Comparative and synergistic effects of digital devices and Child Life services in pediatric clinical practice: a systematic review

Abstract

Background

Examinations and treatments in pediatric healthcare settings may cause anxiety, fear, and psychological distress among children. Child Life services provide psychosocial support through therapeutic play, procedural preparation, and emotional support to help children cope with medical experiences. Meanwhile, digital devices, including virtual reality (VR), augmented reality (AR), tablet-based applications, and video-based tools, have been increasingly applied to support children during healthcare procedures. However, differences in study populations, intervention designs, and outcome assessments make direct comparisons between digital devices and Child Life services difficult. This review aimed to summarize the clinical applications, reported outcomes, and potential complementary roles of these approaches in pediatric healthcare.

Methods

A systematic search was conducted in PubMed, CINAHL, Cochrane Library, Embase, Web of Science, PsycINFO, VIP Database, and Wanfang Database for quantitative studies published from January 2015 to June 1, 2026. Eligible studies included randomized controlled trials (RCTs), non-RCTs, and pre-post studies evaluating digital devices and/or Child Life interventions in pediatric healthcare settings. Study quality was assessed using the Cochrane risk-of-bias tool for RCTs and the Joanna Briggs Institute (JBI) quasi-experimental assessment tool. Due to variations in study designs, intervention characteristics, and outcome measures, meta-analysis was not performed, and findings were synthesized narratively.

Results

Seven RCTs were included. Digital devices used alone were associated with reduced anxiety and fear, improved behavioral responses, and increased satisfaction among children. When combined with Child Life support, digital interventions showed additional benefits, including reduced preoperative anxiety, lower caregiver anxiety, and improved cooperation during anesthesia induction. However, heterogeneity among interventions and assessment methods limited direct comparisons.

Conclusions

Digital devices and Child Life services may serve complementary roles in pediatric healthcare. Digital devices mainly provide immediate support through distraction and engagement, whereas Child Life services focus on preparation, coping, and family support. Combining these approaches may offer additional support for children undergoing healthcare experiences.

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Key findings

• Digital devices and Child Life interventions were associated with reduced anxiety, fear, and distress and improved procedural cooperation among children in pediatric healthcare settings.

What is known and what is new?

• Digital devices and Child Life interventions are increasingly used in pediatric clinical practice to reduce children’s psychological distress and improve cooperation during medical procedures. However, evidence regarding their comparative effects, synergistic mechanisms, and clinical applications remains fragmented.

• This systematic review synthesized evidence on digital devices and Child Life interventions across pediatric healthcare settings. Both interventions demonstrated beneficial effects in reducing anxiety, fear, and distress while improving procedural cooperation and patient/family experiences. Digital interventions may provide interactive distraction and engagement, whereas Child Life services emphasize emotional support, preparation, and coping strategies.

What is the implication, and what should change now?

• Integrating digital technologies with Child Life approaches may provide a more comprehensive model for pediatric psychological care.

• Future studies should establish standardized intervention protocols and evaluate long-term clinical outcomes.

Introduction

The pediatric healthcare environment can impose substantial physical, psychological, and social burdens on children. Medical procedures are frequently accompanied by pain, distress, and anxiety (1). In addition, parental concern regarding illness and treatment may further amplify children’s stress responses (2). Repeated hospital visits may increase distress and, over time, contribute to avoidance of future medical care (3,4). During hospitalization, separation from parents, unfamiliar surroundings, invasive examinations and treatments, and loss of autonomy may all trigger negative experiences, including fear, anxiety, helplessness, and a diminished sense of control (5). Previous studies have reported that 40% to 65% of children experience marked anxiety and fear when separated from their parents, often manifested as crying, trembling, withdrawal, cessation of play, or irritability (6,7). Whether hospitalization is brief or prolonged, children and adolescents may also become disconnected from their families, peers, school environments, and daily routines (8), with potentially lasting adverse effects on emotional, social, and overall physical and mental well-being (9).

Against this background, Child Life services have gradually emerged as an important support model in pediatric care (10,11). Child Life is a professional, child- and family-centered psychosocial care approach that helps children and families cope with the emotional and developmental challenges associated with illness, hospitalization, and medical procedures. It is not limited to providing distraction or recreational activities; rather, it is grounded in child development theory, family-centered care, and psychosocial principles to support children’s understanding of medical experiences and their ability to cope with stress. Certified Child Life Specialists (CCLSs) play a central role in delivering these services by assessing each child’s developmental characteristics, emotional responses, coping needs, and family context. Based on these assessments, they provide individualized interventions, including therapeutic play, preparation for medical procedures, age-appropriate education, emotional support, and family involvement. Through these structured interventions, Child Life helps children reduce fear and uncertainty, develop effective coping strategies, and gain a greater sense of control during healthcare encounters (12). Thus, Child Life should be considered a professional psychosocial intervention model rather than a simple distraction technique or entertainment activity.

