Children’s Fear Scale (CFS)	Children’s Fear Scale (CFS)	NM	Children’s Fear Scale (CFS)	Fear for Medical Procedures Scale (FMPS)	Children’s Fear Scale (CFS)	Children’s Fear Scale (CFS)
Measure of anxiety	Modified Yale Preoperative Anxiety Scale (mYPAS)	Children’s Anxiety Meter Scale (CAMS)	The simplified Chinese version of the modified Yale preoperative anxiety scale (CmYPAS)/Anxiety index (Ai)/State-trait anxiety inventory (STAI)/Visual Analogue scale (VAS)/Heart rate (HR)	Children’s Anxiety Meter Scale (CAMS)	Childhood Anxiety Sensitivity Index (CASI)	NM	Child Anxiety Scale-State (CAS-S)
First measure time	Postoperative	Preoperative	Preoperative	Preoperative	Preoperative	Preoperative	Preoperative
Last measure time	2 hours after operation	Postoperative	At the end of the operation	On the 10th day after operation	Before discharge after operation	4 hours after operation	4 hours after operation
Number of measures	3	2	7	7	3	5	4
Measurer	The principal researchers	Children, parents, nurses, observers.	Blinded researchers	Blinded participants	The research team members	Observers and data analysts	Mothers and the children
Follow up	12h	NM	NM	On the 10th day after operation	NM	NM	NM
Type of anesthesia	General anesthesia	NM	Local anesthesia	General anesthesia	General anesthesia	Local anesthesia	General anesthesia

Note. RCT = randomized controlled trial; NM = not mentioned.

Table 2.

Summary of Continuous Quantitative Outcomes of the Included Studies.

