Support Care Cancer (2016) 24:2421–2427

DOI 10.1007/s00520-015-3040-y

ORIGINAL ARTICLE

Play-based procedural preparation and support intervention

for cranial radiation
Shawna Grissom 1 & Jessika Boles 1 & Katherine Bailey 1 & Kathryn Cantrell 2 &
Amy Kennedy 1 & April Sykes 3 & Belinda N. Mandrell 4

Received: 30 June 2015 / Accepted: 23 November 2015 / Published online: 4 December 2015
# Springer-Verlag Berlin Heidelberg 2015

Abstract significant relationship was found between the total number

Purpose The primary objective of this study was to examine and duration of the interventions and sedation use. The imple-
the relationship between play-based procedural preparation mentation of a play-based procedural preparation and support
and support intervention and use of sedation in children with intervention provided by a certified child life specialist signif-
central nervous system (CNS) tumors during radiation thera- icantly reduced health-care costs by decreasing the necessity
py. The secondary objective was to analyze the cost- of daily sedation.
effectiveness of the intervention compared to costs associated Conclusions Support interventions provided by child life spe-
with daily sedation. cialists significantly decreased both sedation use and the cost
Methods A retrospective chart review was conducted, and associated with daily sedation during cranial radiation therapy
116 children aged 5–12 years met criteria for inclusion. Out- in children with CNS tumors. This study supports the value of
come measures included the total number of radiation treat- the child life professional as a play-based developmental spe-
ments received, the number of treatments received with and cialist and a crucial component of cost-effective healthcare.
without sedation, and the type and duration of interventions,
which consisted of developmentally appropriate play, educa-
Keywords Child life . Radiation therapy . Procedural
tion, preparation, and distraction provided by a certified child
support . Play . Sedation . Cost-effectiveness
life specialist.
Results The results of univariate analyses showed that age,
tumor location, and total number and duration of interventions
were significantly associated with sedation use during radia- Introduction
tion therapy. Multivariate analyses showed that, after adjust-
ment for age, tumor location, and craniospinal radiation, a Central nervous system (CNS) tumors are the most commonly
diagnosed solid tumor in childhood, accounting for nearly
20 % of all pediatric cancers, with 2500 new cases treated in
* Shawna Grissom the USA each year [1, 2]. Radiation therapy is an effective
shawna.grissom@stjude.org treatment modality for many CNS tumors; however, this treat-
ment may produce significant physical and psychosocial
1
Child Life Program, St. Jude Children’s Research Hospital, 262
stress for both the child and parent [3–6]. Radiation therapy
Danny Thomas Place, MS 121, Memphis, TN 38105, USA is particularly stressful for children, who must maintain pre-
2
University of Massachusetts, 100 Morrissey Blvd.,
cise body positioning to ensure delivery of radiation to the
Boston, MA 02125, USA tumor and avoid unintended exposure to the developing brain
3
Department of Biostatistics, St. Jude Children’s Research Hospital,
[7]. To ensure precise positioning, sedation may be required.
262 Danny Thomas Place, MS 723, Memphis, TN 38105, USA However, daily sedation in children may be associated with
4
Department of Pediatric Medicine, Division of Nursing Research, St.
risks for respiratory depression, aspiration, central line infec-
Jude Children’s Research Hospital, 262 Danny Thomas Place, tions [8, 9], learning disabilities, decreased attentiveness, and
MS738, Memphis, TN 38105, USA decreased cognitive functioning [10, 11].
2422 Support Care Cancer (2016) 24:2421–2427