At the same time, digital devices have been increasingly incorporated into pediatric healthcare practice. In this review, digital devices refer to interactive technology-based tools that are used to support pediatric healthcare delivery, including virtual reality (VR), augmented reality (AR), tablet-based applications, and video-based platforms. These technologies can serve multiple purposes, such as procedural preparation, health education, distraction, assessment, and therapeutic support, by providing children with engaging and developmentally appropriate digital experiences. Beyond improving accessibility and flexibility of care (13), digital devices may also enhance clinical efficiency and patient experience (14). In pediatric settings, these tools have been increasingly applied to reduce procedure-related distress, improve cooperation, and support children’s adaptation to medical environments (15), They may also help hospitalized children maintain connections with family, school, and peers, thereby reducing social isolation and supporting academic continuity and socioemotional adjustment (9). In particular, interactive technologies such as VR, AR, and tablet-based devices have been increasingly applied to improve engagement and cooperation among pediatric patients (16-18). VR creates a computer-generated three-dimensional environment that allows children to experience and interact with simulated scenarios (19), which may help reduce attention to stressful medical situations and improve procedural tolerance. AR, in contrast, enhances the real-world environment by integrating computer-generated digital content, such as images, animations, or virtual objects, which can be perceived and interacted with through different sensory modalities (20). By combining real-world surroundings with digital information, AR-based systems may provide children with more interactive and understandable experiences during healthcare activities. In pediatric practice, VR and AR have been explored for procedural preparation, distraction, health education, and emotional support. Existing meta-analyses have shown that digital-device-based distraction interventions can provide moderate relief of pain and distress during painful pediatric medical procedures (21). Among these technologies, VR has attracted particular attention because immersive and controllable simulated environments may reduce children’s subjective experience of aversive stimuli and procedural anxiety (22-24). Previous studies have also suggested that VR may alleviate pain and anxiety across a range of pediatric medical procedures (24).

Although both Child Life interventions and digital-device-based approaches may improve children’s experiences during medical procedures, they differ substantially in their theoretical basis, mechanisms of action, and implementation pathways. Child Life interventions primarily focus on developmentally appropriate preparation, emotional support, coping facilitation, and family-centered care, whereas digital technologies are more often characterized by immersive distraction, interactivity, standardization, and scalability. These differences suggest that the two approaches may not simply represent alternative strategies, but may instead be suited to different clinical circumstances and may also have the potential to complement one another.

Although digital devices and Child Life services have both been increasingly used in pediatric healthcare, the available evidence varies widely across studies. Differences can be observed in patient populations, clinical settings, intervention characteristics, and outcome evaluations, making direct comparisons between these two approaches difficult. Therefore, this review was not designed to determine whether digital devices or Child Life services are more effective. Instead, we aimed to summarize how these interventions have been applied in pediatric practice, their reported effects on healthcare experiences and clinical outcomes, and their potential to complement each other in supporting children and families. Therefore, the aim of this systematic review was to compare the effects of Child Life interventions, digital-device-based interventions, and their combined use during pediatric medical procedures, and to explore their comparative and synergistic value across multiple outcome domains. By doing so, this review seeks to provide evidence-based support for more individualized, developmentally appropriate, and clinically informed non-pharmacological intervention strategies in pediatric care.

This review evaluated the impact of digital devices and Child Life interventions on two types of outcomes: (I) pediatric clinical outcomes, including psychological outcomes, physical well-being, clinical compliance, and family satisfaction; and (II) the safety of digital devices, including adverse reactions in children caused by digital devices. We present this article in accordance with the PRISMA reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0612/rc) (25).

Methods

Data sources and retrieval strategy

This study employed an evidence-based literature search strategy to guide the formulation of search questions and support literature retrieval (26). An adapted PICOS framework (Participants, Interventions, Comparators/Controls, Outcomes, and Study Design) was used to identify and develop search terms, including subject headings and keywords, for each component. However, it should be noted that because subject headings vary across databases, the search strategy was adjusted according to the characteristics of each database. Furthermore, the search strategy only used the letters “P”, “I”, and “S” to broaden the search scope. The search strategy was implemented in PubMed, CINAHL, Embase, Cochrane Library, Web of Science, PsycINFO, VIP Database, and Wanfang Database, covering the period from January 1, 2015, to June 1, 2026. The search was initially conducted in PubMed and subsequently adapted for the other seven databases.

Inclusion criteria

(I) Quantitative studies, including randomized controlled trials (RCTs) and before-and-after controlled trials; (II) studies involving pediatric patients, with no restrictions on age, gender, race, or disease type; (III) interventions that utilize digital devices in combination with or in comparison to other approaches; (IV) studies without a control group, or those using standard care or comprehensive support tools as a control; (V) studies whose results include emotion-related measures (e.g., anxiety, fear, pain) and engagement measures (compliance and satisfaction).

