The impact of skin prick testing on pain perception and anxiety in children and parents

Main Article Content

Betul Karaatmaca
Umit Murat Sahiner
Ozge Soyer
Bulent E Sekerel


anxiety, children, parent, skin prick testing, stress.


Background: Skin prick testing (SPT) is a major diagnostic tool in patients with allergic symptoms. The testing process may involve pain, anxiety, and stress on children and parents. Objective: We aimed to measure the level of pain and anxiety before and after SPT in children and parents, and tried to identify predictive factors.

Methods: The children underwent SPT and parents completed the State-Trait Anxiety Inventory (STAI) S-Anxiety before and after SPT, T-Anxiety before SPT. The study nurse completed Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) scores (<5 years) or Wong-Baker FACES Pain Rating Scale (VAS), (≥5 years) after the SPT, in order to quantify pain.

Results: A total of 523 children (5.3 [2.8–9.1] [median, interquartile range] years old, 59.5% male) were evaluated. Parent gender was a predominant factor for anxiety, as mothers had a higher pre-test STAI (S-Anxiety) score, STAI (T-Anxiety), and post-test STAI (S-Anxiety) score than fathers (p < 0.001). Pre-test STAI (S-Anxiety) scores of parents decreased with increasing age (for 0–<5 years, 5–<12 years, and ≥12 years; [p for trend = 0.016]). The children tested on the back had higher VAS scores compared with the ones tested on the forearm [2[0–4] vs 2[0–2], [p = 0.005]). Risk factors determining higher general anxiety STAI (T-Anxiety) scores above the median were female sex for the parent (OR = 1.68; 95% CI [1.10–2.57]; p = 0.017), and parent’s education level being greater than or equal to high school level (OR = 1.83; 95% CI [1.27–2.64]; p = 0.001).

Conclusion: SPT may cause anxiety and pain in a subgroup of children particularly in younger age, and if performed on the back. Anxiety levels were higher in mothers, and in parents with high education levels.

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1. Bousquet J, Heinzerling L, Bachert C, Papadopoulos, NG, Bousquet, PJ Burney, PG et al. Practical guide to skin prick tests in allergy to aeroallergens. Allergy. 2012;67:18–24.

2. Cox L, Nelson H, Lockey R, Calabria C, Chacko T, Finegold I et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol. 2011;127:S1–S55. https://doi. org/10.1016/j.jaci.2010.09.034

3. Kuo H-C, Pan H-H, Creedy DK, Tsao Y. Distraction-based inter-ventions for children undergoing venipuncture procedures: a randomized controlled study. Clin Nurs Res. 2018;27:467–82.

4. Karibe H, Aoyagi-Naka K, Koda A. Maternal anxiety and child fear during dental procedures: a preliminary study. J Dent Children. 2014;81:72–7.

5. Cohen LL, Blount RL, Cohen RJ, Johnson VC. Dimensions of pediatric procedural distress: children’s anxiety and pain during immunizations. J Clin Psychol Med Settings. 2004;11:41– 7.

6. Koller D, Goldman RD. Distraction techniques for children undergoing procedures: a critical review of pediatric research. J Pediatr Nurs. 2012;27:652–81. pedn.2011.08.001

7. Kühlmann A, De Rooij A, Kroese L, Van Dijk M, Hunink M, Jeekel J. Meta-analysis evaluating music interventions for anxiety and pain in surgery. Br J Surg. 2018;105:773. https://

8. Pipkorn U, Andersson M. Topical dermal anaesthesia inhibits the flare but not the weal response to allergen and histamine in the skin-prick test. Clin Exp Allergy. 1987;17:307–11. https://

9. Sicherer SH, Eggleston PA. EMLA Cream for pain reduction in diagnostic allergy skin testing: effect on wheal and flare responses. Ann Allergy Asthma Immunol. 1997;78:64–8.

10. Dire DJ, Hogan DE. Double-blinded comparison of diphen-hydramine versus lidocaine as a local anesthetic. Ann Emerg Med. 1993;22:1419–22. S0196-0644(05)81989-4

11. Zachariae R, Bjerring P. The effect of hypnotically induced analgesia on flare reaction of the cutaneous histamine prick test. Arch Dermatol Res. 1990;282:539–43. https://doi. org/10.1007/BF00371950

12. Waibel KH, Katial RK. Effect of topical vapocoolant spray on skin test wheal, flare, and pain responses. Ann Allergy Asthma Immunol. 2005;95:149–53. S1081-1206(10)61204-5

13. Tversky JR, Chelladurai Y, McGready J, Hamilton RG. Performance and pain tolerability of current diagnostic allergy skin prick test devices. J Allergy Clin Immunol Pract. 2015;3:888–93.

