Therapeutic play to prepare children for invasive procedures: a systematic review

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Recife, PE, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Brinquedo terapêutico no preparo de crianças para procedimentos invasivos: revisão sistemática" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1954 "Ancho" => 2238 "Tamanyo" => 232462 ] ] "descripcion" => array:1 [ "en" => "Representative flowchart of the selection steps of articles included in the systematic review." ] ] ] "textoCompleto" => "IntroductionThe degree of the children's understanding about the procedure to which they will be submitted may be related to the period of stress and insecurity that they will experience. Their behavior may vary according to age, environment, the presence of strangers, and invasive procedures experienced by the children or observed in others. These factors contribute to the development of unpleasant reactions such as fear, anxiety, and resistance to the procedures that will be performed. Hospitalization means attacking their playful and magical realm, and therefore requires that the assisting professional understands their childhood world.<a class="elsevierStyleCrossRefs" href="#bib0195">1,2</a>Excessive stress and anxiety experienced by children can affect their physical and physiological health, hinder their ability to deal with medical procedures, cause changes in their behavior, and affect their recovery from illness. Therefore, there is an urgent need for clinical researchers to develop, implement, and evaluate interventions that can minimize the children's anxiety level and improve their ability to handle the stress of hospitalization and invasive procedures.<a class="elsevierStyleCrossRef" href="#bib0205">3</a>Over the past decades, several studies that addressed children's health care have discussed different methods of educational interventions for children before or during hospitalization, when surgical and invasive medical procedures are performed.<a class="elsevierStyleCrossRefs" href="#bib0210">4–9</a>The need to play is not eliminated when children become ill or are hospitalized; on the contrary, children who can play may feel safer during the transoperative period, even in a strange environment.<a class="elsevierStyleCrossRef" href="#bib0240">10</a> One aspect of such activities is therapeutic play, which provides a structured play activity, follows the principles of play therapy, and has specific objectives to be achieved. Its use brings relief from anxiety caused by atypical experiences for age that tend to appear as threatening, requiring an intervention that will help the child/family to cope while undergoing a highly complex invasive procedure.<a class="elsevierStyleCrossRef" href="#bib0245">11</a>Studies have shown the benefits of therapeutic play in reducing anxiety and postoperative pain in hospitalized children.<a class="elsevierStyleCrossRef" href="#bib0250">12</a> Clinical trials have shown the positive effects of therapeutic play intervention on perioperative anxiety, postoperative pain, and negative behavior in children submitted to surgical procedures.<a class="elsevierStyleCrossRefs" href="#bib0225">7,9</a>Thus, with the objective of contributing to the knowledge about the use of therapeutic play, which is an important strategy to be used in childcare, this review aimed to systematically assess the evidence regarding the efficacy of using therapeutic play on the behavior and anxiety in children undergoing invasive procedures.MethodThe protocol of this review is registered at the international database for systematic reviews, PROSPERO, under number CRD42016035878, and can be accessed at (<a id="intr0010" class="elsevierStyleInterRef" href="http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016035878">http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016035878</a>). This article was written according to PRISMA recommendations for systematic reviews.<a class="elsevierStyleCrossRef" href="#bib0255">13</a>A systematic review of the literature was carried out between November 2015 and February 2016, through a search in the MEDLINE, LILACS, CENTRAL, and CINAHL databases.A specific strategy crossing the descriptors or keywords for retrieving subjects from scientific literature was created for each search portal.In MEDLINE, through the PubMed search portal, the search strategy was performed using the syntax: ((“Child, Preschool”[Mesh] OR “Child, Hospitalized”[Mesh] OR “Child”[Mesh] OR “Children”[Mesh]) AND (“Play and Playthings”[Mesh] OR “Play Therapy”[Mesh] OR “Therapeutic Play”[Mesh]) AND (“Nurses”[Mesh] OR “Speech”[Mesh] OR “Pediatric Nurse Practitioners”[Mesh] OR “Pain Management”[Mesh] OR “Child Behavior”[Mesh] OR “Psychology, Child”[Mesh] OR “Surgery”[Mesh] OR “Pediatric surgery procedure”[Mesh] OR “Preoperative Care”[Mesh])).In Lilacs, the strategy used was: “CHILD” OR “PRESCHOOLER” AND (play and playthings) OR (Play Therapy through) OR (Therapeutic play) AND (perioperative Nursing) OR (Humanization of assistance) OR Communication OR (Pediatric Nursing) OR (Pain Intervention) OR (Child Behavior) OR (Child Psychology) OR (Pre-Operative Care) OR (Clinical Procedures) OR (Surgery) OR (Pediatric Surgery) OR (Play Therapy)., however, search strategy in Lilacs, was performed with terms in Portuguese.In the CENTRAL and CINAHL databases: ((“Child, Preschool” OR “Child, Hospitalized” OR “Child” OR “Children”) AND (“Play and Playthings” OR “Play Therapy” OR “Therapeutic Play”) AND (“Nurses” OR “Speech” OR “Pediatric Nurse Practitioners” OR “Pain Management” OR “Child Behavior” OR “Psychology, Child” OR “Surgery” OR “Pediatric surgery procedure” OR “Preoperative Care”)).After the articles were located, the eligibility, selection, and exclusion criteria were applied. The following were considered eligible: original articles (clinical trials and quasi-experimental studies) that had preschoolers and school-aged children as the study population and that used therapeutic play as the intervention to prepare children submitted to invasive procedures. Annals from congresses were excluded, as well as theses, dissertations, letters to the editor, and articles not consistent with the study question. There was no limitation regarding the year or language of publication.Initially the article titles were read and, after excluding those that did not meet the eligibility criteria, their abstracts were analyzed according to the same criteria. These steps were performed independently by two authors of this systematic review. In case of disagreement regarding the exclusion of the abstracts, the articles were read in full.After the articles were read in full, a new exclusion was carried out, according to the same study selection criteria. Disagreements were resolved by consensus or after consulting a third reviewer. A standard form prepared by the authors was used for data extraction.The decision regarding the risk of bias was performed in two steps. The first was related to the description of what was reported in each study, in sufficient details so that the decision was made based on this information. The second part consisted of a decision regarding the risk of bias for each of the analyzed parameters, which were classified into three categories: low risk of bias, high risk of bias, and uncertain bias, according to the recommendations of the tool developed by the Cochrane Collaboration for bias risk assessment in randomized clinical trials.<a class="elsevierStyleCrossRefs" href="#bib0260">14,15</a>ResultsA total of 1892 articles were found: 1052 in MEDLINE, 95 in CENTRAL, 722 in CINAHL, and 23 in LILACS. Of these, 1861 were excluded for not meeting the eligibility criteria and 10 were excluded because they were duplicates. After reading the 21 articles in full, the final sample of this review comprised 12 studies, corresponding to 14 articles, taking into account that one of the studies generated three publications. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the process of article selection.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Of the 14 articles, ten were randomized controlled trials and four were quasi-experimental studies. The studies were carried out between 1983 and 2015 in the following countries: five in Brazil, one in the United States, five in China, one in Lebanon, one in Taiwan, and one in Iran. The studies were conducted in large and small hospitals. The participants were aged between 3 and 15 years (938 participants). Detailed information regarding the articles included in this review is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In this review, all studies used therapeutic play to prepare children who would be submitted to invasive procedures. The materials and strategies used during the sessions were varied: representative dolls with size similar to the child,<a class="elsevierStyleCrossRefs" href="#bib0235">9,16–19</a> dolls,<a class="elsevierStyleCrossRefs" href="#bib0290">20–22</a> hospital objects,<a class="elsevierStyleCrossRefs" href="#bib0290">20–25</a> storytelling, role playing, coloring books with all steps of the treatment, clay molding, painting, video games and cartoons projected on the ceiling of the treatment room during the procedure,<a class="elsevierStyleCrossRef" href="#bib0320">26</a> videos about the surgery with pictures of the operating room environment, play activities with the use of toys, games, books, comics, movies, television and drawing materials,<a class="elsevierStyleCrossRefs" href="#bib0225">7,27</a> and demonstration with the use of puppets.<a class="elsevierStyleCrossRef" href="#bib0225">7</a> One study also asked the children to take their favorite doll.<a class="elsevierStyleCrossRef" href="#bib0320">26</a> The duration of each therapeutic play session ranged from 15minutes to one hour.Additionally, some studies also included a visit to the reception, anesthetic induction, operation, and recovery rooms, mimicking the entire treatment process, from the child's admission into the hospital to the operating room.<a class="elsevierStyleCrossRefs" href="#bib0235">9,16–19</a> In ten articles, the children were submitted to elective surgery<a class="elsevierStyleCrossRefs" href="#bib0225">7,9,16–20,24,25,27</a> and the other procedures consisted of radiotherapy,<a class="elsevierStyleCrossRef" href="#bib0320">26</a> vaccination,<a class="elsevierStyleCrossRef" href="#bib0300">22</a> blood collection,<a class="elsevierStyleCrossRef" href="#bib0295">21</a> and dental treatment.<a class="elsevierStyleCrossRef" href="#bib0305">23</a>In this review, the outcomes of interest were the child's anxiety and behavior when submitted to an invasive procedure; of the 14 articles found, four analyzed only anxiety,<a class="elsevierStyleCrossRefs" href="#bib0275">17,19,26,27</a> while another six analyzed behavior,<a class="elsevierStyleCrossRefs" href="#bib0210">4,7,20–22,24</a> and four analyzed both outcomes.<a class="elsevierStyleCrossRefs" href="#bib0235">9,16,18,25</a>Other analyzed outcomes concerned the effect of therapeutic play through the analysis of physiological indicators such as heart rate,<a class="elsevierStyleCrossRefs" href="#bib0305">23,26</a> blood pressure and pulse,<a class="elsevierStyleCrossRef" href="#bib0225">7</a> and salivary cortisol level.<a class="elsevierStyleCrossRef" href="#bib0320">26</a> Additionally, the level of postoperative pain was evaluated in three articles,<a class="elsevierStyleCrossRefs" href="#bib0235">9,18,25</a> and the parents’ satisfaction and anxiety were also verified.