Exclusion criteria

(I) Duplicated publications; (II) studies focusing on measurement, diagnostic methods, or research protocols; (III) conference abstracts or studies for which full-text access is unavailable.

Study selection and data extraction

This review was registered in PROSPERO (No. CRD420261413106). Two researchers (J.D. and L.W.) independently screened titles and abstracts of relevant studies using EndNote software (version X9; Clarivate Analytics). Two researchers (J.D. and L.W.) independently conducted study selection, data extraction, and risk of bias assessment (refer to Table S1) independently. A third researcher (Y.B.) was consulted to resolve any disagreements.

Quality assessment of included studies

The methodological quality and risk of bias of RCTs were assessed using the Cochrane Library RCT assessment tool (27). This tool comprises seven domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting of outcomes, and other biases.

Data synthesis

Initially, a meta-analysis was planned to calculate pooled effect sizes. However, current evidence regarding digital devices and Child Life services remains heterogeneous, with considerable variations in patient characteristics, clinical settings, intervention designs, implementation methods, and outcome assessments. These differences limit the feasibility of directly comparing the effectiveness of the two approaches. Therefore, rather than determining whether digital devices or Child Life services are superior, a comprehensive synthesis of existing evidence is needed to better understand their clinical applications, potential benefits, and complementary roles in pediatric healthcare. Therefore, this study employed descriptive analysis to summarize the effects of digital devices on hospitalized children. The process of conducting descriptive analysis to present study findings involved aggregating various characteristics from the original studies, such as study, population, intervention, comparator, and outcomes, for more details, please refer to Table 1. Two researchers independently extracted this information using a predefined Excel (Microsoft) spreadsheet. Subsequently, the collected data underwent thorough review and validation by both researchers to ensure accuracy and reliability. Disagreements were resolved through discussion to reach consensus. Finally, the extracted data were compared with the planned studies for each specific outcome measure, enabling a comprehensive assessment of the findings. Specifically, this study summarized the relationship between digital devices interventions and patient outcomes, identifying themes such as psychological and emotional well-being, clinical outcomes, adverse reactions, healthcare efficiency and resource utilization, and satisfaction levels.

Table 1. Characteristics of included interventions.

Study	Population	Intervention	Comparator	Outcomes
Stunden 2021 (28)	Pediatric MRI imaging (simulation + actual scan)	VR intervention	Standard preparation manual (SPM) group	Anxiety/fear; procedural cooperation; satisfaction; caregiver outcomes
			Child Life program (CLP) group
Nouh 2026 (29)	Pediatric tonsillectomy	Video/animated educational interventions	Routine care	Anxiety/fear; satisfaction; caregiver outcomes
Burns-Nader 2017 (30)	Hydrotherapy for pediatric burns and wound debridement	Tablet-based digital distraction intervention	Routine care	Anxiety/fear; pain/distress
Wang 2021 (31)	Preoperative care for pediatric strabismus correction surgery	Animated video-based distraction intervention	Routine care	Anxiety/fear; procedural cooperation
Matava 2024 (32)	The induction phase of anesthesia for pediatric surgery	Virtual parenting support + tutoring interventions (video communication)	On-site support + tutoring group	Anxiety/fear; procedural cooperation; caregiver outcomes
			On-site support without tutoring
Canares 2021 (33)	Invasive procedures in the pediatric emergency department	VR intervention	Routine support group for Child Life specialists (no VR)	Anxiety/fear; procedural cooperation; pain/distress; caregiver outcomes
			External reference group without standardized support
Dumoulin 2019 (34)	Procedures involving needles in the pediatric emergency department	VR intervention	Standard care group (gold standard) for children’s living (CL)	Pain/distress; satisfaction
			Minimal distraction control group (TV)

MRI, magnetic resonance imaging; TV, television; VR, virtual reality

Results

Search results

The database search yielded 402 articles. First, EndNote software (version X9) was used to exclude 126 duplicate records. Subsequently, 255 articles were further excluded through title and abstract screening. After detailed evaluation of the full texts of the remaining articles, 14 studies were ultimately excluded for the following reasons: (I) interventions were not relevant to the review question (e.g., did not involve digital devices, Child Life, or their combination) (n=8); (II) incomplete outcome measures (n=1); (III) research protocol (n=1); (IV) systematic reviews (n=1); (V) full texts unavailable (n=3). Ultimately, 7 studies were included in this review. Figure 1 illustrates the study selection process.

Figure 1.

Flowchart of studies screening.

