The Effects of Nonpharmacological Methods Used in Subcutaneous Application on Pain, Anxiety, and Fear Levels in Children

Overview

Childhood cancers are increasing globally and require long-term invasive treatments, particularly subcutaneous applications that often cause pain, swelling, and anxiety. Effective pain and anxiety management is essential, as early traumatic experiences may shape children's future pain responses. Nonpharmacological methods-classified as physical, cognitive, and behavioral-are widely used alongside pharmacological strategies due to their safety, cost-effectiveness, and ease of application. Although studies show these methods reduce pain and anxiety, there is still a need for high-quality research comparing multiple approaches across different age groups and procedures. This study aims to evaluate and compare the effectiveness of combined physical, cognitive, and behavioral interventions in managing pain, anxiety, and fear among children with oncological diagnoses undergoing invasive procedures.

Childhood cancers have become an important public health problem due to their rapidly increasing incidence worldwide. Global and national data indicate not only a significant rise in childhood cancer cases but also show that countries' levels of development affect treatment success (Kutluk et al., 2023; WHO, 2024). Long-term treatment protocols, chemotherapy, and radiotherapy result in many invasive procedures in children, with subcutaneous applications being frequently used. Although subcutaneous administration has fewer systemic side effects compared to other methods, the likelihood of local and acute reactions remains high. The most common physical reactions experienced by children are pain, swelling, and redness at the injection site, while emotional reactions frequently include fear and anxiety (Arasi et al., 2018; Endaryanto \& Nugraha, 2021; Mahler et al., 2020). From birth, children are exposed to many invasive procedures and experience pain and anxiety. McCaffery defined pain as "whatever the experiencing person says it is, existing whenever he says it does," emphasizing its subjective nature (McCaffery, 1968). Painful procedures encountered early in life, if not managed appropriately, may shape children's future pain responses and become a source of trauma (Birnie et al., 2019; Zieliński, Morawska-Kochman \& Zatoński, 2020). Therefore, proper pain management during childhood is crucial in reducing the traumatic impact of painful experiences. This is particularly important for children undergoing repeated and long-term procedures such as immunotherapy, where pain and anxiety should be effectively managed during interventions (Ahmadpour et al., 2020). The American Academy of Pediatrics (AAP) and the American Pain Society recommend alleviating pain and anxiety even during minor procedures. Effective and timely pain control during invasive medical procedures not only reduces immediate distress but also increases tolerance in subsequent procedures. The AAP highlighted the importance of pain management in patient care by defining pain as the "fifth vital sign" to raise awareness among healthcare professionals (AAP, 2022). Pain and anxiety control requires a multidisciplinary team approach, with nurses playing a key role. Accurate identification, assessment, and management of children's pain are central to nursing care (Alotaibi et al., 2018). The American Society for Pain Management Nursing (ASPMN) emphasizes nurses' responsibility in ensuring pain control before, during, and after invasive procedures through both pharmacological and nonpharmacological methods. Multiple strategies exist to reduce pain and anxiety in pediatric invasive procedures. The use of nonpharmacological methods, either alone or in combination with pharmacological treatments, has increased in recent years due to their effectiveness in reducing pain, as well as their safety, ease of use, low cost, and time efficiency. Selection of nonpharmacological interventions should consider the child's cognitive capacity, age, culture, behavioral characteristics, coping skills, and type of pain (Addab et al., 2022; Erdoğan \& Özdemir, 2021; Czech et al., 2021). Nonpharmacological interventions in children are classified into physical, cognitive, and behavioral methods. In the literature, these methods have been applied during vaccinations, injections, blood draws, pre- and postoperative care, and dressing changes (Sivri et al., 2022; Topçu et al., 2022; Yılmaz \& Şahiner, 2022). While existing studies show that nonpharmacological interventions are effective in reducing pain and anxiety during invasive procedures, further high-quality studies are needed to evaluate easily applicable approaches across different age groups. In this context, it is important to conduct research comparing the effectiveness of multiple nonpharmacological methods in controlling pain, anxiety, and fear in various pediatric procedures. This study aims to contribute to the literature by simultaneously applying and comparing three types of interventions-physical, cognitive, and behavioral-among children with oncological diagnoses to evaluate their effectiveness in pain and anxiety management.