<a class="elsevierStyleCrossRefs" href="#bib0235">9,16,19</a>Several tools were used to analyze the level of anxiety, which were mostly scales, including the Chinese version of the State Anxiety Scale for Children (CSAS-C),<a class="elsevierStyleCrossRefs" href="#bib0235">9,16,18,19</a> the Spielberger State Anxiety Scale for children (SSAS-c),<a class="elsevierStyleCrossRef" href="#bib0275">17</a> the Face Anxiety Scale (FAS), the Beck Youth Anxiety Inventory (BAI-Y),<a class="elsevierStyleCrossRef" href="#bib0320">26</a> the State Anxiety Scale for Children (SAS-C),<a class="elsevierStyleCrossRef" href="#bib0315">25</a> and the modified Yale Preoperative Anxiety Scale (YPAS).<a class="elsevierStyleCrossRef" href="#bib0325">27</a>The timing of outcome verification varied in the 12 studies. Most verified the outcome before and after surgery. Other studies verified it at admission and during the preoperative anesthetic injection. One study assessed it two weeks later.<a class="elsevierStyleCrossRef" href="#bib0225">7</a> Other moments were during venipuncture, when the wound dressings were being performed, during anesthetic induction, at the removal of pacemaker wires, and at physical examination, among others.The following tools were used to analyze behavior: the Cooperation Scale and Manifest Upset Scale,<a class="elsevierStyleCrossRefs" href="#bib0225">7,23</a> the Children's Emotional Manifestation Scale,<a class="elsevierStyleCrossRefs" href="#bib0235">9,16,18,25</a> a form created by the researcher,<a class="elsevierStyleCrossRefs" href="#bib0290">20,21,24</a> the Wong and Baker Scale,<a class="elsevierStyleCrossRef" href="#bib0290">20</a> and interview with a parent/guardian.<a class="elsevierStyleCrossRef" href="#bib0300">22</a>As for the methodological quality of the articles, only one study generated the allocation sequence in the groups in a truly random fashion, by using a software program Research Randomizer (Urbaniak. G.C., & Plous. S. (2013). Research Randomizer (Version 4.0) from <a id="intr0015" class="elsevierStyleInterRef" href="http://www.randomizer.org/">http://www.randomizer.org/</a>) and protected concealment by using opaque envelopes of the same size within a box, with participant instruction conducted by telephone.<a class="elsevierStyleCrossRef" href="#bib0315">25</a> Four articles used a simple randomization method by drawing lots, using balls: one identified with the experimental group and the other with the control group – one ball was taken for each child and was then put back into the bag.<a class="elsevierStyleCrossRefs" href="#bib0235">9,16,17,19</a> The others that carried out clinical trials did not report the method used for the randomization.There was no blinding of the participants in any of the studies, as it was not necessary, considering the characteristic of the intervention (therapeutic play). However, the evaluator was blinded in five studies.<a class="elsevierStyleCrossRefs" href="#bib0225">7,16,17,23,25</a> Regarding sample loss, only one study indicated that<a class="elsevierStyleCrossRef" href="#bib0280">18</a> and used the appropriate statistical analysis in a clear manner. Similarly, only one showed protocol publication regarding the research, available online.<a class="elsevierStyleCrossRef" href="#bib0315">25</a>AnxietyIn this review, the articles that analyzed the effectiveness of therapeutic play on the perioperative anxiety level of children undergoing invasive medical procedures used different measurement tools. In the four articles that proposed to verify the effect only on anxiety, this assessment was conducted by measuring it before and after surgery.<a class="elsevierStyleCrossRefs" href="#bib0235">9,16,17,19</a> Another study performed it at admission and during the preoperative anesthetic injection.<a class="elsevierStyleCrossRef" href="#bib0225">7</a>Studies show that after the intervention with the use of therapeutic play the children in the experimental group had lower levels of anxiety when compared to the control group (p<0.05).<a class="elsevierStyleCrossRefs" href="#bib0285">19,26,27</a> Even in a study in which play activities were used at the moment prior to the surgery in a recreation room during a short 15-minute period, it found that 92% of children in the experimental group did not display anxiety.<a class="elsevierStyleCrossRef" href="#bib0325">27</a>When analyzing the effect of time on anxiety levels, a statistically significant variation (F=3.260, p<0.05) was observed in both groups, while there was no statistically significant group effect (F=0.637, p>0.05) and interaction effect (F=0.368, p>0.05), which was confirmed by repeated measurements, after adjusting for possible confounding factors such as gender, age, type of surgery, body weight, duration of surgery, and pain medication use.BehaviorAll articles assessing behavior showed that children in the experimental group were more collaborative and showed more acceptance reactions to the procedure when compared to the control group. Seven studies express these results with a statistically significant difference (p<0.05).One study indicated that the therapeutic play intervention significantly reduced the negative emotional behavior of children before anesthetic induction.<a class="elsevierStyleCrossRef" href="#bib0235">9</a> In the study by Zahr in 1998,<a class="elsevierStyleCrossRef" href="#bib0225">7</a> the children in the experimental group showed fewer negative behaviors within two weeks after surgery, with the change in behavior being measured by Post Hospitalization Behavior Questionnaire (PHBQ).The children in the experimental group were more collaborative; they screamed, demanded, denied, wept, and moved less than those in the control group.<a class="elsevierStyleCrossRef" href="#bib0295">21</a> Regarding the assessment of negative emotional behaviors using the Children's Emotional Manifestation Scale (CEMS), another study found that children in the experimental group had significantly lower mean CEMS scores before anesthetic induction than those in the control group (F=13.452, p<0.01).<a class="elsevierStyleCrossRef" href="#bib0315">25</a>Children who received the therapeutic play intervention exhibited fewer emotions at the anesthetic induction, with a large effect size for the intervention.<a class="elsevierStyleCrossRef" href="#bib0280">18</a> Children who received the intervention exhibited significantly less negative emotional behavior before the anesthetic induction (t [201] ¼ –5.4, p<0.001).<a class="elsevierStyleCrossRef" href="#bib0235">9</a>DiscussionChildren submitted to invasive medical procedures undergo all types of psychological and physical stress, as do their families. Very often, the hospital environment to which the child is exposed is quite frightening, where this child's anxiety and behavioral cycle is altered.<a class="elsevierStyleCrossRef" href="#bib0330">28</a> Thus, it is essential to understand the best ways to mitigate the negative alterations in these factors.This is the first systematic review on therapeutic play intervention in children submitted to several invasive procedures, with no time limit for the publication of studies, considering that a previously published review on this topic had a population of children undergoing elective surgery only and included articles published between 1995 and 2012, in addition to also restricting the publication language.<a class="elsevierStyleCrossRef" href="#bib0335">29</a>The studies included in this review were carried out in developed and developing countries, large and small hospitals, with children's ages within a wide range, submitted to several invasive procedures such as elective surgery, vaccination, blood collection, and dental treatment. This demonstrates the use of therapeutic play in different scenarios, supporting effective communication with the child, seeking to reduce the probability of developing trauma, as well as promoting collaborative behavior before an invasive procedure is performed.Several materials and strategies were used during the therapeutic play sessions. However, of the 14 articles, 13 used a doll and hospital objects to show the children the procedure to which they would be submitted.The use of these tools is in accordance with the statement that, from the pre-operational stage, the child starts to develop the ability to think about objects and events that are not present in her immediate environment and begins to represent them through mental figures, sounds, images, words, or other forms. This new ability allows them to exceed the limits of the “here and now” and begin to understand that a mental image or idea may represent a symbol for an object or a lived experience.<a class="elsevierStyleCrossRef" href="#bib0340">30</a>Five articles<a class="elsevierStyleCrossRefs" href="#bib0235">9,16–19</a> used in the experimental group, in addition to therapeutic play, visits to the reception, surgery, anesthesia induction, and recovery rooms in order to promote the child's familiarization with the environment. In these cases, this may be considered a study limitation, because the association of another therapeutic measure may have overestimated the effect of therapeutic play on the children's anxiety level and behavior in these studies.No standardization exists in the choice of tool to analyze the children's anxiety and behavior. Most studies chose to use validated scales, guaranteeing that their application allows the true measurement of what is to be assessed.<a class="elsevierStyleCrossRef" href="#bib0345">31</a> The use of physiological indicators such as blood pressure, heart rate, and cortisol level is very important to add evidence regarding the impact of therapeutic play use on the child's emotional state; however, these measures have been used in few studies.Most studies have found positive changes in the behavior of children who participated in the therapeutic play session, as well as reduction in anxiety scores after the intervention, when compared to the control group. However, few studies analyzed whether this difference was statistically significant. Some studies showed results only in absolute and relative frequencies, making it difficult to evaluate whether the intervention made a difference regarding the child's anxiety and behavior.Of the nine articles that assessed anxiety, three<a class="elsevierStyleCrossRefs" href="#bib0235">9,18,23</a> did not have enough information on randomization and allocation concealment, which complicates the bias risk analysis in relation to these points, while two studies<a class="elsevierStyleCrossRefs" href="#bib0320">26,27</a> did so inadequately. Whatever the assessed intervention or outcome was, one of the fundamental principles for conducting clinical trials is the randomization of subjects to provide the maximum possible homogeneity between groups and allow the inference that the assessed differences may be due to the intervention.