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International Journal of Nursing Studies Advances logoLink to International Journal of Nursing Studies Advances
. 2026 May 15;10:100550. doi: 10.1016/j.ijnsa.2026.100550

Managing pediatric pain during needle procedures: a narrative review of virtual reality and Buzzy as distraction-based interventions

Maia Medland a,1, Brian Greeley a,1,⁎, Roi Jankelowitz a, Sima Zakani a,b, John Jacob a,b
PMCID: PMC13200113  PMID: 42200004

Abstract

Background

: Needle-induced pain is common in children and can contribute to negative healthcare experiences. While pharmacological treatments can be effective, they may involve delayed onset and potential side effects. This narrative review explores two non-pharmacological alternatives, virtual reality and Buzzy (a device that combines cold therapy and vibration), as pain management tools during pediatric needle procedures. While there have been many studies using these methods, results have been mixed. The overall goal of this narrative review is to summarize higher quality studies on the use of virtual reality and Buzzy for managing needle-related pain in pediatric populations, with particular attention to how concurrent analgesic use, age, and study design may explain the variability observed in previous findings.

Methods

: Eligible articles included randomized controlled trials with a sample size ≥30 per group, typically developing children and youth, a control group, both a pre- and post-procedural self-reported measure of pain, published between 2015 and 2025, and available in English.

Results

: Ninety-nine articles were identified and 86 were excluded, of which 46 (53%) did not report pre-procedural pain. Thirteen articles met the inclusion criteria: ten on virtual reality and three on Buzzy. Results were mixed, however virtual reality and Buzzy were generally more effective in reducing needle-related pain when standard of care did not include analgesics. When examined by age, younger children showed more consistent benefits, particularly with virtual reality, whereas older children and adolescents demonstrated smaller or non-significant effects regardless of analgesic use.

Conclusion

: Virtual reality and Buzzy appear to be effective in managing needle-related pain in children; however, their effectiveness may be influenced by concurrent analgesic use, age, and intervention design. More research is needed to better understand when these interventions are most effective and for whom.

Keywords: Virtual reality, Buzzy, Distraction, Needle-related procedures, Pain management, Children, Pediatrics

What is Known:

  • •

    Needle-induced pain needs to be managed in children.

  • •

    Visual and tactile distraction methods such as virtual reality and Buzzy, respectively, may be effective in managing needle-induced pain in children.

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What is New:

  • •

    Virtual reality and Buzzy may reduce needle-related pain in children, particularly when standard of care does not include analgesics.

  • •

    Younger children showed more consistent benefits, especially with virtual reality, while older children and adolescents more often demonstrated smaller or non-significant effects.

  • •

    It is unknown if VR combined with Buzzy is effective at reducing pain in children.

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Introduction

Five to 28% of children undergoing needle-related procedures experience pain and fear (McMurtry et al., 2015; Taddio et al., 2022), leading to increased procedural time, heightened pain sensitivity, and contribution to future healthcare avoidance (McMurtry et al., 2015; Wong and Choi, 2023). As a result, effective pain management during these procedures is critical to improving immediate and long-term health outcomes in pediatric populations (McMurtry et al., 2015; Taddio et al., 2022). Topical anesthetics can be used to manage needle pain in pediatrics (Lee et al., 2014; Taddio et al., 2015), but they often have a delayed onset and may be associated with side effects (Bilgen Sivri et al., 2023; Shah et al., 2015). For instance, oral analgesics can alleviate procedural pain but require ≥20 min to work (Pope, 2024). Anesthetics can also cause nausea and/or allergic reactions in pediatric populations (Hartling et al., 2016; O’Donnell and Rosen, 2014). Given the frequency of needle-related procedures and the limitations associated with pharmacological interventions (Bilgen Sivri et al., 2023; McMurtry et al., 2015) there is a need to explore alternative, non-pharmacological approaches for managing needle-related pain in children.

Distraction has been shown to be a promising approach for mitigating needle pain. Buzzy, a bee-shaped device that combines vibration and cold therapy (e.g., removable ice wings), has been shown to be effective in reducing needle-related pain (Ballard et al., 2024; Bilgen Sivri et al., 2023). Distraction cards, bubbles, and toys have also shown promise in reducing pain in pediatric populations (Guillari et al., 2024). Still, these distraction methods may not entirely divert a child’s attention, limiting their effectiveness (Wong and Choi, 2023). Notably, active technology-based distractors, such as video games, have been found to outperform passive ones, like watching cartoons (Addab et al., 2022; Niaz et al., 2023), suggesting that more immersive and engaging interventions may be more effective.

Virtual reality offers a fully immersive environment that may manage needle-related pain in children (Addab et al., 2022; Aydın and Özyazıcıoğlu, 2019; Chan et al., 2019; Gerçeker et al., 2025; Gold et al., 2021). Despite virtual reality’s promise, the broader literature tends to include studies with small sample sizes, no control groups, and the reliance on observer-reported pain measures (Canares et al., 2021; Chan et al., 2019; Gold and Mahrer, 2018; Hsu et al., 2022; Simoncini et al., 2023), making it difficult to draw firm conclusions regarding their effectiveness on pain management. Importantly, while both virtual reality and Buzzy have been studied independently, there is an evidence gap in research exploring the combined effectiveness of these two interventions.

