Therapeutic play to prepare children for invasive procedures: a systematic review<sup>,</sup>

Silva, Rosalia Daniela Medeiros da; Austregésilo, Silvia Carréra; Ithamar, Lucas; Lima, Luciane Soares de

doi:10.1016/j.jped.2016.06.005

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Review articles • J. Pediatr. (Rio J.) 93 (1) • Jan/Feb 2017 • https://doi.org/10.1016/j.jped.2016.06.005 copy

Therapeutic play to prepare children for invasive procedures: a systematic review^☆ ☆ Please cite this article as: Silva RD, Austregésilo SC, Ithamar L, Lima LS. Therapeutic play to prepare children for invasive procedures: a systematic review. J Pediatr (Rio J). 2017;93:6-16. ^,^☆☆ ☆☆ Study conducted at Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

Objective:

To analyze the available evidence regarding the efficacy of using therapeutic play on behavior and anxiety in children undergoing invasive procedures.

Data source:

The systematic review search was performed in the MEDLINE, LILACS, CENTRAL and CINAHL databases. There was no limitation on the year or language.

Synthesis of data:

The literature search found 1892 articles and selected 22 for full reading. Eight articles were excluded, as they did not address the objectives assessed in this review. Twelve studies, representing 14 articles, were included. The studies were conducted between 1983 and 2015, five in Brazil, one in the United States, five in China, one in Lebanon, one in Taiwan, and one in Iran. Most studies showed that intervention with therapeutic play promotes reduction in the level of anxiety and promotes collaborative behavior and acceptance of the invasive procedure.

Conclusions:

Evidence related to the use of therapeutic play on anxiety and behavior of children undergoing invasive procedures is still questionable. The absence, in most studies, of the creation of a random sequence to assign the subjects to either the control or the experimental group, as well as allocation concealment, are factors that contribute to these questions. Another issue that characterizes an important source of bias is the absence of blinded evaluators. It is necessary to perform further studies that will take into account greater methodological stringency.

