Simple medical card game reduces preoperative anxiety in children

Preoperative anxiety affects about 60% of children and is linked with poorer cooperation at anesthesia induction, greater postoperative pain, and maladaptive behavioral changes. Structured play, role play, and medical-themed games can reduce anxiety and improve coping, but many proven approaches rely on digital platforms or virtual reality (VR), which can be costly and hard to implement in busy wards. Those tools may be difficult to adopt in routine practice because of cost, equipment requirements, and implementation burden, especially in busy hospital wards with limited staff and space. Given these challenges, further research is needed to evaluate scalable, low-cost, non-digital play interventions for children that can be delivered widely in routine pediatric surgical care.

Researchers at Children's Hospital, Zhejiang University School of Medicine in China reported (DOI: 10.1007/s12519-026-01097-4) the trial online on 19 September 2026 in World Journal of Pediatrics. In the intervention, a trained nurse led a child-life-informed session on the evening before surgery, individually or in groups of up to three children, lasting 40 minutes. Two modules were used: "Time-limited Treasure Hunting," in which children matched medical equipment tokens while receiving brief explanations, and "Surgical Adventure," a board game introducing the ward, operating room, and perioperative procedures.

Of 164 children randomized, 162 were included in the final analysis after two in the intervention group did not complete the game protocol. The study's main outcome was anxiety at operating-room entry, and children in the card-game group appeared less anxious at that point than controls. They were also more likely to cooperate during anesthesia induction, and they showed fewer post-discharge behavioral problems, particularly generalized anxiety, according to caregiver reports. Heart rate and blood pressure changed over time but did not differ between groups.

Caregiver anxiety scores were similar between groups, although they rose in both groups when children separated from caregivers. The authors said the benefit was most evident at operating-room entry, a particularly stressful moment when children separate from caregivers and face the clinical environment directly, and they suggested the effect may reflect distraction, greater familiarity with procedures, improved predictability, and a stronger sense of control. They cautioned, however, that the trial was single-center, restricted to otolaryngology inpatients, unable to blind children and providers, used weekly randomization, and lacked long-term follow-up. The intervention did not reduce caregiver anxiety, suggesting future preparation should pair child-focused play with support for parents and caregivers, and the authors noted no between-group differences at earlier preoperative time points. The findings need confirmation in larger multicenter studies.

The authors said the benefit was most evident at operating room entry, a particularly stressful moment when children separate from caregivers and face the clinical environment directly. They said the effect may reflect a combination of distraction, greater familiarity with procedures, improved predictability, and a stronger sense of control. The group format may also have encouraged emotional sharing and positive peer modeling. They said the findings support structured therapeutic play as a practical addition to pediatric preoperative preparation, while cautioning that the trial was single-center and short-term.

The nurse-led Medical Vanguard card game—delivered in individual or small-group sessions using two simple game modules and brief medical explanations—may be a practical, low-cost, non-pharmacological adjunct to standard preoperative care, especially for children facing separation and direct exposure to the operating room. Because it uses simple materials and can be delivered by trained nurses in small groups, it could be easier to incorporate into busy pediatric surgical pathways than digital or virtual-reality programs. The trial did not reduce caregiver anxiety, suggesting that future preparation should pair child-focused play with support for parents and caregivers. Multicenter studies with longer follow-up are needed to test generalizability, examine whether behavioral benefits persist, and evaluate integrated child-caregiver models. If replicated, the approach could be considered for routine preoperative preparation and future quality-improvement programs.