<a class="elsevierStyleCrossRef" href="#bib0350">32</a>Four articles showed low risk of bias regarding the generation of the subjects’ sequence and allocation. In this sense, the lack of the adequate generation of sequence and allocation concealment compromises the evidence provided by these studies for this outcome, indicating a certain degree of uncertainty of the findings.Regarding the behavior outcome, five studies<a class="elsevierStyleCrossRefs" href="#bib0225">7,20–22,24</a> did not perform random allocation of subjects, making it impossible for all the participants to have the same chance of being allocated in one of the groups (control and intervention). Also, they did not report on allocation concealment. Two articles<a class="elsevierStyleCrossRefs" href="#bib0280">18,23</a> did not have enough information regarding the generation of subject randomization sequence and allocation concealment, which makes it impossible to analyze of the bias risk for these parameters. Therefore, the evidence provided by these studies regarding the effects of the therapeutic play on the behavior of children undergoing invasive procedures is questionable.In educational interventions such as therapeutic play, it is difficult to blind the participants<a class="elsevierStyleCrossRef" href="#bib0355">33</a> because the experimental group members are aware that the therapeutic play intervention is not part of the usual hospital care. In studies where a group is submitted to an intervention and another to the usual routine care, blinding the researcher or the professional who will perform the procedure is not possible. The lack of blinding of participants does not represent an important source of bias, since it is not expected for children to intentionally change their behavior when they know they are being assessed or because they participated in a certain intervention.It is possible to blind the evaluator, but this only occurred in the evaluation after the intervention in two studies that assessed only behavior,<a class="elsevierStyleCrossRefs" href="#bib0225">7,23</a> one that assessed only anxiety,<a class="elsevierStyleCrossRef" href="#bib0285">19</a> and another that assessed anxiety and behavior.<a class="elsevierStyleCrossRef" href="#bib0315">25</a> The lack of evaluator blinding in most studies represents a risk of high bias, which makes the evidence questionable.As for incomplete outcomes, most studies showed insufficient information to assess this risk, as they were unclear whether there was a loss of data, except one<a class="elsevierStyleCrossRef" href="#bib0280">18</a> that assessed anxiety and behavior, and recorded the loss of five members from the intervention group and four in the follow-up. However, the reason was not explained and there was no information regarding whether any adjustment was made in the analysis to consider these losses. In 2015, He et al.<a class="elsevierStyleCrossRef" href="#bib0315">25</a> evaluated anxiety and behavior and reported that no losses occurred during the study, which implies low risk of bias. At this point, the analysis of evidence becomes uncertain.Possible risks to the validity of intervention studies in children have been discussed in the literature, among which are: insufficient statistical power,<a class="elsevierStyleCrossRef" href="#bib0360">34</a> little concern for the reliability and validity of measuring tools,<a class="elsevierStyleCrossRef" href="#bib0365">35</a> insufficient verification of an intervention,<a class="elsevierStyleCrossRef" href="#bib0370">36</a> lack of minimization of attrition bias,<a class="elsevierStyleCrossRef" href="#bib0375">37</a> inability to control observer bias,<a class="elsevierStyleCrossRef" href="#bib0230">8</a> and inability to ensure the integrity and uniformity of treatment.<a class="elsevierStyleCrossRef" href="#bib0380">38</a>ConclusionEvidence 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.Therefore, it is necessary to perform further studies that will take into account greater methodological stringency, especially regarding the allocation of subjects, use of validated tools, and blinded evaluators, so that the risk of bias related to these domains can be minimized.Conflicts of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres794489" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Data source" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Synthesis of data" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec792808" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres794490" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fontes dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Síntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec792809" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Method" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Anxiety" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Behavior" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-05-02" "fechaAceptado" => "2016-05-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec792808" "palabras" => array:5 [ 0 => "Children" 1 => "Play and playthings" 2 => "Anxiety" 3 => "Behavior" 4 => "Hospital care" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec792809" "palabras" => array:5 [ 0 => "Criança" 1 => "Jogos e brinquedos" 2 => "Ansiedade" 3 => "Comportamento" 4 => "Assistência hospitalar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo analyze the available evidence regarding the efficacy of using therapeutic play on behavior and anxiety in children undergoing invasive procedures. Data sourceThe systematic review search was performed in the MEDLINE, LILACS, CENTRAL and CINAHL databases. There was no limitation on the year or language. Synthesis of dataThe 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. ConclusionsEvidence 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." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Data source" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Synthesis of data" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "ObjetivoRevisar, de forma sistemática, as evidências em relação a eficácia da utilização do brinquedo terapêutico sobre o comportamento e a ansiedade de crianças submetidas a procedimentos invasivos. Fontes dos dadosA busca da revisão sistemática foi efetuada nas bases MedLine, Lilacs, CENTRAL e CINAHL. Não houve limitação quanto ao ano ou idioma. Síntese dos dadosNa busca de literatura foram encontrados 1892 artigos e selecionados 22 para leitura integral. Foram excluídos 8 artigos que não respondiam aos objetivos avaliados nesta revisão. Foram incluídos 12 estudos, correspondentes a 14 artigos. Os estudos foram conduzidos entre 1983 e 2015, cinco no Brasil, um nos Estados Unidos, cinco na China, um no Líbano, um em Taiwan e um no Irã. A maioria dos estudos mostrou que a intervenção com brinquedo terapêutico promove redução no nível de ansiedade e favorece um comportamento de colaboração e aceitação do procedimento invasivo. ConclusõesAs evidências relacionadas ao uso do brinquedo terapêutico sobre a ansiedade e comportamento de crianças submetidas a procedimentos invasivos ainda são questionáveis. A ausência, na maioria dos estudos, de uma geração de sequência aleatória para direcionamento dos sujeitos para os grupos controle ou experimental e do sigilo de alocação são fatores que contribuem para este questionamento. Uma outra questão que caracteriza importante fonte de viés é o não cegamento dos avaliadores. Se faz necessário a realização de novas pesquisas que levem em consideração um maior rigor metodológico." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fontes dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Síntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "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." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Study conducted at Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1954 "Ancho" => 2238 "Tamanyo" => 232462 ] ] "descripcion" => array:1 [ "en" => "Representative flowchart of the selection steps of articles included in the systematic review." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "EG, experimental group; CG, control group." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author (year of publication), and place \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study population and sample size \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study design \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Strategy and materials used, duration and moment when the therapeutic play session was carried out \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Assessed outcome and evaluation method \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bruce et al. (1983) USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 children aged 3–4 years, submitted to dental extraction and restoration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Hospital objects. Parents and children acted as patient and professional and simulated the procedure • A 20–25min session on the day before the procedure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Cooperation, negative behavior and heart rate • Manifest Upset Scale • Cooperation Scale Monitoring of heart rate for 2min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The EG related to the procedure was more cooperative than the other two groups \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Li et al. (2007a)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> China \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">203 children aged 7–12 years undergoing elective surgery and their parents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anxiety scores were lower, negative behavior was less frequent, and there was a higher degree of satisfaction among parents from the EG \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaezzadeh et al. (2011) Iran \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">122 children aged between 7 and 12 years submitted to elective surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Anxiety • Spielberger State Anxiety Scale for children (SSAS-c) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yu-Li et al. (2013) Taiwan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 children aged 3–15 years submitted to radiotherapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 15–20min session a day, every afternoon, from Monday through Friday \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Anxiety • The Faces Anxiety Scale (FAS) • Beck Youth Anxiety Inventory (BAI-Y) • Heart rate • Differences in cortisol levels \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ruschel (1995) Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 children aged 3–10 years submitted to congenital heart defect surgery  \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Quasi-experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Materials related to pre and postoperative care. Doll, suture threads, needles, tweezers and scissors • Simulation surgery with doll \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Child's attitude in relation to several procedures • Form \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">There was statistical significance (p<0.05) at the moments: quiet wakening, cooperation during procedures, accepting the absence of the mother, and fluid restriction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">He et al. (2015) China \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95 children aged 6–14 years submitted to elective surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The EG showed less negative emotional behavior before anesthesia induction, low levels of anxiety, and less postoperative pain  \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kiche and Almeida (2009) Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 children aged 3–10 years submitted to minor and medium surgeries \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Quasi-experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Behaviors that showed acceptance and adaptation to the procedure • Form • Wong and Baker scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ribeiro et al. (2001) Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 children aged 3–6 years submitted to blood collection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Quasi-experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Doll, syringe, test tube, cotton, adhesive tape. Scalpel with one catheter and bottle with red liquid • One session before the procedure. