IOSR Journal of Nursing and Health Science (IOSR-JNHS)

e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 9, Issue 1 Ser. X. (Jan - Feb. 2020), PP 09-19
www.iosrjournals.org

Effect of Cryotherapy versus Aromatherapy on Pain of

Arteriovenous Fistula Puncture for Children Undergoing
Hemodialysis
Seham Eid Hashem Elhalafawy1, Rahma Soliman Bahgat 2, Maher Ahmed Abd-
Elhafez 3, Nagafa Hafez Farag 4.
1(Assistant Lecturer of Pediatric Nursing, Faculty of Nursing / Tanta University, Egypt).
2(Professor of Pediatric Nursing, Faculty of Nursing / Tanta University, Egypt).
3(Professor of Pediatrics, Faculty of Medicine / Tanta University, Egypt).
4(Lecturer of Pediatric Nursing, Faculty of Nursing / Tanta University, Egypt)

Abstract :
Background: ArterioVenous Fistula (AVF) puncture pain is a major stressful experience facing children
undergoing hemodialysis (HD). Complementary therapies such as cryotherapy and aromatherapy are used to
manage pain. The study aimed to evaluate the effect of cryotherapy versus aromatherapy on pain of
arteriovenous fistula puncture for children undergoing HD. Subjects and method: A convenience sampling of
sixty children undergoing hemodialysis with AVF participated in the study. The study was conducted at Dialysis
Unit of Pediatric Medical department of Tanta Main University Hospital (TUH) and Dialysis Unit of
Elmenshawy Hospital. Three Tools were used to collect data: Structured Interview Schedule, Wong Baker faces
pain Rating Scale and Observational Scale of Behavioral Distress. The results revealed that during fistula
puncture, mean Wong Baker faces pain and total behavioral distress scale scores was lower among children in
cryotherapy group than those in aromatherapy. Post cryotherapy, children had lower mean pulse, respiration
and higher mean O2 saturation than pre cryotherapy. The study concluded that both cryotherapy and
aromatherapy had a positive effect in reduction of AVF puncture pain for children undergoing HD but
cryotherapy was more effective in pain reduction than aromatherapy. The study recommended that application
of ice massage should to be endorsed as a part of the routine care for hemodialysis children to reduce fistula
puncture pain.
Keywords: Arteriovenous fistula, Aromatherapy, Children, Cryotherapy, Hemodialysis, Pain
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Date of Submission: 21-01-2020 Date of acceptance: 12-02-2020
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I. Introduction
Chronic Kidney Disease (CKD) is a condition characterized by irreversible kidney damage that can
further progress slowly to End Stage Renal Disease (ESRD). It is recognized as a major health problem with
high cost on the community (1). Hemodialysis is the most frequently used therapy for CKD that involve
removing wastes and extra fluid from the blood through diffusion of solute molecules through semi permeable
membrane called a dialyzer, passing from higher concentration to lower concentration to filtering the blood (2).
For HD, a surgeon creates an access to the bloodstream, called a vascular access which mostly is
arteriovenous fistula. On average, children undergo HD three sessions weekly, each session lasting three to four
hours. They face pain experience every session during AVF cannulation that considered one of the most
necessary causes of treatment rejection among them. The frequent pain induced by fistula puncture can result in
depression, avoidance or shortening of session duration and stress for those children (3, 4).
Whereas applying pain management techniques can lead to the acceptance of treatment and improving
their quality of life. So, the nurses should be encouraged to promote pain management as a clinical and research
priority and basic child right for those children. Management of pain includes pharmacological and non-
pharmacological measures. Non-pharmacological measures include massage, distraction and electrical nerve
stimulation through either heat or cold application (5).
Cryotherapy has been acknowledged as a compelling non-pharmacologic intervention for pain
management and ice has been used for centuries as a topical pain reliever. It is easy to learn and inexpensive
strategy that expands the pain threshold. It also decreases the inflammatory response and spasm. Ice massage
produces cold stimulus as indicated by gate control theory as it inhibits the transmission of pain signals through
hinder brain stimulation and perception of pain by the person (6, 7).

