The Comfort, Ask, Relax, Distract (CARD) educational framework reduced needle-related fear/pain among children and was associated with parental satisfaction


“The majority of children are afraid of needles, yet their concerns are not addressed in how needles are administered in practice,” Anna Taddio, PhD, MSc, BScPhm, noted. “This leads to unnecessary pain, fear, and, for some children, negative experiences, which leads to non-compliance with vaccinations and other healthcare interventions involving needles, including life-saving treatments.”

Previous research from Dr. Taddio and colleagues suggests that “8% of children are not vaccinated on time because of concerns of pain/fear,” she continued. “Importantly, pain and fear can be prevented, and kids (and parents) can be taught how to cope with needles.”

To address this, Dr. Taddio and colleagues developed the Comfort, Ask, Relax, Distract—CARD—system, an educational framework for coping with needle-related fear and pain. Each letter category provides evidence-based coping strategies children can choose from to decrease pain, fear, and other stress-related symptoms related to needles.

“We created the game to teach kids (and parents) how to cope with needles,” Dr. Taddio said. “This is a life skill, as needles are part of healthcare—and, with new (injectable) drugs and vaccines continually being developed, including the COVID-19 vaccine, the needle is not going away anytime soon.”

Dr. Taddio and colleagues conducted a study that was published in Vaccine to gauge the benefits of the CARD game using a mixed methods approach that involved virtual observation and an interview-led survey. They included a convenience sample of 15 child-parent dyads; children were aged 6-12.

Children, Parents, & Clinicians All Benefit

Prior to playing the CARD game, 14 children reported a fear of needles to some degree. Following the game, nine of these children (60%) reported being less afraid. Every child was able to remember strategies they learned from the game that could help them cope with needles, and both children and parents said they would use the CARD game to help them with future needle encounters.

“The most important thing is that kids and parents can be educated about coping with needles, and this helps them be more prepared and confident,” Dr. Taddio noted. “Parents say they want to learn about the game from the doctor, who is a credible source, and it’s easy to offer the game—one just needs to let parents/kids know about it.”

Parent feedback was also positive regarding the simplicity of the game and the variety of activities included. The main drawback they described centered on the amount of reading that was required.

Managing pain/fear associated with needles “improves the experience for everyone involved, including clinicians,” she continued. “This is clearly demonstrated in our research on implementing CARD.”

Tips for Implementing the CARD Game

In addition to the improvements about fear/anxiety, children described the CARD game as easy to understand and easy to play (Table). They also reported that it helped teach coping skills they “believed they could implement,” according to the study results.

In addition to introducing the game to parents and children during an exam, Dr. Taddio noted that clinicians can use CARD-related tools in their offices. “A suite of tools is available online to assist with implementing CARD, all of which are freely available for use.”

Dr. Taddio also reminded clinicians that they “need to follow through with supporting child-selected coping requests (eg, using a distraction or a topical anesthetic cream), as this not only will result in a better experience, but will build trusting relationships with families because clinicians show kids they care about them.”

In the future, Dr. Taddio hopes researchers will “examine the downstream effects of teaching people about this—for instance, the prevalence of needle fears and healthcare avoidance behavior (eg, vaccination non-compliance).”