Abstract
Background:
Venipuncture in pediatric emergency departments commonly causes pain, fear, and anxiety in children, particularly those aged 4 to 6 years. Although non-pharmacological distraction techniques are recommended, comparative evidence remains limited. This study aimed to evaluate the effectiveness of Buzzy devices and finger puppet shows in reducing these outcomes.
Methods:
A randomized controlled trial was conducted with 102 children aged 4 to 6 years undergoing venipuncture in a tertiary pediatric emergency department. Participants were randomly assigned to 3 groups: Buzzy device (n = 34), finger puppet distraction (n = 34), and control (n = 34). Pain, fear, and anxiety were assessed using the Wong-Baker FACES Pain Rating Scale, Children’s Fear Scale, and Children’s Anxiety Meter-State before and after the procedure. Data were analyzed using SPSS, and the study was registered (NCT06849648).
Results:
No significant differences were found between groups in pre-procedure scores (P > .05). Post-procedure scores differed significantly (P < .001), with the control group reporting higher pain, fear, and anxiety compared to both intervention groups. Within-group analyses showed significant reductions in all outcomes in the Buzzy and finger puppet groups (P < .001), whereas no significant change was observed in the control group. Effect sizes were large for both interventions and higher in the Buzzy group (fear: η2 = 0.756; anxiety: η2 = 0.825; pain: η2 = 0.659) than the finger puppet group (fear: η2 = 0.657; anxiety: η2 = 0.690; pain: η2 = 0.512). Findings should be interpreted with caution due to baseline imbalances.
Conclusion:
Both interventions effectively reduced pain, fear, and anxiety, with Buzzy showing greater effectiveness. These findings support the use of simple, cost-effective distraction techniques in pediatric emergency care.
Keywords: anxiety, Buzzy, child, emergency department, fear, finger puppet, pain, venipuncture
1. Introduction
Children often undergo painful medical procedures in the hospital.[1] Moreover, hospitals can be unfamiliar environments for children, which may induce feelings of pressure, fear, and anxiety, further complicating their ability to cope with medical experiences effectively. Compared to adult patients, pain can be more challenging to detect and treat effectively in children, and the symptom is frequently underrated or ignored.[2] However, pain management is recognized as a fundamental human right,[3] and it is of great importance that children receive adequate support in this process.[4–6] Due to children’s ongoing cognitive development, they may have difficulty expressing their pain. Furthermore, fear and anxiety during painful medical treatments may not decrease with time or age and may delay or prevent medical intervention in children patients.[6] Therefore, the type and intensity of pain may be perceived differently depending on the age, cognitive level, and disability status of the children, and these factors should be considered when determining appropriate pain assessment tools for each child.[2]
The most frequent invasive procedure performed in an emergency setting before the start of medical treatment is the venipuncture procedure, which is a common source of stress, pain, and anxiety for children.[7,8] Children may react to stress, anxiety, and fear by crying, screaming, or twisting their bodies during the venipuncture procedure.[4] Children may have to be restrained by healthcare staff during the procedure. Such resistance by children prolongs the venipuncture procedure time and increases the number of unsuccessful attempts. This causes extra burden to the family and the children and healthcare staff.[9–11]
Regardless of age or developmental stage, every child should be adequately prepared physically, cognitively, and psychologically before undergoing any invasive procedure.[12] However, how children perceive hospitalization varies according to their age and developmental stage. For instance, school-age children can articulate the specific locations and body parts where they feel pain and describe the characteristics of the pain they experience.[11] These children can even understand the reasons for hospitalization and venipuncture procedures. Preschoolers aged 4 to 6, on the other hand, may perceive the hospital environment as a kind of psychological punishment,[13] particularly during the venipuncture procedure, which makes it much harder for them to express their emotions and distress. Therefore, it is necessary to develop individualized and age-appropriate pain management strategies for the needs of children.
Previous research has demonstrated that distraction techniques can play a crucial role in mitigating anxiety and pain in pediatric patients. For instance, a randomized controlled trial by Longobardi et al[14] found significant reductions in anxiety using playful interventions in emergency care settings, suggesting that interactive methods like those incorporated in this study may be effective. In addition, a recent systematic review showed that various non-pharmacological distraction methods to prevent needle-related procedural pain in children aged 6 to 12 years are effective in reducing pain perception.[15] Non-pharmacological pain management practices are helpful for the successful treatment of pain.[16] While some studies only focus on fear[17] or pain,[18] other studies focus on fear and anxiety[19] or pain and anxiety.[6,20] However, most existing studies have focused on older age groups, such as 6- to 12-year-olds,[6,18,21] or groups covering a wide age range.[5,20] Nevertheless, it is essential to highlight that various interventions must be customized to suit the age-specific requirements of the patient population.[6] Furthermore, the importance of utilizing accessible, sustainable, and cost-effective materials in managing children’s pain, fear, and anxiety in emergency departments cannot be overstated. The literature review revealed a limited number of studies investigating the impact of non-pharmacologic methods on pain and anxiety during venipuncture procedures in children. Currently, there are no studies evaluating the use of the Buzzy device and finger puppets, which are nonpharmacologic methods, concerning the levels of pain, fear, and anxiety in children aged 4 to 6 years undergoing venipuncture procedures in emergency department settings. The current study investigates the effects of 2 specific distraction interventions, Buzzy devices and finger puppet shows, on children’s pain, fear, and anxiety levels during venipuncture. This study seeks to address a critical gap in pediatric emergency care settings by exploring the efficacy of Buzzy devices and finger puppet shows in reducing pain, fear, and anxiety among children undergoing venipuncture.