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Effect of Cryotherapy versus Aromatherapy on Pain of Arteriovenous Fistula Puncture for Children ..

Aromatherapy is another non-pharmacological approaches that it is defined as the therapeutic use of

essential oils that extracted from plants. It is an alternative form of therapy that uses essential oils in order to
improve well being of body and brain and mood. Lavender oil, obtained from the plant named as Lavandula
angustifolia Mill. Lavender oil has many therapeutic actions such as reducing anxiety, pain reliever,
antispasmodic, antifungal, antimicrobial, and wound healing properties (8).
After inhalation of lavender, its particles are transmitted through the nose to the limbic system and this
area is closely connected with other systems that control memory, emotions and hormones, it results in release
of various neurotransmitters such as encephalin, endorphins and serotonin which ultimately lead to reduction of
stress and pain (9).

II. Aim of the study

The study was conducted to evaluate the effect of cryotherapy versus aromatherapy on pain of arteriovenous
fistula puncture for children undergoing hemodialysis.

III. Subjects and Method

This is a quasi-experimental research design. The study was conducted at; Dialysis Unit of Pediatric Medical
department of Tanta Main University Hospital (TUH) and Dialysis Unit of Elmenshawy Hospital.
Sample I: A convenience sampling of sixty children, were included in the study. The sample size was based on
the following parameters confidence level error level 5% type I error 0.05 and power of test 90%.They were
selected and divided randomly (using simple random method) into two equal groups namely: Group (I): Thirty
children who received cryotherapy. Group (II): Thirty children who exposed to aromatherapy. Children having
the following criteria; both sexes, aged from 6-15 years, capable of verbal and non verbal communication,
conscious and willing of them and their parents to participate in the study and have functioning AVF.
Three tools were used to collect data:
Tool I: Structured interview Schedule: It consisted of three parts: Part one: Sociodemographic characteristics
of the studied children: The form covered the personal characteristics of the studied children, including their
age, sex, educational level and residence. Part two: It covered the medical history of children including the
duration of their disease and co-morbidities, the duration and frequency of their hemodialysis and the
characteristics of their AVF as site, duration and their pain expression. Part three: It included data about the
child caregiver such as their age, educational level and their child pain history.
Tool II: Subjective pain assessment by using Wong–Baker faces pain rating scale (10):
It was adopted from Wong (1988). It was used as a self-report scale to measure the subjective pain intensity of
children during fistula puncture. It included six drawn faces expressing various degrees of pain, severity ranging
from “does not hurt” to “hurts very much”. These faces were assigned scores from 0 to 10, with a higher score
indicating a higher severity of pain.
Scoring system of Wong–Baker faces pain rating Scale: No pain (0), mild pain :( 1-3), moderate pain: (4-6)
and sever pain :( 7-10).
Tool III: It consisted of three parts: Part one: Observational Scale of Behavioral Distress (OSBD) (11): It was
adopted from Elliot (1987). It was used to observe children's behavioral reactions before, during and after fistula
puncture which indicate discomfort (cry, scream, physical restraint, verbal resistance, emotional support,
information seeking, verbal pain and flail) at 15 second intervals throughout the procedure (fistula puncture),
giving them score according to the severity of distress shown by the child. The scores were summed for each 15
second interval within phases of the procedure and then were divided by the number of intervals to obtain a
mean score. Each item was classified into (4) points according to the severity of distress whereas: severe distress
(4), moderate distress (3), mild distress (2) and no distress (1).The total score of OSBD:70 % and more indicated
severe distress, Moderate distress if the score was 60 %- >70 % , mild distress if: 50% - > 60% and Less than
50% indicate no distress.
Part two: The physiological measurements that could be influenced by pain were assessed before, during and
after needle insertion. These measurements included respiratory rate, pulse, blood pressure and oxygen
saturation. Part three: Assessment of the AFV puncture site: It was done before and after cryotherapy
implementation to detect any local skin reaction from cryotherapy, such as ecchymosis, swelling and skin
dryness.