Virtual reality and Buzzy are promising non-pharmacological options; however, variability in study quality and design make it difficult to draw clear conclusions. Given these limitations, this review aims to synthesize high quality evidence on the effectiveness of virtual reality and Buzzy in managing needle-related pain in pediatric patients.

Methods

Design

This paper is a narrative review that aims to synthesize and interpret findings from higher quality research using a structured but non-systematic approach. Several recently published meta-analyses have already examined Buzzy (Apuzzo et al., 2025; Da Silva Moura et al., 2026) and virtual reality (Shi et al., 2026) as separate interventions for reducing needle-related pain. Rather than contribute redundantly to this existing body of work, a narrative review synthesizing both non-pharmacological approaches within a single paper and attempting to understand the factors contributing to the variable results, would provide greater added value to the field. The scope of this review follows the Population, Intervention, Comparison, and Outcome format (Richardson et al., 1995) (population: pediatrics [age 3 to 21 years]; intervention: virtual reality and/or Buzzy; comparison: standard of care; outcome: self-reported pain). We relied on several best practice papers to guide our search process (Aguinis et al., 2023; Snyder, 2019).

Search strategy

An initial exploratory search was conducted to find systematic reviews and meta-analyses examining the use of Buzzy and/or virtual reality for managing needle-related procedural pain in pediatric populations. We then used citation chaining and extracted the keywords from (Merino-Lobato et al., 2023) to identify additional articles. We compiled a comprehensive list of search terms, which guided a structured search across PubMed, Google Scholar, and the University of Guelph library databases. As this is a narrative review, the search strategy was designed to identify relevant and higher quality studies rather than to exhaustively capture all available literature. Initial searches were conducted in June, with another search performed in July of 2025. Search terms included “injections”, “venipunctures”, “immunization”, “needle”, “buzzy”, “virtual reality” (for a complete list of terms see Supplementary document).

Selection criteria

Articles were selected based on the inclusion criteria and were downloaded and coded into a spreadsheet. As we were interested in higher quality studies, eligible articles had to be adequately powered (e.g., n ≥ 30) (Goktas and Avci, 2023), include typically developing children and youth, a control group, both a pre- and post-procedural validated self-reported measure(s) of pain as the primary outcome, be a peer-reviewed randomized controlled trial published between 2015 and 2025, and available in English. Articles were required to have primarily studied a pediatric population (although studies that included some adults were included) and involve the use of Buzzy and/or virtual reality during needle-related procedures.

Data extraction

We developed a semi-automated data extraction workflow that incorporated ChatGPT. After retrieving the full set of eligible articles, we created a spreadsheet in which each record was numbered and basic bibliographic details (e.g., search terms, platform used, citation information) were populated manually. ChatGPT (accessed June 2025, version 4.0) was employed to assist in extracting structured information from each article during the initial screening. To ensure reliability, the prompts provided to ChatGPT were iteratively refined through trial and error to optimize accuracy (see Supplementary Methods for final prompt). The tool was used strictly for information organization rather than interpretation, and all extracted information was verified by human reviewers.

We extracted publication year, first author, country of first author, DOI, journal, article type, keywords, study objective(s), sample size (N), participant demographics (mean age, age range, sex distribution), study design, measures used, intervention(s), comparator groups, procedures, primary and secondary outcomes, results, research gaps, and conclusions from each article. All entries were cross-checked against the original articles by two independent reviewers (MM and RJ). Any discrepancies were discussed, and unresolved disagreements were adjudicated by a third reviewer (BG). This approach ensured that ChatGPT functioned only as a facilitator to streamline the extraction process, while the final dataset was fully validated by human reviewers.

Cohen's d was calculated for each study using the reported group means and standard deviations to quantify intervention effectiveness. When means and standard deviations were not reported, Wan and colleagues’ method was used to estimate them from the median, Q1, and Q3 (Wan et al., 2014).

Quality assessment

To evaluate the quality of included articles, we used the Mixed Methods Appraisal Tool (MMAT) Version 2018 (Hong et al., 2018). For each article, reviewers (MM and RJ) independently assessed all relevant MMAT items and recorded responses in a summary table as “yes,” “no,” or “can’t tell”. Additional comments were documented when clarification or justification was required (see Table 2). All fields were checked by a third reviewer (BG).

Table 2.

Quality assessment of each included study using the Mixed Method Appraisal Tool. Questions were taken from the quantitative randomized controlled trials section. The questions are the following S1 = Are there clear research questions?; S2 = Do the collected data allow to address the research questions?; 2.1 = Is randomization appropriately performed? 2.2 = Are the groups comparable at baseline?; 2.3 = Are there complete outcome data?; 2.4 = Are outcome assessors blinded to the intervention provided?; 2.5 = Did the participants adhere to the assigned intervention?. CAS = colour analogue scale; FAS = facial affective scale; FAS-R = faces pain scale revised; SOC = standard of care; VR = virtual reality; VAS = visual analogue scale.

