Structured game and parental education on postoperative pain and anxiety in children with appendicitis

Abstract

BACKGROUND

Acute appendicitis is a common surgical emergency in children. Postoperative pain and anxiety are prevalent among pediatric patients, and parents often experience significant negative emotions during the perioperative period.

AIM

To explore the effect of structured game intervention combined with parental empowerment education model on postoperative pain control and anxiety levels in children undergoing appendicitis surgery.

METHODS

Sixty children with appendicitis who underwent surgical treatment in Shijiazhuang Maternal and Child Health Hospital Department of Pediatric Surgery from February 2022 to February 2025 were prospectively selected for the study. According to the lottery method, the children were randomly divided into the control group (30 people, with standardized care) and the observation group (30 people, with structured game intervention combined with parent empowerment education). The clinical indicators, anxiety, depression, pain within 72 hours after the intervention, postoperative psychological trauma and the occurrence of complications of the two groups of children were compared. The psychological state and nursing satisfaction of the parents of the two groups of children after the intervention were also compared.

RESULTS

After the intervention, the intestinal peristalsis time, feeding time, getting out of bed time, frequency of pain-relieving drug use and hospital stay, modified Yale Perioperative Anxiety Scale score (27.63 ± 1.17) points, Children’s Depression Inventory score (6.42 ± 2.40) points, Face, Legs, Activity, Cry, Consolability scores at 12 hours, 24 hours, 48 hours and 72 hours after surgery, postoperative crying (3.33%), and irritability (6.6) of the children in the observation group. The incidences of 7%, night terrors and insomnia (3.33%), and complications (3.33%) were all significantly lower than those in the control group, P < 0.05; the Hamilton Anxiety Scale score (16.29 ± 4.17) points and Hamilton Depression Rating Scale score (9.13 ± 1.74) points of the parents of the children in the observation group were significantly lower than those in the control group, and the total satisfaction with nursing (96.67%) was significantly higher than that in the control group, P < 0.05.

CONCLUSION

The structured game intervention combined with parent empowerment education model can enhance the postoperative rehabilitation effect of children patients, alleviate their anxiety and pain conditions, reduce the incidence of postoperative psychological trauma and complications, and simultaneously improve the negative emotions of parents and increase their satisfaction.

Key Words: Structured games; Parental empowerment education; Children; Appendicitis; Postoperative pain; Anxiety

Core Tip: This study pioneers a dual-strategy model that combines structured, theme-based games with practical parental coaching for children after appendectomy. This approach actively engages both child and parent in recovery, going beyond routine nursing. Results show it shortens hospital stays, reduces painkiller use, eases children’s emotional distress, and lowers caregiver anxiety. The model provides a practical, family-centered blueprint to improve pediatric surgical outcomes and overall care satisfaction.

INTRODUCTION

Cute appendicitis is the most common cause of acute abdominal pain. Clinical data surveys show that among children who visit the emergency department for acute abdominal pain, approximately 1%-8% are diagnosed with acute appendicitis[1]. The treatment primarily involves surgery. According to statistics, over 70000 children undergo appendectomy each year[2]. However, as this surgery requires general anesthesia and is associated with significant postoperative pain, it can easily lead to anxiety and related complications in children[3]. Research[4] indicates that among children experiencing pain, approximately 19.1% suffer from anxiety and 14.3% from depression. Furthermore, in a clinical trial on pediatric appendicitis conducted by Ferreira et al[5], it was found that up to 80% of parents experience considerable anxiety before their child’s elective surgery. Therefore, exploring an intervention model that can effectively control postoperative pain in children while simultaneously alleviating anxiety in both children and their parents is an important direction in current pediatric perioperative care.

Structured play intervention is an organized and planned form of nursing intervention. It is typically conducted in a predefined setting, with clear themes, fixed start and end times, and timely prompts and assistance provided as needed for the child[6]. Bawaeda et al[7], through a randomized controlled trial, found that during nebulization therapy, structured play intervention combined with standard care effectively reduced children’s anxiety levels compared to the control group, indicating that play intervention can effectively manage children’s anxiety. Parent empowerment education refers to providing parents with disease-related knowledge and skills in a simple and understandable way, thereby reducing their negative emotions, increasing their confidence in disease management, and ultimately improving the treatment outcomes for their children[8]. Dardouri et al[9], in a study involving 77 families, found that compared to the control group, parent empowerment intervention significantly improved the quality of life score for both asthmatic children and their parents. Additionally, the forced vital capacity of children in this group was significantly better. This demonstrates that parent empowerment education has positive effects on the treatment and recovery of pediatric diseases.