Method
This study was approved by Research Ethical Committee REC of Faculty of Nursing at (TUH) 12-1-
2018. Oral consents were obtained from parents and their children to participate in the study after explaining
the aim of the study and their right to withdraw from the study at any time without providing a reason and
without any potential. The tools were presented to a jury of five experts in the field of pediatric nursing,
nephrology and community health nursing to check content validity, clarity, relevance, comprehensiveness,
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Effect of Cryotherapy versus Aromatherapy on Pain of Arteriovenous Fistula Puncture for Children ..

understanding, applicability and ease for implementation. Content validity index was 98.8%. To assess
reliability, the study tools were tested and the value of Cronbach's alpha coefficient was 0.881. A pilot study
was carried out on (10%) of children to test the tools for its clarity, applicability, feasibility and the necessary
modification was done Pilot study was excluded from total sample of the study.
Implementation of the study: The study was conducted through three phases:

1-Assessment phase: It was done by the researcher for all studied subjects to assess children who meet the
inclusion and exclusion criteria then the researcher, firstly met dialysis nurses and resident doctors to explain the
purpose of the study to gain their cooperation. Children and their parent were interviewed by the researcher in
the waiting room.
2-Implementation phase: The researcher attended at 6:30 am or 6:45am till 8:45 am every day except Friday to
collect the data. The parents were asked about sociodemographic and clinical data of their children to fill
questions of tool one. This step took about 10 minutes. Then, the researcher explained Wong Baker faces pain
rating scale to the children and taught them on how to apply this scale by using printed colored paper.

During the first two dialysis sessions (first and second day): the researcher recorded the physiological
measurements of children Tool III part three before needle puncture. ArterioVenous Fistula (AVF) puncture
sites were sterilized by nurses according the routine care of the unit. As the dialysis nurse performed the needle
puncture, the researcher observed and recorded the behavior of children using Tool III part one at 15 second
intervals throughout the puncture of fistula.
Physiological measurements of children were reassessed after puncture then the child asked to fill the subjective
pain scale. The same process was repeated in the next dialysis session. During the next two dialysis sessions
(third and fourth day): The researcher applied the intervention either implementation of cryotherapy or
inhalation of lavender:

Group I (Cryotherapy group): Massage with ice was done by the researcher over the AVF puncture site by
using slow circular fixed interrupted motions until numbness was felt by the child.
Group II (Aromatherapy group): two drops of 100% pure organic lavender oil was poured on cotton that was
fixed by the child at 5 cm distance from the child's nose and asked him to breathe slowly with his eyes closed
for 15 minutes. The nurse began cannulation and pain was measured as mentioned before. Before insertion of
needle, The researcher reassessed the AVF puncture site before the needle puncture to detect any local skin
reaction from cryotherapy and this step took about 1 minute.. Then the nurse inserted the needle while the child
was still observed by the researcher to record his or her behavior during needle insertion and asked about
numbness sensation disappeared and time of massage application.
3- Evaluation phase: It was done to children in both groups regarding pain level subjectively using tool II and
objectively using tool III in four consecutive sessions to assess degree of pain during insertion of needles pre
and post intervention. The data was collected over a period of six months from beginning of March 2018 to
August 2018.
Statistical analysis:
The collected data were organized, tabulated and statistically analyzed using SPSS software (Statistical Package
for the Social Sciences, version 23, SPSS Inc. Chicago, IL, USA). For quantitative data, the range, mean and
standard deviation were calculated. For qualitative data, comparison between two groups and more was done
using Chi-square test (2). For comparison between means of two groups of non-parametric data of independent
samples, Z value of Mann-Whitney test was used. For comparison between means of two groups of parametric
data of independent samples, student t-test was used. For comparison between more than two means of
parametric data, F value of ANOVA test was calculated. For comparison between means of two related groups
(before and after intervention) of parametric data of paired t-test was used. For comparison between more than
two means of non-parametric data, Kruskal-Wallis (X2 value) was calculated. For comparison between means
of three or more related groups (2value) of Friedman test was calculated for non-parametric data. Correlation
between variables was evaluated using Pearson’s correlation coefficient (r). Significance was adopted at P<0.05
for interpretation of results of tests of significance (12).