Author Question number from Quantitative randomized controlled trials
 Comments
S1 S2 2.1 2.2 2.3 2.4 2.5
Virtual Reality
Goktas & Avci (2023) Yes Yes Yes Yes Yes No Yes
Gold & Mahrer (2018) Yes Can’t tell
Comments:
Three pain scales were reported; a fourth (FPS-R) was absent from the methods but used as a primary outcome, where a between-group difference was found		 Yes Yes
Comments: 30% of the control group were Caucasian vs. 12% in the VR group.		 Yes
Comments:
4 control and 2 VR participants were removed.		 No Yes Three pain measures (VAS, CAS, FAS) were reported in the methods, with differences found only in FAS (affective pain). FPS-R was reported in the results but not mentioned in the methods.
Gold et al. (2021) Yes Yes Yes Can’t tell
Comments: No analysis performed / reported on baseline demographics between the two groups.		 Yes
Comments:
6 control and 5 VR participants were excluded.		 No
Comments:
Staff were blinded to group assignment until after baseline assessments were collected.		 Yes
Goldman & Behboudi (2021) Yes Yes Yes No
Comments:
Baseline pain was lower in the VR group (2/10) than in the control group (4/10) but differences in pain scores were used.		 Yes
Comments:
4 participants withdrew after randomization, but their group allocation was not reported.		 No
Comments: Doesn’t discuss blinding.		 Yes
Osmanlliu et al. (2021) Yes Yes
Comments: Yes, for aim 1 and partially for aim 2. Did not provide effect sizes.		 Yes No
Comments:
Baseline pain was not compared between groups, despite being higher in the VR group. A higher % of VR participants were seated and received topical anesthetic, but it is unclear if this was baseline or intervention-related.		 No
Comments: Some missing satisfaction data. Memory of pain at 24 h had a dropoff.		 No Yes
Comments: 90% adhered to intervention. One participant ended the VR because of a headache and another participant wanted to watch the procedure.
Van den Berg et al. (2023) Yes Yes Yes Yes Yes
Comments: 10 VR and 14 control participants were lost.		 No Yes Participants knew their group before baseline date collection.
Wong & Choi (2023) Yes Yes Yes Yes Yes
Comments: 2 VR and 6 control participants were lost to follow-up.		 No Yes
Dilek et al. (2024) Yes Yes Yes Yes
Comments:
Only baseline outcomes (pain, anxiety, fear) measures were assessed. Age and sex in each group is the same.		 Yes No
Comments: Blinding not discussed.		 Yes
Comments:
Adherence not discussed.
Koç Özkan & Polat (2020) Yes Yes Yes Yes Yes No Yes N reported in the abstract differs from N reported in the results table. Sex distribution is not adequately described.
Chan et al. (2019) (a) Yes Yes Yes Yes Yes No
Comments:
Blinding was not feasible.		 Yes
Chan et al. (2019) (b) Yes Yes Yes Yes Yes No
Comments:
Blinding was not feasible.		 Yes
Buzzy
Küçük Alemdar & Yaman Aktaş (2019) Yes Yes Yes Yes
Comments:
More males (62%) in Jet Lidocaine group compared to females (39%).		 No
Comments:
3 from Buzzy, 2 from Jet Lidocaine, 2 from bubble blowing, 3 from aromatherapy, and 5 from control were excluded.		 No Yes Side effects, adherence were unreported; a significant group-by-time interaction was reported, though the timepoint of between-group differences was unclear.
Ballard et al. (2024) Yes Yes Yes Yes No
Comments:
16 lost in the Buzzy group and 8 lost in the topical anesthetic group. An additional 12 excluded from Buzzy and 6 excluded from the topical anesthetic group. 56% of data missing for pain recall.		 No Yes
Sönmez Düzkaya et al. (2024) Yes Yes Yes Yes
Comments: 69% of sample in Helfer group was Female.		 Yes No
Comments:
Does not discuss blinding.		 Yes
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Results

Articles excluded

Ten articles for virtual reality and three for Buzzy were included. From our initial results, 99 articles were initially identified and 86 were excluded. Among those excluded, 46 (53%) did not report pre-procedural pain (i.e., a baseline), 25 (29%) did not meet study design inclusion criteria, 10 (12%) were review articles, three (3%) were of poor methodological quality, one (1%) was not in English, and one (1%) was unavailable (Fig. 1). A summary of the included articles and an assessment of their quality can be found in Table 1, Table 2, respectively.

Fig. 1.

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PRISMA flowchart.

Table 1.

Studies included in the review. CAS = Colour Analogue Scale; ED = emergency department; FPS-R = Faces Pain Scale Revised; SOC = standard of care; WB-FPS = Wong-Baker Faces Pain Rating Scale; VAS = Visual Analogue Scale; VNRS = Verbal Numerical Rating Scale; VR = virtual reality.