1.1. Research hypothesis
H0: There will be no significant difference in pain, fear, and anxiety levels among children undergoing venipuncture across the Buzzy device, finger puppet, and control groups.
H1: The use of the Buzzy device and finger puppet distraction techniques will significantly reduce pain, fear, and anxiety levels in children undergoing venipuncture compared to the control group.
2. Methods
2.1. Study design
This study is a randomized controlled trial and followed the Consolidated Standards of Reporting Trials checklist. The study protocol was registered in the Clinical Trial Protocol Registration and Results System (https://clinicaltrials.gov/; Registration date: February 25, 2025, Registration number: NCT06849648).
2.2. Study setting and time
The children were recruited from the Paediatric Emergency Department (PED) of a tertiary hospital with a 700-bed capacity and located in the southeast of Turkey between February 25, 2025 and March 18, 2025.
2.3. Sample and randomization
The sample calculation was performed using G*Power Software version 3.1.9.2. Based on the statistical comparison results between groups in reference publication,[5] a type 1 error of 5% and a test power of 80% were set. Accordingly, the minimum sample size was calculated as 72 in total. The minimum number of participants for each group was 24, but considering the possible losses, 34 children were included in each group. The study sample comprised 102 children who met the inclusion criteria (Fig. 1).
Figure 1.
Consort flow diagram showing the participants. CAM-S = children’s anxiety meter-state, CAM-T = children’s anxiety meter-trait, CFS = Children’s Fear Scale, WBFPS = Wong-Baker FACES Pain Rating Scale.
Participants were divided into 3 groups using a randomization method. Children within each group were assigned to the research and control groups (CGs) by block randomization using a list created through www.randomizer.org. Randomization was done to ensure the difference between the groups was not statistically significant. Block randomization was performed using a computer-generated randomization list created via www.randomizer.org prior to participant recruitment. Participants were enrolled by the researcher responsible for eligibility assessment (KOA). Group assignments were made sequentially according to the pre-generated randomization list at the time of enrollment. The same researcher conducted both enrollment and assignment procedures.
2.3.1. Inclusion criteria
Children aged 4 to 6 years, of both genders, who had been admitted to the PED and required venepuncture procedures for blood tests.
2.3.2. Exclusion criteria
The study excluded children with chronic disease, those who had neuro-developmentally delayed verbal difficulties, hearing or visual impairments, who had received analgesia or sedation within the previous 24 hours or had a history of syncope, and those were unconscious. Also, children with bleeding disorders, infection, rash, and damaged skin on the arm where the device will be placed will be excluded from the study. In addition, children with cold sensitivity diseases and those who refuse to wear the Buzzy device were excluded from the study.
2.4. Data collection tools
2.4.1. Descriptive information form
This form was developed by the researchers. This form was piloted with 5 participants and amended based on the feedback received before the actual data collection process.