However, existing studies tend to focus on single outcome measures and have not sufficiently explored the combined effects of these two approaches on children’s pain and anxiety. Based on this, the present study aims to investigate the impact of combining structured play intervention with parent empowerment education on postoperative pain control and anxiety levels in children with appendicitis, providing new insights for the postoperative care of children with appendicitis.

MATERIALS AND METHODS

General information

A total of 60 pediatric appendicitis patients who underwent surgical treatment in the Shijiazhuang Maternal and Child Health Hospital Department of Pediatric Surgery from February 2022 to February 2025 were prospectively selected for this study. Using the lottery method, the patients were randomly divided into a control group (n = 30) receiving routine care and an observation group (n = 30) receiving structured play intervention combined with parent empowerment education.

Inclusion criteria: (1) Diagnosed with appendicitis according to relevant criteria[10] and showing unsatisfactory outcomes after conservative treatment; (2) Aged between 5 and 14 years; (3) Meeting the indications for laparoscopic surgical treatment; (4) Parents’ educational level at primary school or above; and (5) Legal guardians of the patients provided informed consent and signed the consent form.

Exclusion criteria: (1) Presence of mechanical intestinal obstruction; (2) Abnormalities in heart, lung, or other organ functions, or coagulation disorders; (3) History of previous laparotomy; (4) Presence of severe septic shock; and (5) Presence of language or hearing impairments, making it impossible to cooperate with assessments. Comparison of general data, such as gender and age, between the two groups showed a foundation for subsequent research (P > 0.05), as shown in Table 1. This study has been approved by the hospital’s ethics committee.

Table 1 Comparison of general information between two groups, n (%)/mean ± SD.

Indicator		Observation group (n = 30)	Control group (n = 30)	t/χ2	P value
Gender	Male	18 (60.00)	19 (63.33)	0.071	0.500
	Female	12 (40.00)	11 (36.67)
Average age (year)		8.33 ± 3.59	8.47 ± 3.44	0.147	0.884
Average weight (kg)		34.23 ± 16.52	34.50 ± 15.41	0.065	0.949
Average disease duration (day)		3.93 ± 0.45	4.07 ± 0.52	1.061	0.293
Pathological type	Simple appendicitis	7 (23.33)	8 (26.67)	0.101	1.000
	Purulent appendicitis	15 (50.00)	14 (46.67)
	Gangrenous appendicitis	8 (26.67)	8 (26.67)

Method

Control group: Received routine care. This included analgesic administration as prescribed by the doctor, monitoring of vital signs, guidance on activity and diet, routine verbal health education, as well as answering parents’ questions and providing routine psychological support.