General characteristics of the study population

This study ultimately included seven studies published between 2015 and 2026, all of which were RCTs (28-34). Geographically, these studies spanned multiple countries. Chinese mainland was involved in one study (31), Canada in three (28,32,34), the United States in two (30,33), and Egypt in one (29). Sample sizes varied considerably across studies, but most included more than 30 participants, with one study reaching a sample size of 240 (29). Regarding intervention methods, three studies compared digital device interventions with Child Life programs (28,33,34); four studies combined digital devices with Child Life professional support (29-32).

Methodological quality and risk of bias in included studies

In the included studies, all provided detailed descriptions of the methods used to generate random sequences, including specific approaches such as the use of random number tables, computer-generated sequences, or web-based sequence generators (28-34). Two studies (32,34) implemented allocation concealment. Due to the specific nature of the interventions, six studies stated that blinding of participants and researchers was not applicable (28,29,31-34). Regarding blinding procedures, two studies (32,33) reported implementing blinding for outcome assessment. All studies (28-34) did specify the participant dropout rate. Additionally, all controlled trials were considered to have a low risk of selective outcome reporting. Regarding “other biases”, six studies (28-33) reported sample size calculations. All studies conducted baseline assessments, with no significant differences reported. All seven studies clearly reported their inclusion and exclusion criteria, methods for assessing efficacy, and data analysis methods. Four studies (28,31,33,34) described adverse events during the intervention period. For further details, please refer to Table S1.

Analysis results

Effects on psychological outcomes

A total of six studies evaluated the effects of digital-device-based interventions and Child Life interventions on children’s anxiety during hospitalization.

Four studies examined digital interventions delivered in combination with Child Life principles or professional support. In the perioperative setting, a preoperative animated video accompaniment intervention designed under the Child Life philosophy of humanistic care significantly reduced children’s anxiety, as evidenced by lower modified Yale Perioperative Anxiety Scale (mYPAS) scores in the intervention group (P<0.001). In addition, the proportion of children with clinically significant anxiety (mYPAS >30) decreased markedly from 87.5% before the intervention to 52.5% after the intervention, with a significant between-group difference (P=0.0002) (31). In contrast, in a simulated MRI setting, a VR-based intervention incorporating Child Life principles did not significantly reduce self-reported anxiety compared with the control group at any observation time point. Anxiety was assessed using the Venham Picture Test (VPT), a picture-based tool that measures children’s situational anxiety through images representing different emotional states (29). Two further studies used tablet-based interventions integrated with Child Life support and empathy-based care principles. One study implemented a Child Life model that combined an iPad with videoconferencing to facilitate virtual parental presence during induction of anesthesia. Although this intervention did not significantly reduce mYPAS scores (P=0.052), it was the only intervention among the included approaches to demonstrate a reduction in children’s anxiety relative to baseline (32). Another study combined an iPad-based distraction intervention with Child Life care during hydrotherapy for pediatric burn patients. By engaging children in interactive digital activities that diverted attention from treatment-related stressors, the intervention significantly reduced hospital-related stress and anxiety (P=0.001) (30).

The remaining two studies directly compared digital-device-based interventions with conventional Child Life interventions. One study found that a digital intervention using structured Child Life videos significantly reduced anxiety in children undergoing venipuncture compared with standard Child Life care, with significant improvements in both state and trait anxiety scores (P<0.001 for both) (33). Similarly, another study conducted in a venipuncture setting showed that VR intervention was effective in alleviating anxiety compared with conventional Child Life intervention. Although no statistically significant difference was observed in children’s self-reported anxiety scores, the VR intervention demonstrated an advantage in objective behavioral performance by improving children’s coping behaviors and stress-related responses during the procedure (28).

Overall, the evidence suggests that digital-device-based interventions may reduce pediatric anxiety, particularly when integrated with Child Life principles or when used in highly structured perioperative and procedural settings. However, the magnitude and consistency of the effect varied according to clinical context and outcome measure.

Effects on children’s physiological perceptions

Three RCTs assessed the effects of digital-device-based interventions, including VR and tablet-based approaches, on children’s pain perception during medical procedures, in comparison with Child Life interventions or standard care. Overall, the findings varied across clinical settings. Two studies were conducted in the venipuncture setting and compared VR-based interventions with Child Life support. In the study by Canares et al. (33), participants were assigned to one of three groups: VR combined with Child Life support, Child Life support alone, or no standardized supportive care. No statistically significant difference was found among the three groups in changes in self-reported pain intensity (P=0.19). Likewise, Dumoulin et al. (34) compared a VR intervention group, a Child Life intervention group, and a television distraction group during venipuncture. Although pain intensity scores decreased to some extent in all three groups, there was no statistically significant difference in overall pain reduction between groups. In contrast, Burns-Nader et al. (30) investigated pediatric burn patients undergoing hydrotherapy and compared a Child-Life-guided tablet intervention with standard care. The findings revealed a discrepancy between subjective and objective pain assessments. Nurse-rated pain scores were significantly lower in the digital intervention group than in the standard care group (P=0.03), whereas no significant between-group difference was observed in children’s self-reported pain scores on the Faces Pain Scale (FACES) (P=0.29).