2.4.2. Children’s Fear Scale (CFS)
The CFS is a self-report instrument used to assess the intensity of fear related to medical procedures in children aged 5 to 10 years.[22] Gerçeker et al[23] evaluated the validity and reliability of the Turkish version of the CFS for Turkish children aged 4 to 10 years using test-retest method, correlation analysis, and regression analysis. They found that the use of the scale for this age group is valid and reliable. In this scale, gender-neutral faces are given a fear score according to numerical values and are shown different amounts of being scared. Children were asked to rate how much fear they felt from a needle stick using this scale, which was shown into matching face categories; Face 0 “not scared at all”; Face 1 “a little bit more scared”; Face 2 “a bit more scared”; Face 3 “more scared,” and Face 4 “extremely scared.” Therefore, scale scoring ranges from neutral (0 = not scared at all) to frightened (4 = extremely scared), indicating that as the score increases, the level of fear increases.[23]
2.4.3. Children’s anxiety meter-state (CAM-S)
The children’s anxiety meter is a thermometer-shaped scale with a bulb at the bottom and horizontal lines ascending, designed for children aged 4 to 10 years.[24] The Turkish validity and reliability of this scale have been confirmed by Gerçeker et al.[23] Children were instructed to visualize their worry or nervousness as filling the thermometer’s bulb.[24,25] They marked a line showing their anxiety level, with higher placements indicating greater anxiety. An alternative explanation used a simple rising scale analogy for children unfamiliar with a thermometer. To measure state anxiety (CAM-S), children marked how they felt “right now,” while for trait anxiety (CAM-T), they indicated “how they usually feel at home” with examples like playing outside or watching TV. Before completing CAM-S and CAM-T, children’s sorting skills were assessed (e.g., Identifying the larger number between 7 and 4). Those who did not complete CAM-S or CAM-T tasks were excluded. After data collection, the researcher (KOA) reviewed and scored children’s anxiety meter ratings using a transparent overlay with ½-point increments, rounding to the nearest half-point. Scores ranged from 0 to 10.[24]
2.4.4. Wong-Baker Faces Pain Rating Scale
The validity and reliability of the Wong-Baker Faces Pain Rating Scale (WBFPS) in children aged 3 and older have been established for rating children’s pain level in pediatric emergency setting.[26] This scale gives faces a pain score according to numerical values. Using this scale, children were asked to rate how much pain they felt from a needle stick, which was shown in matching face categories. This numerical rating scale ranges from 0 to 10, with facial expressions representing emotions ranging from a smiling face (0 = very happy/no pain) to a crying face (10 = worst pain).[27] This scale was assessed through children’s self-report. The WBFPS is reliable and widely utilized in the Turkish population[18,19] and permission to use the scale in the study was obtained from https://wongbakerfaces.org.[27]
The primary outcome of this study was pain intensity measured using the WBFPS. Secondary outcomes included children’s fear and anxiety levels, assessed using the CFS and the CAM-S, respectively.
2.5. Intervention groups
2.5.1. The Buzzy device and its usage
This study used plastic devices called “Buzzy,” shaped like a bee or ladybug, with a reusable battery and designed for multiple-patient disinfection. These devices help to manage pain by combining cold application and vibration with wing-shaped ice packs. In this study, we specifically used the ladybug-shaped Buzzy (Buzzy Healthcare mini ladybuzz, code BKHM3). According to the manufacturer’s instructions, the device was held just above the injection site for 30 seconds, then moved 3 to 5 cm proximal to the site just before injection and kept in place throughout the needle insertion. Ice packs were kept in the freezer but were removed a few minutes before the venipuncture procedure to acclimate to room temperature, preventing excessive cold or discomfort for the child. Once the participant and nurse were ready, the frozen wings were placed on the back of the ladybugs using fixed elastic bands and placed 15 to 30 seconds above the venipuncture site per the manufacturer’s guidelines. The Buzzy device was then positioned 3 to 5 cm above the planned puncture site on the forearm and secured with a tourniquet. A venipuncture was performed while continuous vibration was maintained, and the device remained in place for 15 to 30 seconds after blood sampling before being turned off and removed. After the procedure, the cooling pad was wiped thoroughly with 70% alcohol and returned to the freezer for reuse. The total intervention time was approximately 2 to 5 minutes. Parents in all groups accompanied their children throughout the procedure but were not allowed to actively comfort them in order to standardize the procedure and minimize potential confounding effects. Parental involvement during medical procedures has been reported to influence children’s pain and anxiety responses.[25] The Buzzy device and its usage were provided in Figure 2.
Figure 2.
The Buzzy device and its usage.
2.5.2. Finger puppet and its usage
Finger puppets were used to distract children during the venepuncture procedure. Children are allowed to pick their favorite animals. These soft variously shaped finger puppets can be placed on an adult’s fingers. One minute before the venipuncture procedure, the researcher (KOA) engaged the participants in finger puppet play and initiated the conversation by asking, ‘Hello, how are you? What is this figure? Do you know where this animal/figure lives? Have you ever seen this animal/figure alive? Have you been in a zoo? Additionally, techniques such as having the animals sing or interact with each other were employed to capture the child’s attention to the finger puppets. No additional distraction techniques were used prior to the procedure. Parents in all groups accompanied their children during the procedure but were not permitted to comfort them. Finger puppets are presented in Figure 3.
Figure 3.
Finger puppet.
2.6. Control group
Children in this group underwent venipuncture according to the standard procedure applied in the PED. No distraction techniques were used, and parents were not permitted to comfort their children during the procedure. Pain was assessed using the Wong-Baker Faces Pain Rating Scale based on the children’s self-report.
2.7. Data collection procedure
All venipuncture procedures were performed by the same nurse (chief nurse) working in the PED, who had at least 5 years of experience with pediatric venipuncture. Additionally, the nurse received training on operating the Buzzy device during the procedure. Venipuncture was conducted with a vacutainer.
Patients in intervention group 1 received the Buzzy device group during venipuncture, while patients in intervention group 2 received distraction with finger puppets. Patients in the CG did not receive any intervention. All groups were subjected to the standard venipuncture procedure.