Study	Outcomes
Bulut et al. (2020)		Music group	Kaleidoscope group	Hand massage group	Combined intervention group	Control group
	WBS^a
	Pre-treatment	4.11 (0.67)	3.91 (0.65)	4.34 (0.91)	4.12 (0.76)	3.91 (0.88)
	Post-treatment	1.68 (1.13)	1.08 (0.98)	1.31 (1.1)	1.35 (1.08)	2.45 (0.95)
	Change value	−2.43 (0.98)	−2.83 (0.86)	−3.03 (1.01)	−2.77 (0.96)	−1.46 (0.91)
	CFS^a
	Pre-treatment	3.25 (0.65)	3.14 (0.69)	3.42 (0.91)	3.26 (0.75)	3.62 (0.94)
	Post-treatment	1.31 (1.05)	0.82 (0.92)	0.88 (0.79)	1 (0.94)	2.08 (1.06)
	Change value	−1.94 (0.91)	−2.32 (0.82)	−2.54 (0.85)	−2.26 (0.86)	−1.54 (1)
	mYPAS^a
	Pre-treatment	18.54 (4.18)	18.22 (2.62)	17.88 (1.74)	18.21 (2.99)	19.22 (2.88)
	Post-treatment	10.42 (4.59)	7.74 (3.31)	8.82 (3.5)	8.99 (3.95)	15.2 (2.08)
	Change value	−8.12 (4.39)	−10.48 (3.02)	−9.06 (3.03)	−9.22 (3.56)	−4.02 (2.57)
Buyuk et al. (2021)		VR group	Control group
	CAMS^a
	Pre-treatment	1.6 (1)	3.32 (2.45)
	Post-treatment	3.28 (3.01)	7.03 (3)
	Change value	1.68 (2.65)	3.71 (2.76)
	CFS^a
	Pre-treatment	0.56 (0.55)	0.84 (0.97)
	Post-treatment	1.18 (0.97)	2.26 (1.24)
	Change value	0.62 (0.84)	1.42 (1.12)
Luo et al. (2023)		Biophilic VR group	Indoor VR group	Combined intervention group	Control group
	Pi^a
	Pre-treatment	2.3 (1.3)	2.2 (1.4)	2.24 (1.34)	2.4 (1.7)
	Post-treatment	2.1 (1.7)	2.1 (1.7)	2.1 (1.68)	2.4 (1.7)
	Change value	−0.2 (1.57)	0.1 (1.57)	−0.14 (1.53)	0 (1.7)
	Ai^a
	Pre-treatment	42.1 (18.3)	45.4 (16.7)	43.79 (17.44)	44.1 (12)
	Post-treatment	38.9 (14.7)	39.2 (14.5)	39.05 (14.49)	49 (15.6)
	Change value	−3.2 (16.79)	−6.2 (15.71)	−4.74 (16.16)	4.9 (14.14)
Pazarcikci & Efe (2023)		Therapeutic play group	Control group
	CAMS^a
	Pre-treatment	4.4 (2.87)	4,45 (3.09)
	Post-treatment	2.21 (1.82)	3.03 (2.3)
	Change value	−2.19 (2.51)	−1.42 (2.78)
	CFS^a
	Pre-treatment	1.35 (0.97)	1.36 (1.24)
	Post-treatment	0.76 (0.85)	1.31 (1.08)
	Change value	−0.59 (0.91)	−0.05 (1.16)
Ayan & Şahin (2023)		Therapeutic play group	Control group
	CASI^a
	Pre-treatment	38.53 (1.94)	37.96 (2.69)
	Post-treatment	29.33 (2.52)	36.66 (3.82)
	Change value	−9.2 (2.28)	−1.3 (3.39)
	FMPS^a
	Pre-treatment	62 (2.5)	60.83 (3.76)
	Post-treatment	45.3 (4.17)	57.16 (5.54)
	Change value	−16.7 (3.63)	−3.67 (4.89)
Yeniay et al. (2023)		Video group	Music group	Combined intervention group	Control group
	CFS^a
	Pre-treatment	2 (0.86)	1.5 (0.86)	1.75 (0.88)	1.5 (0.86)
	Post-treatment	2.5 (0.86)	1.5 (0.86)	2 (0.99)	0.33 (0.86)
	Change value	0.5 (0.86)	0 (0.86)	0.25 (0.93)	−1.17 (0.86)
Tuncay & Tüfekci (2023)		Therapeutic play group	Video group	Combined intervention group	Control group
	WBS^a
	Pre-treatment	0.1 (0.54)	0.13 (0.5)	0.11 (0.51)	0.06 (0.25)
	Post-treatment	6.56 (1.61)	6.4 (1.79)	6.48 (1.68)	7.7 (1.66)
	Change value	6.46 (1.41)	6.27 (1.59)	6.37 (1.49)	7.64 (1.55)
	CAS-S^a
	Pre-treatment	6.26 (2)	5.01 (2.11)	5.63 (2.13)	5.55 (2.34)
	Post-treatment	5.91 (1.55)	5.63 (1.31)	5.77 (1.42)	7.25 (1.61)
	Change value	−0.35 (1.81)	0.62 (1.84)	0.14 (1.87)	1.7 (2.07)
	CFS^a
	Pre-treatment	1.71 (1.01)	1.83 (0.95)	1.77 (0.97)	1.95 (0.98)
	Post-treatment	2.28 (0.79)	2.16 (0.74)	2.22 (0.76)	2.76 (0.79)
	Change value	0.57 (0.91)	0.33 (0.86)	0.45 (0.88)	0.81 (0.9)

Note. WBS = Wong-Baker Faces Pain Rating Scale; CFS = Children’s Fear Scale; mYPAS = Modified Yale Preoperative Anxiety Scale; CAMS = Children’s Anxiety Meter Scale; Pi = Pain Index; Ai = Anxiety Index; CASI = Childhood Anxiety Sensitivity Index; FMPS = Fear for Medical Procedures Scale; CAS-S = Child Anxiety Scale-State.

Mean (Standard Deviation [SD]).

Figure 2.

(A) Risk of Bias of the Included Studies. (B) Summary of Risk of Bias.