Many pediatric health-care institutions use intervention the primary oncologist, radiation oncologist, and interdisci-
programs delivered by certified child life specialists (CCLS) plinary staff. The hospital employs one full-time CCLS within
to provide developmentally targeted psychosocial support and the radiation oncology clinic to provide play-based procedural
thereby promote successful coping in children and families preparation and support interventions. The child life program
facing a variety of stressful illnesses and procedures has provided services for this clinic for 6 years, with the CCLS
[12–14]. The CCLS uses a theoretical foundation in child functioning as a member of the interdisciplinary health-care
development, therapeutic play, stress and coping, and play- team.
based procedural preparation and support interventions to re-
duce stress and anxiety for children undergoing diagnostic or Participants
therapeutic procedures. Child life specialists are therefore
uniquely positioned within the interdisciplinary team to indi- A total of 164 children aged 5–12 years were identified as
vidualize psychosocial treatment plans that incorporate the having a CNS tumor and referred for cranial radiation therapy
child’s development, coping abilities, and strengths into the from October 15, 2009 to December 31, 2013. Patients aged
health-care plan. 5–12 years were chosen, as this is the developmental age
Play-based procedural support and preparation refers to a range most often referred for child life services in the radiation
specific child life intervention that aims to promote the child’s oncology clinic. Those with pre-existing developmental de-
coping with new and unfamiliar medical experiences, such as lays or posterior fossa syndrome were excluded from analysis,
invasive procedures or treatments. These interventions include leaving a total of 129 eligible patient records for review. Of the
using familiar play materials and unfamiliar medical materials 129 identified children, 116 received child life services that
to merge the child’s primary means of learning and commu- included play-based procedural preparation and support inter-
nication—play—with the child’s developing understandings ventions, with the intervention documented in the electronic
of current illness and treatment. By increasing familiarity with medical record or in an internal productivity statistics database
the equipment and steps involved in the procedure through maintained by the child life program director.
play, the child can better anticipate and prepare for the se-
quence of treatment events. Measures
Specifically in the context of radiation therapy, procedural
preparation—including demonstration and education during Child life electronic documentation and statistics and clinical
simulation—may reduce the stress of the radiation experience documentation from radiation oncology and anesthesia were
for the child and parent. Intuitively, successful preparation available for all study participants. To facilitate collection of
interventions alleviating the need for sedation should reduce these data, a data abstraction instrument was designed to sys-
health-care costs; however, prior studies have not explored the tematically categorize demographic data, sedation patterns,
potential economic benefit of a CCLS preparation interven- and child life interventions.
tion. Therefore, the primary aim of this study was to assess the Demographic data included each child’s sex, age, tumor loca-
relationship between play-based procedural preparation and tion (infratentorial, supratentorial), position during radiation treat-
support interventions and the ability of young children with ment (prone, supine), total radiation treatment dose, average mi-
CNS tumors to undergo cranial radiation without sedation. nutes of daily radiation treatment, number of days over which
Secondly, we assessed the effect of this play-based interven- radiation was administered, and need for sedation during radia-
tion on health-care costs. tion treatment (all, partial, none). Partial sedation was defined as
the child receiving at least one radiation treatment with sedation
and at least four treatments without sedation. Play-based proce-
Methods dural preparation and support intervention data included the
number of child life sessions and the average duration of each
Setting session. Three investigators separately reviewed each child’s
medical record to ensure inter-rater reliability.
This retrospective study assessed the effect of a play-based
procedural preparation and support intervention provided by Intervention
a CCLS within an outpatient radiation oncology clinic in a
free-standing children’s oncology hospital. The radiation on- The objectives of the play-based procedural preparation and
cology clinic provides radiation therapy from birth to young support intervention provided by the CCLS included anxiety
adulthood for children with a variety of solid tumor, leukemia, reduction through developmentally appropriate education, as-
and CNS tumor diagnoses. Treatment plans are individualized sessment and application of the child’s individual coping strat-
based on tumor type, location, and specifications outlined by egies. The ultimate goal of the intervention was to assist the
clinical trials or non-protocol treatment plans developed with child in becoming comfortable with the radiation treatment
Support Care Cancer (2016) 24:2421–2427 2423