Effects on clinical compliance and procedural efficiency

Effects on procedural compliance

Four RCTs assessed the impact of digital devices, compared with Child Life interventions or conventional preparation, on children’s compliance during medical procedures. Overall, digital interventions appeared to provide some benefit in improving procedural cooperation, although findings were not consistent across all settings.

Three studies examined the effects of digital interventions incorporating Child Life principles on cooperation, primarily using the Induction Compliance Checklist (ICC). Wang et al. (31) evaluated a continuous animated video intervention during the preoperative waiting period and anesthesia induction in pediatric surgical patients. Children in the animated video group had significantly lower ICC scores than those in the conventional preparation group (P<0.001). Moreover, the proportion of children demonstrating perfect cooperation (ICC =0) was substantially higher in the video group (37.5%) than in the routine care group (12.5%), whereas the proportion with poor cooperation (ICC =4–10) was markedly lower (17.5% vs. 45.0%). These findings indicate that animated video accompaniment can effectively improve children’s cooperation during inhalational anesthesia induction. Matava et al. (32) compared virtual parent presence during induction of anesthesia (vPPIA), physical parent presence during induction of anesthesia (pPPIA), and Child Life intervention, administered either alone or in combination. No statistically significant differences in ICC scores were observed among groups (P=0.19). Nevertheless, the mean ICC score was lowest in the vPPIA plus Child Life group, suggesting a potential, although non-significant, benefit of this combined approach. In contrast, Canares et al. (35) found that VR combined with Child Life intervention did not significantly improve venipuncture success rates compared with standard care or Child Life intervention alone. In addition, the VR-based intervention increased the average procedure time by 4–6 minutes and was associated with a higher proportion of physical restraint use. Similarly, another study comparing VR-MRI simulation with Child Life intervention alone reported relatively low scan success rates in both groups, with completion rates of 30% in the VR-MRI group and 47% in the Child Life group (28) Neither intervention achieved an ideal clinical success rate. Further analysis showed that, in the VR-MRI group, eight children failed to complete the scan because of insufficient cooperation, accounting for 25% of failed cases in that group.

Effects on procedural efficiency

Two RCTs evaluated the impact of digital interventions incorporating Child Life principles on procedural duration and related efficiency outcomes.

Burns-Nader et al. (30) studied pediatric burn patients undergoing hydrotherapy, during which a CCLS used a tablet to provide interactive games for distraction. No significant difference was found in hydrotherapy duration between the digital intervention and conventional care groups. In another study involving preschool-aged children undergoing strabismus surgery, Wang et al. (31) provided self-selected animated videos during preoperative waiting and anesthesia induction. Compared with standard preparation, the animated video intervention did not significantly affect postoperative recovery time, the incidence of recovery room adverse events, or the overall rate of postoperative adverse events.

Effects on families and caregivers outcome

Four studies evaluated the effects of digital interventions and Child Life interventions on caregiver anxiety.

Two studies specifically examined digital interventions combined with Child Life support. Matava et al. (32) found that although the intervention did not significantly reduce children’s anxiety, postoperative anxiety scores among parents in the vPPIA group were significantly lower than those among parents in the pPPIA group. A similar pattern was observed in a study involving children undergoing tonsillectomy (29). In that study, the intervention did not significantly alter the children’s anxiety levels, but it significantly reduced caregiver anxiety (P<0.001), whereas no significant change was observed among caregivers in the standard care group.

Two additional studies directly compared VR intervention with Child Life intervention. In the venipuncture setting, caregivers in the Child Life intervention group reported the lowest scores for their perception of the child’s anxiety and distress (P=0.03), highlighting the value of professional psychosocial support in alleviating caregiver distress and in shaping parental perceptions of the child’s procedural experience (33). Caregivers in the VR group also demonstrated reduced anxiety compared with the standard care group, although no statistically significant difference was found between the VR and Child Life groups. Importantly, caregivers did not report obvious negative emotional reactions during the VR intervention. In a simulated pediatric MRI setting, VR intervention similarly reduced caregivers’ state anxiety, with effects comparable to those of conventional Child Life intervention (28).

Effects on intervention satisfaction and safety

Child satisfaction

Three studies evaluated children’s satisfaction with the intervention. In a randomized trial of pre-MRI preparation, children receiving the VR-MRI intervention reported a satisfaction score of 80/100, whereas those receiving Child Life intervention reported a higher score of 90/100. Satisfaction in both groups exceeded that of the standard manual preparation group (73.5/100) (28). In a study of needle-related procedures in a pediatric emergency department, satisfaction scores were nearly identical in the VR group and the Child Life standard care group (both 59.31 on a standardized scale), and both were significantly higher than that in the television intervention group (40.88) (34). Another study involving children undergoing tonsillectomy reported a child satisfaction score of 75.67±22.38 in the Child Life intervention group; the corresponding parent satisfaction score was 77.67±22.38 (29).