Outcome Measures

Changes in Pain Scores

Pain was assessed by the Wong-Baker Faces Pain Rating Scale (WBS) and pain index (PI). The intervention effect was evaluated according to the change in pain score before and after distraction technology intervention. Three studies were included, including 235 male children in the intervention group and 101 male children in the control group (Bulut et al., 2020; Luo et al., 2023; Tuncay & Tüfekci, 2023). The outcomes of different intervention subgroups in the included studies were combined and analyzed to obtain the overall pain relief effect of distraction technology on male children undergoing circumcision. Decreased scores indicated decreased pain levels. The result showed that there was no significant difference between the intervention group and the control group (SMD -0.76, 95%CI -1.52 to 0, p = .05). The heterogeneity of the result was high (I² = 90%, p < .0001). The result of meta-analysis of pain score changes is presented in Figure 3.

Figure 3.

Forest Plot of Change of Pain Score.

Changes in Fear Scores and Subgroup Analysis

Children’s Fear Scale (CFS) and Fear for Medical Procedures Scale (FMPs) were used to assess fear. The intervention effect was evaluated according to the change in fear score before and after distraction technology intervention. Six studies were included, including 347 male children in the intervention group and 209 male children in the control group (Ayan & Şahin, 2023; Bulut et al., 2020; Buyuk et al., 2021; Pazarcikci & Efe, 2023; Tuncay & Tüfekci, 2023; Yeniay et al., 2023). The outcomes of the different intervention subgroups included in the study were combined and analyzed to obtain the alleviation effect of distraction technology on the fear of male children undergoing circumcision. Decreased scores indicated decreased fear levels. The result showed that there was no significant difference between the intervention group and the control group (SMD −0.64, 95% CI [−1.54 to 0.27], p = .17). The heterogeneity of the result was high (I² = 96%, p < .00001). The result of meta-analysis of fear score changes is presented in Figure 4A.

Figure 4.

(A) Forest Plot of Change of Fear Score. (B) Forest Plot of Subgroup Analysis of Fear Score.

Subgroup analysis was conducted according to the types of distraction techniques to explore the alleviating effects of music, video, and therapeutic play on the level of fear. The results showed that there was no significant difference between the intervention group and the control group in the music group (SMD 0.46, 95% CI [−1.26 to 2.18], p = .6), video group (SMD 0.68, 95% CI [−1.72 to 3.09], p = .58) and therapeutic play group (SMD -1.22, 95% CI [−2.58 to 0.14], p = .08). The results of music Group (I² = 95%, p < .00001), video group (I² = 97%, p < .00001) and therapeutic play group (I² = 95%, p < .00001) were highly heterogeneous. The result of the subgroup analysis of fear score changes is presented in Figure 4B.

Changes in Anxiety Scores and Subgroup Analysis

Anxiety was assessed by Modified Yale Preoperative Anxiety Scale (mYAPS), Children’s Anxiety Meter scale (CAMS), anxiety index (AI), Child Anxiety Sensitivity Index (CASI), and Child Anxiety Scale-State (CAS-S). The intervention effect was evaluated according to the change of anxiety score before and after distraction technology intervention. Six studies were included, including 357 male children in the intervention group and 215 male children in the control group (Ayan & Şahin, 2023; Bulut et al., 2020; Buyuk et al., 2021; Luo et al., 2023; Pazarcikci & Efe, 2023; Tuncay & Tüfekci, 2023). The outcomes of different intervention subgroups in the included study were combined and analyzed to obtain the overall effect of distraction technology on relieving anxiety of male children undergoing circumcision. Decreased scores indicated decreased anxiety levels. The result showed that there was a significant difference between the intervention group and the control group (SMD −1.07, 95%CI [−1.64 to −0.51], p = .0002). The heterogeneity of the result was high (I² = 89%, p < .00001). The result of the meta-analysis of anxiety score changes is presented in Figure 5A.

Figure 5.

(A) Forest Plot of Change of Anxiety Score. (B) Forest Plot of Subgroup Analysis of Anxiety Score.

Subgroup analysis was conducted according to the types of distraction techniques to explore the relieving effects of therapeutic play and virtual reality (VR) on anxiety levels. The results showed that there were significant differences between the intervention group and the control group in the therapeutic play group (SMD −1.31, 95%CI [−2.59 to −0.04], p = .04) and the VR group (SMD −0.67, 95%CI [−0.98 to −0.37], P < .0001). The heterogeneity of results was high in the therapeutic game group (I² = 94%, p < .00001) but low in the VR group (I² = 0%, p = .69). The result of subgroup analysis of anxiety score changes is presented in Figure 5B.