14. Nelson HS, Lopez P, Curran-Everett D. Evaluation of a skin test device designed to be less painful. J Allergy Clin Immunol. 2012;130:1422–3.

15. Buyuktiryaki B, Sahiner UM, Karabulut E, Cavkaytar O, Tuncer A, Sekerel BE. Optimizing the use of a skin prick test device on children. Int Arch Allergy Immunol. 2013;162:65–70. https://

16. Jeffs DA. A pilot study of distraction for adolescents during allergy testing. J Specialists Pediatr Nurs. 2007;12:170–85.

17. Requena G, Sánchez C, Corzo-Higueras JL, Reyes-Alvarado S, Rivas-Ruiz F, Vico, F et al. Melomics music medicine (M3) to lessen pain perception during pediatric prick test procedure. Pediatr Allergy Immunol. 2014;25:721–4. https://doi. org/10.1111/pai.12263

18. Goldberg A, Stauber T, Peleg O, Hanuka P, Eshayek L, Confino-Cohen R. Medical clowns ease anxiety and pain perceived by children undergoing allergy prick skin tests. Allergy. 2014;69:1372–9.

19. Noel M, Chambers CT, McGrath PJ, Klein RM, Stewart SH. The influence of children’s pain memories on subsequent pain experience. Pain®. 2012;153:1563–72. https://doi. org/10.1016/j.pain.2012.02.020

20. Şahiner UM, Civelek E, Yavuz ST, Büyüktiryaki AB, Tuncer A, Şekerel BE. Skin prick testing to aeroallergen extracts: what is the optimal panel in children and adolescents in Turkey? Int Arch Allergy Immunol. 2012;157:391–8. https://doi. org/10.1159/000329870

21. Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs. 1988;14:9–17.

22. Zhang W, Zeng J, Liao J, Yang T, Ren J, Zhou X et al. A comprehensive clinical study about patching after strabismus surgery. Eur J Ophthalmol. 2014;24:819–23. ejo.5000445

23. El Tumi H, Johnson M, Dantas P, Maynard M, Tashani O. Age-related changes in pain sensitivity in healthy humans: a systematic review with meta-analysis. Eur J Pain. 2017;21:955–64.

24. Thrane SE, Wanless S, Cohen SM, Danford CA. The assessment and non-pharmacologic treatment of procedural pain from infancy to school age through a developmental lens: a synthesis of evidence with recommendations. J Pediatr Nurs. 2016;31:e23–32.

25. Spielberger C, Gorsuch R, Lushene R. State-trait anxiety inventory STAI (Form Y). Redwood City: Mind Garden; 1983.
26. Young KD. Pediatric procedural pain. Ann Emerg Med. 2005;45:160–71. 09.019

27. Wolff NJ, Darlington A-SE, Hunfeld JA, Verhulst FC, Jaddoe VWV, Moll, HA et al. The association of parent behaviors, chronic pain, and psychological problems with venipuncture distress in infants: the Generation R study. Health Psychol. 2009;28:605.

28. Bernard RS, Cohen LL. Parent anxiety and infant pain during pediatric immunizations. J Clin Psychol Med Settings. 2006;13:282–7.

29. de Castro Morais Machado G, Van Wijk A, Van Der Heijden G, Costa LR. Does parental anxiety, coping, and pain catastrophizing influence child behavior during sedation? Pediatr Dentist. 2018;40:365–9.

30. Augustyn M ,Frank DA, Zuckerman BS. Developmental-behavioral pediatrics (Fourth edition). In: WB Carey, AC Crocker, WL Coleman, E.R. Elias, HM Feldman, editors. Infancy and toddler years. Elsevier; 2009: 24–38. https://doi. org/10.1016/B978-1-4160-3370-7.00003-1. Philadelphia,

31. Wamboldt MZ, Wamboldt FS. Role of the family in the onset and outcome of childhood disorders: Selected research find-ings. J Am Acad Child Adolesc Psychiatry. 2000;39:1212–19.

32. Serinken M, Kocyigit A, Karcioglu O, Sengül C, Hatipoğlu C, Elicabuk H. Parental anxiety and affecting factors in acute paediatric blunt head injury. Emerg Med J. 2014;31:637–40.