Therapeutic play-based guidance for children with pneumonia: Impact on treatment compliance, anxiety, and fear

Abstract

BACKGROUND

Routine intervention alone is inadequate to meet the complex medical needs of children with pneumonia, and improved management approaches are urgently needed.

AIM

To analyze the effects of a therapeutic play-based guidance program on treatment compliance, anxiety, and fear in children with pneumonia.

METHODS

A total of 108 pediatric pneumonia cases who presented to Yidu Central Hospital of Weifang from July 2023 to October 2025 were selected. The control group included 50 cases who received routine intervention, whereas the research group included 58 cases who received additional intervention with a therapeutic play-based guidance program. Comparative assessments were conducted for treatment compliance, anxiety (Screen for Child Anxiety-Related Emotional Disorders), fear (Child Medical Fear Scale), symptom recovery (cough, expectoration, wheezing, and fever), pulmonary function; forced expiratory volume, forced expiratory volume; vital capacity, vital capacity; maximal voluntary ventilation, maximal voluntary ventilation; peak expiratory flow, and parental satisfaction.

RESULTS

The research group performed better than the control group across all assessed domains, with statistically higher treatment compliance rates, better pulmonary function indices, superior overall parental satisfaction, lower Screen for Child Anxiety-Related Emotional Disorders and Child Medical Fear Scale scores, and accelerated symptom resolution.

CONCLUSION

The results demonstrate the effectiveness of the therapeutic play-based guidance program in enhancing treatment compliance among pediatric pneumonia patients and mitigating anxiety and fear.

Key Words: Therapeutic play-based guidance program; Pneumonia; Treatment compliance; Anxiety; Fear

Core Tip: This retrospective study clarified the effects of a therapeutic play-based guidance program on treatment compliance, anxiety, and fear in children with pneumonia. The analyses showed that therapeutic play-based guidance, combined with routine intervention, produced better clinical outcomes than routine intervention alone. This approach improved treatment compliance and overall parental satisfaction, reduced negative emotions, promoted symptom recovery, and enhanced lung function.

INTRODUCTION

Pneumonia, one of the most common and serious bacterial infections in children, accounts for 69% of pediatric admissions[1]. More than 40 million cases of early childhood respiratory infection, including pneumonia, are reported annually, with 650 thousand associated deaths[2]. Etiologically, pneumonia is related to complex interactions between susceptible populations and environmental factors, such as breastfeeding, improper ventilation, traffic pollution, and tobacco smoke[3]. Pediatric pneumonia is typically characterized by cough, expectoration, wheezing, fever, weight loss, and fatigue. Progression to aphagia, inability to drink, hypothermia, unconsciousness, convulsions, anoxia, and similar manifestations may lead to life-threatening severe pneumonia[4,5]. The disease can cause physical dysfunction in children and various psychological effects, including anxiety and fear related to the illness and treatment, as well as compromised treatment compliance[6,7]. Pediatric pneumonia can be managed with pharmacotherapy, nebulizer inhalation, and intravenous infusion therapy. However, because children have immature psychophysiological development and suboptimal treatment compliance, the therapeutic effect may not be maximized[8]. Current standard intervention includes condition assessment, comfortable ward arrangement, symptomatic treatment according to medical advice, communication with parents about disease progression, instruction on daily diet and precautions during treatment, and related measures. It provides only basic medical and daily care and lacks intervention strategies targeting treatment resistance, anxiety, and fear[9]. The therapeutic play-based guidance program is a new management model that integrates pleasure into learning. By designing targeted evidence-based games, this approach can help children develop correct cognition, alleviate medical anxiety and fear, and enhance adaptability and treatment compliance[10]. Interactive video games have also been shown to help alleviate pain and anxiety in pediatric patients undergoing surgery, with high procedural acceptability and satisfaction[11].

At present, little is known about how the therapeutic play-based guidance program influences treatment compliance, anxiety, and fear in children with pneumonia. This study, therefore, conducted relevant analyses to further optimize the management of pediatric pneumonia.