process, thus eliminating or decreasing the number of radia- the treatment position as a result of the practice session. Once the
tion treatments under sedation. The play-based procedural patient demonstrated success during the practice session, an at-
preparation and support intervention was defined as age- tempt was made to deliver radiation therapy without sedation. If
appropriate play, education, preparation, and/or distraction three radiation treatments were completed successfully without
that helped to provide children with a sense of mastery over sedation, then sedation orders were removed from the child’s
their environment. These elements of intervention can be as- radiation treatment schedule for the remaining weeks of therapy.
sembled and provided to meet the individual child’s develop- Children received an individualized treatment coping plan devel-
mental level, learning style, and coping preferences. The play- oped with the CCLS for any radiation therapy treatment not
based procedural preparation portion of the intervention spe- requiring sedation. The treatment coping plans included options
cifically used play to introduce the child to sensory stimulation such as listening to a personalized music playlist or audio book
anticipated during the medical treatment or procedure; the during treatment, hearing guided imagery or relaxation scripts,
procedural support component involved active listening, emo- being updated on treatment timing during a session, and altering
tional support, and diversionary play provided during the ac- the treatment environment if needed, such as lowering lights or
tual radiation simulation procedure to promote coping and placing holes in the treatment mask (see Table 1).
normalcy within the treatment environment. The play-based
procedural preparation and support intervention was designed
and delivered to the 116 children in this study. First, the child Statistical analyses
was referred to the CCLS for assessment after the patient’s
initial consult with the radiation oncology team. During the Patient demographics were summarized by descriptive statis-
assessment, the CCLS would gather information on the child’s tics. Multinomial logistic regression was used to examine the
current understanding of radiation treatment, previous medical relationship between a play-based procedural preparation and
experiences, coping style, temperament, attention span, ability support intervention and the use of sedation during radiation
to separate from caregivers, and level of comfort in the hospi-
tal setting and with medical staff. Table 1 Play-based procedural preparation and support intervention
Second, the CCLS used this information to develop a care Before radiation therapy
plan based upon the child’s development, learning style, and Assessment
assessment of the child’s ability to undergo treatment without • Consultation with radiation oncology medical team
sedation. The CCLS’s care plan for intervention included prepa- • Referral to CCLS
ration, planning for rehearsal and practice sessions (if needed), • CCLS meets with patient and family for rapport building, play, and
and support during radiation therapy. In order to prepare patients expressive activities
for the experience of radiation therapy, the CCLS would use • CCLS gathers information (patient’s understanding of treatment,
teaching materials such as a picture preparation book, a video, previous hospital experiences, ability to separate from caregiver,
a teaching doll, or even hands on exploration of medical items in attention span, temperament, learning style, and level of comfort
with medical staff)
one of the treatment spaces [15]. During the initial preparation
Developmentally appropriate preparation
session, the sequence of events was explained, and sensory in-
• Teaching materials shown (video, picture preparation book,
formation, including what the child would see, feel, and hear
teaching doll)
during treatment, was provided by the CCLS using developmen-
• Sequence of events explained
tally appropriate language. This session also allowed patients to
• Sensory information explained
ask questions and for the CCLS to clarify any misconceptions. At
• CCLS clarifies any misconceptions
this point, the child and family worked with the CCLS to develop
• Individualized coping plan developed with patient and family
an individualized coping plan and determine if a child would
Rehearsal and practice sessions
need rehearsal or practice sessions at the initiation of radiation
• Increased opportunities to explore immobilization device
therapy. Some children were assessed to require no sedation for
• Increased opportunities to acclimate to treatment position
their treatment, while others were assessed to require sedation for
• Increased opportunities to experience treatment environment
all treatment sessions, while others were assessed as likely to
benefit from practice sessions with the potential for partial seda-
During radiation therapy
tion. Practice sessions offered children an opportunity to simulate
Support
therapy with body position and cranial immobilization device,
• Personalized music playlist or choice of audio book
treatment environment and holding still for the treatment dura-
• Guided imagery and relaxation scripts
tion. This gave the child a chance to practice coping strategies
• Updating patient on treatment progress
and gain confidence with the requirements of radiation therapy in
• Altered treatment environment (i.e., lowered lights, adjusted
a nonthreatening environment. The practice sessions were con- temperature, nose holes in mask, and weights on feet)
sidered effective if the child demonstrated the ability to maintain
2424 Support Care Cancer (2016) 24:2421–2427

