Emergence of path-breaking and smart health technologies in

paediatric field
Key words Paediatric surgery, play therapy, smart technologies
Abstract
One of the important challenges today for paediatric health service providers is to engage
children with activities and therapies, while allowing medical interventions to be carried out
smoothly on them. Hospitalized children often feel loss of freedom, which increases the need for
emotional containment and hence it is important to design therapies, which can distract them and
dissuade them about medical interventions being carried out on them. Different interventions
including play therapies, therapies involving music art and animals, also the recent ones
supported by technologies are increasingly being used in the health arena to calm childrens
anxieties and fears prior to medical procedures. The face of pediatric surgery today is changing
and with childrens wards in hospital being transformed into colorful and vibrant places with
active playrooms, access to computers, movies, and games.
The research paper discusses the challenges that paediatric surgery and other medical
intervention pose on children, including anxiety and trauma, as well as the reasons as to why
they exist amongst children. It focuses on the impact of such stressful experiences of
hospitalization on children pre and post surgical procedures.
The kernel of the paper aims to explore some of the technological as well as non-technological
platforms, whichcanbeusedbypediatricianstoallayanxietyandfearofmedicalintervention
amongstchildren.Thepaperalsointendstofocusonnovelideasforstartups,whichcanusea
combinationofthemedimages,lightandsoundtobuildinterventionsthatcancomfortyoung
patientspriortomedicalinterventions.

Prologue
Surgery presents unique challenges for children as well as adults. Children who are usually
accustomed to daily routines liking going to school, day care, hobby or recreational classes feel
restricted to alter their behavior for medical or surgical procedures. Their inability to change their
behavior leads to a state of anxiety, when confronted with new experiences, such as identification
bracelets, getting blood pressure checked, funny smells of cleaning products, new sounds,
scratchy hospital gowns, meeting hospital staff and separation from known caregivers. The idea
of hospitalization and surgery can be an emotionally threatening and psychologically
traumatizing experience, especially for children (Li HC, 2003 ). (Lingnell & Dunn, 1999)
Hospitalized children often feel loss of freedom, perceived actual, which increases the need for
emotional containment and processing. Apart from that hospitalization also raises the potential
for unresolved anxiety, which produces long-term psychological trauma. Traumas presence in
children can be observed behaviorally, emotionally, and may also be indicated through
psychological symptoms such as nervousness, aggression, anger, guilt, pain and rage (Lerwick,
2013).
Health care providers understand that anxiety is a common concern not only for children but also
for their parents, who undergo the scalpel, for life saving procedures. Moreover parental anxiety
as well criticism can also lead to increased distress in children (DeMaso & Snell, 2013).
Research also indicates that parental concern or anxiety can often lead to dissatisfaction towards
the hospital staff or the doctors, as to how their child is treated and can make them even more
worried about the outcome pertaining to the surgical or medical event (Hilton, 2014). Excessive
parental attention to a child's distress through too much reassurance, excessive empathy, or
apologies has also been associated with increased emotional and behavioral distress in the child
and thee is also available evidence that the inverse is true i.e. calm parental presence can help
children to cope during a medical procedure and is often appreciated by children (Cohen, Blount,
& Cohen, 1999).
Several pre-surgery psychosocial interventions can assist to cope in the medical settings;
although the thought of surgery and hospitalization does tend to create some level of distress and
disruption even amongst most mature children
A number of protocols exist to reduce the effects of anxiety prior to surgical procedures,
including education about upcoming procedures, a tour of the hospital and operating room, a
review of picture books about the experience, and video introductions. Science alert, which
publishes path-breaking discoveries, has found that anxiety in children can be alleviated to a
great extent through distraction, which includes clown doctors, hypnotherapy, low sensory
stimulation and hand-held video games. Pediatricians today are keen to use these techniques, to
ease anxiety amongst children who undergo life saving surgeries, face medical scans, and other
procedures.