MATERIALS AND METHODS

General information

This study selected 108 pediatric pneumonia cases who presented to the Yidu Central Hospital of Weifang, from July 2023 to October 2025. A total of 50 cases in the control group received routine intervention, and 58 cases in the research group received additional intervention with the therapeutic play-based guidance program. The two groups were generally balanced and clinically comparable (P > 0.05).

Case selection criteria

Eligible cases met all of the following criteria: A pneumonia diagnosis based on lung computed tomography and blood tests[12]; cough, expectoration, wheezing, fever, and other symptoms with fixed moist rales; age of 8-12 years; stable disease; basic language communication and comprehension skills; and complete clinical data.

Cases were excluded if they met any of the following criteria: Presence of a foreign body in the airway; congenital bronchial dysplasia, wheezing, or coagulation/immune dysfunction; visual or hearing impairment; poor parental cooperation; severe or refractory pneumonia; liver, kidney, heart, or other organ dysfunction; or malignant tumors. Figure 1 presents the specific patient screening process.

Figure 1  Flowchart of patient screening.

Treatment methods

After admission, children in both groups received antipyretic treatment, sputum aspiration, anti-infection therapy, and inhalation of budesonide suspension for nebulization (twice daily for 1 week). Ibuprofen suspension (5-10 mg/kg, administered at intervals of ≥ 6 hours) or acetaminophen (10-15 mg/kg, administered at intervals of ≥ 4 hours) was administered as needed when body temperature was ≥ 38.5 °C for antipyretic therapy. Sputum aspiration was performed in accordance with operation standards for pediatric pneumonia, with negative pressure maintained at 80-120 mmHg and each session lasting less than 15 seconds. For anti-infection therapy, antibacterial drugs were selected according to pathogenic results and susceptibility tests. Amoxicillin (90 mg/kg/day, administered orally or intravenously in two or three divided doses) was the first choice for empirical treatment, and macrolide antibiotics (e.g., azithromycin at 10 mg/kg/day for 5-7 days) were indicated for patients who were allergic to penicillin or suspected of having atypical pathogens. Routine intervention was provided to the control group, including condition evaluation, comfortable ward arrangement, symptomatic treatment according to medical advice, communication with parents about condition progression, reminders about daily diet and precautions during treatment, and introduction of the accompanying care system and ward environment. The control group received the same frequency of inpatient visits and parent communication as the research group, twice daily for 20 minutes to 30 minutes each time, to control the potential effect of total interaction time on the study results.

In addition to the aforementioned routine intervention, the research group received the therapeutic play-based guidance program, as follows: (1) Organization and venue preparation: A pediatric pneumonia therapeutic play group was established to develop the intervention plan. A therapeutic play-specific room was set up to reduce children’s unfamiliarity with the environment. The room was spacious and quiet, decorated with lively elements such as cartoon illustrations and decorations, equipped with children’s books and toys, and maintained at an appropriate temperature and humidity; (2) Therapeutic play-based guidance implementation: The intervention was implemented twice daily (morning and afternoon) for 20-30 minutes per session until discharge. All operations were carried out according to the Standardized Operating Manual for Medical Coaching Games, and the intervention team was supervised weekly to ensure intervention consistency. Adaptive intervention (within 24 hours of admission): Through game tasks such as “Looking for the Stethoscope”, the children were helped to become familiar with the medical environment and equipment, thereby reducing unfamiliarity and anxiety. Education and cognitive intervention: After admission, the children’s and parents’ awareness of pneumonia, psychological states, and cooperation levels were evaluated through one-on-one communication. In addition, medical processes, such as identification of relevant body parts, intravenous injection, and physical examination, were explained in child-friendly language using the “Hospital Little Warrior Game Pack”. Virtual rehearsal and scenario simulation: Within 24 hours before the invasive procedure, a PICO4 VR headset (Hainan Chuangjian Future Technology Co., Ltd., China) was used to play customized VR scenes simulating venipuncture and nebulizer inhalation procedures, with each session lasting 5-8 minutes. One trained doctor was present to provide guidance and explanation. Within 30 minutes after VR training, the children were organized to play role-playing games with their parents (e.g., the child played the role of medical staff and the parents played patients), in which pulmonary function (PF) exercises, nebulizer therapy, venipuncture, and other procedures were simulated. The game lasted approximately 30 minutes each time and was conducted on the first and third days of admission. Cooperation and encouragement: A multiplayer cooperative game, such as the “Lung Cleaning Team”, was designed to encourage children and their parents to complete PF exercises once daily for approximately 20 minutes each time. Toys, cards, and other rewards were given to children who actively participated in or answered questions correctly, along with verbal encouragement to improve cooperation; and (3) Family engagement: Parents were encouraged to accompany their children in watching popular science cartoons and participating in game interactions to promote children’s emotional support and treatment compliance.