IV. Result
Table (1): As regards the age, it was evident that more than half of children (56.7%) and 43.3% were
between 12 -15 years old with the mean age (11.37±2.84 and 11.27±2.67) years in cryotherapy and
aromatherapy group respectively. In relation to sex, it was clear that 60% and two third (66.7%) of children
were females respectively, in cryotherapy and aromatherapy group.

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Effect of Cryotherapy versus Aromatherapy on Pain of Arteriovenous Fistula Puncture for Children ..

Regarding their residence, most of children (80%) and more than two third (66.35%) of them
respectively were from rural areas in each of cryotherapy and aromatherapy group. Regarding their educational
level, it was found that 60% of children in cryotherapy group were in primary school, while half of children
(50%) of the aromatherapy group were in preparatory school.
Figure (1): Regarding cryotherapy group, it was observed that the mean score of Wong Baker faces
pain score during fistula puncture was 7.266 and 5.667 respectively in day 1 and 2 which decreased to 2.666 and
1.733 respectively in day 3 and 4. While aromatherapy group, it was evident that the mean score of Wong Baker
faces pain rating scale during fistula puncture was 6.66 and 6.20 respectively in day 1 and 2 which decreased to
4.86 and 4.13 respectively in day 3 and 4.
Table (2): clarifies percentage distribution of the studied children according to their level of behavioral
distress scores before, during and after fistula puncture. It was found that there were statistically significant
differences among children in the cryotherapy group where (P=0.000, P=0.000, and P=0.017) respectively
before, during and after fistula puncture regarding their level of behavioral distress scores in 1st, 2nd, 3rd and 4th
day.
Moreover, during fistula puncture half and nearly half (46.7%) of the children of cryotherapy group
had mild behavioral distress score in the 1st and 2nd day respectively. While after implementation of cryotherapy,
most of them (86.7%) and all of them respectively had no distress in the 3 rd and 4th day. Regarding
aromatherapy group, it was observed that half and more than half (53.3%) of children respectively had mild
behavioral distress score in the 1 st and 2nd day before lavender inhalation while after it less than 60% and 80% of
them respectively had no behavioral distress in the 3rd and 4th day.
In addition, there were statistically significant differences among children in aromatherapy where
(P=0.000 and P=0.000) respectively before and during fistula puncture regarding their severity level of
behavioral distress scores that became not significant after fistula puncture where (P=0.388) in 1 st, 2nd, 3rd and
4th day. Also, it was clear that there were statistically significant differences among children of both groups
before, during and after fistula puncture where (P=0.000, P=0.000, P=0.001 and P=0.000) respectively in 1st,
2nd, 3rd and 4th day regarding their level of behavioral distress.
Table (3) demonstrates distribution of the studied children according to their mean change of total
severity level of behavioral distress scores before, during and after fistula puncture. It was noticed that mean ±
SD of change in total behavioral distress scores pre and post the intervention (II than I) was 4.383±2.15,
4.850±2.88 and 3.183±1.76 respectively before, during and after fistula puncture among children in
cryotherapy group.
In contrast to aromatherapy group, mean ± SD of change in total behavioral distress scores pre and post
the intervention (II than I) among children was 2.400 ± 2.53 before fistula puncture then became 3.800±3.10
during fistula puncture and became 0.850 ± 2.32 after fistula puncture. The table also showed that there were
significant differences where (P=0.000, P=0.000 and P=0.000) respectively before, during and after fistula
puncture among children of cryotherapy and aromatherapy group regarding the mean change of total severity
level of behavioral distress scores.
In addition, there were statistically significant differences between the studied children where
(P=0.000, P=0.020, and P=0.000) respectively before , during and after fistula puncture regarding total
behavioral distress scores pre the intervention (I) between cryotherapy and aromatherapy group in day 1 and 2.
Also, there were statistically significant differences between the studied children where (P=0.000, P=0.002, and
P=0.000) respectively before, during and after fistula puncture respectively regarding total behavioral distress
scores post the intervention (II) between cryotherapy and aromatherapy group in day 3 and 4.
Table (4) presents correlation between Wong Baker pain scores of the studied children of both groups
and their physiological measurements before, during and after fistula puncture. Regarding respiration, it was
revealed that there was positive significant correlation where (P=0.027) between it and Wong Baker faces scores
in fourth day during fistula puncture in cryotherapy group. While in aromatherapy group, there was positive
significant correlation where (P=0.029) between it and Wong Baker pain scores in third day before fistula
puncture.
There was negative non significant correlation between pulse and Wong Baker pain scores before,
during and after fistula puncture among children in both groups in 3rd and 4th day. In relation to systolic and
diastolic blood pressure, there was positive significant correlation where (P=0.003 and P=0.029) respectively
between them and Wong Baker pain scores in third day during fistula puncture among children of cryotherapy
group. In addition, there was negative significant correlation where (P=0.035) between O 2 saturation and Wong
Baker faces scores in third day before fistula puncture among children of cryotherapy group. While in
aromatherapy group a negative significant correlation was observed where (P=0.038) in the same day but after
fistula puncture.
Table (5) explains correlation between behavioral distress scores (severity) of the studied children of
cryotherapy and aromatherapy group and their sociodemographic and hemodialysis characteristics. It was found

