The impact of music, play, and pet therapies in managing pain and anxiety in paediatric patients in hospital: a rapid systematic review

Abstract

Background

Hospitalized children face pain and anxiety associated with the environment and procedures.

Objective

This review aimed to assess the impact of music, play, pet and art therapies on pain and anxiety in hospitalized paediatric patients. RCTs assessing the impact of music, play, pet, and/or art therapies on pain and/or anxiety in hospitalized paediatric patients were eligible.

Methods

Database searching and citation screening was completed to identify studies. A narrative synthesis was used to summarize study findings and certainty of evidence was assessed using GRADE. Of the 761 documents identified, 29 were included spanning music (n = 15), play (n = 12), and pet (n = 3) therapies.

Results

A high certainty of evidence supported play in reducing pain and moderate certainty for music and pet. A moderate certainty of evidence supported music and play in reducing anxiety.

Conclusion

Complementary therapies utilized alongside conventional medical treatment may mitigate pain and anxiety in hospitalized paediatric patients.

INTRODUCTION

Complementary therapies such as music, play, pet, and art therapy have been implemented into many paediatric settings in conventional medical care given their unique ability to mitigate distress, anxiety, and pain in patients and improve caregiver satisfaction with minimal risk of adverse events (1–5). Specific to paediatrics, these therapies can positively impact a child’s hospital experience through engagement in activities that support their development and optimize their physical and emotional well-being (1,2,6). For example, music therapy has been found to decrease pain and anxiety scores in children undergoing painful procedures such as lumbar puncture (6). Further, play therapy has been found to aid in the development of problem-solving skills, while simultaneously equipping children with healthy coping strategies that minimize feelings of helplessness (7). These complementary therapies can help normalize and bring familiarity to the hospital environment, while decreasing anxiety levels and lowering the physical pain and emotional distress associated with hospitalization (1).

The use of complementary therapies presents an opportunity to support the psychosocial development of paediatric patients while mitigating the potential physical, emotional, and psychological trauma associated with hospital stays and medical procedures (1,2). The aim of this review was to systematically assess the impact of music, play, pet, and art therapy on pain and anxiety in paediatric patients in hospital.

METHODS

This manuscript was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Protocols (PRISMA-P) reporting guidelines (8). The protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) and amendments with reasons are documented (CRD42021246058) (9).

Eligibility criteria

Randomized controlled trials (RCTs) examining the impact of music, play, pet, and/or art therapies on pain and/or anxiety in paediatric patients aged 0–18 years were eligible. Studies had to state that they were assessing the therapeutic effects of music (music therapy, music intervention), play (play therapy, therapeutic play, medical play, play intervention), pet (pet/animal-assisted therapy, pet/animal-assisted intervention), or art (art therapy, art intervention) to be eligible for inclusion. No restrictions were placed on the comparator. Abstracts detailing RCTs were not eligible for inclusion. Studies were limited to those in which the interventions of interest took place in the hospital (inpatient and/or outpatient) and/or emergency department settings. Finally, studies were limited to those published in English.

Information sources

MEDLINE, CINAHL, Cochrane Library, and EMBASE were searched from database inception to November 2020. A research librarian was consulted in the development of search strategies. Keywords and medical subject headings were used to identify relevant studies. In the case the search identified an abstract or clinical trial registry page, full-text RCTs were identified by targeted Google searches. Citation screening of all included trials was conducted. Search strategies used for all the databases are available in Supplementary Table 1.

Study selection

Prior to initiating the document screening process, reviewers underwent a training exercise with 10% of the study sample to ensure high inter-rater reliability for both title/abstract and full-text screening (10). Following the training set, the remaining articles were screened by two reviewers independently and in duplicate against predefined inclusion and exclusion criteria using Covidence data management software. Articles deemed potentially eligible then underwent a full-text review by three reviewers independently and in duplicate. Reasons for exclusion were documented to facilitate the creation of a PRISMA flow diagram (Supplementary Figure 1) (8). All discrepancies were resolved through discussion between reviewers and, if needed, consultation with a third reviewer.

Data collection processes

Data collection was performed using a standardized form developed using REDCap software (11). The form was piloted by reviewers prior to the data extraction process to ensure that it captured relevant study information. Data was extracted by three reviewers independently and in duplicate. Discrepancies in data extraction were resolved through discussion between reviewers and consultation with a third reviewer when necessary.

Data items

Study characteristics (authors, year of publication, title of study, journal, study design, setting, and trial size), participant characteristics (age, sex, diagnosis, and number), intervention and comparator details, outcome results, outcome measurement instruments, and adverse events were extracted.