Author Country N Age range (mean) Number of Females (%) Procedure and setting Intervention group(s)
(n)		 Control
Group (n)		 Use of Pain Relief Medication (%) Measure (s) Results
Virtual Reality
Goktas & Avci (2023) Turkey 144 7 to 12 (not reported) 72 (50%) Deltoid vaccination, venipuncture, or a blood draw at pediatric ED VR (36);
Music (36);
Kaleidoscope (36)		 Parental presence and verbal distraction (36). No mention of pain relief mediation. WB-FPS The control group had more pain compared to the three distraction groups.
Gold & Mahrer (2018) USA 143 10 to 21 (15.4) 72 (50%) Blood draw at children’s hospital VR (70) Low volume cartoons played on a TV (73). None of the patients received local anesthetics. VAS, CAS, FAS, and FPS-R The VR group had lower affective pain (FAS) relative to control.
Gold et al. (2021) USA 107 10 to 21 (not reported) 44 (41%) Peripheral IV catheterization at pediatric academic medical center VR (53) Listening to music, colouring, and talking. Numbing cream and spray was offered to all, but often declined by VR participants, with no data on uptake. FPS-R The VR group had lower pain relative to those in the control group.
Goldman & Behboudi (2021) Canada 66 6 to 17 (not reported) 30 (45%) IV catheterization
at pediatric ED		 VR (35) Books, movies, iPads, or bubbles and support from a child life specialist (31). Analgesic use included oral medications (acetaminophen, ibuprofen, intranasal opioids; VR: 46% control: 61%) and
topical anesthetics (4% amethocaine gel, vapocoolant [Pain Ease],lidocaine/prilocaine eutectic mixture [EMLA]; VR: 94%, control: 87%).		 FPS-R No difference in pain between the groups.
Osmanlliu et al. (2021) Canada 62 7 to 17 (11.1) 38 (61%) IV insertion or venipuncture at pediatric ED VR (31) Parental presence encouraged, distraction done by parent or healthcare provider (31). Distraction method not described. VR (77%) and control (61%) received numbing cream (Maxilene-Liposomal Lidocaine 4%). 26% of participants in both groups received either oral (acetaminophen and/or ibuprofen) or intra-nasal (Fentanyl 1 mg/kg) analgesics. VNRS No difference in pain between groups.
Van den Berg et al. (2023) Netherlands 114 6 to 18 (not reported) 62 (54%) Needle-related procedures at pediatric department of hospital VR hypnosis (60) Medical hypnosis induced by a trained healthcare provider (54). All participants received topical anesthesia (lidocaine/tetracaine patches and/or lidocaine/prilocaine cream). WB-FPS No difference between groups
Wong & Choi (2023) Hong Kong 149 4 to 12 (7.2) 86 (58%) Venipuncture at public hospital VR (75) Explanation of procedure and comforting words (74). VR (20%) and control (23%) participants used analgesic medication (not specified). FPS-R The VR group showed a smaller increase in pain relative to the control group.
Dilek et al. (2024) Turkey 126 4 (4) 63 (50%) MMR vaccine at pediatric clinic VR (42); Kaleidoscope (42) Sat on parents’ lap with no distraction (42). None of the patients received local anesthetics. WB-FPS No difference in pain between the kaleidoscope and VR, or the VR and SOC groups.
Koç Özkan & Polat (2020) Turkey 135 4 to 10 (not reported) Not reported Venipuncture at health clinic VR (46); Kaleidoscope (46) No description of the control group (43). None of the patients received local anesthetics. VAS and WB-FPS Pain was lower in the VR and kaleidoscope
group relative to controls.
Chan et al. (2019) (a) Australia 123 4 to 11 (not reported) 56 (46%) IV or venipuncture at ED VR (64) TV, phone, or tablet distraction (59). VR (89%) and control (85%) participants used topical local anesthetic (not specified). FPS-R VR group showed a reduction in pain compared to SOC.
Chan et al. (2019) (b) Australia 129 4 to 11 (not reported) 55 (43%) Venipuncture at outpatient pathology VR (63) Distraction with electronic media (66). VR (13%) and control (14%) participants used topical local anesthetic (not specified). FPS-R The VR group showed an increase in pain but less so compared to controls.
Buzzy
Küçük Alemdar & Yaman Aktaş (2019) Turkey 195 5 to 10 (7.3) 90 (46%) Blood draw at children’s hospital Buzzy (39);
Jet lidocaine (39);
Bubbles (39);
Aromatherapy (39)		 Nothing (39). None of the patients received local anesthetics, except the Jet Lidocaine group. Oucher scale The Buzzy group had lower pain relative to the control group.
Ballard et al. (2024) Canada 346 4 to 17 (9.8) 177 (51%) IV catheter insertion or venipuncture at pediatric ED Buzzy (172) Numbing cream (174). Buzzy (39%) and control (37%) participants received an analgesic (not specified) in addition to numbing cream (4% liposomal topical anesthetic cream [Maxilene]). CAS and FPS-R No difference in pain between the groups.
Sönmez Düzkaya et al. (2024) Turkey 96 4 (4) 51 (53%) MMR vaccination at family health center Buzzy (32);
Helfer skin tapping (32)		 Nothing (32). None of the patients received local anesthetics. WB-FPS Buzzy had lower pain relative to Helfer skin tapping and control groups.
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Virtual reality as distraction