Rationale - Stress of hospitalization and transforming environments in

hospitals
Several researchers have identified the idea of stressful experiences on children, and they define
that, such experiences as any painful procedure involving needles, or requiring shots as a not so
pleasant experience by children (Bossert, 1994) (Coyne, 2006) (Lindeke, Nakai, & Johnson,
2006) (Melnyk, 2000). Apart from that other stressful experience also include not knowing what
to expect in the hospital, having activity restrictions and decreased independence, missing
school, and being separated from family and friends (Wilson, Megel, Enenbach, & Carlson,
2010)
Literature review indicates that children have the tendency to be negatively affected by different
stressors prior to surgical procedures. Stressors that impact children include to heightened
anxiety levels, as well as potential psychological trauma if not appropriately treated (Foley,
Higdon, & White, 2006). Research estimates that prevalence of medical anxiety is as high as 7%
in the pediatric population, and estimates of behavior management problems range from 9% to
11% (Rackley & Bostwick, 2013).
Researchers documenting the outcomes of post hospitalization procedures have indicated the
presence of regression, separation anxiety, sleep disturbances, and emotions such as sadness and
apathy. Sadly, some of these outcomes can persist for months or years, particularly in children
with repeated or lengthy hospital stays.
Hospitals and health care centers going forward must re-examine as to what their staff know as
supposed to what they think they know so as to effectively meet the needs of hospitalized
children. Adverse effects of surgery persist to test the skills of doctors, nurses as well as health
care providers and definitely call upon researchers, organization to address the issues in the area.
The trauma and the anxiety that children undergo before surgery as well as during hospitalization
is an important aspect that needs to be taken into account, for improving the experience of
children before they undergo the scalpel or are admitted in hospitals for chronic diseases.
Hospital environments have witnessed positive changes with the increasing complexity of
medical and surgical procedures. For instance medical problems, which require fewer
observations or can be resolved without surgeries, are now undertaken in the outpatient setting.
In-patient admissions are reserved for children experiencing severe or chronic illnesses and often
involving surgical procedures and repeated hospitalizations.
Hospitalization experience has been altered considerably in the last two decades with several
interventions being undertaken to improve hospital environments for children. The face of
pediatric surgery today is changing and with childrens wards in hospital being transformed into
colorful and vibrant places with active play rooms, access to computers, movies, and games, and
special therapies such as pet and music therapy. Apart from the ambience of the hospitals, the
staff stationed at the hospitals also attends to the psychosocial as well as the physical needs of the
children (Hasenfuss & Franceschi, 2003)

Understanding stress and anxiety levels through play therapies and modern
day technologies
Environmentsandmethodswhichsuccessfullyengageandaninvolvechildrenprovetobeuseful
forelicitingachildsfeelingsandthushelpsthemtoexpresstheirproblemsinabetterwaywhen
theyfacechronicillness.Invitingchildrentoexpresstheirexperiencesandfeelingsthroughplay
fashionsanemotionaldistancethatprovidesasafetybarriertoprotectthemfromfeeling
overwhelmed(Lerwick,2013).Curtin(2001)outlinedseveraltechniques,whichinclude
drawing,storytelling,acting,writinginadiary,explainingavideotapeormovie,andtalking
throughadollortoytelephone.Withthepassageoftimeandthechangeintechnologyhospitals
arenowprovidingimmersiveexperiencestochildren,andtherebyprovidingstrongdistractions
tosharetheirfeelingsandemotionspriortosurgicalormedicalprocedures.
Forinstanceoneofthetraditionalmethodstogaugechildrensfeelingsencompassedof
projectivetechniquessuchasstorytelling,whichhasbeenusedsincethe1940stoobtain
informationthatmightbedifficulttoobtainthroughstandardinterviewingormedicalprocedures
(Poster,1989).Outcomesofprojectivetechniquesarebelievedtoprovideprovideinsightsinto
thechildsinneremotions,perceptions,andfears(Bellack&Fleming,1996).Oneoftheother
thematicappreciativetest,istheBartonHospitalPictureTest(BHPT)whichcomprisesofeight
drawingsofspecifichospitalsituationswhichinclude(admissiontohospital,separationfrom
parents,beingexaminedbydoctor,beingaloneinhospitalroom,receivingoralmedication,
receivinganinjection,beingintheoperatingroom,andbeingintheplayroom).Childrens
responsesarerecordedaftershowingthemthepicturestoframestoriesandgeneratetexts,onthe
basisofwhichtheirstresslevelsaremeasured.
Oneoftheothermethods,whichaddresstheissueofemotionalcontainmentinchildren,isChild
CenteredPlayTherapy(CCPTthatfocusessolelyonthechildpatient.CCPTisauniqueformof
childtherapyfocusingonthechildratherthantheproblemandthepresentratherthanthepast
(Landreth,2002).Feelingsarecapitalizedoverthoughtsoractsandunderstandingmattersmore
thanexplanation(Landreth,2002).Itaimstoreducebehavioralissuesbyofferingdirectedplay
activitiesandthusencouragingexpression,control,andautonomyduringhospitalization.Play
therapyreducesbehavioralissuesbygivingthechildaplaceoffreedom,control,andautonomy
duringhospitalizationtherebysupportingchildrenemotionallyintheirtimeofchaos,fear,and
pain.Theideabehindplaytherapyistoincreaseinterestandinvolvementfromchildrenand
allowchildrentogaincourageandselfconfidencebyreducinganxietyandexpressingtheir
fears.
Withtheadvancementintechnologyandtheadventofnewgadgets,pediatriciansare
increasinglyexperimentingwiththeconceptofscreentimetodistractkidsandminimizetheir
emotionslikeanxiety,painandthefearoftraumapriortoundergoingmedicalprocedures.
Piecemealeffortsbyvariouspediatrichospitalsarediscoveringthroughindependentstudiesand
personalexperiencethatelectronicgamesandotherentertainmenttechnologyarehelping
childrenduringtoughtimesofmedicalinterventions.Researcherstoanextenthaveconcluded