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Behavior during blood collection • Form \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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”  \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pontes et al. (2015) Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 children aged 3–6 years submitted to vaccination procedure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Quasi-experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Doll, disposable syringes, needles, cotton and stickers for venipuncture • One 20-minute session before the vaccination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Child's reactions • Observation during vaccination • Interview with parent/guardian \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Li et al. (2014) China \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">108 children aged 7–12 years admitted to undergo elective surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weber (2010) Brazil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 children aged 5–12 years submitted to surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Recreational activities with the use of games, toys, books, comic books, movies, TV and materials for drawing • One session 15min after entering the Ambulatory Surgical Center, lasting 15min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Anxiety level • Observation when entering the operating room and 15min after entering the room • Modified Yale Preoperative Anxiety Scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92% of the children in EG did not have anxiety, while in the CG, 84% were still anxious  \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zahr (1998) Lebanon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 children aged 3–6 years submitted to elective surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Behavior, blood pressure and pulse • Manifest Upset Scale • Cooperation Scale • Post-Hospital Behavior Questionnaire (PHBQ) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Li and Lopez<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> (2008) China \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">203 children aged 7–12 years submitted to surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Li et al.<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> (2007b) China \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">203 children aged 7–12 years submitted to elective surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Experimental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Visits to the reception, anesthetic induction, surgery and recovery rooms • Demonstration of procedures on a doll with size similar to that of a child \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• 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) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">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 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1328908.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "The articles Li et al., 2007a, Li et al., 2007b and Li and Lopes, 2008 are results of the same study." ] ] ] "descripcion" => array:1 [ "en" => "Synthesis of the articles." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percepc¿a¿o de crianc¿as hospitalizadas sobre realizac¿a¿o de exames" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "V.V. 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Brinquedo terapêutico no preparo de crianças para procedimentos invasivos: revisão sistemática

Rosalia Daniela Medeiros da Silvaa,

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rosaliadaniela@hotmail.com

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, Silvia Carréra Austregésiloa, Lucas Ithamara, Luciane Soares de Limaa,b

a Universidade Federal de Pernambuco (UFPE), Programa de Pós-graduação em Saúde da Criança e do Adolescente, Recife, PE, Brazil

b Universidade Federal de Pernambuco (UFPE), Programa de Pós-graduação em Enfermagem, Recife, PE, Brazil

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The degree of the children&#39;s understanding about the procedure to which they will be submitted may be related to the period of stress and insecurity that they will experience&#46; Their behavior may vary according to age&#44; environment&#44; the presence of strangers&#44; and invasive procedures experienced by the children or observed in others&#46; These factors contribute to the development of unpleasant reactions such as fear&#44; anxiety&#44; and resistance to the procedures that will be performed&#46; Hospitalization means attacking their playful and magical realm&#44; and therefore requires that the assisting professional understands their childhood world&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Excessive stress and anxiety experienced by children can affect their physical and physiological health&#44; hinder their ability to deal with medical procedures&#44; cause changes in their behavior&#44; and affect their recovery from illness&#46; Therefore&#44; there is an urgent need for clinical researchers to develop&#44; implement&#44; and evaluate interventions that can minimize the children&#39;s anxiety level and improve their ability to handle the stress of hospitalization and invasive procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Over the past decades&#44; several studies that addressed children&#39;s health care have discussed different methods of educational interventions for children before or during hospitalization&#44; when surgical and invasive medical procedures are performed&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#8211;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The need to play is not eliminated when children become ill or are hospitalized&#59; on the contrary&#44; children who can play may feel safer during the transoperative period&#44; even in a strange environment&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> One aspect of such activities is therapeutic play&#44; which provides a structured play activity&#44; follows the principles of play therapy&#44; and has specific objectives to be achieved&#46; Its use brings relief from anxiety caused by atypical experiences for age that tend to appear as threatening&#44; requiring an intervention that will help the child&#47;family to cope while undergoing a highly complex invasive procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Studies have shown the benefits of therapeutic play in reducing anxiety and postoperative pain in hospitalized children&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> Clinical trials have shown the positive effects of therapeutic play intervention on perioperative anxiety&#44; postoperative pain&#44; and negative behavior in children submitted to surgical procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Thus&#44; with the objective of contributing to the knowledge about the use of therapeutic play&#44; which is an important strategy to be used in childcare&#44; this review aimed to systematically assess the evidence regarding the efficacy of using therapeutic play on the behavior and anxiety in children undergoing invasive procedures&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0035" class="elsevierStylePara elsevierViewall">The protocol of this review is registered at the international database for systematic reviews&#44; PROSPERO&#44; under number CRD42016035878&#44; and can be accessed at &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016035878">http&#58;&#47;&#47;www&#46;crd&#46;york&#46;ac&#46;uk&#47;PROSPERO&#47;display&#95;record&#46;asp&#63;ID&#61;CRD42016035878</a>&#41;&#46; This article was written according to PRISMA recommendations for systematic reviews&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A systematic review of the literature was carried out between November 2015 and February 2016&#44; through a search in the MEDLINE&#44; LILACS&#44; CENTRAL&#44; and CINAHL databases&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A specific strategy crossing the descriptors or keywords for retrieving subjects from scientific literature was created for each search portal&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In MEDLINE&#44; through the PubMed search portal&#44; the search strategy was performed using the syntax&#58; &#40;&#40;&#8220;Child&#44; Preschool&#8221;&#91;Mesh&#93; OR &#8220;Child&#44; Hospitalized&#8221;&#91;Mesh&#93; OR &#8220;Child&#8221;&#91;Mesh&#93; OR &#8220;Children&#8221;&#91;Mesh&#93;&#41; AND &#40;&#8220;Play and Playthings&#8221;&#91;Mesh&#93; OR &#8220;Play Therapy&#8221;&#91;Mesh&#93; OR &#8220;Therapeutic Play&#8221;&#91;Mesh&#93;&#41; AND &#40;&#8220;Nurses&#8221;&#91;Mesh&#93; OR &#8220;Speech&#8221;&#91;Mesh&#93; OR &#8220;Pediatric Nurse Practitioners&#8221;&#91;Mesh&#93; OR &#8220;Pain Management&#8221;&#91;Mesh&#93; OR &#8220;Child Behavior&#8221;&#91;Mesh&#93; OR &#8220;Psychology&#44; Child&#8221;&#91;Mesh&#93; OR &#8220;Surgery&#8221;&#91;Mesh&#93; OR &#8220;Pediatric surgery procedure&#8221;&#91;Mesh&#93; OR &#8220;Preoperative Care&#8221;&#91;Mesh&#93;&#41;&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In Lilacs&#44; the strategy used was&#58; &#8220;CHILD&#8221; OR &#8220;PRESCHOOLER&#8221; AND &#40;play and playthings&#41; OR &#40;Play Therapy through&#41; OR &#40;Therapeutic play&#41; AND &#40;perioperative Nursing&#41; OR &#40;Humanization of assistance&#41; OR Communication OR &#40;Pediatric Nursing&#41; OR &#40;Pain Intervention&#41; OR &#40;Child Behavior&#41; OR &#40;Child Psychology&#41; OR &#40;Pre-Operative Care&#41; OR &#40;Clinical Procedures&#41; OR &#40;Surgery&#41; OR &#40;Pediatric Surgery&#41; OR &#40;Play Therapy&#41;&#46;&#44; however&#44; search strategy in Lilacs&#44; was performed with terms in Portuguese&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the CENTRAL and CINAHL databases&#58; &#40;&#40;&#8220;Child&#44; Preschool&#8221; OR &#8220;Child&#44; Hospitalized&#8221; OR &#8220;Child&#8221; OR &#8220;Children&#8221;&#41; AND &#40;&#8220;Play and Playthings&#8221; OR &#8220;Play Therapy&#8221; OR &#8220;Therapeutic Play&#8221;&#41; AND &#40;&#8220;Nurses&#8221; OR &#8220;Speech&#8221; OR &#8220;Pediatric Nurse Practitioners&#8221; OR &#8220;Pain Management&#8221; OR &#8220;Child Behavior&#8221; OR &#8220;Psychology&#44; Child&#8221; OR &#8220;Surgery&#8221; OR &#8220;Pediatric surgery procedure&#8221; OR &#8220;Preoperative Care&#8221;&#41;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">After the articles were located&#44; the eligibility&#44; selection&#44; and exclusion criteria were applied&#46; The following were considered eligible&#58; original articles &#40;clinical trials and quasi-experimental studies&#41; that had preschoolers and school-aged children as the study population and that used therapeutic play as the intervention to prepare children submitted to invasive procedures&#46; Annals from congresses were excluded&#44; as well as theses&#44; dissertations&#44; letters to the editor&#44; and articles not consistent with the study question&#46; There was no limitation regarding the year or language of