Detection indicators

Treatment compliance: Treatment compliance was categorized as follows: Complete compliance[13], when the child took medicine according to medical advice and voluntarily cooperated with clinical interventions and procedures, with essentially no crying or fussing; large compliance, when mild resistance was present but could be soothed, allowing clinical interventions and procedures to be completed successfully; partial compliance, when the child showed obvious resistance but was able to complete some clinical interventions and procedures after soothing; and non-compliance, when clinical interventions and procedures were difficult to complete. Total treatment compliance = (complete compliance + large compliance + partial compliance)/total cases.

Emotional status: Anxiety and fear were assessed using the Screen for Child Anxiety-Related Emotional Disorders (SCARED) and the Child Medical Fear Scale (CMFS), respectively[14,15]. Three domains of the five-domain SCARED tool were assessed, including somatic panic, general anxiety, and separation anxiety, with a total of 30 items scored using a three-level scoring method (0-2 points/item; score range: 0-60). The score was positively correlated with anxiety severity. Cronbach’s alpha for the simplified SCARED scale is 0.876, indicating good reliability and validity. The CMFS consists of 17 items scored on a 1- to 3-point scale, yielding a total score of 17-51. Higher scores indicate greater fear. Cronbach’s alpha for the CMFS is 0.871, indicating good reliability and validity.

Time to symptom recovery: The time to resolution of cough, expectoration, wheezing, and fever after treatment was observed and recorded.

PF: Before and after the intervention, forced expiratory volume, vital capacity, maximal voluntary ventilation, and peak expiratory flow were measured with a PF tester. During the test, a uniformly trained respiratory therapist instructed the children to sit, seal the mouthpiece between the lips, and clamp the nose clip. After three repeatable flow-volume curves were obtained (a < 5% difference between the two largest values), the optimal value was used for analysis. The postintervention assessment was performed at discharge, when the children were in the non-acute infection stage, and the completion and accuracy of PF detection would not be affected by factors such as cough reflex, respiratory inflammation, or forced exhalation-induced airway spasms.

Parental satisfaction: Parental satisfaction was surveyed using a self-designed satisfaction questionnaire from the perspectives of intervention methods, service attitudes, and intervention outcomes[16]. Parents scored satisfaction, with higher scores indicating greater satisfaction (very satisfied, ≥ 90; satisfied, 75-90; dissatisfied, < 75).

Statistical analysis

Data were analyzed using SPSS 24.0. Measurement data that deviated from a normal distribution are represented as the median (interquartile range), with between-group differences evaluated using Mann-Whitney U tests. Otherwise, data are presented as the mean ± SD, with t-tests used for between-group comparisons and paired t-tests used for pre- vs post-treatment assessments. Categorical data are presented as the n (%), and between-group comparisons were performed using χ² tests. Statistical significance was established at P < 0.05.

RESULTS

Comparative evaluation of general data between the two groups

The evaluation (Table 1) showed well-balanced distributions of age, sex, disease duration, type of pneumonia, illness severity, and parental education across the groups (P > 0.05).

Table 1 Comparative analysis of baseline data, n (%)/median (interquartile range).