thatwhenchildrenareinvolvedwithactivedistraction,likeplayingavideogamethrough
distinctapps,theirpaintoleranceincreased(Ondash,2013).

Smart health platforms to mitigate anxiety and fear in children

Researchershavefocusedonageappropriateplaytherapiestoassistchildrenduringthecourse
ofhospitalizationtoreducestress,psychologicaltrauma,anxiety,andbehavioralissues
(Lerwick,2013)(Potasz,DeVarela,DeCarvalho,&DoPrado,2013).However,expertsaftera
systematicreviewofstudiesindicatethattheflipsideofplaytherapiesisthatitcanmake
youngerchildrenmoreanxious(Hilton,2014).Thepaperdiscussesafewmoderndaytherapies
thatmitigateanxietyandfearinchildrenbeforepresurgicalormedicalinterventions
Distractionrooms
Hospitalstodayusedistractionrooms,whichcomprisetheuseoflight,soundandimage
technologyaswellasotherinterventions,priortoprocedureslikeComputedTomography(CT)
scans,magneticresonanceimaging(MRI),andnuclearmedicineprocedures.Someofthe
evolvingmodelswithtransformationsinhospitalambienceincludeprojectiontechniques,music,
softenedlightsintheroom,andceilingswithdiscoballs.Forinstancemanyhospitalshaveeven
swappedtheirwhitewallsforamuralwithanunderwaterscenesothatkidscouldexperience
enteringtheCTscannerasiftheywereembarkingonavoyageunderthesea.
Distractionroomsalsoaredesignedonvariousthemes,suchasspacethemes,whichsensitize
childrenbeforetheyundergoMRIscans.Childrenputoncinemagoggles,asiftheyaregoingto
watchamovieinthespace.Theyareevenprovidedwithheadphones,whichcancelthenoiseof
theMRI,andthusthemedroomsactasgreatsimulatorsandenablechildrentogetsensitized
withthescanningroomprocedures(Hilton,2014).
Artmusicandpetsasstressbusters
Hospitalshavealsostartedengagingkiddistractionexperts,whoengageinartandmusicand
oftenworkwiththehospitalsoccupationalandphysicaltherapists.Suchatherapyhelps
childrenescapetheanxietyandartallowsthemtoimmerseinselfexpression.
Researchtodayisalsobeingundertakentoseehowpettherapyspecificallyimpactschildren
anxietyaboutthingssuchaspain.Youngchildrenareprovidedthesupportofcaninesfor
distractionsandcomfort.Forinstanceresearcherstodayareconductingtrialswherechildren
childrenwithcerebralpalsyreceivepettherapybefore,during,andafterBotoxinjectionsto
relaxtheirspasms,whichreducespainrelatedtomusclerigidity.
AnestheticsApp
Oneofthemostcommonissuesfacedbypediatricianspriortosurgeries,isthelossoftheatre
timewhileattemptingtosedatechildren.Physicianshavebeenreportedtospendmorethan20
minutes(sometimesoveranhour)whiletryingtopreparechildrenforsurgeryorothermedical
procedure.
ArecentappcalledRelax,whichwontheAcornChallenge,reducesthepreparationtime