publication&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Initially the article titles were read and&#44; after excluding those that did not meet the eligibility criteria&#44; their abstracts were analyzed according to the same criteria&#46; These steps were performed independently by two authors of this systematic review&#46; In case of disagreement regarding the exclusion of the abstracts&#44; 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1052 in MEDLINE&#44; 95 in CENTRAL&#44; 722 in CINAHL&#44; and 23 in LILACS&#46; Of these&#44; 1861 were excluded for not meeting the eligibility criteria and 10 were excluded because they were duplicates&#46; After reading the 21 articles in full&#44; the final sample of this review comprised 12 studies&#44; corresponding to 14 articles&#44; taking into account that one of the studies generated three publications&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the process of article selection&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Of the 14 articles&#44; ten were randomized controlled trials and four were quasi-experimental studies&#46; The studies were carried out between 1983 and 2015 in the following countries&#58; five in Brazil&#44; one in the United States&#44; five in China&#44; one in Lebanon&#44; one in Taiwan&#44; and one in Iran&#46; The studies were conducted in large and small hospitals&#46; The participants were aged between 3 and 15 years &#40;938 participants&#41;&#46; Detailed information regarding the articles included in this review is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">In this review&#44; all studies used therapeutic play to prepare children who would be submitted to invasive procedures&#46; The materials and strategies used during the sessions were varied&#58; representative dolls with size similar to the child&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;16&#8211;19</span></a> dolls&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#8211;22</span></a> hospital objects&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#8211;25</span></a> storytelling&#44; role playing&#44; coloring books with all steps of the treatment&#44; clay molding&#44; painting&#44; video games and cartoons projected on the ceiling of the treatment room during the procedure&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> videos about the surgery with pictures of the operating room environment&#44; play activities with the use of toys&#44; games&#44; books&#44; comics&#44; movies&#44; television and drawing materials&#44;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;27</span></a> and demonstration with the use of puppets&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> One study also asked the children to take their favorite doll&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> The duration of each therapeutic play session ranged from 15<span class="elsevierStyleHsp" style=""></span>minutes to one hour&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Additionally&#44; some studies also included a visit to the reception&#44; anesthetic induction&#44; operation&#44; and recovery rooms&#44; mimicking the entire treatment process&#44; from the child&#39;s admission into the hospital to the operating room&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;16&#8211;19</span></a> In ten articles&#44; the children were submitted to elective surgery<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;9&#44;16&#8211;20&#44;24&#44;25&#44;27</span></a> and the other procedures consisted of radiotherapy&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> vaccination&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a> blood collection&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> and dental treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In this review&#44; the outcomes of interest were the child&#39;s anxiety and behavior when submitted to an invasive procedure&#59; of the 14 articles found&#44; four analyzed only anxiety&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#44;19&#44;26&#44;27</span></a> while another six analyzed behavior&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;7&#44;20&#8211;22&#44;24</span></a> and four analyzed both outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;16&#44;18&#44;25</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Other analyzed outcomes concerned the effect of therapeutic play through the analysis of physiological indicators such as heart rate&#44;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">23&#44;26</span></a> blood pressure and pulse&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> and salivary cortisol level&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> Additionally&#44; the level of postoperative pain was evaluated in three articles&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;18&#44;25</span></a> and the parents&#8217; satisfaction and anxiety were also verified&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;16&#44;19</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Several tools were used to analyze the level of anxiety&#44; which were mostly scales&#44; including the Chinese version of the State Anxiety Scale for Children &#40;CSAS-C&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;16&#44;18&#44;19</span></a> the Spielberger State Anxiety Scale for children &#40;SSAS-c&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> the Face Anxiety Scale &#40;FAS&#41;&#44; the Beck Youth Anxiety Inventory &#40;BAI-Y&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> the State Anxiety Scale for Children &#40;SAS-C&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> and the modified Yale Preoperative Anxiety Scale &#40;YPAS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The timing of outcome verification varied in the 12 studies&#46; Most verified the outcome before and after surgery&#46; Other studies verified it at admission and during the preoperative anesthetic injection&#46; One study assessed it two weeks later&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> Other moments were during venipuncture&#44; when the wound dressings were being performed&#44; during anesthetic induction&#44; at the removal of pacemaker wires&#44; and at physical examination&#44; among others&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The following tools were used to analyze behavior&#58; the Cooperation Scale and Manifest Upset Scale&#44;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;23</span></a> the Children&#39;s Emotional Manifestation Scale&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;16&#44;18&#44;25</span></a> a form created by the researcher&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;21&#44;24</span></a> the Wong and Baker Scale&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> and interview with a parent&#47;guardian&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">As for the methodological quality of the articles&#44; only one study generated the allocation sequence in the groups in a truly random fashion&#44; by using a software program Research Randomizer &#40;Urbaniak&#46; G&#46;C&#46;&#44; &#38; Plous&#46; S&#46; &#40;2013&#41;&#46; Research Randomizer &#40;Version 4&#46;0&#41; from <a id="intr0015" class="elsevierStyleInterRef" href="http://www.randomizer.org/">http&#58;&#47;&#47;www&#46;randomizer&#46;org&#47;</a>&#41; and protected concealment by using opaque envelopes of the same size within a box&#44; with participant instruction conducted by telephone&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> Four articles used a simple randomization method by drawing lots&#44; using balls&#58; one identified with the experimental group and the other with the control group &#8211; one ball was taken for each child and was then put back into the bag&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;16&#44;17&#44;19</span></a> The others that carried out clinical trials did not report the method used for the randomization&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">There was no blinding of the participants in any of the studies&#44; as it was not necessary&#44; considering the characteristic of the intervention &#40;therapeutic play&#41;&#46; However&#44; the evaluator was blinded in five studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;16&#44;17&#44;23&#44;25</span></a> Regarding sample loss&#44; only one study indicated that<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> and used the appropriate statistical analysis in a clear manner&#46; Similarly&#44; only one showed protocol publication regarding the research&#44; available online&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Anxiety</span><p id="par0140" class="elsevierStylePara elsevierViewall">In this review&#44; the articles that analyzed the effectiveness of therapeutic play on the perioperative anxiety level of children undergoing invasive medical procedures used different measurement tools&#46; In the four articles that proposed to verify the effect only on anxiety&#44; this assessment was conducted by measuring it before and after surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;16&#44;17&#44;19</span></a> Another study performed it at admission and during the preoperative anesthetic injection&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Studies show that after the intervention with the use of therapeutic play the children in the experimental group had lower levels of anxiety when compared to the control group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">19&#44;26&#44;27</span></a> Even in a study in which play activities were used at the moment prior to the surgery in a recreation room during a short 15-minute period&#44; it found that 92&#37; of children in the experimental group did not display anxiety&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">When analyzing the effect of time on anxiety levels&#44; a statistically significant variation &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;260&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; was observed in both groups&#44; while there was no statistically significant group effect &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;637&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and interaction effect &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;368&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; which was confirmed by repeated measurements&#44; after adjusting for possible confounding factors such as gender&#44; age&#44; type of surgery&#44; body weight&#44; duration of surgery&#44; and pain medication use&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Behavior</span><p id="par0155" class="elsevierStylePara elsevierViewall">All articles assessing behavior showed that children in the experimental group were more collaborative and showed more acceptance reactions to the procedure when compared to the control group&#46; Seven studies express these results with a statistically significant difference &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">One study indicated that the therapeutic play intervention significantly reduced the negative emotional behavior of children before anesthetic induction&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a> In the study by Zahr in 1998&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> the children in the experimental group showed fewer negative behaviors within two weeks after surgery&#44; with the change in behavior being measured by Post Hospitalization Behavior