Sensitivity Analysis

Sensitivity analysis was performed using the one-by-one elimination method. The meta-analysis result of pain level changes was unstable. After excluding the research of Luo et al. (2023), there was a significant difference between the intervention group and the control group (MD -1.3, 95%CI [−1.61 to −0.99], p < .00001). The result is presented in Figure 6A. The meta-analysis result of fear level changes was unstable. After excluding the research of Yeniay et al. (2023), there was a significant difference between the intervention group and the control group (SMD −1.04, 95%CI [−1.68 to −0.4], p = .001). The result is presented in Figure 6B. Similarly, the subgroup analysis results of fear level changes were unstable. After excluding the studies of Ayan and Şahin (2023) and Yeniay et al. (2023), there was a significant difference between the intervention group and the control group in the therapeutic play group (MD −0.4, 95%CI [−0.71 to −0.1], p = .01). The result is presented in Figure 6C. The results of the music group and the video group were considered unreliable. The meta-analysis results of anxiety level and its subgroup analysis were stable.

Figure 6.

(A) Forest Plot of Change of Pain Score After Sensitivity Analysis.(B) Forest Plot of Change of Fear Score After Sensitivity Analysis. (C) Forest Plot of Fear Score of Therapeutic Play Group After Sensitivity Analysis.

Discussion

“Distraction” is defined as “distracting the patient from harmful stimuli.” Previous relevant studies have summarized the distraction techniques that can be applied in clinical practice for children, mainly including active and passive types. Active distraction technology includes video games, VR, breath control, guided imaging and relaxation, and passive distraction technology includes music and TV programs (Koller & Goldman, 2012).

Over the years, many studies have been exploring how to find distraction techniques suitable for children to reduce the negative physiological and psychological reactions caused by medical measures. Mason et al. (1999) believed that active distraction technology is more conducive to reduce the pain and negative emotions of children caused by medical procedures. While Maclaren and Cohen (2005) believed that for children, the requirements for active distraction technology participation are too stringent, and passive distraction technology is more easily accepted by children. Coyne et al. (2009) believed that children’s opinions should be valued and summarized qualitatively, which helps researchers deepen their understanding of children’s needs. Donna et al. (Koller & Goldman, 2012) concluded in the study that the task of current and future researchers is to study specific diseases to obtain more accurate and effective suggestions.

Our study focused on circumcision, combined with the existing high-quality research to explore the distraction technology suitable for children from the perspective of a single disease. The types of distraction techniques included in this study include music, video, therapeutic play, VR, kaleidoscope, and relaxing hand massage. This study suggests that, in general, the intervention of distraction technology can reduce negative physiological and psychological reactions such as pain, fear, and anxiety in children during the perioperative period of circumcision. For the analyzable single type of distraction technology, therapeutic play can alleviate fear and anxiety. VR can alleviate anxiety.