therapy, with and without adjustment for covariates. The total use. A 1-year increase in age was associated with significantly
number and the duration of all intervention sessions were used higher odds of receiving cranial radiation without sedation
as measures for the effect of the intervention and were evalu- over full sedation (OR 3.24; 95 % CI 2.12–4.95; P<0.001)
ated separately in all analyses. Covariates were selected by and significantly higher odds of receiving cranial radiation
using the criterion of P<0.1 for inclusion in the adjusted mod- with partial sedation over full sedation (OR 2.00; 95 % CI
el. The following demographic and clinical parameters were 1.28–3.12; P = 0.002). Compared to patients with
considered as potential covariates: age at the time of treatment, supratentorial tumors, patients with infratentorial tumors were
sex, tumor location (infratentorial, supratentorial), patient po- less likely to receive cranial radiation without sedation over
sition during treatment (prone, supine, prone/supine), and full sedation (OR 0.19; 95 % CI 0.07–0.48; P<0.001). There
craniospinal radiation (Table 2). The Wilcoxon rank-sum test was a trend toward significance for the association between
was used to compare the combined total cost of treatment and craniospinal radiation and sedation use; compared to patients
intervention between sedation groups. A two-sided signifi- that did not receive craniospinal radiation, patients that re-
cance level of P<0.05 was used for all statistical tests. Statis- ceived craniospinal radiation were less likely to receive cranial
tical analyses were performed by using SAS version 9.3 (SAS radiation without sedation over full sedation (OR 0.41; 95 %
Institute, Cary, NC). CI 0.17–1.003; P=0.051). The results from multinomial lo-
gistic regression models examining the association between
intervention measures and sedation use are shown in Table 4.
Results The total number and duration of all intervention sessions
were significantly associated with the use of sedation, with
Effect of child life intervention on sedation and without adjustment for covariates. After adjustment for
age, tumor location, and receipt of craniospinal radiation, each
A total of 116 patients received the child life intervention and additional intervention session was associated with a 23 %
were included in the analysis. The multinomial logistic regres- increase in the odds of receiving cranial radiation with partial
sion models examined the association between demographic sedation over full sedation (OR 1.23; 95 % CI 1.001–1.507;
and clinical characteristics and sedation (Table 3). Age and P=0.048). After adjustment for age, tumor location, and re-
tumor location were significantly associated with sedation ceipt of craniospinal radiation, each additional minute of the

Table 2 Patient characteristic by

sedation use Sedation use

All (N=116) None (n=61) Partial (n=15) Full (n=40)

Age at time of treatment (year)

Mean (SD) 8.1 (2.2) 9.4 (1.8) 7.7 (2.2) 6.3 (1.4)
Sex
Female 50 (43%) 27 (44%) 5 (33%) 18 (45%)
Male 66 (57%) 34 (56%) 10 (67%) 22 (55%)
Tumor location
Infratentorial 73 (63%) 28 (46%) 13 (87%) 32 (80%)
Supratentorial 42 (36%) 33 (54%) 2 (13%) 7 (17.5%)
Infratentorial/supratentorial 1 (1%) 0 (0%) 0 (0%) 1 (2.5%)
Patient position during treatment
Prone 32 (27.6%) 11 (18%) 5 (33.3%) 16 (40%)
Supine 74 (63.8%) 45 (74%) 8 (53.3%) 21 (52.5%)
Prone/supine 10 (8.6%) 5 (8%) 2 (13.3%) 3 (7.5%)
Received craniospinal radiation
No 83 (72%) 49 (80%) 9 (60%) 25 (62.5%)
Yes 33 (28%) 12 (20%) 6 (40%) 15 (37.5%)
Total number of intervention sessions
Mean (SD) 4.5 (3.1) 4.1 (2.9) 6.5 (3.9) 4.2 (3.1)
Duration of all intervention sessions (min)
Mean (SD) 210.4 (164.0) 217.1 (153.5) 300.3 (213.8) 166.6 (146.6)

SD standard deviation
Support Care Cancer (2016) 24:2421–2427 2425

Table 3 Multinomial logistic

regression modeling of sedation No. sedation Partial sedation
use as predicted by demographic
and clinical characteristics Demographic/clinical characteristics OR (95 % CI) P OR (95 % CI) P

Age at time of treatment (year) 3.24* (2.12–4.95) <0.001 2.00* (1.28–3.12) 0.002
Sex
Male Reference Reference
Female 0.97 (0.43–2.16) 0.942 0.61 (0.18–2.11) 0.437
Tumor locationa
Supratentorial Reference Reference
Infratentorial 0.19* (0.07–0.48) <0.001 1.42 (0.26–7.77) 0.685
Patient position during treatment
Prone/supine Reference Reference
Prone 0.41 (0.08–2.09) 0.285 0.47 (0.06–3.65) 0.469
Supine 1.29 (0.28–5.89) 0.746 0.57 (0.08–4.08) 0.577
Received craniospinal radiation
No Reference Reference
Yes 0.41 (0.17–1.003) 0.051 1.11 (0.33–3.75) 0.865