Risk of bias assessment

Risk of bias was assessed independently and in duplicate by three reviewers with the Cochrane risk of bias tool for randomized trials (RoB 2.0) using the intention-to-treat framework (12). Risk of bias was assessed across five domains including risk of bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result, and then reported in a predeveloped REDCap form (11,12). Risk of bias judgements were made for each domain and across all domains, and categorized as “low”, “some concerns”, or “high” (12). Additionally, a risk of bias assessment was completed for all studies reporting on the same intervention and outcome, to inform the quality of evidence assessment (12). Findings are presented by intervention in summary plots developed using the Robvis tool (Supplementary Figures 2–4) (13).

Data synthesis methods

Study characteristics are presented using tables and text. A narrative synthesis of study outcome effects was conducted using Synthesis Without Meta-analysis (SWiM) guidelines (14). Heterogeneity across studies was evaluated by analyzing the consistency of the direction and difference in magnitude of effect across studies, and used to inform inconsistency in the certainty of evidence assessment (15).

Certainty of evidence assessment

Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) across five domains including risk of bias, inconsistency, indirectness, imprecision, and publication (16). Given the limited number of studies available for each intervention and the heterogeneous methodologies used to measure outcomes of interest, a narrative summary of studies informing the effect of each intervention on pain and anxiety was completed (14–16). Findings are presented in summary of findings tables developed using the GRADEpro tool (Supplementary Tables 2–4) (17).

RESULTS

Study selection and characteristics

The search yielded 761 articles, of which 29 RCTs were included (Supplementary Figure 1). Most of the studies identified examined the impact of music therapy (n = 15) and play therapy (n = 12), followed by pet therapy (n = 3) (Table 1). No studies examining the impact of art therapy were identified. One study evaluated the impact of both music and play therapy. Fifteen studies reported on anxiety, eight reported on pain, and six reported on both pain and anxiety (Table 1).

Table 1.

Characteristics of included RCTs (n = 29)

Study (Author, year)	Participant characteristics		Comparator	Outcome(s)	Primary OMId
	Agea	n
Music therapy (n = 15)
Karbandi 2020 (18)	8–12 y	83	Cards; Cards and music	Anxiety (A)	SCAS
Primary OMIVan der Heijden 2019 (19)	3–13 y	191	Standard care (SC)	Pain (P)	AHTPS
Rennick 2018 (20)	2–14 y	20	SC	A	CMAS
Uggla 2018 (21)	0–17 y	29	SC	A; P	PedsQL 3.0; VAS
Van der Heijden 2018 (22)	0–13 y	135	SC	P	COMFORT-Behavioural Scale
Buehler 2017 (23)	4–16 y	135	Placebo (P)	A; P	PHBQ; CHEOPSc
Qiu 2017 (24)	0–2 w	74	SC	P	PIPP
Kesselman 2016 (25)	1–10 y	44	SC	A	Heart rate
Park 2015 (26)	0–4 y	62	SC	A	VAS
Hartling 2013 (5)	1 m–18 y	42	SC	P	FPS-R
Kazemi 2012 (27)	9–12 y	60	SC	A	STAI-CH
Nguyen 2010 (6)	7–12 y	40	Earphones without music	A; P	STAI-CH; NRSc
Caprilli 2007 (28)	4–13 y	108	SC	P	WBFPRS
Kain 2001 (29)	2–7 y	70	SC	A	mYPA
Chetta 1981 (30)	3–8 y	75	SC	A	Observation
Play therapy (n = 13)
Mohammadi 2021(31)	7–12 y	25	SC	A; P	FAS; WBFPRSc
Ali 2020 (32)	6–11 y	85	SC	P	FPS-R
Karbandi 2020 (18)	8–12 y	83	Cards; Cards and music	A	SCAS
Suzan 2020 (33)	7–11 y	80	SC	A; P	STAI-CH; WBFPRSc
Da Silva 2017 (34)	6–11 y	28	SC	A	CH:D
Orhan 2017 (35)	8–10 y	40	SC	A	STAI-CH
Ullán 2014 (36)	1–7 y	95	SC	P	FLACC
Vaezzadeh 2011(37)	7–12 y	122	SC	A	STAI-CH
Li 2007b (38)	7–12 y	203	SC	A; P	CSAS-C; VASc
Zahr 1998 (39)	3–6 y	100	SC	A	PHBQ
Fosson 1990(40)	5–9.9 y	100	P	A	STAI-CH
Rae 1989 (41)	5–10 y	36	SC	A	ZAC
Pet therapy (n = 3)
McCollough 2018 (42)	3–17 y	106	SC	A	STAI-CH, STAI
Branson 2017 (43)	7–17 y	48	Jigsaw puzzles	A	STAI-CH
Calcaterra 2015 (44)	3–17 y	40	SC	P	WBFPRS

^aWeeks (w), months (m), and years (y), represented as ranges.

^bFour studies utilizing the same dataset were identified for inclusion.

^cIndicates OMI for pain.