The researcher (KOA) evaluated participants’ baseline information to assess eligibility requirements. Parents of participants in the Buzzy device group and finger puppets groups were informed that the Buzzy device and finger puppet play would be used for their children during venipuncture, respectively. Additionally, participants were instructed on how to use the Buzzy device and finger puppet play in an age-appropriate language during the procedure.
In the CG, parents were informed that only children’s pain, fear, and anxiety would be measured during the venipuncture. Due to the nature of the interventions, blinding of participants, parents, and the nurse performing the procedure was not feasible. This may have introduced potential performance and detection bias. Parents in the intervention groups were informed about the procedures, and the nurse was trained to apply the Buzzy device. Outcome measures were based on children’s self-reports using validated scales to help minimize potential assessment bias. The children’s self-assessed pain, fear, and anxiety levels were measured before and 1 minute after the venipuncture procedure in all groups.
2.8. Data analysis
The data obtained in the study were analyzed using SPSS (Statistical Package for the Social Sciences) for Windows version 22.0. Number, percentage, mean, and standard deviation were used as descriptive statistical methods to analyze the data. Differences between the rates of categorical variables in independent groups were analyzed using Chi-Square tests. Kurtosis and skewness values were analyzed to determine whether the research variables were normally distributed. The kurtosis and skewness values of the variables were as follows: CAM-T pretest (−0.314, −0.657), CAM-T posttest (−0.688, 0.488), CAM-S pretest (1.041, 0.808), CAM-S posttest (1.036, 0.770), Wong-Baker pretest (−0.881, 0.092), and Wong-Baker posttest (0.253, 0.449). According to the related literature, kurtosis and skewness values between + 1.5 and −1.5[28] or + 2.0 and −2.0[29] indicate normal distribution. It was determined that the variables exhibited normal distribution. Parametric methods were used to analyze the data. The one-way ANOVA test was used to compare quantitative continuous data between groups. The Scheffé test was used as a complementary post hoc analysis to determine the differences after the ANOVA test. A repeated measures ANOVA test and the complementary Bonferroni test were used to compare within-group measurements.
2.9. Ethical consideration
Ethical approval was obtained from Mardin Artuklu University Ethics Committee (Date: November 5, 2024, Decision No: 2024/11-3). In addition, the necessary permissions were obtained from the Mardin Provincial Directorate of Health (Date: November 20, 2024, Reference number: E-68051626-770-260098598). In addition, written informed consent forms were obtained from all participants. Written informed consent to participate was obtained from the parents or legal guardians of any participant under the age of 16. In this study, we did not apply any harmful interventions to patients. The research was carried out in accordance with the principles of the Declaration of Helsinki.
3. Results
The descriptive characteristics of the participants in the Buzzy, finger puppet, and CGs are presented in Table 1.
Table 1.
Descriptive characteristics of the participants.
| Buzzy | Finger puppet | Control | P | ||||
|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | ||
| Gender | |||||||
| Male | 18 | 52.9 | 8 | 23.5 | 19 | 55.9 |
X2 = 8.828 P = .012* |
| Female | 16 | 47.1 | 26 | 76.5 | 15 | 44.1 | |
| Relation to the child | |||||||
| Mother | 21 | 61.8 | 18 | 52.9 | 16 | 47.1 |
X2 = 1.499 P = .473* |
| Father | 13 | 38.2 | 16 | 47.1 | 18 | 52.9 | |
| Mother’s level of education | |||||||
| Primary school | 10 | 29.4 | 8 | 23.5 | 10 | 29.4 |
X2 = 6.631 P = .577* |
| Secondary school | 7 | 20.6 | 7 | 20.6 | 11 | 32.4 | |
| High school | 6 | 17.6 | 11 | 32.4 | 8 | 23.5 | |
| Bachelor’s degree and higher | 11 | 32.3 | 8 | 23.5 | 5 | 14.7 | |
| Father’s level of education | |||||||
| Primary school | 0 | 0.0 | 1 | 2.9 | 0 | 0.0 |
X2 = 13.416 P = .201* |
| Secondary school | 4 | 11.8 | 2 | 5.9 | 3 | 8.8 | |
