Pediatric play and stress

1. Paediatric Journal Club
Critical appraisal of a randomised clinical trial
“Effect of play activities on hospitalized children’s stress: a randomized clinical
trial “
Scandinavian Journal of Occupational Therapy 2012; Early on-line, 1-9
Presented by: Jude Pain

2. Population/Problem
Population:
• Children aged 4 -14 years old, who were
hospitalised for respiratory diseases
Problem:
• How to help children cope with stress of a
hospitalisation period

3. Intervention
• Unstructured play activity and the
study of urinary cortisol levels.
Comparison
• Leisurely walk around the hospital gardens
and the study of urinary cortisol levels

4. Outcome
• Decrease in levels of urinary cortisol
(LC) after play activities

5. Internal Validity
• Recruitment ..were the subjects representative
Setting: Public paediatric hospital for respiratory diseases.
Inclusion criteria :
o 53 children, boys & girls aged 4 to 14 years of age
o Minimum hospital stay of 6 days
Exclusion criteria:
o Neurological or psychiatric disorders
o Locomotion restrictions
o Common childhood diseases
o Hx of any medication previous to or during
hospitalization that could influence LC

6. Internal Validity
• Allocation ..was the allocation randomised and
concealed…?
o 53 children were divided in to two groups Play Group
(PG) 27 children (50.80%) and Non Playing Group
(NPG) 26 children (49.12%)
o Randomly designated to one of the two wards by
physicians who were unaware of the study.
o Ward was designated to include the PG or
NPG by a raffle

7. Internal Validity
• Allocation:. so that the groups were comparable at the start of the
trial?
o Identification card with child’s data and previous
experience of hospitalization filled out by parents or
guardians
o Assessment of economic and social parameters by Pelotas
Social Scale
o The Child’s Depression Inventory (CDI) to
detect traits of depression

8. Internal Validity
Assessment tools used:
• Children’s Depression Inventory (CDI)
o The CDI evaluates the presence of specific depressive
symptoms
• Pelotas Social Scale
o Assesses nutritional status of infant/children
o Socio-economic, demographic reproductive and
health characteristics of family

9. Internal Validity
(In this study, children who presented CDI scores higher
than 18 were excluded and referred to the psychiatrist
on staff)
o These variables were included to eliminate any bias
due to stress or traits of depression that might
influence levels of urinary cortisol

10. Internal Validity
• Sample stratification:
Three subgroups according to age range, following developmental
criteria
o Age range 1(from 4 to 7 years)
o Age range 2(from 7.1 to 11 years)
o Age range 3 (from 11.1 to 14 years)
Stratification according to age ranges intended to
control the variation in LC due to puberty as well
as due to maturity levels in relation to coping
strategies and perceived stress

11. Internal Validity
• Maintenance:
Did the groups have equal co-interventions?
o Children in the PG attended the toy library every day
(including weekends) at 10.30hrs and played until 11.30hrs
and again in the afternoon from 1400hrs until 1500hrs.
They could also take toys to their beds, which were collected
at the end of the day to follow cleaning protocols
There was no adult intervention in the play activities unless
a child asked.
In addition no adult stimulated the child to play

12. Internal Validity
• Maintenance:
o Children in the NPG did not attend recreational activities,
but were taken out of their rooms every day at the same time
that the PG went to the Toy Library. The NPG went for
a walk in the hospital gardens.
Taking the NPG out of their rooms for the same amount
of time as the PG lessened possible bias that could result
from only one group being exposed to environmental
conditions that could lower stress.
This group of children did not receive any kind of toy
in their beds and carers were closely
monitored and instructed to avoid any object
which could be used as a toy

13. Internal Validity
• Maintenance:
Data Collection
o On the first visit to the child’s bed, one of the
researchers completed the Pelotas Social Scale
and the CDI for both the PG and the NPG
o A 24 hour urine collection from both groups was completed
to establish a baseline cortisol level.
Analysis of urinary cortisol was chosen to avoid
added invasive procedures during hospitalisation
o The play routines as well as the strolling routine were
performed each day of hospitalisation
o On the fifth day of hospitalization, the 24 hour
urine collection was repeated for all children

14. Internal Validity
Maintenance… and was there adequate follow-up?
o A range of 6 to 15 children at each session in the
Toy Library-not all included in study
o 5 to 15 children participated in the strolling activity
each day

15. What do the results mean
• Compared with the NPG, the amount of children who
showed a reduction in LC was larger in the PG.
• At the end of the intervention period, 20 children in the
PG showed a reduction in LC of 20% over baseline values (AR=71.4%),
• While in the NPG only 12 children presented a
reduction in LC (AR=41.4%)
• The AR reduction was 30% (RR = 1.73; CI95%=1.03 to 12.53;
NNT = 3.32 and p = 0.04)

16. Are these results applicable to our patients?
• Is our patient group so different from those in the study that
the results can’t apply?
o Demographics might vary slightly
o Higher incidence of prior experience to hospitalization
• Is the treatment feasible in our setting?
o Among school aged children on 5B
o 7b patients too young to benefit from this particular
intervention
What are our patient's potential benefit’s and harm
from therapy?
o Unstructured play activities seem to be a useful
tool for dealing with the stress of hospitalization
What are the patient’s values and expectations for both the outcome
we are trying to prevent and the treatment we are offering?