KEYWORDS
Children; Play and playthings; Anxiety; Behavior; Hospital care

Author (year of publication), and place	Study population and sample size	Study design	Strategy and materials used, duration and moment when the therapeutic play session was carried out	Assessed outcome and evaluation method	Results
Bruce et al. (1983) USA	45 children aged 3-4 years, submitted to dental extraction and restoration	Experimental	• Hospital objects. Parents and children acted as patient and professional and simulated the procedure • A 20-25 min session on the day before the procedure	• Cooperation, negative behavior and heart rate • Manifest Upset Scale • Cooperation Scale Monitoring of heart rate for 2 min	The EG related to the procedure was more cooperative than the other two groups
Li et al. (2007a)^a a The articles Li et al., 2007a, Li et al., 2007b and Li and Lopes, 2008 are results of the same study. China	203 children aged 7-12 years undergoing elective surgery and their parents	Experimental	• Visits the reception, anesthetic induction, operation and recovery rooms • Representative doll with a size similar to the child's • Representation of the obtaining of vital signs, anesthetic induction and venipuncture • A one-hour session a week before the procedure	• Child and parents' anxiety, emotional behavior during anesthesia, postoperative pain and parents' satisfaction • Chinese version of the State Anxiety Scale for Children (CSAS-C) • Chinese version of the State Anxiety Scale for Adults • Children's Emotional Manifestation Scale (CEMS) Visual analog scale (VAS)	Anxiety scores were lower, negative behavior was less frequent, and there was a higher degree of satisfaction among parents from the EG
Vaezzadeh et al. (2011) Iran	122 children aged between 7 and 12 years submitted to elective surgery.	Experimental	• Visits the reception, operation and recovery rooms • Demonstration in a pediatric manikin similar in size to a child aged 6-8 years • Children handled the equipment and then demonstrated the procedures on the doll • A one-hour session, one day before surgery	• Anxiety • Spielberger State Anxiety Scale for children (SSAS-c)	There was a higher reduction in mean anxiety scores in the EG preoperatively (31.44 ± 5.87) than in the CG (38.31 ± 7.44)
Yu-Li et al. (2013) Taiwan	19 children aged 3-15 years submitted to radiotherapy	Experimental	• Storytelling, role-playing game, coloring books with every step of the treatment process. Child-like doll, clay molding, painting, video games and cartoons projected on the ceiling of the treatment room during radiotherapy. One 15-20 min session a day, every afternoon, from Monday through Friday	• Anxiety • The Faces Anxiety Scale (FAS) • Beck Youth Anxiety Inventory (BAI-Y) • Heart rate • Differences in cortisol levels	The EG showed a significantly lower score/level of anxiety (1.89 ± 0.93) when compared to the CG (3.00 ± 1.33) before radiotherapy
Ruschel (1995) Brazil	60 children aged 3-10 years submitted to congenital heart defect surgery	Quasi-experimental	• Materials related to pre and postoperative care. Doll, suture threads, needles, tweezers and scissors • Simulation surgery with doll	• Child's attitude in relation to several procedures • Form	There was statistical significance (p < 0.05) at the moments: quiet wakening, cooperation during procedures, accepting the absence of the mother, and fluid restriction
He et al. (2015) China	95 children aged 6-14 years submitted to elective surgery	Experimental	• Video about the surgery with pictures of the operating room environment. Demonstration with doll of the preoperative procedures. Demonstration by the child • Manual with medical objects and equipment used during surgery. A one-hour session three to seven days before the procedure	• Perioperative anxiety, negative emotional expression and post-operative pain • State Anxiety Scale for Children (SAS-C) • Children's Emotional Manifestation Scale (CEMS) • The Numeric Rating Scale (NRS) Medical record	The EG showed less negative emotional behavior before anesthesia induction, low levels of anxiety, and less postoperative pain
Kiche and Almeida (2009) Brazil	34 children aged 3-10 years submitted to minor and medium surgeries	Quasi-experimental	• Doll, saline solution, gauze, adhesive tape, masks, scissors, dressing forceps, gloves, splints and other specific items according to the child's dressing • Two sessions, one after the dressing and the second session on the following day, before changing dressing	• Behaviors that showed acceptance and adaptation to the procedure • Form • Wong and Baker scale	The behaviors that show lower acceptance and adaptation to the procedure decreased, and those showing greater acceptance and adaptation increased after the therapeutic play session
Ribeiro et al. (2001) Brazil	42 children aged 3-6 years submitted to blood collection	Quasi-experimental	• Doll, syringe, test tube, cotton, adhesive tape. Scalpel with one catheter and bottle with red liquid • One session before the procedure.	• Behavior during blood collection • Form	The EG showed a reduction in the behaviors of "aggression, verbal expression, body movement, expression of emotion, and dependence" and showed an increase in the behaviors of "being quiet"
Pontes et al. (2015) Brazil	60 children aged 3-6 years submitted to vaccination procedure	Quasi-experimental	• Doll, disposable syringes, needles, cotton and stickers for venipuncture • One 20-minute session before the vaccination	• Child's reactions • Observation during vaccination • Interview with parent/guardian	The EG had more reactions of "being quiet" and "collaborating spontaneously"; behaviors such as "pushing," "clinging to parents," "asking to be picked up," and "stiffness" were less present. Behaviors of "crying," "clinging to parents," "flushing," and "moving/agitating" were more present in the CG
Li et al. (2014) China	108 children aged 7-12 years admitted to undergo elective surgery	Experimental	• Visits to the operating room and presentation of equipment • Demonstration in the operating room with a doll on the following procedures. The post-anesthetic recovery period is explained • Demonstration by the child of the procedures on the doll • A 1-hour session	• Anxiety, emotional responses during anesthesia induction and satisfaction of parents • State Anxiety Scale for children and adults • Children's Emotional Manifestation Scale • Questionnaire and semi-structured interview	The EG showed a lower level of anxiety, demonstrated fewer emotions during the anesthetic induction, and the parents of the children from the group reported more satisfaction after surgery
Weber (2010) Brazil	50 children aged 5-12 years submitted to surgery	Experimental	• Recreational activities with the use of games, toys, books, comic books, movies, TV and materials for drawing • One session 15 min after entering the Ambulatory Surgical Center, lasting 15 min	• Anxiety level • Observation when entering the operating room and 15 min after entering the room • Modified Yale Preoperative Anxiety Scale	92% of the children in EG did not have anxiety, while in the CG, 84% were still anxious
Zahr (1998) Lebanon	100 children aged 3-6 years submitted to elective surgery	Experimental	• Materials for painting, dolls, puzzles and bicycles • Demonstration using puppets of the sequence of events from admission, surgery to discharge • The child was encouraged to play, handle the equipment and re-present the play • One session carried out the day before the procedure	• Behavior, blood pressure and pulse • Manifest Upset Scale • Cooperation Scale • Post-Hospital Behavior Questionnaire (PHBQ)	Children from the EG were calmer than those from the CG (2.52 ± 1.28 vs. 3.76 ± 1.16, t = -5.08; p = 0.001)
Li and Lopez^a a The articles Li et al., 2007a, Li et al., 2007b and Li and Lopes, 2008 are results of the same study. (2008) China	203 children aged 7-12 years submitted to surgery	Experimental	• Visits to the reception, anesthetic induction, surgery and recovery rooms • Demonstration of procedures on a doll with size similar to that of a child • A one-hour session carried out one week before the procedure	• Anxiety of the children and their parents and parental satisfaction • Chinese version of the State Anxiety Scale for Children (CSAS-C) • Chinese version of the State Anxiety Scale for Adults • The Postoperative Parents' Satisfaction Questionnaire (PPSQ)	The EG showed statistically lower anxiety scores in the pre- and postoperative periods (F [1,201] ¼ 5:36, p < 0.02) and less frequent negative behavior than the CG and their parents showed a greater degree of satisfaction
Li et al.^a a The articles Li et al., 2007a, Li et al., 2007b and Li and Lopes, 2008 are results of the same study. (2007b) China	203 children aged 7-12 years submitted to elective surgery	Experimental	• Visits to the reception, anesthetic induction, surgery and recovery rooms • Demonstration of procedures on a doll with size similar to that of a child	• Child's anxiety, behavior and level of postoperative pain • Chinese version of the State Anxiety Scale for Children (CSAS-C) • Children's Emotional Manifestation Scale (CEMS) • Visual analog scale (VAS)	Children from the EG and their parents showed lower anxiety scores in the pre- and postoperative periods (F [1,201] ¼ 5.36, p < 0.02); less frequent negative behavior (t [201] ¼ _5.4, i < .0001) and their parents showed a greater degree of satisfaction

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[1] * Corresponding author. E-mail:rosaliadaniela@hotmail.com (R.D. Silva).