Observation group: The structured play intervention combined with parent empowerment education model was implemented. The specific protocol is as follows: (1) From admission to before surgery: The research nurse conducted an initial empowerment interview with the child’s family, lasting approximately 20-30 minutes. This assessed the parent’s anxiety levels and information needs, and distributed the Family Care Empowerment Handbook for Pediatric Post-Appendectomy. Skills Rehearsal (approximately 15 minutes): The research nurse taught the parents how to use the Wong-Baker FACES Pain Rating Scale to assess their child’s pain, and taught them how to guide the child in deep breathing using “pinwheel blowing” or “bubble blowing” games; and (2) Within 24 hours postoperatively: (a) Bedside empowerment reinforcement (6-12 hours post-op, approx. 15 minutes): Guided parents to: Provide gentle massage in non-incision areas to soothe the child. Use calm, affirmative language when communicating with the child; (b) Teach parents to recognize early signs of anxiety in the child. Initiate structured play (first session within 24 hours post-op, approximately 20 minutes): The research nurse showed the child “bravery badge” stickers. Guided the child and parent to play the “pinwheel blowing” or “bubble blowing” game together. After each successful deep breath, the parent placed a “bravery badge” sticker on the child; (c) From postoperative day 2 until discharge: Daily structured play (once daily, 25-30 minutes each): In the ward play area or at the bedside, using a specially designed doll with a detachable appendix and band-aids, the research nurse demonstrated “the bad appendix being removed by the doctor, and the tummy slowly healing”. The child and parent were encouraged to put a band-aid on the doll’s “wound” together. Setting short-distance goals (e.g., from bed to chair, to the door) as “treasure hunt points”. Parents assisted and encouraged the child to complete getting out of bed and walking. Upon reaching the point, the child received a sticker or small card. Providing paper and colored pencils, inviting the child to draw “how I feel now” or “what the wound looks like”. The research nurse and parents used the drawings to guide the child in expressing emotions and provided positive interpretations; (d) Parent participation and feedback: After each daily play session, the research nurse had a brief exchange with the parents (approximately 5 minutes) to provide feedback on the child’s performance during play, answer questions, and encourage parents to repeat simple play elements during non-intervention times; and (e) The day before discharge: The research team conducted a family rehabilitation empowerment meeting, lasting approximately 20-30 minutes: Reviewed the child’s recovery progress and acknowledged the joint efforts of the parents and child. Developed a simple family rehabilitation play plan, suggesting daily 10-15 minutes parent-child play sessions after returning home. Clarified warning symptoms requiring a return to the hospital.

Observation indicators

Clinical indicators: Observe the intestinal peristalsis time, feeding time, getting out of bed time, frequency of analgesic drug use, and length of hospital stay of the patient during hospitalization.

Emotional state of children: The modified Yale Perioperative Anxiety Scale (mYPAS)[11] was used to assess anxiety levels. It consists of 27 items divided into five categories: Activity, emotional expressiveness, state of apparent arousal, vocalization, and use of parents. Scores range from 23.3 to 100, with higher scores indicating higher anxiety levels. The Children’s Depression Inventory (CDI)[12] was used to assess depression. The scale consists of 27 items, with total scores ranging from 0 to 54. A total score > 15 indicates the presence of depression, with higher scores indicating more severe depressive symptoms.

Pain level in children: The Face, Legs, Activity, Cry, Consolability (FLACC) scale[13] was used to assess the pain levels of the children at 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours postoperatively. It includes five categories: Facial expression, leg movement, activity, cry, and consolability. Each category is scored from 0 to 2 based on observed behaviors. The total score ranges from 0 (no pain) to 10 (worst possible pain).

Psychological trauma in children: Psychological trauma in children during hospitalization was observed, including crying/fussiness, irritability, and night terrors/insomnia.

Emotional state of parents: The Hamilton Anxiety Scale (HAMA)[14] was used to assess the anxiety levels of the children’s parents before and after the intervention. A score < 7 indicates no anxiety, ≥ 14 indicates definite anxiety, ≥ 21 suggests significant anxiety, and ≥ 29 indicates severe anxiety. Scores range from 0 to 56, with higher scores indicating greater anxiety severity. The 17-item Hamilton Depression Rating Scale (HAMD)[15] was used to assess the severity of depressive symptoms in the parents. It consists of 17 items, including mood, sleep, appetite, guilt, libido, and loss of interest, each scored on a scale of 0 to 4. Total scores range from 0 to 52, with higher scores indicating more severe depression.

Parental satisfaction with care: A nursing satisfaction questionnaire developed by Shijiazhuang Maternal and Child Health Hospital Department of Pediatric Surgery was used to survey parental satisfaction with care. It consists of 20 items, with a total score of 100. A score ≥ 85 indicates “very satisfied”, 60-85 indicates “satisfied”, and < 60 indicates “dissatisfied”.

Incidence of complications in children: The occurrence of postoperative complications in children during hospitalization was observed, including incision infection, gastrointestinal reactions, intestinal adhesions, etc.

Statistical analysis

Using SPSS27.0 software for data analysis, all metric data that conforms to normal distribution are represented in the form of (mean ± SD), and t-test is used for data comparison; count data is expressed as n (%), and comparison between groups is performed using the χ² test. P < 0.05 indicates statistically significant differences.