considerably.Theonscreenappcombinedwithtablettechnologyisveryeffectiveinrelaxing
anddistractingchildrenwhilebeinganesthetised.Theappisdesignedforchildrenbetweenages
216anditmakesuseofmusic,artandgamestodistractandrelaxchildrenbygatheringthe
basicinformationofthepatientincludingage,genderandlevelofstress.Italsofacilitateseasy
usage,asthetabletcanbewipedafterusagewithstandardinfectionwipestopreventcross
infectionorthedevisecanalsobeusedinclearplasticbag,ifchildrenaretreatedinisolation.
Theoveralladvantageoftheonscreenappisthatitreducestheamountsofanaestheticgivento
childrenpriortosurgery,leadingtoaspeedierrecovery.Secondlyitalsoleadstosavingin
theatrecosts1asthehospitalcanoptforintravenousmethods,foranaestheticadministration
ratherthangasinhalation,whichisamoreexpensivemethod.
Onscreengamingconsoleswithanestheticadministrationandmonitoringsystems
Amedicalgadgetbuiltuplikeaheadsetconnectedtoagamingconsoleorportabledigitalmusic
calledPedistate,isassistingpediatriciansinagreatway.Thedeviceisdesignedtodistract
children,andprovidesthemfunwhilekeepingthemengagedandhencehelpingthemstaycalm
andcomfortableduringtheprocessofbeingsedatedpriortoasurgeryoranyothermedical
procedure.Thegadgetalsocomprisesofapulseoximeterwithintheheadsetmonitors
oxygenationandacapnometer,whichmonitorssecondtosecondrespiratoryrate.Theanesthetic
isthendeliveredviathesnorkel.Thegadgetcanbeusedmorethanonceeachday,and
comprisesofanestheticadministrationaswellasthemonitoringsystem.
Wearabledisplays
OneofthedisruptivestartupsbasedoutofBoston,DesigncontinuumInc.hasbeguntopilota
combinationanesthesiamaskandheadsetthatwouldallowpatientstoplayvideogamesorlisten
tomusic.Thispieceofhardwareproduceshighquality,miniatureLCDdisplaysandenables
childrentoview2Dand3Dcontentasiftheywerewatchingahighdefinition,widescreen
televisionfromsixfeetaway.Thetechnology,whichisyetinatrialphase,promisestomitigate
thetraumainchildrenpriortosurgeryprocedures,whichincludetheperiloflongterm
psychologicalproblems,includingnightmares,bedwettingandfearofbeingalone.Thegadget
ensurescomfortability,customizabilityandanunobtrusivedesignduetoitshumancentre
design.
SensoryRoverDistractionUnits(SRDUnits)
Sensoryroverdistractionunitsareamobileunitdesignedspecificallyforchildrentoprovide
sensorysimulationanditsimulatesthesensestouch,smell,hearingandvisual.Theportable
deviceincludesabubbletube,along,flexiblefiberopticstrandsthatchangecolors,aprojector
thatshootsanimageontothewallorceilingandastereotoplaymusic.SRDunitsfacilitateto
divertchildrensmindfromcomplicatedmedicalprocedures,astheyusuallywrapthemselvesup
withthefibreopticstrand,oralsousuallyimmersedintoimagesthatareprojectedonthewalls
orceilingsandhenceareunawareoftheeventsaroundtheirsurroundings.MoreovertheSRD
unitscanalsobemodifiedtoseetherequirementsofpatientswithdisabilities,disorder
1Costofanasethetisingchildrenintravenouslyat5ischeaper,thangasinhalation,whichamountsto13per
child.

conditions,braininjuries,chronicpain,autismandalsothoseininpalliativecare.