Questionnaire &#40;PHBQ&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The children in the experimental group were more collaborative&#59; they screamed&#44; demanded&#44; denied&#44; wept&#44; and moved less than those in the control group&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> Regarding the assessment of negative emotional behaviors using the Children&#39;s Emotional Manifestation Scale &#40;CEMS&#41;&#44; another study found that children in the experimental group had significantly lower mean CEMS scores before anesthetic induction than those in the control group &#40;<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#46;452&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Children who received the therapeutic play intervention exhibited fewer emotions at the anesthetic induction&#44; with a large effect size for the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> Children who received the intervention exhibited significantly less negative emotional behavior before the anesthetic induction &#40;<span class="elsevierStyleItalic">t</span> &#91;201&#93; &#188; &#8211;5&#46;4&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0175" class="elsevierStylePara elsevierViewall">Children submitted to invasive medical procedures undergo all types of psychological and physical stress&#44; as do their families&#46; Very often&#44; the hospital environment to which the child is exposed is quite frightening&#44; where this child&#39;s anxiety and behavioral cycle is altered&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> Thus&#44; it is essential to understand the best ways to mitigate the negative alterations in these factors&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">This is the first systematic review on therapeutic play intervention in children submitted to several invasive procedures&#44; with no time limit for the publication of studies&#44; considering that a previously published review on this topic had a population of children undergoing elective surgery only and included articles published between 1995 and 2012&#44; in addition to also restricting the publication language&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The studies included in this review were carried out in developed and developing countries&#44; large and small hospitals&#44; with children&#39;s ages within a wide range&#44; submitted to several invasive procedures such as elective surgery&#44; vaccination&#44; blood collection&#44; and dental treatment&#46; This demonstrates the use of therapeutic play in different scenarios&#44; supporting effective communication with the child&#44; seeking to reduce the probability of developing trauma&#44; as well as promoting collaborative behavior before an invasive procedure is performed&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Several materials and strategies were used during the therapeutic play sessions&#46; However&#44; of the 14 articles&#44; 13 used a doll and hospital objects to show the children the procedure to which they would be submitted&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The use of these tools is in accordance with the statement that&#44; from the pre-operational stage&#44; the child starts to develop the ability to think about objects and events that are not present in her immediate environment and begins to represent them through mental figures&#44; sounds&#44; images&#44; words&#44; or other forms&#46; This new ability allows them to exceed the limits of the &#8220;here and now&#8221; and begin to understand that a mental image or idea may represent a symbol for an object or a lived experience&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Five articles<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;16&#8211;19</span></a> used in the experimental group&#44; in addition to therapeutic play&#44; visits to the reception&#44; surgery&#44; anesthesia induction&#44; and recovery rooms in order to promote the child&#39;s familiarization with the environment&#46; In these cases&#44; this may be considered a study limitation&#44; because the association of another therapeutic measure may have overestimated the effect of therapeutic play on the children&#39;s anxiety level and behavior in these studies&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">No standardization exists in the choice of tool to analyze the children&#39;s anxiety and behavior&#46; Most studies chose to use validated scales&#44; guaranteeing that their application allows the true measurement of what is to be assessed&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a> The use of physiological indicators such as blood pressure&#44; heart rate&#44; and cortisol level is very important to add evidence regarding the impact of therapeutic play use on the child&#39;s emotional state&#59; however&#44; these measures have been used in few studies&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Most studies have found positive changes in the behavior of children who participated in the therapeutic play session&#44; as well as reduction in anxiety scores after the intervention&#44; when compared to the control group&#46; However&#44; few studies analyzed whether this difference was statistically significant&#46; Some studies showed results only in absolute and relative frequencies&#44; making it difficult to evaluate whether the intervention made a difference regarding the child&#39;s anxiety and behavior&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Of the nine articles that assessed anxiety&#44; three<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;18&#44;23</span></a> did not have enough information on randomization and allocation concealment&#44; which complicates the bias risk analysis in relation to these points&#44; while two studies<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">26&#44;27</span></a> did so inadequately&#46; Whatever the assessed intervention or outcome was&#44; one of the fundamental principles for conducting clinical trials is the randomization of subjects to provide the maximum possible homogeneity between groups and allow the inference that the assessed differences may be due to the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Four articles showed low risk of bias regarding the generation of the subjects&#8217; sequence and allocation&#46; In this sense&#44; the lack of the adequate generation of sequence and allocation concealment compromises the evidence provided by these studies for this outcome&#44; indicating a certain degree of uncertainty of the findings&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Regarding the behavior outcome&#44; five studies<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;20&#8211;22&#44;24</span></a> did not perform random allocation of subjects&#44; making it impossible for all the participants to have the same chance of being allocated in one of the groups &#40;control and intervention&#41;&#46; Also&#44; they did not report on allocation concealment&#46; Two articles<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">18&#44;23</span></a> did not have enough information regarding the generation of subject randomization sequence and allocation concealment&#44; which makes it impossible to analyze of the bias risk for these parameters&#46; Therefore&#44; the evidence provided by these studies regarding the effects of the therapeutic play on the behavior of children undergoing invasive procedures is questionable&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In educational interventions such as therapeutic play&#44; it is difficult to blind the participants<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a> because the experimental group members are aware that the therapeutic play intervention is not part of the usual hospital care&#46; In studies where a group is submitted to an intervention and another to the usual routine care&#44; blinding the researcher or the professional who will perform the procedure is not possible&#46; The lack of blinding of participants does not represent an important source of bias&#44; since it is not expected for children to intentionally change their behavior when they know they are being assessed or because they participated in a certain intervention&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">It is possible to blind the evaluator&#44; but this only occurred in the evaluation after the intervention in two studies that assessed only behavior&#44;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;23</span></a> one that assessed only anxiety&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> and another that assessed anxiety and behavior&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> The lack of evaluator blinding in most studies represents a risk of high bias&#44; which makes the evidence questionable&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">As for incomplete outcomes&#44; most studies showed insufficient information to assess this risk&#44; as they were unclear whether there was a loss of data&#44; except one<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> that assessed anxiety and behavior&#44; and recorded the loss of five members from the intervention group and four in the follow-up&#46; However&#44; the reason was not explained and there was no information regarding whether any adjustment was made in the analysis to consider these losses&#46; In 2015&#44; He et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> evaluated anxiety and behavior and reported that no losses occurred during the study&#44; which implies low risk of bias&#46; At this point&#44; the analysis of evidence becomes uncertain&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Possible risks to the validity of intervention studies in children have been discussed in the literature&#44; among which are&#58; insufficient statistical power&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> little concern for the reliability and validity of measuring tools&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a> insufficient verification of an intervention&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> lack of minimization of attrition bias&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> inability to control observer bias&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> and inability to ensure the integrity and uniformity of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0250" class="elsevierStylePara elsevierViewall">Evidence related to the use of therapeutic play on anxiety and behavior of children undergoing invasive procedures is still questionable&#46; The absence&#44; in most studies&#44; of the creation of a random sequence to assign the subjects to either the control or the experimental group&#44; as well as allocation concealment&#44; are factors that contribute to these questions&#46; Another issue that characterizes an important source of bias is the absence of blinded evaluators&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Therefore&#44; it is necessary to perform further studies that will take into account greater methodological stringency&#44; especially regarding the allocation of subjects&#44; use of validated tools&#44; and blinded evaluators&#44; so that the risk of bias related to these domains can be minimized&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "sec0030"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conclusion"
        ]
        9 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-05-02"