^dSpence Children’s Anxiety Scale (SCAS); Alder Hey Triage Pain Score (AHTPS); Children’s Manifest Anciety Scale (CMAS); Visual Analog Scale (VAS); Post Hospitalization Behavioural Questionnaire (PHBQ); Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS); Premature Infant Pain Profile (PIPP); Faces Pain Scale-Revised (FPS-R); State-Trait Anxiety Inventory for Children (STAI-CH); Numeric Rating Scale (NRS); Wong-Baker FACES Pain Rating Scale (WBFPRS); Yale Preoperative Anxiety Scale (mYPAS); Faces Anxiety Scale (FAS); Child Drawing: Hospital (CH:D); Face, Legs, Activity, Cry, Consolability Scale (FLACC); Chinese State Anxiety Scale for Children (CSAS-C); Zuckerman Adjective Checklist (ZAC).

Included studies evaluated children in hospital in the inpatient (n = 18) or outpatient (n = 5) setting or both (n = 3), and in the emergency department (n = 3). Many studies evaluated patients’ response to medical procedures performed while in hospital including venipuncture, lumbar puncture, surgery, and various imaging modalities at various timepoints (Supplementary Tables 5–7). The State-Trait Anxiety Inventory for Children (n = 7) (6,27,35,37,40,42,43) and the Wong-Baker FACES Pain Rating Scale (n = 4) were the most commonly used outcome measurement instruments (OMI) for anxiety and pain, respectively (Table 1) (28,31,33,44).

Music therapy—pain

Eight studies (participant n = 754) evaluated the impact of music therapy on pain scores reported by paediatric patients in hospital for various painful procedures such as venipuncture, wound care procedures, and lumbar puncture (Supplementary Table 5) (5,6,19,21–24,28). The overall certainty of evidence was rated as moderate (Table 2, Supplementary Table 2). Five studies found a significant reduction in pain levels in the music therapy group compared to the control, measured at various timepoints (5,6,19,24,28). Three studies demonstrated no significant decrease in pain scores between groups after the intervention (21–23).

Table 2.

Summary of evidence by intervention and outcome and GRADE certainty of evidence

Interventions	Outcomes
	Pain			Anxiety
	n	Comments	Certainty	n	Comments	Certainty
Music therapy	8	May decrease pain (n = 5a)	⊕⊕⊕◯ Moderate	10	May decrease anxiety (n = 8a)	⊕⊕⊕◯ Moderate
Play therapy	5	May decrease pain (n = 3a)	⊕⊕⊕⊕ High	10	May decrease anxiety (n = 7a)	⊕⊕⊕◯ Moderate
Pet therapy	1	May decrease pain (n = 1a)	⊕⊕⊕◯ Moderate	2	There may be no difference (n = 2a)	⊕⊕⊕⊕ High

^aNumber of studies out of the total (N) that support the comment.

Music therapy—anxiety

Ten studies (n = 618) assessed the impact of music therapy on anxiety scores, in children undergoing anaesthesia induction, imaging techniques, and surgery measured before, during, and/or after the intervention, for which the certainty of evidence was rated as moderate (Table 2, Supplementary Tables 2 and 5) (6,18,20,21,23,25–27,29,30). Eight studies identified a statistically significant decrease in anxiety in individuals participating in the music therapy intervention compared to the control (6,18,20,25–27,29,30). Two studies found non-significant declines in anxiety scores (21,23).

Play therapy—pain

Five studies (n = 393) were identified that assessed the effect of play therapy on pain scores in paediatric patients undergoing surgery, chemotherapy, and IV insertion measured before and/or after the intervention (Supplementary Table 6) (31–33,36,38). Certainty of evidence was graded as high (Table 2, Supplementary Table 3). Three studies showed significantly decreased pain scores in the play therapy group compared to the control group (31,33,36). Two studies found no difference or non-significant declines in pain scores (32,38).

Play therapy—anxiety

Ten studies (n = 817) were evaluated to determine the effect of play therapy on anxiety experienced by paediatric patients for surgical procedures and treatment of acute/chronic illnesses (Supplementary Table 6) (18,31,33–35,37–41). Certainty of evidence was rated as moderate across studies (Table 2, Supplementary Table 3). Seven of these studies showed significantly decreased anxiety scores in the play therapy group before, during, and/or after various procedures (18,31,33,35,37–39). Three studies showed either no differences or non-significant declines in anxiety scores measured before and/or after the intervention (34,40,41).

Pet therapy—pain

One study (total participants n = 40) was identified that evaluated the impact of pet therapy on paediatric pain scores after surgery, for which the certainty evidence was graded as moderate (Table 2, Supplementary Tables 4 and 7) (44). The pet therapy was delivered by a trained dog and handler (44). The study found that pet therapy led to a statistically significant reduction in child self-reported pain, as measured by the Wong-Baker FACES Pain Rating Scale (WBFPS) (44,45).