The reference category is full sedation

ORodds ratio, CIconfidence interval
a
One patient with an infratentorial and supratentorial tumor was excluded
*Statistically significant value

child life intervention session was associated with a 0.4 % $5233.63 with sedation and $1811.31 without sedation. The
increase in the odds of receiving cranial radiation with partial total cost of child life intervention was estimated by the total
sedation over full sedation (OR 1.004; 95 % CI 1.000–1.008; time spent in all child life interventions: the cost of a 45-min
P=0.036). child life intervention session was $18.95. These average
costs are based on staff salaries, supplies, and services. The
Economic effect of a child life intervention on sedation use total treatment cost, total child life intervention cost, and the
combined total cost of treatment and intervention are shown in
Economic data were provided by the institution’s financial Table 5, with all costs increasing with the use of sedation
services division. The total cost of treatment was estimated during cranial radiation. The cost of child life intervention
by averaging the cost of the total number of treatments with was highest for patients receiving partial sedation, and lowest
and without sedation: the average cost of one treatment was for those receiving full sedation. Undergoing more sessions or

Table 4 Multinomial logistic regression modeling of sedation use as predicted by intervention measures

No. sedation Partial sedation

Unadjusted Adjusteda Unadjusted Adjusteda

Intervention OR (95 % CI) P OR (95 % CI) P OR (95 % CI) P OR (95 % CI) P

measures

Total no. of intervention sessions 0.99 (0.86–1.13) 0.874 0.97 (0.81–1.18) 0.789 1.22* (1.02–1.46) 0.029 1.23* (1.001– 0.048
1.507)
Duration of all intervention sessions 1.002 (0.999– 0.111 1.002 (0.998– 0.347 1.005* (1.001– 0.009 1.004* (1.000– 0.036
(min) 1.005) 1.005) 1.009) 1.008)

The reference category is full sedation

ORodds ratio, CIconfidence interval
a
Adjusted for age at time of treatment, tumor location, and receipt of craniospinal radiation
*Statistically significant value
2426 Support Care Cancer (2016) 24:2421–2427

Table 5 Cost of treatment and

intervention by sedation use No. sedation Partial sedation Full sedation
(n=61) (n=15) (n=40)

Cost variables Mean SD Mean SD Mean SD

No. of treatments with sedation NA NA 7.7 7.0 30.4 1.4

No. of treatments without sedation 30.1 3.2 22.6 6.7 0 0.2
Total duration of all child life intervention 217.1 153.5 300.3 213.8 166.6 146.6
sessions (min)
Total treatment costa $54,607 $5755 $81,409 $25,085 $159,278 $7638
Total child life intervention costb $91 $65 $126 $90 $70 $62
Total treatment and intervention costc $54,698 $5749 $81,535 $25,116 $159,349 $7639

All cost variables have been rounded to the nearest dollar

NA not applicable, SD standard deviation
a
(No. of treatments with sedation×$5233.63)+(no. of treatments without sedation×$1811.31)
b
(Total min spent in all child life interventions/45 min)×$18.95
c
Total treatment cost+total child life intervention cost