This study has some limitations. First, the number of high-quality studies included is small, and the role of evidence-based medicine in clinical guidance is weak. Second, the heterogeneity of meta-analysis results is high, especially when different types of distraction techniques in each study are combined into a general analysis, which means that there are great differences among the included studies, and the conclusion is not reliable. Therefore, we performed subgroup analysis according to the type of distraction technology, but unfortunately, only in the VR intervention subgroup, the heterogeneity of the meta-analysis results of anxiety was effectively reduced (I² = 0%, p = .69). We analyzed that subgroup analysis of the types of distracting techniques is reasonable, but the effect of subgroup analysis depends on whether the specific intervention schemes of the same distracting technique in different studies have large differences. In the meta-analysis of anxiety in the therapeutic play intervention subgroup, the intervention measures defined as “therapeutic play” have different implementation methods. For example, the intervention measure of Pazarcikci and Efe (2023) is a new nursing method with interactive play participated by parents. Its core is the “comfort theory,” which aims to meet the comfort needs of children in multiple dimensions. The intervention measure of Ayan and Şahin (2023) is to simulate the operation process by using the toys prepared in advance, and its purpose is to make the children who are about to undergo the operation understand the operation to a certain extent. The intervention measure of Tuncay and Tüfekci (2023) is puppet show. Compared with technology products with strict definitions such as VR, the definition of “therapeutic game” is relatively vague and broad. It can be seen that it is necessary to have a correct classification of technology types, which affects the reliability of the results. Finally, the results of the sensitivity analysis show that the conclusion of the meta-analysis is not robust. The impact of each included study on the results was analyzed by eliminating it one by one. The sensitivity analysis result of the intervention effect of distraction technology in general on pain level shows that when the study of Luo et al. (2023) was excluded, the direction of the meta-analysis result changed, and the heterogeneity was significantly reduced (I² = 0%, p = .92). Similarly, the sensitivity analysis results of the intervention effect of distraction technology in general and the therapeutic play subgroup on fear level show that when the researches of Yeniay et al. (2023) and Ayan and Şahin (2023) were excluded, the directions of the corresponding meta-analysis results changed and the heterogeneities decreased. And due to the influence of the study of Yeniay et al. (2023), we finally abandoned the evaluation of the intervention effect of the music subgroup and video subgroup on fear level, because we still have doubts about the results of the excluded study. Our speculation on the results of sensitivity analysis is due to the differences in the types of distraction techniques and the design of experimental schemes, resulting in a huge deviation in the overall research direction caused by a certain study.

There are still many problems worthy of our attention and solutions in future research. First, we need more high-quality RCTs to provide evidence for evidence-based medicine. Different intervention techniques or the same intervention technique in different evaluation dimensions may have differences (Koller & Goldman, 2012), which is an important reason for the heterogeneity between different studies. Using standardized intervention programs as much as possible and combining the same types of distraction techniques can reduce methodological heterogeneity. For example, we can understand the types of distraction techniques that local children prefer through regional questionnaires; clinical practice guidelines can also be formulated by organizing medical conferences to guide the adjustment and unification of clinical distraction technical parameters. The choice of distracting technology types is affected by the development and introduction of technology. We should pay attention to the intervention effect of new technology on patients, especially for children who are more inclined to pursue novelty, and the effect of new technology on distracting attention is more obvious (Koller & Goldman, 2012). For children of different ages, different types of distraction techniques should be allocated to achieve the best effect. For example, for young children with poor cognitive ability, intervention forms that are easier to understand can be adopted, such as early education in music, animation; for older children with certain understanding abilities, more complex intervention means can be used, such as interactive games with task nature. The acceptance of medical procedures and distraction techniques by different study participants is also a factor leading to heterogeneity. Factors such as geographical location, socio-economic conditions, medical and health care conditions, education level, religious beliefs, and so on should be taken into account. In detail, economically developed and medically advanced regions have more resources to ensure residents to perform circumcision and promote the promotion of distraction technology; people with high education levels are more likely to accept health education; believers will start from the religious level to ensure that the intervention measures they receive are in line with their religious doctrines (Blank et al., 2012; Frisch et al., 2013; Hargreave, 2010; Tomkins et al., 2015). Finally, using the same outcome measurement tools, ensuring the objectivity of data recording (selecting data from third-party observers rather than parents and children themselves), and avoiding data loss can also reduce errors.

This study summarizes the existing distraction techniques that can be applied in clinical practice and affirms their role in alleviating patients’ negative emotions. Although the conclusions of this study are subjective and weak due to the heterogeneity between different studies, the auxiliary role of distraction technology in treatment is still a clinical research topic worthy of further exploration in the future.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Xiaofeng Wang

Gonglin Tang

Fengze Sun

Jitao Wu

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The Effect of Distraction Techniques on Pain,Fear,and Anxiety in Children Undergoing Circumcision: A Meta-Analysis of Randomized Controlled Trials

Abstract

Keywords

Introduction

Method

Search for Included Studies

Selection of Included Studies

Data Extraction

Data Synthesis and Analysis

Results

Literature Search

Study Characteristics

Outcome Measures

Changes in Pain Scores

Changes in Fear Scores and Subgroup Analysis

Changes in Anxiety Scores and Subgroup Analysis

Sensitivity Analysis

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

References