| High school | 14 | 41.2 | 18 | 52.9 | 22 | 64.7 | |
| Bachelor’s degree and higher | 16 | 47.0 | 13 | 38.2 | 9 | 26.5 | |
| Employment status of mother | |||||||
| Employed | 11 | 32.4 | 7 | 20.6 | 4 | 11.8 |
X2 = 4.289 P = .117* |
| Unemployed | 23 | 67.6 | 27 | 79.4 | 30 | 88.2 | |
| Employment status of father | |||||||
| Employed | 34 | 100.0 | 34 | 100.0 | 34 | 100.0 |
X2 = 0.000 P < .001* |
| Occupation | |||||||
| Housewife | 13 | 38.2 | 13 | 38.2 | 13 | 38.2 |
X2 = 5.291 P = .507* |
| Worker | 2 | 5.9 | 5 | 14.7 | 7 | 20.6 | |
| Civil servant | 15 | 44.1 | 11 | 32.4 | 8 | 23.5 | |
| Self-employment | 4 | 11.8 | 5 | 14.7 | 6 | 17.6 | |
| Place of residence | |||||||
| City center | 27 | 79.4 | 27 | 79.4 | 24 | 70.6 |
X2 = 1.356 P = .852* |
| District | 4 | 11.8 | 5 | 14.7 | 7 | 20.6 | |
| Village | 3 | 8.8 | 2 | 5.9 | 3 | 8.8 | |
| Income | |||||||
| Income is less than expenses | 8 | 23.5 | 11 | 32.4 | 15 | 44.1 |
X2 = 3.348 P = .501* |
| Income equals expenditure | 21 | 61.8 | 19 | 55.9 | 15 | 44.1 | |
| Income is more than expenses | 5 | 14.7 | 4 | 11.8 | 4 | 11.8 | |
| Family type | |||||||
| Nuclear family | 32 | 94.1 | 33 | 97.1 | 31 | 91.2 |
X2 = 1.063 P = .588* |
| Extended family | 2 | 5.9 | 1 | 2.9 | 3 | 8.8 | |
| Partly | 1 | 2.9 | 0 | 0.0 | 9 | 26.5 | |
| Mean | SD | Mean | SD | Mean | SD | F/P | |
|---|---|---|---|---|---|---|---|
| Age of the child | 5.710 | 1.194 | 5.880 | 1.122 | 5.620 | 1.206 | 0.448/.640 |
| Age of the mother | 34.030 | 4.939 | 34.620 | 5.135 | 36.500 | 5.035 | 2.232/.113 |
| Age of the father | 37.090 | 6.895 | 37.350 | 5.353 | 39.290 | 5.475 | 1.394/.253 |
| Number of children in the family | 2.590 | 1.282 | 3.030 | 1.000 | 3.530 | 1.187 | 5.583/.005 (3 > 1) |
Chi-Square analysis.
A statistically significant difference was observed between the groups in terms of gender distribution (X2 = 8.828, P = .012) with the proportion of males being 52.9% in the Buzzy group, 23.5% in the finger puppet group, and 55.9% in the CG. No statistically significant differences were found between the groups regarding parental characteristics, including mother’s and father’s education level, employment status, occupation, place of residence, income level, and family type (X2 = 6631, P = .577).
The mean age of the children was similar across the groups (Buzzy: 5.71 ± 1.19; finger puppet: 5.88 ± 1.12; control: 5.62 ± 1.21), with no statistically significant difference (F = 0.448, P = .640). Similarly, no significant differences were observed in the mean ages of mothers and fathers (P > .05). However, a statistically significant difference was identified in the number of children in the family (F = 5.583, P = .005), with the lowest mean observed in the Buzzy group (2.59 ± 1.28) and the highest mean in the CG (3.53 ± 1.19). These findings indicate the presence of baseline imbalances between groups, particularly in gender distribution and family size.
The results of the CFS are presented in Table 2. There was no statistically significant difference between the groups in terms of pre-procedure fear levels (P = .399). However, a significant difference was observed in post-procedure fear scores (P < .001), with children in the CG reporting significantly higher levels of fear compared to those in the Buzzy and finger puppet groups (3 > 1.2). Within-group comparisons showed that fear levels decreased significantly in both the Buzzy and finger puppet groups (P < .001), whereas no significant change was observed in the CG (P = .221). Effect size analysis revealed a very large effect in both intervention groups, with η2 = 0.756 for the Buzzy group and η2 = 0.657 for the finger puppet group.
Table 2.
Comparison of CFS mean scores by groups and processing time.
| Groups | Buzzy | Finger puppet | Control | F * | P | Difference |
|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | ||||
| Before venipuncture (Pretest; CFS) | 2650 ± 1203 | 2590 ± 1395 | 2240 ± 1437 | 0.927 | .399 | |
| After venipuncture (Posttest; CFS) | 0.650 ± 0.646 | 0.620 ± 0.954 | 2500 ± 1022 | 49.996 | .000 | 3 > 1.2 |
| F † | 102,000 | 63,171 | 1553 | |||
| P | .000 | .000 | .221 | |||
| Eta-squared | 0.756 | 0.657 | ||||
ANOVA = analysis of variance, CFS = Children’s Fear Scale.
One-way ANOVA.
Repetitive measurements ANOVA test.