longer sessions was associated with a greater likelihood that Although our results support the use of child life
the child would receive partial sedation over full sedation. interventions for children with CNS tumors undergoing
Thus, child life intervention could significantly reduce the radiation therapy, there are noted limitations. First, due
health-care cost by reducing the need for sedation from full to logistic restraints, our study was retrospective and
to partial, with a potential mean cost difference of $77,814 lacked a randomized control group: a prospective meth-
(95% CI $69,022–$86,604; P<0.001). odology would have allowed for a real-time estimation
of costs and would allow for other important patient-
reported outcomes including coping, stress, and anxiety
Discussion associated with treatment. Secondly, the retrospective
data reflects a time in which the radiation oncology
These findings support previous literature confirming that child life program was in its early stage of program
play-based procedural preparation significantly decreases the development. Over time, the program has grown in
need for sedation in pediatric populations [16–18]. Similar to scope and time spent with each child, thus, our reported
other psychological preparation programs for young children, results may underestimate the program’s current value to
our program confirms that early introduction into the radiation the institution. Finally, although age was included as a
unit helps the child incorporate coping strategies for immobi- factor for analysis, age may not always account for
lization during radiation therapy [13], which thereby de- individual differences related to development; this fur-
creases the need for sedation during radiation therapy. ther highlights the importance of individually targeted
Decreasing sedation use has a long-term effect on the and developmentally focused psychosocial intervention
well-being of the child and family by protecting the provided by a child life specialist.
patient from potential physiological and cognitive defi- Play is the most universal tool used by CCLSs to
cits [2, 10, 11, 13, 19]. In addition, decreasing sedation support coping in children during the illness experience.
use may have financial benefits for the institution. Un- By gradually introducing unfamiliar or anxiety-
like previous studies, our findings also emphasize the producing procedures and equipment through play, chil-
cost-effectiveness of reduced sedation through interven- dren attain a greater understanding of and control over
tions facilitated by a CCLS [20, 21], thus saving thou- their environment [22]. This study provides evidence to
sands of dollars in health-care costs. We have found emphasize the importance of a child life program within
that the child life intervention was associated with sig- pediatric settings as a service that supports patients’
nificant reduction in health-care costs, and findings pro- coping during anxiety producing procedures with the
vide supporting evidence for the implementation of potential to reduce health-care costs. Furthermore, these
child life programs within radiation and diagnostic im- programs, specifically in radiation therapy settings, may
aging units. In summary, play-based programming im- contribute to a reduction in health-care costs, therefore
plemented by a CCLS supports the child’s psychosocial augmenting childhood coping while also promoting
development and mastery over the health-care environ- cost-effective and high-quality care for children with
ment while also being related to reduced treatment cost. CNS tumors and their families.
Support Care Cancer (2016) 24:2421–2427 2427