Safety and device-specific adverse effects

Only one included study examined adverse events associated with a digital intervention based on Child life principles, and no statistically significant difference in adverse reactions was found between the intervention and control groups (31).

Two studies reported device-specific adverse effects related to VR use. Dumoulin et al. (34) found no statistically significant difference in the mean severity of nausea before and after VR immersion (t=0.37), suggesting that VR-related motion sickness was mild and did not significantly worsen following the intervention. However, the authors estimated that approximately 800 participants would be required to detect a statistically significant difference (α=0.05, power =0.80), indicating that the sample size may have been insufficient to adequately assess this side effect. Another study reported that although children did not show a significant subjective increase in motion sickness symptoms before and after VR use, approximately one-quarter were unable to complete the intervention because of device-related discomfort (33).

Subgroup analysis by intervention type

The researchers also conducted subgroup analyses. These analyses further explored the comparative and combined effects of digital-device-based interventions and Child Life interventions across different intervention models.

In subgroup A, the studies compared digital-device-based interventions with Child Life interventions (28,34). These studies showed that standalone digital interventions were generally comparable to Child Life support across several pediatric outcomes. These outcomes included anxiety reduction, observable coping, fear of pain, and satisfaction. In some areas, especially during brief procedures, digital interventions showed modest advantages. These findings suggest that digital interventions may be feasible and scalable options for short-term distress management.

In subgroup B, the studies compared digital devices integrated with Child Life support against standard care (29-32). These studies showed broader and more consistent benefits. The combined interventions were linked to lower preoperative anxiety. They were also linked to fewer distress-related behaviors, lower caregiver anxiety, and better cooperation during anesthesia induction. The wider range of benefits in this subgroup, compared with subgroup A, suggests a possible synergistic effect. In other words, the combination may offer more than either approach used alone.

In subgroup C, only one study compared digital devices combined with Child Life interventions against Child Life interventions alone (33). The evidence in this subgroup was limited. However, the findings suggested that digital devices may provide added benefits when combined with Child Life support. This result offers preliminary support for an additive or synergistic effect. At the same time, it highlights the current lack of sufficient evidence for firm conclusions.

Discussion

This systematic review compared the effects of digital-device-based interventions, Child Life interventions, and their combined application during pediatric medical procedures, and synthesized the evidence across multiple domains, including psychological outcomes, physiological responses, procedural compliance and efficiency, family and caregiver outcomes, satisfaction, and safety. Overall, the findings suggest that digital devices and Child Life interventions should not be regarded as interchangeable strategies. Rather, they represent distinct but complementary approaches that differ in their level of intervention, primary targets, and mechanisms of action. Digital devices alone demonstrated independent clinical value, particularly in reducing immediate anxiety, alleviating fear of pain, improving selected behavioral responses, and increasing satisfaction. However, when digital tools were embedded within Child Life-led support processes, their function appeared to extend beyond short-term distraction toward a broader process of cognitive preparation, emotional regulation, and family support, thereby producing more consistent and multidimensional benefits. These findings suggest that, in pediatric non-pharmacological care, digital technology should not be conceptualized merely as a means of replacing human resources, but rather as a collaborative medium that can enhance the quality of psychosocial support when guided by trained professionals.

Digital devices and child life are complementary rather than competing interventions

One of the central findings of this review is that although both digital devices and Child Life interventions may improve the medical experience of pediatric patients, they appear to operate at different levels. Across procedural contexts such as venipuncture, emergency needle-related procedures, and MRI simulation, standalone digital interventions, including VR and structured video-based approaches, often produced outcomes comparable to those of conventional Child Life programs in terms of reducing anxiety, alleviating fear of pain, improving objective coping behaviors, and enhancing satisfaction. In some outcomes, digital approaches even showed a slight advantage. These findings indicate that digital devices, as immersive and sensory-engaging tools, have independent value in managing procedure-related distress.

However, comparable short-term effectiveness should not be interpreted as equivalence in function. Child Life is fundamentally a professional psychosocial care model grounded in child development theory (36,37) and family-centered care (38,39). Its core purpose is not merely to distract or calm children, but to help them understand medical experiences, reduce uncertainty and loss of control, develop developmentally appropriate coping strategies, and regulate emotional responses through family involvement and therapeutic support. By contrast, when used alone, digital devices function primarily as mediating tools whose direct effects are concentrated on attentional capture and attenuation of immediate threat cues. In other words, digital interventions mainly influence the child’s immediate procedural experience, whereas Child Life more broadly shapes how the child understands, anticipates, and integrates the overall medical event.