Pet therapy—anxiety

Two studies (total participants n = 154) assessed the impact of pet therapy delivered by a trained dog and handler at paediatric patients’ bedsides on anxiety scores measured before and after pet therapy, for children undergoing surgery and treatment for acute/chronic illnesses (Supplementary Table 7). Certainty of evidence was rated as high (Table 2, Supplementary Table 4) (42,43). Both studies reported no significant difference between control and experimental groups, as measured by the STAI-CH (42,43).

Adverse events

No adverse events were reported. There were no reports of music, play, or pet therapy increasing pain or anxiety in study participants.

DISCUSSION

Hospitalization and associated medical procedures can be anxiety provoking and cause significant pain and distress in children (1,2,4). This is often due to the unfamiliar hospital environment, as well as the mental and physical stressors that accompany illness (46). There is a need for therapies that address the negative psychological effects of medical treatment while minimizing the potential adverse effects that may exacerbate a child’s medical condition (4,46,47). Complementary therapies such as music, play, and pet present multiple adjuvant treatment options for the paediatric population (1, 2, 6, 7, 44). The review findings elucidate the significant positive role that music and play therapies can have in reducing anxiety and pain in these patients while in hospital.

Most studies found that music therapy resulted in a significant decrease in pain and anxiety. This finding coincides with the previously established beneficial role of music therapy in adult populations (48,49). Music therapy utilizes the creation, appreciation, and improvisation of music (50). The patient listens to music to evoke certain emotional and physical responses and/or composes music to allow for expression and emotional connection (50). Additionally, it is posited that music can be a method of communication for those with conditions impacting communication, such as autism spectrum disorder (50). The acceptance for music therapy in the paediatric population is among the highest for complementary medicine modalities (50,51). Study findings present an intriguing avenue for pain and anxiety management in the paediatric population, as well as an opportunity to provide support for the emotional well-being of children throughout physically and mentally traumatizing medical procedures.

Many studies investigating the effects of play therapy found significant decreases in pain and anxiety scores. Play therapy utilizes sensory activities such as playing with toys and/or cognitive activities such as board games to introduce a child to medical procedures and their medical condition, distract them from negative experiences, and promote their psychosocial development (7). The familiarity and comfort of play to the child and family is an important factor in assisting them in adjusting to the unfamiliar hospital environment (7). Further, play therapy can easily be utilized outside of the hospital environment and can improve post-discharge adaptation, ultimately decreasing negative emotions and behaviours at home (52).

The three RCTs analyzing the effect of pet therapy demonstrated that pet therapy may decrease self-reported pain in paediatric patients but does not have a significant effect on anxiety. In pet therapy, the child receives a visit from an animal or partakes in caring for an animal alongside a trained handler (53). Although anxiety was not significantly decreased, this therapy has been reported to improve the patient’s mood, socialization, and acceptance of the hospital environment (53). The animal provides a means of distraction while creating a more engaging and comfortable environment for the child (53). Special considerations may have to be made for children undergoing pet therapy who are significantly immunocompromised, given their higher risk of infection (53).

Collectively, music, and play therapies can transform children’s perceptions of their medical stay by engaging them in activities that support their development and optimize their physical and emotional well-being (1,2). Importantly, all the studied therapies were found to be safe. Further research is needed to explore the long-term benefits of these therapies and their benefits following hospitalization. Further studies should be conducted to establish the benefit of pet therapy on pain reduction. Additionally, more research should be conducted to explore the impact that art therapy may have on mitigating pain and anxiety in the paediatric population.

Strengths and limitations

Study methods adhered to the PRISMA-P systematic review guideline (8). The search strategy was developed in collaboration with a trained research librarian and multiple data sources were used to provide a comprehensive review of the literature. Researchers involved in the review underwent training prior to beginning their respective roles.

A narrative synthesis was conducted in place of a meta-analysis due to the limited number of studies included in each intervention reporting on each outcome. The transparency and structure of presented results were optimized by referring to the SWiM reporting guidelines in addition to PRISMA-P (8,14). Furthermore, only studies published in English were included in this review. Our results cannot be extrapolated to make conclusions about studies reported in other languages.

CONCLUSIONS

Given their positive impact, music, and play therapies should be implemented into the treatment of pain and anxiety in paediatric patients in hospital. More research is needed to explore the impact of art and pet therapies in this population. Complementary therapies play an important role in supporting the health and well-being of paediatric patients while in hospital.

FUNDING

The authors acknowledge financial support from the Schulich School of Medicine and Dentistry Hippocratic Council.

POTENTIAL CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare.

AVAILABILITY OF DATA, CODE, AND OTHER MATERIALS

Data can be provided at your request. Please email the corresponding author.