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Effect of Cryotherapy versus Aromatherapy on Pain of Arteriovenous Fistula Puncture for Children ..

that there was negative non significant correlation between age and sex of children in both groups and their
behavioral distress scores before, during and after fistula puncture in 3rd and 4th day.
A positive non significant correlation was revealed between behavioral distress scores and duration of
disease among children of both groups except in 3rd day where it became significant where (P=0.033) among
children of cryotherapy group during fistula puncture. A positive non significant correlation was found between
duration of fistula and hemodialysis among children in both groups and their behavioral distress scores before,
during and after fistula puncture in 3rd and 4th day.
Table (6) presents correlation between behavioral distress scores and physiological measurements
among the studied children of both groups. Regarding respiration, there was negative significant correlation
where (P=0.008, P=0.044 and P=0.033) respectively between it and behavioral distress scores during and after
fistula puncture in 3rd day and before fistula puncture in the 4th day for cryotherapy group children.
In addition, there was negative non significant correlation between pulse and behavioral distress scores
and after fistula puncture where (P=0.101 and P=0.702) respectively among children of cryotherapy group in 3rd
and 4th day. Concerning systolic blood pressure, there was positive significant correlation where (P=0.005)
between it and behavioral distress scores in third day during fistula puncture among children of cryotherapy
group. In addition, there was negative non significant correlation between O2 saturation and behavioral distress
scores before, during and after fistula puncture among children in both groups in 3rd and 4th day.

Table (1): Percentage distribution of the studied children according to their sociodemographic
characteristics
Group I Group II
Characteristics of the studied children (Cryotherapy) (Aromatherapy)
(n=30) (n=30)

No. % No. %
Age (years):
6->9 6 20 6 20.0
9->12 7 23.3 11 36.7
12-≥15
17 56.7 13 43.3
Range 6 -15 6 -15
Mean ± SD 11.37 ± 2.84 11.27 ± 2.67
Median 12.0 11.5
Sex:
Male 12 40.0 10 33.3
Female 18 60.0 20 66.7
Residence:
Urban 6 20 10 33.3
Rural 24 80 20 66.7
Educational level:
Primary school 18 60.0 15 50
Preparatory school 10 33.3 13 43.3
Secondary school 2 6.7 2 6.7

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Effect of Cryotherapy versus Aromatherapy on Pain of Arteriovenous Fistula Puncture for Children ..

Figure (1): Mean score of the studied children according to their Wong Baker faces pain rating scale
scores during needle insertion

Table (2): Percentage distribution of the studied children according to their level of behavioral distress
scores before, during and after fistula puncture

*Statistically Significant difference at (P<0.05)

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Effect of Cryotherapy versus Aromatherapy on Pain of Arteriovenous Fistula Puncture for Children ..

Table (3): Distribution of the studied children according to their mean change of severity level of
behavioral distress scores before, during and after fistula puncture

*Statistically Significant difference at (P<0.05) I (1st and 2nd day-routine care or no

intervention)
II (3rd and 4th day- intervention (ice massage or lavender inhalation).