Data	Control group (n = 50)	Research group (n = 58)	χ2/Z	P value
Age (years)	10.00 (9.00, 11.00)	10.00 (8.75, 10.00)	-1.534	0.125
Sex			0.197	0.657
Male	22 (44.00)	28 (48.28)
Female	28 (56.00)	30 (51.72)
Disease duration (day)	4.00 (3.00, 5.00)	3.00 (2.00, 4.25)	-1.918	0.055
Type of pneumonia			1.257	0.533
Interstitial pneumonia	15 (30.00)	20 (34.48)
Bronchopneumonia	19 (38.00)	25 (43.10)
Lobar pneumonia	16 (32.00)	13 (22.41)
Disease severity			0.172	0.678
Mild	23 (46.00)	29 (50.00)
Moderate	27 (54.00)	29 (50.00)
Parents’ educational background			0.149	0.700
Below senior high school	24 (48.00)	30 (51.72)
Senior high school or above	26 (52.00)	28 (48.28)

Treatment compliance comparison

The evaluation shown in Table 2 revealed that the numbers of completely, largely, partially, and non-compliant cases in the control group were 15, 14, 13, and 8, respectively, compared with 23, 23, 10, and 2 in the research group. Fisher’s exact test indicated a significantly higher treatment compliance rate in the research group than in the control group (96.55% vs 84.00%, P = 0.042).

Table 2 Comparative treatment compliance evaluation, n (%).

Treatment compliance	Control group (n = 50)	Research group (n = 58)	P value
Completely compliant	15 (30.00)	23 (39.66)
Largely compliant	14 (28.00)	23 (39.66)
Partially compliant	13 (26.00)	10 (17.24)
Non-compliant	8 (16.00)	2 (3.45)
Treatment compliance	42 (84.00)	56 (96.55)	0.042

Anxiety and fear assessments

The groups showed similar baseline SCARED and CMFS scores (P > 0.05). Both scores decreased significantly after the intervention in both cohorts (P < 0.05), with greater reductions in the research group (P < 0.05; Figure 2).

Figure 2 Comparative anxiety and fear evaluations. A: Screen for Child Anxiety-Related Emotional Disorders-based anxiety assessment across groups; B: Child Medical Fear Scale-based fear assessment across groups. ^aP < 0.05, ^bP < 0.01 vs baseline; ^cP < 0.05 vs control. SCARED: Screen for Child Anxiety-Related Emotional Disorders; CMFS: Child Medical Fear Scale.

Comparison of symptom recovery

The assessment (Figure 3) showed accelerated resolution of cough, expectoration, wheezing, and fever in the research group compared with the control group (P < 0.05).

Figure 3 Comparative assessment of symptom resolution. A: Time to cough resolution across the research and control groups; B: Time to expectoration resolution across groups; C: Time to wheezing resolution across groups; D: Time to fever resolution across the study groups. ^aP < 0.05 vs control.

Comparative PF evaluation

As shown in Figure 4, baseline forced expiratory volume, vital capacity, maximal voluntary ventilation, and peak expiratory flow were comparable between the groups (P > 0.05). All PF parameters increased significantly after the intervention in both cohorts (P < 0.05), with more pronounced increases in the research group (P < 0.05).

Figure 4 Comparative pulmonary function evaluation. A: Forced expiratory volume levels across the research and control groups; B: Vital capacity levels across groups; C: Maximal voluntary ventilation levels in both cohorts; D: Peak expiratory flow levels across the research and control groups. ^aP < 0.05, ^bP < 0.01 vs baseline; ^cP < 0.05 vs control. FEV: Forced expiratory volume; VC: Vital capacity; MVV: Maximal voluntary ventilation; PEF: Peak expiratory flow.

Comparative parental satisfaction assessment

The numbers of cases in the control group who were highly satisfied, satisfied, and dissatisfied were 17, 21, and 12, respectively, with corresponding numbers of 29, 24, and 5 in the research group (Table 3). The χ² test showed significantly higher total satisfaction in the research group than in the control group (91.38% vs 76.00%, P = 0.029).

