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Importance: Fear and distress during immunization may lead to long-term preprocedural anxiety and nonadherence to immunization schedules. Pictorial stories provide a way of educating the parent and child about the procedure. Objective: To determine the efficacy of pictorial stories in reducing pain perception among children and anxiety among mothers during immunization. Design: Three-arm randomized controlled trial Setting: Immunization clinic of a tertiary care hospital in South India. Participants: Fifty children ages 5 to 6 yr, who reported to the hospital for measles, mumps, and rubella and typhoid conjugate virus vaccines. Inclusion criteria were that the child was accompanied by the mother and maternal knowledge of either Tamil or English. Exclusion criteria were child hospitalization in the past year or neonatal intensive care unit admission in the neonatal period. Intervention: Pictorial story regarding immunization before the procedure that contained information related to immunization, coping strategies, and distraction techniques. Outcomes and Measures: Pain perception was evaluated using the Sound, Eye, Motor Scale; the Observation Scale of Behavioral Distress; and the Wong-Baker FACES Pain Rating Scale (FACES). Maternal anxiety was measured using the General Anxiety–Visual Analog Scale. Results: Of 50 children recruited, 17 were in the control group, 15 were in the placebo group, and 18 were in the intervention group. Children in the intervention group reported lower pain scores on the FACES (p =.04) compared with the placebo and control groups. Conclusions and Relevance: A pictorial story is a simple and cost-effective intervention to reduce pain perception among children. What This Article Adds: Pictorial stories may be a feasible, simple, and cost-effective intervention to reduce pain perception during immunization. Using a pictorial story that includes information related to immunization, coping strategies, and distraction techniques may be a feasible, simple, and cost-effective intervention to reduce pain perception among children during immunization and provide a way of educating the parent and child about the procedure. [ABSTRACT FROM AUTHOR]