This distinction may help explain why digital devices improved certain short-term outcomes, such as immediate anxiety or behavioral performance, but showed inconsistent or limited effects on self-reported pain, caregiver anxiety, procedural success in complex contexts, and broader psychosocial adaptation. Pediatric procedural distress is not solely a sensory experience; rather, it is a multidimensional stress response influenced by pain, uncertainty, loss of control, family emotions, and previous medical experiences. Accordingly, treating digital devices and Child Life as homogeneous interventions may underestimate the professional value of Child Life and overestimate the independent capacity of technology in more complex pediatric settings.

Child Life-guided digital interventions are not equivalent to simply providing a child with a device

The present findings also support the need to distinguish conceptually between Child Life-guided digital interventions and the unsupervised use of digital devices. These approaches differ not only in format, but also in structure, intent, and mechanism.

The use of a device alone is essentially a form of media-based distraction. Through games, videos, or immersive VR content, children may temporarily redirect attention away from pain or fear. However, such diversion does not necessarily translate into better understanding, increased security, or more stable coping behaviors. In some children, particularly those who are very young, highly anxious, repeatedly exposed to invasive procedures, or developmentally vulnerable, standalone device use may even increase frustration or reduce perceived control if the content is poorly matched, interaction fails, sensory discomfort occurs, or the experience lacks meaningful emotional support.

By contrast, under the guidance of Child Life professionals, digital devices become part of an ongoing therapeutic process. Before use, the intervention can be tailored through an assessment of the child’s developmental stage, level of understanding, anxiety, prior traumatic experiences, and family context. During use, digital content is not delivered in isolation, but is integrated with explanation, encouragement, validation, breathing support, empowerment through choice, and real-time emotional attunement. In this setting, the device becomes a shared platform through which the professional can build joint attention and guide coping. After the procedure, the Child Life professional may help the child reflect on the experience, label emotions, and reinforce successful coping responses, thereby reducing the likelihood that distressing experiences become consolidated as negative medical memories.

Accordingly, a Child Life-guided digital intervention should not be understood as a simple combination of “device plus support”. Rather, it represents a model in which professionals transform technology into a developmentally appropriate therapeutic vehicle. This interpretation is consistent with the subgroup findings of the present review, in which combined interventions generally produced broader benefits than standard care, particularly in preoperative anxiety, procedural distress, caregiver anxiety, and cooperation during anesthesia induction.

Digital devices are not merely distraction tools; within Child Life practice, they may function as therapeutic communication media

The findings of this review suggest that the role of digital devices in pediatric care should be differentiated at two levels. At the first level, they function as distraction tools. At the second level, when embedded within Child Life practice, they may evolve into therapeutic communication media.

When used alone, the primary mechanism of interventions such as VR, tablet-based games, and animated videos is likely to involve attentional engagement. By occupying children’s limited cognitive resources with visual, auditory, and interactive input, these tools may reduce the processing of pain signals, medical equipment, and environmental threat cues (40). This mechanism is consistent with attention-gating and distraction-based models (41), and aligns with the present findings showing favorable effects of standalone digital interventions on fear of pain, some anxiety indicators, and observable coping behavior. Such a mechanism offers several practical advantages, including rapid onset, standardized delivery, and high reproducibility, making digital tools particularly suitable for short, routine, and moderately stressful procedures.

At the same time, distraction-based mechanisms have inherent limitations. They primarily reduce the child’s immediate experience of distress, but do not necessarily address deeper questions such as whether the child understands what is happening, feels safe, perceives control, or experiences relational support. This may explain why digital-only interventions showed inconsistent effects on self-reported pain and more limited effects on caregiver anxiety, emotional adjustment after procedures, and sustained cooperation during more complex interventions.

When integrated with Child Life support, the function of digital devices appears to shift qualitatively. In this context, they are no longer used simply to occupy attention, but to facilitate explanation, preparation, encouragement, emotional attunement, choice, and relational interaction. In other words, they become media for therapeutic communication. This transformation may be reflected in at least three interrelated functions. First, digital tools may enhance cognitive preparation by making abstract and potentially frightening procedures more concrete, predictable, and understandable through videos, animations, or simulations. Second, they may support emotional attunement, as Child Life professionals use shared digital content to identify and respond to anxiety, withdrawal, or fear in real time. Third, they may strengthen the child’s sense of control and agency by allowing active participation through content selection, interactive engagement, coping rehearsal, or supported parent–child involvement. These functions may help explain why combined interventions appeared to show greater benefits in outcomes that are inherently relational or systemic, including caregiver anxiety, procedural cooperation, and satisfaction.

Subgroup findings support both comparative equivalence in selected outcomes and synergistic enhancement in combined models

The subgroup analyses further clarify the dual relationship between digital devices and Child Life in terms of both comparison and synergy.