RESULTS

Comparison of clinical indicators between two groups of pediatric patients

The results showed that the observation group had significantly lower intestinal peristalsis time (18.68 ± 1.43 hours vs 32.12 ± 2.21 hours), feeding time (15.52 ± 1.51 hours vs 24.42 ± 1.45 hours), getting out of bed time (32.13 ± 2.54 hours vs 42.35 ± 3.42 hours), frequency of analgesic drug use (3.43 ± 0.31 times vs 5.18 ± 0.45 times), and hospital stay (6.94 ± 0.62 days vs 8.13 ± 1.51 days) compared to the control group, P < 0.05 (Figure 1).

Figure 1 Comparison of clinical indicators between two groups of pediatric patients. ^aP < 0.05. A: Two groups of intestinal peristalsis, feeding, and getting out of bed time; B: Number of times painkillers are used; C: Hospitalization time.

Comparison of emotional states between two groups of children

After intervention, the mYPAS score (27.63 ± 1.17) and CDI score (6.42 ± 2.40) of the observation group were significantly lower than those of the control group (34.88 ± 1.86) and (8.97 ± 3.94), respectively, P < 0.05 (Figure 2).

Figure 2 Comparison of emotional states between two groups of children. ^aP < 0.05. A: Modified Yale Perioperative Anxiety Scale score; B: Children’s Depression Inventory score. mYPAS: Modified Yale Perioperative Anxiety Scale; CDI: Children’s Depression Inventory.

Comparison of psychological trauma between two groups of children

The results showed that the incidence of crying (3.33%), irritability (6.67%), and insomnia (3.33%) during hospitalization in the observation group was significantly lower than that in the control group (30.00%, 26.67%, 26.67%), with P < 0.05 (Figure 3).

Figure 3 Comparison of psychological trauma between two groups of children. A: Crying and fussing; B: Easy to provoke; C: Night startle and insomnia.

Comparison of pain conditions between two groups of children

The FLACC scores of the observation group were significantly lower than those of the control group at 12 hours (3.72 ± 0.67 hours vs 4.37 ± 0.62 hours), 24 hours (3.13 ± 0.37 hours vs 4.03 ± 0.58 hours), 48 hours (2.54 ± 0.26 hours vs 3.37 ± 0.45 hours), and 72 hours (1.69 ± 0.28 hours vs 2.58 ± 0.33 hours) postoperatively, P < 0.05 (Table 2).

Table 2 Comparison of pain levels between two groups of children, mean ± SD.

Group	Countdown	FLACC rating
		6 hours after surgery	12 hours after surgery	24 hours after surgery	48 hours after surgery	72 hours after surgery
Observation group	30	2.60 ± 0.62	3.13 ± 0.35	3.13 ± 0.35	2.54 ± 0.26	1.69 ± 0.28
Control group	30	2.79 ± 0.41	4.37 ± 0.62	4.03 ± 0.58	3.37 ± 0.45	2.58 ± 0.33
t value		1.377	9.523	7.240	8.781	11.343
P value		0.174	0.000	0.000	0.000	0.000

FLACC: Face, legs, activity, cry, consolability.

Comparison of emotional states between parents of two groups of children

After intervention, the HAMA score (16.29 ± 4.17) and HAMD score (9.13 ± 1.74) of parents of children in the observation group were significantly lower than those in the control group (23.83 ± 5.20) and (14.12 ± 2.57), respectively, P < 0.05 (Table 3).

Table 3 Comparison of emotional states of parents of two groups of children, mean ± SD.

Group	Countdown	HAMA rating		HAMD rating
		Pre-intervention	Post-intervention	Pre-intervention	Post-intervention
Observation group	30	23.27 ± 5.12	11.27 ± 3.17	21.63 ± 5.39	9.13 ± 1.74
Control group	30	24.70 ± 5.31	17.83 ± 5.20	21.33 ± 5.62	14.10 ± 2.56
t value		1.064	5.905	0.211	8.784
P value		0.292	0.000	0.834	0.000

HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Rating Scale.