    "fechaAceptado" => "2016-05-11"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec792808"
          "palabras" => array:5 [
            0 => "Children"
            1 => "Play and playthings"
            2 => "Anxiety"
            3 => "Behavior"
            4 => "Hospital care"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec792809"
          "palabras" => array:5 [
            0 => "Crian&#231;a"
            1 => "Jogos e brinquedos"
            2 => "Ansiedade"
            3 => "Comportamento"
            4 => "Assist&#234;ncia hospitalar"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the available evidence regarding the efficacy of using therapeutic play on behavior and anxiety in children undergoing invasive procedures&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Data source</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The systematic review search was performed in the MEDLINE&#44; LILACS&#44; CENTRAL and CINAHL databases&#46; There was no limitation on the year or language&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Synthesis of data</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The literature search found 1892 articles and selected 22 for full reading&#46; Eight articles were excluded&#44; as they did not address the objectives assessed in this review&#46; Twelve studies&#44; representing 14 articles&#44; were included&#46; The studies were conducted between 1983 and 2015&#44; five in Brazil&#44; one in the United States&#44; five in China&#44; one in Lebanon&#44; one in Taiwan&#44; and one in Iran&#46; 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&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Evidence related to the use of therapeutic play on anxiety and behavior of children undergoing invasive procedures is still questionable&#46; The absence&#44; in most studies&#44; of the creation of a random sequence to assign the subjects to either the control or the experimental group&#44; as well as allocation concealment&#44; are factors that contribute to these questions&#46; Another issue that characterizes an important source of bias is the absence of blinded evaluators&#46; It is necessary to perform further studies that will take into account greater methodological stringency&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Data source"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Synthesis of data"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Revisar&#44; de forma sistem&#225;tica&#44; as evid&#234;ncias em rela&#231;&#227;o a efic&#225;cia da utiliza&#231;&#227;o do brinquedo terap&#234;utico sobre o comportamento e a ansiedade de crian&#231;as submetidas a procedimentos invasivos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fontes dos dados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A busca da revis&#227;o sistem&#225;tica foi efetuada nas bases MedLine&#44; Lilacs&#44; CENTRAL e CINAHL&#46; N&#227;o houve limita&#231;&#227;o quanto ao ano ou idioma&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">S&#237;ntese dos dados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Na busca de literatura foram encontrados 1892 artigos e selecionados 22 para leitura integral&#46; Foram exclu&#237;dos 8 artigos que n&#227;o respondiam aos objetivos avaliados nesta revis&#227;o&#46; Foram inclu&#237;dos 12 estudos&#44; correspondentes a 14 artigos&#46; Os estudos foram conduzidos entre 1983 e 2015&#44; cinco no Brasil&#44; um nos Estados Unidos&#44; cinco na China&#44; um no L&#237;bano&#44; um em Taiwan e um no Ir&#227;&#46; A maioria dos estudos mostrou que a interven&#231;&#227;o com brinquedo terap&#234;utico promove redu&#231;&#227;o no n&#237;vel de ansiedade e favorece um comportamento de colabora&#231;&#227;o e aceita&#231;&#227;o do procedimento invasivo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">As evid&#234;ncias relacionadas ao uso do brinquedo terap&#234;utico sobre a ansiedade e comportamento de crian&#231;as submetidas a procedimentos invasivos ainda s&#227;o question&#225;veis&#46; A aus&#234;ncia&#44; na maioria dos estudos&#44; de uma gera&#231;&#227;o de sequ&#234;ncia aleat&#243;ria para direcionamento dos sujeitos para os grupos controle ou experimental e do sigilo de aloca&#231;&#227;o s&#227;o fatores que contribuem para este questionamento&#46; Uma outra quest&#227;o que caracteriza importante fonte de vi&#233;s &#233; o n&#227;o cegamento dos avaliadores&#46; Se faz necess&#225;rio a realiza&#231;&#227;o de novas pesquisas que levem em considera&#231;&#227;o um maior rigor metodol&#243;gico&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Fontes dos dados"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "S&#237;ntese dos dados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Silva RD&#44; Austreg&#233;silo SC&#44; Ithamar L&#44; Lima LS&#46; Therapeutic play to prepare children for invasive procedures&#58; a systematic review&#46; J Pediatr &#40;Rio J&#41;&#46; 2017&#59;93&#58;6&#8211;16&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Study conducted at Universidade Federal de Pernambuco &#40;UFPE&#41;&#44; Recife&#44; PE&#44; Brazil&#46;</p>"
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Representative flowchart of the selection steps of articles included in the systematic review&#46;</p>"
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">EG&#44; experimental group&#59; CG&#44; control group&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author &#40;year of publication&#41;&#44; and place&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study population and sample size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Strategy and materials used&#44; duration and moment when the therapeutic play session was carried out&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Assessed outcome and evaluation method&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bruce et al&#46; &#40;1983&#41;<br>USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45 children aged 3&#8211;4 years&#44; submitted to dental extraction and restoration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Hospital objects&#46; Parents and children acted as patient and professional and simulated the procedure<br>&#8226; A 20&#8211;25<span class="elsevierStyleHsp" style=""></span>min session on the day before the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Cooperation&#44; negative behavior and heart rate<br>&#8226; Manifest Upset Scale<br>&#8226; Cooperation Scale<br>Monitoring of heart rate for 2<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The EG related to the procedure was more cooperative than the other two groups&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Li et al&#46; &#40;2007a&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">203 children aged 7&#8211;12 years undergoing elective surgery and their parents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Visits the reception&#44; anesthetic induction&#44; operation and recovery rooms<br>&#8226; Representative doll with a size similar to the child&#39;s<br>&#8226; Representation of the obtaining of vital signs&#44; anesthetic induction and venipuncture<br>&#8226; A one-hour session a week before the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Child and parents&#8217; anxiety&#44; emotional behavior during anesthesia&#44; postoperative pain and parents&#8217; satisfaction<br>&#8226; Chinese version of the State Anxiety Scale for Children &#40;CSAS-C&#41;<br>&#8226; Chinese version of the State Anxiety Scale for Adults<br>&#8226; Children&#39;s Emotional Manifestation Scale &#40;CEMS&#41;<br>Visual analog scale &#40;VAS&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anxiety scores were lower&#44; negative behavior was less frequent&#44; and there was a higher degree of satisfaction among parents from the EG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaezzadeh et al&#46; &#40;2011&#41;<br>Iran&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">122 children aged between 7 and 12 years submitted to elective surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Visits the reception&#44; operation and recovery rooms<br>&#8226; Demonstration in a pediatric manikin similar in size to a child aged 6&#8211;8 years<br>&#8226; Children handled the equipment and then demonstrated the procedures on the doll<br>&#8226; A one-hour session&#44; one day before surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Anxiety<br>&#8226; Spielberger State Anxiety Scale for children &#40;SSAS-c&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There was a higher reduction in mean anxiety scores in the EG preoperatively &#40;31&#46;44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;87&#41; than in the CG &#40;38&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yu-Li et al&#46; &#40;2013&#41;<br>Taiwan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 children aged 3&#8211;15 years submitted to radiotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Storytelling&#44; role-playing game&#44; coloring books with every step of the treatment process&#46; Child-like doll&#44; clay molding&#44; painting&#44; video games and cartoons projected on the ceiling of the treatment room during radiotherapy&#46; One 15&#8211;20<span class="elsevierStyleHsp" style=""></span>min session a day&#44; every afternoon&#44; from Monday through Friday&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Anxiety<br>&#8226; The Faces Anxiety Scale &#40;FAS&#41;<br>&#8226; Beck Youth Anxiety Inventory &#40;BAI-Y&#41;<br>&#8226; Heart rate<br>&#8226; Differences in cortisol levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The EG showed a significantly lower score&#47;level of anxiety &#40;1&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;93&#41; when compared to the CG &#40;3&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;33&#41; before radiotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ruschel &#40;1995&#41;<br>Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60 children aged 3&#8211;10 years submitted to congenital heart defect surgery<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Quasi-experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Materials related to pre and postoperative care&#46; Doll&#44; suture threads&#44; needles&#44; tweezers and scissors<br>&#8226; Simulation surgery with doll&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Child&#39;s attitude in relation to several procedures<br>&#8226; Form&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There was statistical significance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; at the moments&#58; quiet wakening&#44; cooperation during procedures&#44; accepting the absence of the mother&#44; and fluid restriction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">He et al&#46; &#40;2015&#41;<br>China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95 children aged 6&#8211;14 years submitted to elective surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Video about the surgery with pictures of the operating room environment&#46; Demonstration with doll of the preoperative procedures&#46; Demonstration by the child<br>&#8226; Manual with medical objects and equipment used during surgery&#46;<br>A one-hour session three to seven days before the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Perioperative anxiety&#44; negative emotional expression and post-operative pain<br>&#8226; State Anxiety Scale for Children &#40;SAS-C&#41;<br>&#8226; Children&#39;s Emotional Manifestation Scale &#40;CEMS&#41;<br>&#8226; The