Table (4): Correlation between Wong Baker faces scores of the studied children of both groups and their
physiological measurements before, during and after fistula puncture

*statistically Significant difference at (P<0.05)

r =Correlation Coefficient

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Effect of Cryotherapy versus Aromatherapy on Pain of Arteriovenous Fistula Puncture for Children ..

Table (5): Correlation between Observational Scale of Behavioral Distress scores (severity) of the studied
children of cryotherapy and aromatherapy group and their sociodemographic and hemodialysis
characteristics

*Statistically Significant difference at (P<0.05)

r =Correlation Coefficient

Table (6): Correlation between behavioral distress scores (severity) the studied children of both groups
and their physiological measurements

*statistically Significant difference at (P<0.05)

r =Correlation Coefficient

V. Discussion
Arteriovenous fistula is an inevitable element for children receiving maintenance hemodialysis. They
experienced severe pain during AVF cannulation. Inadequate relief of pain during such distressing procedures
may permanently decrease pain tolerance and increase pain responses. The use of complementary therapy has
increased as non-pharmacological measures to reduce pain (13).
Complementary therapies such as cryotherapy and aromatherapy are safer than pharmacotherapy and
have few or no side effects. Cryotherapy is the application of any material that removes heat from the body
resulting in decreased tissue temperature which produces analgesic effect. As cold application seems to decrease
the ability of sensory transmission and thus reduces acetyl-choline release influencing the pain threshold.
Aromatherapy is the utilization of vaporizable and unstable oils extracted from aroma plants for many purposes
that was used in Egypt as a remedy thousands years ago (14).

The present study showed that pain level after ice massage application decreased from moderate and
severe pain in most of children in the first and second day to mild pain and no pain in the third and fourth day.
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Effect of Cryotherapy versus Aromatherapy on Pain of Arteriovenous Fistula Puncture for Children ..

This result may be explained on the basis that ice massage decreases the skin temperature that result in slowing
velocity of conduction of peripheral nerve fibers and decreasing release of inflammatory and nociceptive
mediators that lead to skin anesthesia and local anesthetic effect relatively quickly.
Elsayed (2017) was congruent with this result and mentioned that the mean of pain score during AVF
puncture reduced in the studied children post application of cryotherapy than pre cryotherapy. They concluded
cryotherapy was effective on diminishing pain intensity at puncture sites of AVF among children undergoing
hemodialysis (15).
Al Amer (2017) was in same line with this result who noticed that a highly significant difference was
found between pre test and post test mean score on level of pain (16). On the other hand, Waterhouse (2013)
disagreed with this result and stated that vapocoolant spray may be more effective than ice as an analgesic for
pediatric intravenous catheter insertion (17).
The current study revealed also that the reduction in the mean of Wong-Baker faces pain score and
behavioral distress scores during fistula puncture in the cryotherapy group in fourth day was more than that in
third day. There were statistically significant differences between pre and post intervention.
This may could be related to that children in the fourth day became more adapted, relaxed and more
interested with the procedure that produce more analgesic effect that observed in the fourth day than third day of
application. Patidar (2015) and Canbulat (2015) results was congruent with this result and they stated that cold
application reduced the objective and subjective level of pain during venipuncture in children (18, 14).
In addition, Shanmugam (2017) reported that there was highly statistical significant difference
between level of pain before and after application of cryotherapy (19). On the other hand, Fareed (2014)
disagreed with these results and reported that more than half of the studied children had moderate score of
objective pain before using the ice massage while after using it more than two third of them had mild objective
pain score during the second session and they had no pain during the third session, respectively (20).
As regards aromatherapy group children, the current study revealed that the mean score of pain reduced
in the third and fourth day after inhalation of lavender oil than mean of pain score in first and second day where
they received routine care. This may be attributed to that the inhaled lavender oil enter directly through the large
surface area of the nasal mucosa direct to the brain then exerting its relaxing effects on all body systems and
mind.
Bikmoradi (2017) were in the same direction with this result who found that mean of pain severity
immediately, five minutes and ten minutes after intravenous catheter insertion had significant differences after
aromatherapy inhalation (21). Tasana (2019) were in agreement with this result who found that the pain mean
score of vascular access was decreased after the implementation of lavender oil inhalation (22).
Besides, Ghods (2015) results were consistent with these results who reported that lavender
aromatherapy may be an effective technique to reduce pain following needle insertion into a fistula for patient
undergoing hemodialysis (23).While, Salamati (2014) was against this result and found that there was no
statistically significant difference before and after aromatherapy and proved that lavender essential oil inhalation
has no effect on reducing the pain (24). Lucas (2012) results also were against this result as they mentioned that
inhalation aromatherapy was not effective for reducing anxiety, nausea, or pain among children and adolescents
undergoing invasive procedures (25).
The result of the present study showed that lavender oil inhalation did not cause any negative side
effects on the children undergoing hemodialysis except five of children who felt sleepy. This may be due to the
relaxing effect of lavender oil to their body systems. Tasana (2019) supported this result and observed that
applying lavender oil inhalation to patients undergoing hemodialysis decreased their pain level experienced
during vascular access and caused no negative effects on them (22).
The findings of the present study clarified that there was a negative correlation between the age of
children in both cryotherapy and aromatherapy group and behavioral distress score before, during and after
needle insertion. This result can be explained that mean age of children in both groups was nearly equal as
mentioned in the results before and also as child age increased, they displayed more verbal expressions rather
than behavioral signs. Madadi (2017) were consistent with these findings and stated in that there was no
significant relationship between age of children as one of demographic characteristics of children and pain
distress score of AVF puncture (26).
In addition, Bagheriyan (2013) reached the same result and notified that there was a negative
correlation between age of children and their behavioral pain distress scores (27). On the other hand, Czub and
piscorz (2018) were inconsistent with the present result because their study results revealed that the age of
children did not correlate in a significant way with the level of experienced pain and the level of distress (28).