Conclusion 5. Houtrow AJ, Yock TI, Delahaye J, Kuhlthau K (2012) The family
impacts of proton radiation therapy for children with brain tumors. J
Pediatr Oncol Nurs 29(3):171–179
The treatment experience for children with CNS tumors can be 6. Hocking MC, Alderfer MA (2012) Neuropsychological sequelae of
daunting. To assist with the stress and anxiety of radiation childhood cancer, Pediatric Psycho-oncology: Psychosocial
therapy, sedation is often used; however, sedation may in- Aspects and Clinical Interventions., p 177
crease the child’s clinical risks, as well as being time- 7. Stone HB, Coleman CN, Anscher MS, McBride WH (2003) Effects
of radiation on normal tissue: consequences and mechanisms.
consuming and costly. This retrospective study describes the Lancet Oncol 4(9):529–536
efficacy of child life interventions and the decrease of sedation 8. Scheiber G, Ribeiro FC, Karpienski H, Strehl K (1996) Deep seda-
use within an outpatient radiation oncology clinic treating chil- tion with propofol in preschool children undergoing radiation ther-
dren with CNS tumors. By retrospectively reviewing the med- apy. Paediatr Anaesth 6(3):209–213
ical records and child life documentation, we assessed play- 9. Tobias JD (2000) Tolerance, withdrawal, and physical dependency
after long-term sedation and analgesia of children in the pediatric
based procedural preparation and support interventions and intensive care unit. Crit Care Med 28(6):2122–2132
the associated use of sedation in children (aged 5 to 12 years) 10. Wilder RT, Flick RP, Sprung J, Katusic SK, Barbaresi WJ,
receiving radiation therapy for a CNS tumor. The implications Mickelson C, Gleich SJ, Schroeder DR, Weaver AL, Warner
of this study are two-fold: individual treatment-related coping DO (2009) Early exposure to anesthesia and learning disabil-
ities in a population-based birth cohort. Anesthesiology
plans and play-based procedural preparation and support in-
110(4):796–798
terventions developed by child life specialists are associated 11. De Ruiter MA, Van Mourik R, Schouten-ven Meetreren AY,
with reduced need for sedation during treatment, even for Grootenhuis MA, Oosterlaan J (2013) Neurocognitive conse-
young children; and child life specialists are a cost-effective quences of a paediatric brain tumour and its treatment: a meta‐
means for decreasing health-care costs. Additional prospective analysis. Dev Med Child Neurol 55(5):408–417
12. Metzger T, Mignogna K, Reilly L (2013) Child life specialists: key
research is needed to validate the association between a child members of the team in pediatric radiology. J Radiol Nurs 32(4):
life program and clinical and financial outcomes, as well as the 153–159
most effective play-based procedural preparation and support 13. Slifer KJ, Bucholtz JD, Cataldo MD (1994) Behavioral training of
interventions for children with oncological diseases undergo- motion control in young children undergoing radiation treatment
ing medical procedures and treatment. without sedation. J Pediatr Oncol Nurs 11(2):55–63
14. Slifer KJ (1996) A video system to help children cooperate with
motion control for radiation treatment without sedation. J Pediatr
Acknowledgments This study was supported in part by the Child Life Oncol Nurs 13(2):91–97
Council’s Advancing the Field of Play for Hospitalized Children Initiative
15. Kain ZN, Caldwell-Andrews AA, Mayes L, Weinberg ME, Wang
grant from The Walt Disney Company, by the Cancer Center Core Grant
SM, MacLaren JE, Blount RL (2007) Family-centered preparation
CA 21765 from the National Institutes of Health, and by the American
for surgery improves perioperative outcomes in children: a random-
Lebanese Syrian Associated Charities (ALSAC).
ized controlled trial. Anesthesiology 106(1):65–74
16. Carter AJ, Greer M-LC, Gray SE, Ware RS (2010) Mock MRI:
Compliance with ethical standards
reducing the need for anaesthesia in children. Pediatr Radiol
40(8):1368–1374
Conflict of interest The authors declare that they have no competing
interests. 17. Brewer S, Gleditsch SL, Syblik D, Tietjens ME, Vacik HW (2006)
Pediatric anxiety: child life intervention in day surgery. J Pediatr
Informed consent The study was approved by the hospital's institu- Nurs 21(1):13–22
tional review board as exempt research with wavier of consent and assent. 18. Cejda KR, Smeltzer MP, Hansbury EN, McCarville ME, Helton
KJ, Hankins JS (2012) The impact of preparation and support pro-
cedures for children with sickle cell disease undergoing MRI.
Pediatr Radiol 42(10):1223–1228
References 19. Tsai YL, Tsai SC, Yen SH, Huang KL, Mu PF, Liou HC,
Wong TT, Lai IC, Liu P, Lou HL, Chiang IT, Chen YW
1. Siegel R, Naishadham D, Jemal A (2013) Cancer statistics, 2013. (2013) Efficacy of therapeutic play for pediatric brain tumor
CA Cancer J Clin 63(1):11–30 patients during external beam radiotherapy. Childs Nerv Syst
2. Anghelescu DL, Burgoyne LL, Lu W, Hankins GM, Cheng C, 29:1123–1129
Beckham PA, Shearer J, Norris AL, Kun LE, Bikhazi GB (2008) 20. Scott L, Langton F, O’Donoghue J (2002) Minimising the use of
Safe anesthesia for radiotherapy in pediatric oncology: St. Jude sedation/anaesthesia in young children receiving radiotherapy
Children’s Research Hospital Experience, 2004–2006. Int J through an effective play preparation programme. Eur J Oncol
Radiat Oncol Biol Phys 7(2):491–497 Nurs 61(1):15–22
3. Hutchinson KC, Willard VW, Hardy KK, Bonner MJ (2009) 21. Jessee PO, Gaynard L (2009) Paradigms of play. In: Thompson RH
Adjustment of caregivers of pediatric patients with brain tumors: (ed) The handbook of child life: a guide for pediatric psychosocial
a cross-sectional analysis. Psycho-Oncology 18(5):515–523 care. Thomas Books, Springfield, IL, pp 136–159
4. Kreitler S, Krivoy E, Toren A (2012) Psychosocial aspects of ra- 22. Perry JN, Hooper VD, Masiongale J (2012) Reduction of
diotherapy in pediatric cancer patients, Pediatric Psycho-Oncology: preopterative anxiety in pediatric surgery patients using age-
Psychosocial Aspects and Clinical Interventions, Second Edition., appropriate teaching interventions. Journal of PeriAnesthesia
pp 62–70 Nursing, 27(2):69–81