Table 3 Comparative evaluation of parental satisfaction, n (%).

Parental satisfaction	Control group (n = 50)	Research group (n = 58)	χ2	P value
Very satisfied	17 (34.00)	29 (50.00)
Satisfied	21 (42.00)	24 (41.38)
Dissatisfied	12 (24.00)	5 (8.62)
Overall satisfaction	38 (76.00)	53 (91.38)	4.789	0.029

DISCUSSION

Previous researchers have also explored efforts to optimize pediatric pneumonia management based on routine intervention. Yu et al[17] reported that targeted sedation and comprehensive care for children with severe pneumonia can prevent adverse reactions, relieve pain and discomfort, and improve sedation. In another study by Khoury et al[18], medical clown intervention for children with pneumonia has been reported to significantly reduce respiratory and heart rates as well as leukocyte and absolute neutrophil counts compared to routine intervention, while helping shorten hospital stays and reducing the need for intravenous antibiotics. There is also evidence that oral pentoxifylline in combination with standard antibiotics and supportive treatment for pediatric community-acquired pneumonia is advantageous over the standard treatment regimen in ameliorating clinical conditions, inhibiting systemic inflammatory responses, and reducing imaging lesions[19].

This study comparatively evaluated whether the therapeutic play-based guidance program combined with routine intervention outperformed routine intervention alone in terms of treatment compliance, anxiety, and fear among pediatric pneumonia cases. First, we observed a significant improvement in treatment compliance under the play-based guidance intervention, with the compliance rate increasing to 96.55%. This may be attributed to the creation of a comfortable and relaxed environment; the design of diverse, child-friendly games; parental engagement; and appropriate verbal encouragement. Together, these elements lowered the psychological threshold of children and improved their adaptability, thereby effectively improving treatment compliance[15]. Further SCARED- and CMFS-based evaluations showed that the therapeutic play-based guidance program effectively reduced anxiety and fear in children with pneumonia. Games such as “Looking for the Stethoscope”, “Hospital Little Warrior Game Pack”, and “Lung Cleaning Team”, designed under the play-based guidance intervention, helped increase children’s awareness of the disease and treatment process, enhanced their sense of control over the disease, and thus helped mitigate anxiety and fear. Luo et al[20] reported that 2D game intervention in pediatric surgery patients can reduce perioperative anxiety and increase treatment compliance, supporting our observations.

Regarding symptom recovery, the therapeutic play-based guidance program plus routine intervention effectively shortened the time to cough, expectoration, wheezing, and fever resolution in children with pneumonia. This may be because the therapeutic play-based guidance program can reduce children’s unfamiliarity with and fear of the medical environment through adaptive intervention and a child-friendly environment, thereby alleviating psychological stress. This, in turn, helps improve homeostasis and accelerate symptom relief. In addition, improved treatment compliance under the therapeutic play-based guidance program helped maximize the therapeutic effect and promote rapid recovery. Regarding PF, we observed greater PF enhancement under the therapeutic play-based guidance intervention. This may be related to the children gradually developing an understanding of the treatment process through therapeutic play-based guidance, which reduced medical fear and anxiety about the unknown and significantly enhanced acceptance of treatment. Moreover, higher treatment compliance helped ensure improvement in PF. Finally, therapeutic play-based guidance led to higher total parental satisfaction. This can be partly explained by the high-quality medical services received by children in the research group during the intervention, which was directly reflected in increased cooperation and reduced anxiety and fear. Meanwhile, parents’ sense of participation and control was enhanced, improving their recognition of this intervention model. Hüzmeli et al[21] reported that applying therapeutic play to pediatric oncology patients not only helps alleviate fear and anxiety about chemotherapy but also improves parental satisfaction, echoing our findings.

CONCLUSION

Therapeutic play-based guidance added to routine intervention provides significant clinical advantages in treating children with pneumonia. It significantly improves treatment compliance and overall parental satisfaction, attenuates anxiety and fear, promotes symptom recovery, and improves PF. These results provide evidence for better clinical management of pediatric pneumonia.