Preoperative anxiety affects about 60% of children and is linked with poorer cooperation at anesthesia induction, greater postoperative pain, and maladaptive behavioral changes. Many proven interventions rely on digital platforms or virtual reality, which can be costly and difficult to implement in busy wards. Now, a single-center trial conducted at Children's Hospital, Zhejiang University School of Medicine in China suggests that a structured, low-cost, non-digital card game led by nurses may help ease children's anxiety at a particularly stressful point in surgery—entry to the operating room—and may improve cooperation during anesthesia induction and early postoperative behavior.
The findings, reported (DOI: 10.1007/s12519-026-01097-4) online on 19 September 2026 in the World Journal of Pediatrics, offer preliminary support for structured therapeutic play as a practical addition to pediatric preoperative preparation. The trial randomized 164 children, with 162 included in the final analysis after two in the intervention group did not complete the game protocol. A trained nurse led a child-life-informed session on the evening before surgery, individually or in groups of up to three children, lasting 40 minutes. Two modules were used: "Time-limited Treasure Hunting," in which children matched medical equipment tokens while receiving brief explanations, and "Surgical Adventure," a board game introducing the ward, operating room, and perioperative procedures.
Children in the card-game group appeared less anxious at operating-room entry than controls, were more likely to cooperate during anesthesia induction, and showed fewer post-discharge behavioral problems, particularly generalized anxiety, according to caregiver reports. Heart rate and blood pressure changed over time but did not differ between groups. Caregiver anxiety scores were similar between groups, although they rose in both groups when children separated from caregivers. The authors said the benefit was most evident at operating-room entry, a particularly stressful moment when children separate from caregivers and face the clinical environment directly, and suggested the effect may reflect distraction, greater familiarity with procedures, improved predictability, and a stronger sense of control. The group format may also have encouraged emotional sharing and positive peer modeling.
However, the authors cautioned that the trial was single-center, restricted to otolaryngology inpatients, unable to blind children and providers, used weekly randomization, and lacked long-term follow-up. The intervention did not reduce caregiver anxiety, suggesting future preparation should pair child-focused play with support for parents and caregivers. The findings need confirmation in larger multicenter studies before wider adoption. If replicated, the approach could be considered for routine preoperative preparation and future quality-improvement programs.
The potential significance extends beyond the immediate preoperative period. Because the game uses simple materials and can be delivered by trained nurses in small groups, it could be easier to incorporate into busy pediatric surgical pathways than digital or virtual-reality programs, which may be difficult to adopt in routine practice because of cost, equipment requirements, and implementation burden. As hospitals seek scalable, low-cost ways to improve the surgical experience for children, this trial provides an early signal that non-digital therapeutic play may be a valuable tool. The authors noted that further research is needed to evaluate scalable, low-cost, non-digital play interventions for children that can be delivered widely in routine pediatric surgical care. The study was supported by Medical Technology and Education of Zhejiang Province of China (Grant No. Y202352389). Additional information is available through Chuanlink Innovations.