Virtual reality does not reduce pain relative to standard of care

One study included 62 children (61% female), aged 7 to 17 years, undergoing an IV insertion or venipuncture (Osmanlliu et al., 2021). The control group received standard of care, which may have included parental presence, an offering of a topical anesthetic, and/or distraction (not described) done by the parent or healthcare provider, as reported by the authors. The experimental group received standard of care and virtual reality distraction (an active point and shoot game). No difference in pain between the groups (Verbal Numerical Rating Scale) was found (d = 0.04).

Goldman & Behboudi (2021) assessed pain in 66 children (45% female), aged 6 to 17 years, requiring IV catheterization. The standard of care group had access to distraction tools (e.g., books, movies, iPads, bubbles, and support from a child life specialist) as well as oral analgesics and topical anesthetics. The virtual reality group watched a passive 360° roller coaster ride. There were no differences in pain between the groups (d = 0.27) based on the Faces Pain Scale Revised (Hicks et al., 2001).

Van Den Berg et al. (2023) included 114 children (54% female), aged 6 to 18 years, undergoing needle-related procedures. All participants received topical anesthesia prior to the procedure and were assigned to a medical hypnosis group, induced by a trained healthcare provider, or a virtual reality hypnosis group, which received the same instructions but with pictures viewed in virtual reality. Pain scores did not differ between groups (d = 0.29) as measured by the Wong-Baker Faces Pain Rating Scale (Wong and Baker, 1988).

In a study by Dilek et al. (2024), 126 four year olds (50% female) undergoing routine vaccination were randomized to receive virtual reality or kaleidoscope distraction, or standard of care. Children in the virtual reality group watched one of two roller coaster videos featuring a popular character, children in the kaleidoscope group played with a kaleidoscope, and children in standard of care received no distraction during the procedure. Children in the kaleidoscope group reported lower pain compared to the standard of care group (d = 0.89), while no differences were observed between the virtual reality and either the kaleidoscope (d = 0.22) or standard of care (d = 0.60) groups on the Wong-Baker Faces Pain Rating Scale.

Virtual reality reduces pain relative to standard of care

Wong & Choi (2023) conducted a study that included 149 children (58% female), aged 4 to 12 years, undergoing venipuncture. The standard of care group included an explanation of the procedure and comforting words, while the virtual reality distraction group watched an avatar undergoing venipuncture. Analgesics were offered to all participants. The virtual reality group experienced a smaller increase in pain compared to standard of care as measured by the Faces Pain Scale Revised (d = 0.80).

In a study by Chan et al. (2019), virtual reality was compared to standard of care across two randomized controlled trials involving 252 children (44% female), aged 4 to 11 years, undergoing venipuncture or intravenous cannulation (reported as Chan et al. (2019)(a) and Chan et al. (2019)(b)) in Table 1, Table 2). Systemic analgesia and topical anesthetic were given to participants at discretion. The standard of care group received no distraction or distraction aids (e.g., child life therapy, toys, books, and electronic devices), whereas the virtual reality group played an interactive underwater game. The virtual reality group exhibited either a greater reduction in pain (d = 0.43) (a) or their pain scores increased but less so compared to standard of care (d = 0.38) (b), as measured by the Faces Pain Scale Revised.

In another study, Gold et al. (2021) collected data across 107 participants (41% female), aged 10 to 21 years, undergoing placement of a peripheral intravenous catheter. The standard of care group received distraction techniques (e.g., listening to music, colouring) and numbing cream, while the intervention group played an adventure game in virtual reality in addition to standard of care. Participants in the virtual reality group reported lower pain scores compared to those in the standard of care group (d = 0.54) (Faces Pain Scale Revised).

A randomized controlled trial carried out by Goktas & Avci (2023) included 144 children (50% female), aged 7 to 12 years old, undergoing a deltoid vaccination, venipuncture, or a blood draw. Participants either watched a video in virtual reality, listened to songs through headphones, played with a kaleidoscope, or received standard of care with parental presence and verbal distraction. The standard of care group reported higher pain scores compared to each intervention group (d = 0.95) (Wong-Baker Faces Pain Rating Scale), however, no comparisons were made between the intervention groups.

Koç Özkan & Polat (2020) completed a study across 135 children (sex not adequately described), aged 4 to 10, receiving venipuncture. For distraction, participants either watched a video in virtual reality or played with a kaleidoscope prior and during their procedure. The control group received standard of care (not described). The virtual reality group reported less pain than both the control (d = 2.7) and kaleidoscope groups (d = 0.62), and the kaleidoscope group also reported lower pain than the control group (d = 1.94) (Wong-Baker Faces Pain Rating Scale).