In the subgroup directly comparing digital interventions with Child Life interventions, the available evidence suggests that standalone digital devices, particularly VR-based approaches, are generally comparable to Child Life in reducing children’s anxiety, improving observable coping behaviors, reducing fear of pain, and enhancing satisfaction. In selected outcomes, digital tools even showed modest advantages. These results suggest that for brief procedural settings in which the main goal is immediate distress reduction, digital devices may offer a practical and potentially scalable alternative for short-term calming and distraction.

However, this subgroup also highlights the limits of digital interventions when used alone. Across studies, digital devices did not consistently outperform Child Life in self-reported pain intensity, procedure success, deeper psychosocial adaptation, or some caregiver-perceived outcomes. This pattern suggests that the main strengths of digital interventions may remain concentrated at the symptomatic and immediate procedural level, rather than extending reliably to broader cognitive-emotional or family-centered domains.

By contrast, in the subgroup comparing digital devices integrated with Child Life support versus standard care, combined interventions were associated with improvement across several important outcomes, including reduced preoperative anxiety, fewer distress-related behaviors, lower caregiver anxiety, and better cooperation during anesthesia induction. Notably, the magnitude and breadth of benefit in this subgroup appeared greater than the differences observed in the direct comparison between digital devices and Child Life alone. This pattern supports the interpretation that the combined model is not simply a matter of one approach replacing the other, but rather reflects synergistic enhancement. A plausible explanation is that digital devices provide immersive, engaging, and standardized sensory or informational input, whereas Child Life specialists contribute developmental assessment, emotional support, explanatory scaffolding, family integration, and coping reinforcement. Because these elements address different components of pediatric procedural distress, their combination may create a more comprehensive intervention pathway than either strategy alone.

Taken together, the subgroup findings suggest that the most appropriate relationship between digital devices and Child Life is not substitution, but tiered application, complementary use, and synergy.

Implications for pediatric non-pharmacological care: from replacement models to human-technology collaboration

An important practical implication of this review is that digital devices should not be viewed as low-cost substitutes for Child Life services. In resource-limited settings, or during brief and low-complexity procedures, standalone digital interventions may serve as feasible and efficient supplementary tools. But, in situations characterized by high stress, repeated invasive procedures, younger age, developmental vulnerability, or substantial caregiver anxiety, the key clinical question is unlikely to be whether devices should replace professionals. Rather, it is how digital tools can be used most effectively within professionally guided support.

From this perspective, the future direction of pediatric non-pharmacological care may be better framed as human-technology collaboration. In such a model, digital devices provide immersive, standardized, and highly accessible sensory and informational input, while Child Life professionals provide assessment, matching, communication, emotional regulation, family support, and experience integration. This collaborative structure may improve not only intervention efficiency, but also the developmental and relational appropriateness of pediatric care. More broadly, it aligns with the core principle that pediatric healthcare should support not only the child’s immediate symptoms, but also the child’s understanding, coping, and family experience throughout the medical encounter.

Limitations and future directions

Several limitations of this review should be acknowledged. First, the number of included studies was limited. Most studies also had relatively small sample sizes. In addition, the studies showed substantial heterogeneity. This heterogeneity involved device type, intervention intensity, procedural context, comparator conditions, and outcome measures. These differences limited direct comparison across studies. They also reduced the strength of the overall conclusions.

Second, the current evidence base mainly addresses short-term procedural outcomes. Long-term outcomes remain insufficiently studied. These outcomes include later medical avoidance, sustained coping capacity, and adaptation to repeated procedures.

Future research should prioritize adequately powered, three-arm RCTs. These trials should compare three conditions. The first condition should be digital-device interventions alone. The second condition should be Child Life interventions alone. The third condition should be digital devices integrated with Child Life interventions. This design would allow clearer separation of the independent effects of digital tools, the independent effects of Child Life support, and their potential synergistic effects.

Conclusions

In summary, this systematic review indicates that digital devices and Child Life interventions should not be understood as competing alternatives for the management of pediatric medical anxiety and pain. Rather, they represent two distinct but complementary forms of non-pharmacological support that operate at different levels and may generate synergistic effects when combined. Standalone digital devices appear to improve immediate distress and selected behavioral outcomes primarily through distraction-based mechanisms, whereas Child Life interventions address broader cognitive, emotional, and relational needs through developmentally appropriate preparation, emotional support, and family involvement. When integrated into Child Life practice, digital devices may evolve from distraction tools into therapeutic communication media, thereby producing broader benefits across multiple domains, including child anxiety, pain-related distress, procedural cooperation, caregiver anxiety, and satisfaction. These findings provide evidence-based support for a more individualized and developmentally informed integration of digital technology and Child Life services in pediatric clinical care.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.