Comparison of parental satisfaction with nursing care between two groups of pediatric patients

After intervention, the overall satisfaction rate of nursing care among parents of the observation group (96.67%) was significantly higher than that of the control group (73.33%), with P < 0.05 (Table 4).

Table 4 Comparison of parental satisfaction with nursing care between two groups of pediatric patients, n (%).

Group	Countdown	Nursing satisfaction			Overall satisfied
		Very satisfied	Fairly satisfied	Dissatisfied
Observation group	30	16 (53.33)	13 (43.33)	1 (3.33)	29 (96.67)
Control group	30	11 (36.67)	11 (36.67)	8 (26.67)	22 (73.33)
χ2					6.405
P value					0.026

Comparison of complications between two groups of children

After intervention, the total incidence of postoperative complications in the observation group (3.33%) was significantly lower than that in the control group (26.67%), with P < 0.05 (Table 5).

Table 5 Comparison of complications between two groups of children, n (%).

Group	Countdown	Incision infection	Gastrointestinal reactions	Intestinal adhesions	Overall incidence rate
Observation group	30	0 (0.00)	1 (3.33)	0 (0.00)	1 (3.33)
Control group	30	2 (6.67)	4 (13.33)	2 (6.67)	8 (26.67)
χ2					6.405
P value					0.026

DISCUSSION

Appendicitis is a common inflammatory disease in surgical practice, characterized by rapid onset and acute progression. It has a higher incidence among children, and laparoscopic appendectomy is the primary treatment. However, this approach can cause significant stress to pediatric patients and exacerbate postoperative pain. Additionally, due to limited knowledge about the procedure among both children and their families, postoperative anxiety and other negative emotions are common, severely impacting recovery. Based on this, the current study combined structured play intervention with parent empowerment education to implement interventions for pediatric patients undergoing appendectomy, demonstrating favorable outcomes.

In this study, the clinical indicators of children in the observation group were significantly lower than those in the control group, indicating that the combined model of structured play intervention and parent empowerment education can enhance the clinical efficacy of pediatric patients. The reason for this is that the research nurse designed “treasure hunt” games with short-distance goals, such as moving from the bed to a chair or to the door, and provided rewards upon completion. This encouraged the children to actively engage in regular out-of-bed activities, thereby improving gastrointestinal motility and directly accelerating the recovery of their gastrointestinal function[16]. Additionally, during the intervention, parents were invited to encourage and assist their children in completing fun games, and to repeat simple games in daily activities. This ensured the continuous implementation of the children’s rehabilitation plan, thereby promoting their overall recovery. These findings are consistent with the research results of Carbó et al[17].

In this study, the mYPAS scores, depression scores, and proportion of psychological trauma cases in the observation group were significantly lower than those in the control group. This indicates that the combined model of structured play intervention and parent empowerment education is effective in alleviating negative emotions in pediatric patients. The main reasons for this are twofold: On one hand, game activities such as the “broken appendix doll” demonstration and “wound drawing” transform the abstract and unfamiliar medical process into a concrete, visible, and controllable experience through playful engagement. Children transition from being “passive recipients” to becoming “active participants” in the games”. This provides them with a new perspective on the medical environment and helps them gain knowledge about their condition and treatment, thereby reducing anxiety stemming from the unknown. Additionally, structured games like “blowing bubbles” and “treasure hunt adventures” require children to focus their attention and complete specific tasks to earn rewards. This effectively shifts their focus away from wound pain to engaging activities, directly alleviating their anxiety. On the other hand, research nurses participating in the games alongside the children help build trust more quickly. The games encourage children to express their fears and concerns more naturally, enabling nurses to better understand their psychological needs[18] and subsequently address their negative emotions. An experimental study by Ayan et al[19] found that implementing a therapeutic play training program for children undergoing surgery significantly reduced their preoperative and postoperative anxiety levels, further supporting the findings of this study. Furthermore, a scoping review by Mathias et al[20] indicated that children with higher preoperative anxiety levels tend to experience greater postoperative pain, delayed recovery, and an increased risk of complications. In this study, it was observed that the FLACC scores of children in the observation group showed more significant improvement from 12 hours to 72 hours postoperatively compared to the control group. This suggests that the combined model of structured play intervention and parent empowerment education can effectively manage children’s pain. The reasons for this are as follows: Fun activities such as “spinning the pinwheel”, “blowing bubbles”, and “treasure hunts” require children’s full engagement, shifting their focus from pain to the game itself. This actively distracts them from the sensation of pain and discomfort, reducing their sensitivity to pain signals[21]. Simultaneously, the pleasurable stimulation from the games activates the prefrontal cortex, nucleus accumbens, and amygdala in the child’s brain. This, in turn, triggers the descending pain inhibitory pathway involving the periaqueductal gray matter and ventrolateral medulla, stimulating the release of β-endorphins, enkephalins, and endocannabinoids in the spinal cord. These substances block the transmission of pain impulses at the presynaptic space, thereby inhibiting the relay of pain signals through the spinothalamic tract. As a result, this intervention reduces pain perception both psychologically and physiologically[22-24]. Moreover, after educating parents on correctly using pain scales, performing gentle touch on non-incision areas, and guiding deep breathing exercises for pain relief, parents were able to provide timely intervention during the early stages of the child’s pain. This ensured stable analgesic effects from medication. Additionally, parents offered 24-hour pain management support in the absence of nurses, providing children with a sense of security and preventing exacerbation of pain due to helplessness and tension[25]. Lee et al[26] also demonstrated in their research that empowerment education enhances parents’ understanding of pain and encourages them to take responsibility for pain management, which aligns with the findings of this study.