The results of the CAM-S are presented in Table 3. No statistically significant difference was found between the groups in pre-procedure anxiety levels (P = .333). However, post-procedure anxiety scores differed significantly between groups (P < .001), with the CG exhibiting higher anxiety levels than the Buzzy and finger puppet groups (3 > 1,2). Within-group comparisons demonstrated a significant reduction in anxiety levels in both intervention groups (P < .001), whereas no significant change was observed in the CG (P = .339). In terms of effect size, very large effects were observed for both interventions, with η2 = 0.825 in the Buzzy group and η2 = 0.690 in the finger puppet group. No statistically significant differences were observed between the groups in terms of trait anxiety (CAM-T) scores in either pre- or post-procedure measurements (P > .05).
Table 3.
Comparison of CAM mean scores by groups and processing time.
| Groups | Buzzy | Finger puppet | Control | F * | P | Difference |
|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | ||||
| Before venipuncture (Pretest) CAM-S | 7240 ± 2230 | 7060 ± 2570 | 6350 ± 2901 | 1112 | .333 | |
| After venipuncture (Posttest) CAM-S | 3030 ± 1749 | 2740 ± 1847 | 6850 ± 2324 | 45.328 | .000 | 3 > 1.2 |
| F † | 155,595 | 73,477 | 0.940 | |||
| P | .000 | .000 | .339 | |||
| Eta-squared | 0.825 | 0.690 | ||||
| Before venipuncture (Pretest) CAM-T | 1150 ± 0.436 | 1180 ± 0.626 | 1120 ± 0.409 | 0.118 | .889 | |
| After venipuncture (Posttest) CAM-T | 1120 ± 0.409 | 1150 ± 0.610 | 1090 ± 0.452 | 0.119 | .888 | |
| F † | 1000 | 1000 | 1000 | |||
| P | .325 | .325 | .325 | |||
ANOVA = analysis of variance, CAM = children’s anxiety meter, CAM-S = children’s anxiety meter-state, CAM-T = children’s anxiety meter-trait.
One-way ANOVA.
Repetitive measurements ANOVA test.
The results of the WBFPS are presented in Table 4. There was no statistically significant difference between the groups in pre-procedure pain scores (P = .617). However, post-procedure pain scores showed a statistically significant difference (P < .001), with children in the CG reporting higher pain levels compared to those in the Buzzy and finger puppet groups (3 > 1.2). Within-group analyses indicated a significant reduction in pain levels in both intervention groups (P < .001), while no significant change was observed in the CG (P = .184). Effect size analysis demonstrated large effects for both interventions, with η2 = 0.659 for the Buzzy group and η2 = 0.512 for the finger puppet group.
Table 4.
Comparison of WBFPS mean scores by groups and processing time.
| Groups | Buzzy | Finger puppet | Control | F * | P | Difference |
|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | ||||
| Before venipuncture (Pretest) WBFPS | 6120 ± 2649 | 6120 ± 3073 | 5530 ± 2788 | 0.486 | .617 | |
| After venipuncture (Posttest) WBFPS | 2820 ± 1642 | 2820 ± 2096 | 6060 ± 2335 | 28.384 | .000 | 3 > 1.2 |
| F † | 63,724 | 34,681 | 1845 | |||
| P | .000 | .000 | .184 | |||
| Eta-squared | 0.659 | 0.512 | ||||
ANOVA = analysis of variance, WBFPS = Wong-Baker FACES Pain Rating Scale.
One-way ANOVA.
Repetitive measurements ANOVA test.
4. Discussion
The results of this study provide insight into the effectiveness of 2 distraction techniques, Buzzy devices and finger puppet shows, in reducing pain, fear, and anxiety among children undergoing venipuncture in the PED. The significance of non-pharmacological interventions, particularly distraction techniques, is increasingly recognized in pediatric care as a means to enhance the psychological comfort of children during potentially traumatic medical procedures. This study aimed to evaluate the effectiveness of the Buzzy device and finger puppet show methods in reducing pain, fear, and anxiety levels in children during venipuncture procedure in the PED. When the intervention and CGs of the study were examined, it was found that there was no statistically significant difference between the groups in terms of most descriptive characteristics (Table 1). However, some baseline imbalances were observed, particularly in sex distribution and number of children in the family. Therefore, the findings should be interpreted with caution, as these differences may have influenced the study outcomes and should be considered when interpreting the results.
Venipuncture is a common and often the first invasive procedure performed on children in emergency departments, but it is also a significant source of stress, pain, and anxiety.[7,8] Pharmacological interventions, such as local anesthetics, have been used to manage needle-related pain, but they can have side effects and may not adequately address the emotional aspects of the experience.[30] Non-pharmacological pain and stress management techniques have emerged as valuable alternatives to reduce the burden of pain and anxiety in pediatric healthcare settings.