Gold & Mahrer (2018) included 143 participants (50% female), aged 10 to 21 years, undergoing a blood draw. The standard of care group watched cartoons on a TV, whereas those in the virtual reality group played an adventure game, with cartoons playing in the background. Pain intensity was assessed using the Visual Analogue Scale and the Colour Analogue Scale (McGrath et al., 1996), and affective pain (worry and bother) was measured using the Facial Affective Scale (McGrath et al., 1984). Participants in the virtual reality group reported lower affective pain (d = 0.52) (Facial Affective Scale), but not overall pain (Colour Analogue Scale or Visual Analogue Scale). The authors also reported finding lower pain in the virtual reality group using the Faces Pain Scale Revised, a fourth pain measure not initially disclosed in the methods (d = 0.32).

Buzzy as a distraction

Buzzy does not reduce pain relative to standard of care

Ballard et al. (2024) reported a study including 346 children (51% female), aged 4 to 17 years, undergoing IV catheter insertion or venipuncture. Participants in the Buzzy group had the device applied near the injection site for the duration of the procedure, whereas those in standard of care group received lidocaine cream. Results showed no difference in pain between the two groups (d = 0.15) (Colour Analogue Scale, Faces Pain Scale Revised).

Buzzy reduces pain relative to standard of care

Ninety six children (53% female), all aged four, receiving a vaccination, were randomly assigned to a standard of care group that received no additional intervention (including no analgesics or numbing cream), a Buzzy group where the device was held at the injection site for 30 s before, during, and after the procedure, or a Helfer skin tapping group, where the injection site is tapped in a rhythmic pattern (Sönmez Düzkaya et al., 2024). Buzzy reduced pain compared to both the standard of care group (d = 0.85) and the Helfer technique (d = 0.39) (Wong-Baker Faces Pain Rating Scale).

One study included 195 children (46% female), aged 5 to 10 years, undergoing a blood draw across three timepoints (Küçük Alemdar and Yaman Aktaş, 2019). Participants were assigned to receive either Buzzy (with cold and vibration applied before and during the procedure), Jet Lidocaine (a needle-free anesthetic delivery device), bubble blowing (used one minute before the procedure), aromatherapy (administered starting five minutes before and continuing five minutes after the procedure), or a control group that received no intervention. The Buzzy group reported lower pain scores compared to the control group (d = 0.74) as measured by the Oucher Scale (Aradine et al., 1988); however, the authors did not disclose at what time point the group difference occurred. It is unknown whether there were differences between other intervention groups and Buzzy.

Discussion

We summarized the findings of 13 randomized controlled trials that used virtual reality or Buzzy distraction techniques to reduce needle-related pain in pediatric populations. In general, virtual reality and Buzzy appear to be effective in reducing procedural pain relative to standard of care with the caveat that virtual reality and Buzzy did not outperform standard of care groups that received analgesics.

The quality of the articles included in this review were satisfactory, however, the virtual reality and Buzzy distraction literature contain serious methodological flaws. Out of the 99 articles screened, 46 (53%) did not include a pre-procedural pain assessment, including three studies comparing Buzzy to virtual reality (Erdogan and Aytekin Ozdemir, 2021; Yilmaz and Canbulat Sahiner, 2023; Yıldırım and Gerçeker, 2023). Collecting a baseline prior to any intervention is imperative to properly assess randomization and ensure that any outcome differences are attributable to the intervention rather than group differences (Burgess et al., 2003; Vickers and Altman, 2001). All interventional research should always include baseline assessments.

While the majority of studies that used virtual reality to reduce pain found a beneficial effect, virtual reality was not superior in reducing pain when compared to standard of care groups who received anesthetics (Goldman and Behboudi, 2021; Osmanlliu et al., 2021; Van Den Berg et al., 2023), which may suggest that the effectiveness of virtual reality is reduced when anesthetics are also used. Four out of the 10 virtual reality studies reported no benefit of virtual reality in reducing pain compared to standard of care, of which three included a standard of care group that received anesthetics. A study outside the scope of this review reported pain increasing by 1.3 in the Faces Pain Scale Revised for those who received lidocaine during cannulation (Taddio, 2005). One study in our review that also used the Faces Pain Scale Revised to measure pain found that those who received virtual reality distraction also reported an increase in pain by 1.3 (Wong and Choi, 2023), suggesting that virtual reality may offer comparable reductions in pain to lidocaine and that both are interchangeable. However, lidocaine requires ≥30 min to take effect, during which the patient occupies a clinical space and staff resources, increasing overall procedural costs, and may also induce skin reactions (Taddio, 2005). Alternatively, virtual reality can be effective immediately and side effects are infrequent and mild (Bexson et al., 2024). No study has directly compared the pain management of virtual reality distraction to lidocaine in needle-related procedures including their associated side effects in pediatric populations. More research on this topic is needed to thoroughly quantify the effectiveness of pain reducing methods in needle-related procedures.