Numeric Rating Scale &#40;NRS&#41;<br>Medical record&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The EG showed less negative emotional behavior before anesthesia induction&#44; low levels of anxiety&#44; and less postoperative pain<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kiche and Almeida &#40;2009&#41;<br>Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34 children aged 3&#8211;10 years submitted to minor and medium surgeries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Quasi-experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Doll&#44; saline solution&#44; gauze&#44; adhesive tape&#44; masks&#44; scissors&#44; dressing forceps&#44; gloves&#44; splints and other specific items according to the child&#39;s dressing<br>&#8226; Two sessions&#44; one after the dressing and the second session on the following day&#44; before changing dressing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Behaviors that showed acceptance and adaptation to the procedure<br>&#8226; Form<br>&#8226; Wong and Baker scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The behaviors that show lower acceptance and adaptation to the procedure decreased&#44; and those showing greater acceptance and adaptation increased after the therapeutic play session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ribeiro et al&#46; &#40;2001&#41;<br>Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42 children aged 3&#8211;6 years submitted to blood collection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Quasi-experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Doll&#44; syringe&#44; test tube&#44; cotton&#44; adhesive tape&#46; Scalpel with one catheter and bottle with red liquid<br>&#8226; One session before the procedure&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Behavior during blood collection<br>&#8226; Form&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The EG showed a reduction in the behaviors of &#8220;aggression&#44; verbal expression&#44; body movement&#44; expression of emotion&#44; and dependence&#8221; and showed an increase in the behaviors of &#8220;being quiet&#8221;<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pontes et al&#46; &#40;2015&#41;<br>Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60 children aged 3&#8211;6 years submitted to vaccination procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Quasi-experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Doll&#44; disposable syringes&#44; needles&#44; cotton and stickers for venipuncture<br>&#8226; One 20-minute session before the vaccination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Child&#39;s reactions<br>&#8226; Observation during vaccination<br>&#8226; Interview with parent&#47;guardian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The EG had more reactions of &#8220;being quiet&#8221; and &#8220;collaborating spontaneously&#8221;&#59; behaviors such as &#8220;pushing&#44;&#8221; &#8220;clinging to parents&#44;&#8221; &#8220;asking to be picked up&#44;&#8221; and &#8220;stiffness&#8221; were less present&#46;<br>Behaviors of &#8220;crying&#44;&#8221; &#8220;clinging to parents&#44;&#8221; &#8220;flushing&#44;&#8221; and &#8220;moving&#47;agitating&#8221; were more present in the CG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Li et al&#46; &#40;2014&#41;<br>China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">108 children aged 7&#8211;12 years admitted to undergo elective surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Visits to the operating room and presentation of equipment<br>&#8226; Demonstration in the operating room with a doll on the following procedures&#46; The post-anesthetic recovery period is explained<br>&#8226; Demonstration by the child of the procedures on the doll<br>&#8226; A 1-hour session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Anxiety&#44; emotional responses during anesthesia induction and satisfaction of parents<br>&#8226; State Anxiety Scale for children and adults<br>&#8226; Children&#39;s Emotional Manifestation Scale<br>&#8226; Questionnaire and semi-structured interview&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The EG showed a lower level of anxiety&#44; demonstrated fewer emotions during the anesthetic induction&#44; and the parents of the children from the group reported more satisfaction after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weber &#40;2010&#41;<br>Brazil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50 children aged 5&#8211;12 years submitted to surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Recreational activities with the use of games&#44; toys&#44; books&#44; comic books&#44; movies&#44; TV and materials for drawing<br>&#8226; One session 15<span class="elsevierStyleHsp" style=""></span>min after entering the Ambulatory Surgical Center&#44; lasting 15<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Anxiety level<br>&#8226; Observation when entering the operating room and 15<span class="elsevierStyleHsp" style=""></span>min after entering the room<br>&#8226; Modified Yale Preoperative Anxiety Scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92&#37; of the children in EG did not have anxiety&#44; while in the CG&#44; 84&#37; were still anxious<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zahr &#40;1998&#41;<br>Lebanon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100 children aged 3&#8211;6 years submitted to elective surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Materials for painting&#44; dolls&#44; puzzles and bicycles<br>&#8226; Demonstration using puppets of the sequence of events from admission&#44; surgery to discharge<br>&#8226; The child was encouraged to play&#44; handle the equipment and re-present the play<br>&#8226; One session carried out the day before the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Behavior&#44; blood pressure and pulse<br>&#8226; Manifest Upset Scale<br>&#8226; Cooperation Scale<br>&#8226; Post-Hospital Behavior Questionnaire &#40;PHBQ&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Children from the EG were calmer than those from the CG &#40;2&#46;52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;28 vs&#46; 3&#46;76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;16&#44; <span class="elsevierStyleItalic">t</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;5&#46;08&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Li and Lopez<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;2008&#41;<br>China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">203 children aged 7&#8211;12 years submitted to surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Visits to the reception&#44; anesthetic induction&#44; surgery and recovery rooms<br>&#8226; Demonstration of procedures on a doll with size similar to that of a child<br>&#8226; A one-hour session carried out one week before the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Anxiety of the children and their parents and parental satisfaction<br>&#8226; Chinese version of the State Anxiety Scale for Children &#40;CSAS-C&#41;<br>&#8226; Chinese version of the State Anxiety Scale for Adults<br>&#8226; The Postoperative Parents&#8217; Satisfaction Questionnaire<br>&#40;PPSQ&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The EG showed statistically lower anxiety scores in the pre- and postoperative periods &#40;<span class="elsevierStyleItalic">F</span> &#91;1&#44;201&#93; &#188; 5&#58;36&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; and less frequent negative behavior than the CG and their parents showed a greater degree of satisfaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Li et al&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;2007b&#41;<br>China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">203 children aged 7&#8211;12 years submitted to elective surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Visits to the reception&#44; anesthetic induction&#44; surgery and recovery rooms<br>&#8226; Demonstration of procedures on a doll with size similar to that of a child&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Child&#39;s anxiety&#44; behavior and level of postoperative pain<br>&#8226; Chinese version of the State Anxiety Scale for Children &#40;CSAS-C&#41;<br>&#8226; Children&#39;s Emotional Manifestation Scale &#40;CEMS&#41;<br>&#8226; Visual analog scale &#40;VAS&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Children from the EG and their parents showed lower anxiety scores in the pre- and postoperative periods<br>&#40;<span class="elsevierStyleItalic">F</span> &#91;1&#44;201&#93; &#188; 5&#46;36&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#59; less frequent negative behavior &#40;<span class="elsevierStyleItalic">t</span> &#91;201&#93; &#188; &#95;5&#46;4&#44; i<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41; and their parents showed a greater degree of satisfaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The articles Li et al&#46;&#44; 2007a&#44; Li et al&#46;&#44; 2007b and Li and Lopes&#44; 2008 are results of the same study&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Synthesis of the articles&#46;</p>"
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Article information

ISSN: 00217557
Original language: English

DOI:10.1016/j.jped.2016.06.005

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Year/Month	Html	Pdf	Total

2024 November	7	3	10
2024 October	29	145	174
2024 September	34	111	145
2024 August	55	64	119
2024 July	52	49	101
2024 June	31	22	53
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2024 April	34	17	51
2024 March	23	20	43
2024 February	22	26	48
2024 January	19	22	41
2023 December	14	22	36
2023 November	39	24	63
2023 October	28	31	59
2023 September	24	34	58
2023 August	15	17	32
2023 July	17	21	38
2023 June	14	11	25
2023 May	19	14	33
2023 April	18	17	35
2023 March	41	22	63
2023 February	30	16	46
2023 January	24	22	46
2022 December	56	29	85
2022 November	35	29	64
2022 October	54	37	91
2022 September	29	23	52
2022 August	34	32	66
2022 July	27	30	57
2022 June	21	27	48
2022 May	22	31	53
2022 April	27	32	59
2022 March	24	35	59
2022 February	15	25	40
2022 January	20	23	43
2021 December	24	22	46
2021 November	12	13	25
2021 October	12	26	38
2021 September	7	22	29
2021 August	11	11	22
2021 July	8	17	25
2021 June	10	15	25
2021 May	14	24	38
2021 April	19	20	39
2021 March	15	23	38
2021 February	6	4	10
2021 January	4	7	11
2020 December	9	9	18
2020 November	11	13	24
2020 October	10	13	23
2020 September	12	13	25
2020 August	19	9	28
2020 July	8	8	16
2020 June	9	6	15
2020 May	12	8	20
2020 April	15	19	34
2020 March	10	3	13
2020 February	17	14	31
2020 January	19	23	42
2019 December	20	10	30
2019 November	13	6	19
2019 October	20	14	34
2019 September	44	13	57
2019 August	8	10	18
2019 July	25	9	34
2019 June	8	13	21
2019 May	13	14	27
2019 April	20	10	30
2019 March	8	3	11
2019 February	13	8	21
2019 January	16	4	20
2018 December	10	7	17
2018 November	41	7	48
2018 October	162	22	184
2018 September	79	3	82
2018 August	10	2	12
2018 July	7	3	10
2018 June	10	5	15
2018 May	38	9	47
2018 April	15	0	15
2018 March	8	2	10
2018 February	12	2	14
2018 January	10	5	15
2017 December	9	1	10
2017 November	21	2	23
2017 October	19	2	21
2017 September	6	12	18
2017 August	8	4	12
2017 July	4	1	5
2017 June	13	4	17
2017 May	23	8	31
2017 April	43	6	49
2017 March	38	17	55
2017 February	28	16	44
2017 January	5	15	20
2016 December	3	13	16
2016 November	1	11	12
2016 October	1	9	10
2016 September	5	5	10
2016 August	13	9	22

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