This study’s results indicate that these interventions (Buzzy and finger puppet) have a statistically significant impact on alleviating children’s negative emotional and physical experiences. Notably, children in the CG, who did not receive any distraction, exhibited consistently high levels of fear, anxiety, and pain (P = 001, 3 > 1.2) highlighting the importance of distraction techniques. The study demonstrates that both Buzzy and finger puppet interventions significantly reduced anxiety levels in children, consistent with prior research indicating that play and distraction can effectively mitigate children’s negative emotional responses during medical procedures.[31] Consistent with existing literature, this study supports the use of Buzzy device[5,32,33] and finger puppet play[34,35] as an effective non-pharmacological pain management strategy.
The use of finger puppetry as a therapeutic tool demonstrated a robust ability to engage children’s imaginations and distract from distressing stimuli. Finger puppets have been effectively utilized in different contexts to reduce fear and anxiety, as highlighted by Tuncay and Tüfekci,[12] who noted that puppet therapy could significantly lessen fear associated with medical interventions.[12] Such distraction strategies bolster children’s coping mechanisms in stressful situations.[36] The playful nature of finger puppet plays invites children into a narrative, potentially transforming their perspective on the medical procedure itself, thereby contributing to a calming effect during venipuncture.
To the best of our knowledge, no previous studies have specifically and comparatively evaluated the effectiveness of the Buzzy Device and finger puppet play in alleviating pain, fear, and anxiety levels in children during the venipuncture procedure within the PED. Given the frequency of venous access in the ED, which often requires midline catheter insertion,[37] this study addressed a critical gap in the literature and offer valuable insights into practical, non-pharmacological methods for improving the pediatric patient experience in this high-stress setting. As non-pharmacological methods of pain management during venipuncture represent an easy way to achieve an increased level of compliance among children and parents.[38] Nurses can easily implement a non-pharmacological approach by creating a comfortable and supportive environment and educating families,[39] the benefit of our proposed method is considerable.
When comparing the Buzzy device method to the finger puppet method, our results suggest the Buzzy method had a greater impact on reducing fear (η2 = 0.756), anxiety (η2 = 0.825), and pain (η2 = 0.659). These results align with studies showing Buzzy effectiveness in reducing pain and anxiety associated with needle procedures.[40] The Buzzy device was found to be effective in relieving pain in children during phlebotomy, similar to bubble-blowing.[40] Their research demonstrated that the Buzzy group experienced significantly lower pain levels during and after phlebotomy compared to Jet Lidocaine and Bubble-blowing.[40] It is worth noting that while both methods (Buzzy and finger puppet) are effective, the magnitude of the effect, as indicated by eta-squared values, was higher for the Buzzy device compared to finger puppet in our study.
In this study, while the finger puppet method may not have as high an effect size as the Buzzy device, it remains an effective and valuable method for managing children’s pain, fear, and anxiety in the PED. As it makes use of accessible, sustainable, and cost-effective materials, finger puppet play presents a desirable option for pain management in children, especially where resources are limited. Integrating play using everyday items can also enhance hand therapy for pediatric patients.[41]
In addition, the results regarding the use of the WBFPS enhance the reliability of this study. The WBFPS is designed as a self-report measure for children to assess their own pain.[27] However, there are inconsistencies in the literature regarding its application. For instance, some studies have used the WBFPS with researchers or parents as observers to assess children’s pain.[33,42] The Wong-Baker FACES Foundation emphasizes that the scale is intended for self-assessment by the child.[27] Furthermore, a study by Lawson et al[43] revealed low agreement between caregivers and children when using the WBFPS to assess acute pain in the emergency department. In this study, the scales were applied in accordance with the specified methods,[27] which strengthens the validity and reliability of the results and contributes evidence-based, accurate information to the literature.
4.1. Implications and recommendations
The results from this study suggest significant implications for clinical practice regarding the management of pain, fear, and anxiety in children undergoing venipuncture in PEDs. The effective application of both Buzzy devices and finger puppet shows demonstrates the potential for non-pharmacological interventions to enhance the comfort and experience of pediatric patients during invasive procedures. As healthcare providers increasingly recognize the importance of addressing not just physical, but also psychological well-being in pediatric care, the integration of such distraction techniques represents a valuable addition to standard care practices.
The results of this randomized controlled trial affirm the effectiveness of Buzzy devices and finger puppet shows in alleviating pain, fear, and anxiety in children undergoing venipuncture. These interventions support the growing body of literature advocating for the integration of non-pharmacological strategies in pediatric emergency care. These findings suggest that Buzzy devices and finger puppet interventions may be useful non-pharmacological strategies for reducing pain, fear, and anxiety in children during venipuncture. Such strategies not only reduce anxiety and perceived pain but also engage children in a way that promotes a sense of control and agency during medical encounters. These interventions are simple, low-cost, and feasible for routine clinical use, requiring only minimal training for healthcare staff. Establishing protocols for implementing these effective distraction strategies may lead to improved patient satisfaction and compliance with treatment.