Buzzy was also found to be more effective at reducing pain compared to no intervention or basic distraction techniques, however, when comparing Buzzy to standard of care that included analgesics, no significant differences were reported between groups (Ballard et al., 2024), suggesting that its effectiveness is less apparent when pharmacological pain management is also used. Although potentially comparable, Buzzy has the advantage of being effective immediately and has minimal side effects (Ballard et al., 2018, 2024). Conversely, studies where lidocaine was not part of the standard of care suggested that Buzzy may offer greater pain reduction (Küçük Alemdar and Yaman Aktaş, 2019; Sönmez Düzkaya et al., 2024). Importantly, one study did not report at what time point pain scores from those in the Buzzy group differed from pain scores in the standard of care group, or whether Buzzy was superior compared to other interventions (Küçük Alemdar and Yaman Aktaş, 2019), making conclusions difficult. Overall, more research is needed comparing Buzzy to pharmacological interventions and whether Buzzy is superior to other distraction techniques in managing needle-related pain in children.

Although analgesic use appears to have affected the effectiveness of virtual reality and Buzzy, we found evidence that age may be a moderating factor. Across studies, interventions were less likely to outperform standard of care when analgesics were included, however, this pattern was not consistent when results were examined by age group. Younger children (approximately 4 to 12) generally demonstrated more consistent reductions in pain, particularly in studies that used virtual reality, which showed variable, yet significant effects (Chan et al., 2019; Goktas and Avci, 2023; Koç Özkan and Polat, 2020; Wong and Choi, 2023). These effects were observed both in the presence (Chan et al., 2019; Wong and Choi, 2023) and absence of analgesics (Goktas and Avci, 2023; Koç Özkan and Polat, 2020), suggesting that virtual reality’s effectiveness may not be entirely influenced by concurrent pharmacological use, but may also depend on attentional engagement and/or immersion, which have been shown to modulate pain processing (Mehesz et al., 2021). Buzzy also demonstrated moderate to large effects; however, in both studies that used Buzzy, analgesic use was not reported (Küçük Alemdar and Yaman Aktaş, 2019; Sönmez Düzkaya et al., 2024), making conclusions about the effect of age difficult. In contrast, among older children and adolescents (12 years or older), both virtual reality and Buzzy generally demonstrated smaller or non-significant effects regardless of whether analgesics were included in standard care (Ballard et al., 2024; Gold and Mahrer, 2018; Goldman and Behboudi, 2021; Van Den Berg et al., 2023). However, the mean age of participants in the Ballard et al. (2024) study was approximately 10 years, overlapping with the younger age group. As such, the lack of effect may be more related to the use of topical anesthetic rather than age alone.

Establishing a clear decision tree for selecting virtual reality versus Buzzy for managing needle-related pain is difficult, as the effectiveness of each appears to be driven by a combination of age, mechanism of action, and methodological approach rather than simply the presence of concurrent analgesic use. With respect to age, we found that virtual reality consistently demonstrated moderate to large reductions in pain in younger children (Chan et al., 2019; Goktas and Avci, 2023; Koç Özkan and Polat, 2020; Wong and Choi, 2023) compared to older children and adolescents (Gold and Mahrer, 2018; Goldman and Behboudi, 2021; Van Den Berg et al., 2023), suggesting that an immersive, attention-demanding intervention may be particularly beneficial for younger children. However, the content delivered during virtual reality is likely also important. A recent study found that a passive virtual reality intervention playing “child-oriented animated content” reduced pain in children aged 4 to 11 relative to a control group, whereas pain was similar for adolescents aged 12 to 18 in both conditions (Tinka et al., 2026). It is likely that the older children and adolescents found the content less engaging because it was passive andless immersive than active virtual reality. As active virtual reality requires participation to sustain attention, it may be more effective than passive distraction alone (Soltani et al., 2018). Buzzy also demonstrated moderate to large effect sizes, however these effects were generally smaller than those observed for virtual reality (Küçük Alemdar and Yaman Aktaş, 2019; Sönmez Düzkaya et al., 2024), suggesting that while sensory-based distraction is beneficial, more immersive interventions may provide greater pain relief in pediatric populations.

The use of self-reported pain assessments scales across studies also likely contributes to variability in outcomes reported across the literature. Selecting a pain assessment scale that is developmentally appropriate for the study population represents a methodological challenge (Birnie et al., 2019; Trottier et al., 2022). This challenge is reflected in the included studies, as three studies in this review used more than one pain scale with two of those studies spanning 10 to 21 year olds and the other spanning 4 to 17 year olds (see Table 1), suggesting that no single scale was deemed sufficient to capture pain across such wide developmental ranges. Conversely, four studies relied on a single pain assessment scale despite each spanning a wide age range (e.g., 10–21, 6–17, 7–17, 6–18), raising concerns about the appropriateness of a single measure across all ages sampled. Assessment scales that use numerical values such as the Visual Analogue Scale, for example, are recommended for children aged 7 years and older (Srouji et al., 2010), however, at least one study outside this review found that only one-third of children aged 5 to 14 understood the concept of the Visual Analogue Scale for pain management (Shields et al., 2003). Future studies should carefully consider (and potentially limit) the age range of their participants and tailor the assessment to meet the developmental needs of those participants, or choose multiple pain assessment scales but only administer each to the participants for whom it was intended.