This study also found that after the intervention, the HAMA and HAMD scores of the parents in the observation group were significantly lower than those in the control group, indicating that the combined model of structured play intervention and parent empowerment education also improved the emotional state of the parents. The reasons for this are likely twofold. First, under the combined model, nurses conducted empowerment interviews, skills rehearsals, and daily feedback sessions with the parents. This transformed the parents’ anxieties about postoperative care into predictable and manageable situations. By teaching them skills such as assessing their child’s pain, identifying signs of anxiety, and providing non-pharmacological comfort, parents were empowered to proactively address their child’s needs. This directly reduced the anxiety and depression stemming from uncertainty about the surgery and concern for their child[27]. Second, after receiving empowerment education, parents were able to participate in the games alongside their children. This allowed them to directly observe positive feedback, such as their child’s pain expressions easing and their emotions becoming more stable. This alleviated the psychological stress parents experienced due to their child’s postoperative suffering, thereby reducing their levels of negative emotions. Furthermore, previous studies have also demonstrated that parental anxiety levels are closely related to their child’s anxiety levels[28]. Additionally, the study revealed that after the intervention, the satisfaction of the parents in the observation group was significantly higher than that in the control group. Moreover, the incidence of postoperative complications in children in the observation group was significantly lower. This demonstrates that the combined model of structured play intervention and parent empowerment education is more effective in improving pediatric treatment outcomes and nursing efficacy.

In conclusion, the combined model of structured play intervention and parent empowerment education can enhance postoperative recovery in children, alleviate their anxiety and pain, reduce the incidence of postoperative psychological trauma and complications, while simultaneously improving the negative emotions of parents and increasing their satisfaction. However, this study still has certain limitations: First, this study is a single-center, small-sample study, which limits the generalizability of the results. Second, the lottery method used for randomization has poor allocation concealment. Third, the nature of the intervention in this study made complete blinding impossible, which may introduce measurement bias. Fourth, we only observed short-term outcomes during hospitalization and lacked long-term follow-up. Fifth, we did not perform subgroup analyses on individual differences. Future research should be based on multicenter, large-sample, and rigorously randomized controlled designs, with extended follow-up and expanded age range, to further evaluate the clinical value of this model.

CONCLUSION

In summary, the structured play intervention combined with the parental empowerment education model can effectively promote postoperative recovery in children undergoing appendicitis surgery, alleviate their anxiety and pain levels, reduce the incidence of postoperative psychological trauma and complications, while simultaneously improving parents’ negative emotions and increasing their nursing satisfaction. This model organically integrates play therapy with parental education, providing a feasible, effective, and easily disseminable non-pharmacological intervention strategy for perioperative nursing care in pediatric surgery.