In addition, this study suggested to provide training for nurses and healthcare staff in the effective usage of distraction techniques, such as the Buzzy device and finger puppet, to alleviate children’s pain, fear, and anxiety. Moreover, the successful outcomes of this study should encourage the adoption of a more patient-centered care model in PED. By prioritizing psychosocial methods alongside traditional medical interventions, healthcare staff may be able to improve children’s experiences during potentially painful procedures by incorporating distraction-based interventions. Policies integrating distraction methods can be further evaluated, ensuring they meet the psychological needs of pediatric patients across various procedural contexts. Future research could explore the combination of these techniques with primary care provision, ensuring a holistic approach to pain management in pediatric settings while addressing the psychological and emotional needs of children.
4.2. Strengths and limitations
This study possesses several notable strengths. First, this study was designed as a randomized controlled trial and followed the Consolidated Standards of Reporting Trials checklist. Secondly, this study used 2 different intervention methods: the Buzzy device and finger puppet play. Lastly, by adhering to established methodologies in our application of these scales, we enhanced the robustness of the results, providing valuable and reliable data to the existing literature. However, the study is not without limitation. Blinding was not feasible due to the nature of the interventions, which may have introduced potential performance and detection bias. In addition, baseline differences between groups should be considered when interpreting the findings. The sample was derived from a single center, which may limit the generalizability of the results to other settings or populations.
5. Conclusion
This randomized controlled trial suggests that both the Buzzy device and finger puppet shows may be effective distraction techniques for reducing pain, fear, and anxiety in children undergoing venipuncture in the PED. The findings indicate that these non-pharmacological interventions may improve children’s experiences by providing a more child-friendly approach to managing the emotional and physical discomfort associated with medical procedures. These methods may be useful in pediatric clinical settings, with the Buzzy device showing relatively greater effects. Healthcare staff can integrate these distraction techniques into routine procedures to alleviate children’s pain, fear, and anxiety. However, these findings should be interpreted within the context of a single-center study, and further multi-center studies are needed to confirm their generalizability.
Acknowledgments
The authors would like to thank all the children and parents who agreed to participate in the study to the hospital management teams for their help with participant recruitment.
Author contributions
Conceptualization: Ahmet Butun, Sema Bayraktar, Meltem Çatalbaş-Acarsoy, Kadriye Olğaç Ak.
Data curation: Ahmet Butun, Sema Bayraktar, Meltem Çatalbaş-Acarsoy, Kadriye Olğaç Ak.
Formal analysis: Ahmet Butun, Sema Bayraktar, Meltem Çatalbaş-Acarsoy.
Methodology: Ahmet Butun, Sema Bayraktar, Meltem Çatalbaş-Acarsoy, Kadriye Olğaç Ak.
Project administration: Ahmet Butun, Sema Bayraktar, Meltem Çatalbaş-Acarsoy.
Resources: Ahmet Butun, Sema Bayraktar, Meltem Çatalbaş-Acarsoy, Kadriye Olğaç Ak.
Supervision: Ahmet Butun.
Validation: Ahmet Butun, Meltem Çatalbaş-Acarsoy.
Visualization: Ahmet Butun, Sema Bayraktar, Meltem Çatalbaş-Acarsoy, Kadriye Olğaç Ak.
Writing – original draft: Ahmet Butun, Sema Bayraktar, Meltem Çatalbaş-Acarsoy.
Writing – review & editing: Ahmet Butun, Sema Bayraktar, Meltem Çatalbaş-Acarsoy.
Abbreviations:
- CAM-S
- children’s anxiety meter-state
- CAM-T
- children’s anxiety meter-trait
- CFS
- Children’s Fear Scale
- CG
- control group
- PED
- pediatric emergency department
- WBFPS
- Wong-Baker FACES Pain Rating Scale
Ethical approval was obtained from Mardin Artuklu University Ethics Committee (Date: November 5, 2024, Decision No: 2024/11-3). In addition, the necessary permissions were obtained from the Mardin Provincial Directorate of Health (Date: November 20, 2024, Reference number: E-68051626-770-260098598). In addition, written informed consent forms were obtained from all participants. Written informed consent to participate was obtained from the parents or legal guardians of any participant under the age of 16. In this study, we did not apply any harmful interventions to patients. The research was carried out in accordance with the principles of the Declaration of Helsinki.
The study protocol was registered in the Clinical Trial Protocol Registration and Results System (https://clinicaltrials.gov/; Registration date: February 25, 2025, Registration number: NCT06849648).
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Butun A, Bayraktar S, Çatalbaş-Acarsoy M, Olğaç Ak K. The effect of buzzy and finger puppet show on children’s pain, fear, and anxiety during venipuncture in the pediatric emergency department: a randomized controlled trial. Medicine 2026;105:23(e49134).
Contributor Information
Sema Bayraktar, Email: sema.bayraktar@istanbul.edu.tr.
Meltem Çatalbaş-Acarsoy, Email: meltem.catalbas@ksbu.edu.tr.
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