The studies included in this review revealed several knowledge gaps. Notably, no study in our review examined the combined use of virtual reality and Buzzy on pain during needle-related procedures, despite their potential for synergistic pain reducing effects. Future research should explore whether their combined use could outperform either intervention alone or anesthetics. Furthermore, although the results of this review suggest that virtual reality and Buzzy are not superior to lidocaine or other analgesics; time, cost, and a lack of side effects highlight the potential superiority of virtual reality and Buzzy in reducing needle-related procedural pain. Importantly, no study we included completed a cost analysis of these interventions, and only one study compared procedure time (Goldman and Behboudi, 2021). Including a cost analysis and procedure time in future distraction-based research would be a valuable and comprehensive approach to understanding the financial impact of distraction-based approaches.

While this review has many strengths, it contains several limitations. No pooled analyses were conducted, making comparisons between virtual reality, Buzzy, and standard care difficult. However, the purpose of this review was to synthesize existing findings and identify key moderating variables rather than perform a meta-analysis. As a narrative review, this paper did not aim to provide an exhaustive overview of all available literature, and findings should be interpreted within this context. Several meta-analyses on the effectiveness of Buzzy and virtual reality have been completed (Addab et al., 2022; Jin et al., 2024; Merino-Lobato et al., 2023), but they include many of the articles we excluded due to critical missing baseline data. Despite this limitation, our findings align with previous reviews that also reported mixed results while also indicating an overall reduction in pain for those that received virtual reality (Addab et al., 2022; Merino-Lobato et al., 2023) or Buzzy (Jin et al., 2024; Merino-Lobato et al., 2023) compared to standard of care. A limitation of these reviews and the original studies is the lack of discussion on the potential confounding effect of analgesic use in standard of care, which has not been discussed previously.

Another limitation was the broad age range used in many of the included articles. Several studies grouped younger children and adolescents together (e.g., 6 to 18 years), making it difficult to determine whether age independently influenced intervention effectiveness. Often, age group results were combined without subgroup analysis, making it unclear whether findings were attributable to age (Ballard et al., 2024; Van Den Berg et al., 2023). When studies primarily included older participants, smaller or non-significant effects were more commonly observed, suggesting that developmental stage may be important. Overall, these findings remain difficult to interpret due to the lack of age-specific analyses. Future research should use smaller age ranges and directly examine age as a moderating factor to better understand when VR and Buzzy are more effective across pediatric populations.

Conclusion

Virtual reality and Buzzy appear to be superior to no intervention or low-tech distraction methods in reducing procedural needle pain in pediatrics. Virtual reality often demonstrated larger effects, particularly in younger children, suggesting that attention-based, immersive interventions may provide greater pain reduction than sensory-based approaches such as Buzzy. However, the effectiveness of both interventions appears to be influenced by age, concurrent analgesic use, and methodological decisions. Future research is needed to determine which patients are most likely to benefit from each intervention prior to widespread adoption. Future studies should also consistently include baseline pain measures and explore the potential benefits of combining interventions, such as virtual reality and Buzzy.

What is Known:

  • •

    Needle-induced pain needs to be managed in children.

  • •

    Visual and tactile distraction methods such as virtual reality and Buzzy, respectively, may be effective in managing needle-induced pain in children.

What is New:

  • •

    Virtual reality and Buzzy may reduce needle-related pain in children, particularly when standard of care does not include analgesics.

  • •

    Younger children showed more consistent benefits, especially with virtual reality, while older children and adolescents more often demonstrated smaller or non-significant effects.

  • •

    It is unknown if VR combined with Buzzy is effective at reducing pain in children.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Supplementary information

Supplementary material can be found online at:

Declaration of generative AI and AI-assisted technologies in the manuscript preparation process

During the preparation of this work the authors used ChatGPT to assist with extracting basic article information for this review (as described in the methods section). After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

CRediT authorship contribution statement

Maia Medland: Writing – review & editing, Writing – original draft, Visualization, Investigation, Formal analysis, Data curation. Brian Greeley: Writing – review & editing, Writing – original draft, Visualization, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Roi Jankelowitz: Writing – review & editing, Visualization, Investigation, Data curation. Sima Zakani: Writing – review & editing, Supervision, Resources, Project administration, Methodology, Conceptualization. John Jacob: Writing – review & editing, Supervision, Resources, Project administration, Methodology, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

N/A

Footnotes

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijnsa.2026.100550.

Appendix. Supplementary materials

mmc1.docx (8.4KB, docx)

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