Preoperative anxiety affects about 60% of children and is linked with poorer cooperation at anesthesia induction, greater postoperative pain, and maladaptive behavioral changes. A new single-center trial suggests that a nurse-led card game may help ease children's anxiety at a particularly stressful point in surgery—entry to the operating room—and may improve cooperation during anesthesia induction and early postoperative behavior. The findings, reported (DOI: 10.1007/s12519-026-01097-4) online on 19 September 2026 in the World Journal of Pediatrics, offer preliminary support for structured, low-cost, non-digital therapeutic play as a practical addition to pediatric preoperative preparation.
The trial, conducted at Children's Hospital, Zhejiang University School of Medicine in China, randomized 164 children, with 162 included in the final analysis after two in the intervention group did not complete the game protocol. 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.
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. They suggested the effect may reflect distraction, greater familiarity with procedures, improved predictability, and a stronger sense of control. The group format may also have encouraged emotional sharing and positive peer modeling.
Many proven approaches to reduce preoperative anxiety rely on digital platforms or virtual reality, which can be costly and hard to implement in busy wards. The nurse-led Medical Vanguard card game uses simple materials and can be delivered by trained nurses in small groups, making it easier to incorporate into busy pediatric surgical pathways than digital or virtual-reality programs. The findings need confirmation in larger, multicenter studies before wider adoption.
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 that future preparation should pair child-focused play with support for parents and caregivers. The authors noted no between-group differences at earlier preoperative time points. 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.