The present study indicated that there was no significant correlation between Wong Baker faces or behavioral
distress scores and sociodemographic variables in both groups. This result in the same direction with John
(2019) who mentioned that there was no significant relationship between the pain score and variables such as

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Effect of Cryotherapy versus Aromatherapy on Pain of Arteriovenous Fistula Puncture for Children ..

gender, duration of dialysis and fistula duration (29). Also, Shivcharan (2016) who proved that there was no
significant correlation between AVF puncture pain scores and demographic variables such as sex , the duration
of arteriovenous fistula use (30).Contrary to the results of Bartley and Fillingim (2013) were against the results
of the present study as they mentioned that the prevalence of pain was higher among females than males and
females reported greater pain after invasive procedures than males (31).

VI. Conclusion
Based on the findings of the present study, it can be concluded that both cryotherapy and aromatherapy had a
positive effect on reduction of AVF puncture pain for children undergoing HD but cryotherapy was more
effective in pain reduction than aromatherapy. Both cryotherapy and aromatherapy techniques had a positive
effect in decreasing physiological signs and behavioral distress that associated with AVF puncture.

Recommendations
Based on the findings of the present study, the following recommendations are suggested:
1. Educational training programs should be conducted for dialysis nursing staff about the application of
cryotherapy and aromatherapy and its effect on minimizing AVF puncture pain.
2. Application of ice massage and lavender inhalation should to be endorsed as a part of the routine care
for hemodialysis children to reduce AVF puncture pain.
3. Cryotherapy and aromatherapy as non pharmacological method for AVF puncture pain management
can be included into the curriculum of graduates and post graduates students of faculty of nursing.
4. Hospital managers are encouraged to include cryotherapy and aromatherapy techniques in the training
program for dialysis nurses and recommended to be included in the hospital protocol for management of AVF
puncture pain.

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Seham Eid Hashem Elhalafawy, etal. “Effect of Cryotherapy versus Aromatherapy on Pain of
Arteriovenous Fistula Puncture for Children Undergoing Hemodialysis". IOSR Journal of
Nursing and Health Science (IOSR-JNHS), 9(01), 2020, pp. 09-19.

DOI: 10.9790/1959-0901100919 www.iosrjournals.org 19 | Page