Experimentationbytechnologydisruptivestartupswith imagerytechniquescombining
soundandlight
Recentresearchonpatientwellbeingoutlinesfourstrategicpillarsforbuildinganambient
experiencewithimages,soundandlight,forpresurgicalormedicalinterventions.
Firstlycomfortcontributingtowardsthewellbeingofthechildpatient;second,maximizing
interactionbetweenpatient,staffandlovedones;thirdly,childrenneedtobegivenasenseof
controlovertheirenvironmentandexperience;andfinallyenablingasmoothworkflowamongst
thehospitalstaffthroughefficiencyandeffectiveness.Disruptivestartupstodayareexploring
someinterventionsonthebelowideaswiththedistinctformsofimagerycombinedwith
melodiousjinglesandrhythmiclights.
Themedanimatedimagery
Oneofthewaystoreduceanxietyamongstchildrenisthroughtheusageofanimatedimageryby
creatinganimmersivemultisensorialexperience.Theideawouldbetointroducechildrentoa
setofthemedimages,withastorylinewrappedinanimatedformtocreateanambient
experience.Anonscreenappcanproduceasetofprojectedthemes,coupledwithcalming
soundsandaccompanyingthematicimages,tograbtheattentionofthechildrentogivethema
senseofrelaxedambience.Ifthechildrenneedtobeengagedforalongerduration,thanan
optionalupdateprogramcanallowthestafftomakechangestothethematiclibrary.Thedistinct
themescanbebuiltintotheappanddownloadedintothedevice,andthusgivesmorefreedomof
choicetothechildpatient,incaseiftheyfeeldisengagedordistractedbythesurgicalprocedures
goingaround.
MattePaintingImagingtechnique
MattePaintingimagingtechniqueswhichcombinestwoormoreimagesintoasingleimagefile
arealsobeingconsideredassuitableplatformsofdistractionsforchildren.Oncetheimagesare
blendedtheseblendedimagescanbefusedwithrhythmiclight/soundtoproduceapowerful
simulationusingthechromakeyingtechnique.
Therhythmiclight/soundcombinationwillhaveapowerfuleffectonmoodandemotionsof
children.Thisimagerytechniquecanbeusedforseveralpurposesincludingreducingstress,
promotingdeepsleepandassistinginachievingcalmandmeditativestates.
Creatinganimmersiveexperiencethroughemotiveimages
Childrenareinterestedtoexplorenewthings,learnnewwordsandalsocurioustoexploretheir
emotions;andimagesareapowerfulsourcetoelicitanemotionalresponse.Thepowerofan

imagecaninspire,informandentertainandexploreavarietyofemotionsinchildren.
Forinstance,aninterestingAppcalledAvokiddoEmotions 2whichtriestoexploreavarietyof
emotionsandtheirrelationshipswiththestimuli.Theappcomprisesofthreeanimals;agiraffe,
zebra,andsheep.Randompropsfallingonthescreendistractchildrenandengagetheminthe
game.Thesepropswouldincludehats,meals,drinks,musicalinstruments,andtoysandchildren
candragthesepropstoaselectedanimal,andviewtheirreactions.
Accessoriesfallingonthescreenmayalsocausetheapptodisplayathemedbackground.For
example,ifchildrenputonabeaniewinterhat,thebackgroundwilltransformintocablecars
flying ina snowcovered mountain withJingle Bells music plays in theinthebackground.
Childrencantryfeedinganimalswithvariousfruits,vegetables,candies,andmeatsandwatch
animalsreactdifferentlytothedistinctmeals.
Suchanimaginativecombinationofanimalcharacters,propsandmusiccanbeasoothingrelief
tochildrenandimmersiveexperiencessuchasthese,canfacilitateeasysedativeprocedureson
childrenpriortolifesavingsurgeries.
PhysicalSimulatoryimagesandpuzzles
Startupsuptodayarealsoexperimentingwithphysicalsimulatorapps,whichusesimulation
images toenablechildrentoview thewaydifferentobjectsareaffectedbydistinctstimuli.
Childrenareattractedtowardsdynamicalsimulationsandhencetheyarecuriostoknowmore
abouttheimageryandwillbeengagedintheprocessofexploringsuchimagery.
Thevideogamesindustryexploitsthiskindofimagerytocaptureattentionspanofchildrenand
keepthemengagedinthegames.Imageryintheformofpuzzlescanalsodistractchildrentoa
greatextentandreducetheiranxietiestoagreatextent.
Conclusion
Itisimperativethatpediatrichospitalscultivateastrongdoctorpatientrelationship,andthisis
possibleonlywhenmedicalinstitutionsunderstandthedifferentdevelopmentalstagesof
childrenanddesigninterventionsaccordingly.Anapp,whichmightthrillateenager,mightbeof
leastinteresttochildrenbetweentheages5to10.Familiesofchildpatientalsoneedtobetaken
intoconfidencebyfacilitatingtheirparticipationintheconsultationroomandbyaddressingtheir
fearsaboutsurgery,bybuildingtheirtrustandrapport.
Theideaofcontrollingchildrensanxietyinhospitalsettingisofgreatimportanceasstrategies
toreducetheiranxietycanhavebigimpactsonchildrensexperiences,qualityofcare,and
healthcarecosts.Screentherapy,playtherapy,hypnotherapy,lowsensorystimulationhandheld
videogames,tablets,guidedimagerycanhelpinreducingstress,psychologicaltrauma,anxiety,
andbehavioralissues.
Creatingkidcentricenvironmentsnotonlyattractspatientsbutalsohasthepotentialtodraw
2https://vimeo.com/99036696

highqualitypediatriciansassuchenvironmentsdonottendtofrightenchildren,whichmakesa
hugedifferencetopeoplewhoworkaroundchildren.