Journal of

1. Introduction
The prevalence of cardiovascular and circulatory diseases is increasing worldwide accounting for 48% of all deaths. Heart disease is a serious problem for children because children are more prone to heart diseases. Diagnosis is fast and accurate treatment with medication or surgery will help children have a normal life. The number of children with heart defects undergoing cardiac catheterization has increased. Pediatric heart catheterization is a life-threatening and dangerous procedure. More than 260000 heart angiographies are performed annually in Iran [1, 2]. This danger worries parents and relatives and they are stressed and afraid that the child will be in danger. Patients not only suffer from anxiety due to the aggressive nature of this procedure but also have pain and discomfort for several hours after the operation. Most diagnostic tests are aggressive for patients with anxiety. In addition to diagnostic tests, hospitalization creates different levels of anxiety. Lack of patient familiarity with coronary angiography is one of the main causes of anxiety. This lack of information leads to over-stimulation of their nervous system [3].
Nurses have an important role in helping medical practices and achieving the goals and quality of patients’ safety. Despite the growing trend of work over the past few decades that defines the roles and value of nursing, the limited information that describes the impact of nurses on health care outcomes in specialized treatment areas such as radiology is still limited [4]. Nurses need to create an environment that minimizes stress. Nurses in intensive care units such as coronary angiography laboratories should balance the potential benefits of reducing anxiety with the potential side effects of sedatives such as drugs and benzodiazepines, and discover alternative, cheaper, and more effective ways to reduce patients’ anxiety. Various methods have been used to reduce patients’ anxiety before coronary angiography. The use of anti-anxiety drugs and nursing care is not always done and patients’ perception of anxiety is not reduced [5]. Additional non-pharmacological interventions are needed to reduce children’s stress and anxiety, but there are few articles in this area since most studies have focused on adult patients.
2. Materials and Methods
Elsevier, Scientific Information Database (SID), Magiran, Scopus, PubMed, and Google Scholar databases were searched using keywords such as coronary angiography, nonpharmacological interventions, nursing interventions, pediatric, infant, children, and complementary therapies during 1984-2021. The main inclusion criteria were all studies conducted on children aged Birth to 22 years [6], cases studied by children or their mothers who underwent angiography or cardiac catheterization. The exclusion criteria were studies conducted on patients who were not in the mentioned age range. After studying the full texts of the articles by 1 researcher, based on the inclusion and exclusion criteria, appropriate articles were included in the study as shown in Figure 1. All selected articles were discussed by 2 researchers, and then the final articles were selected by the agreement between these researchers. Research questions were reviewed for answers in the two sections: [1] What nursing care is there for children undergoing angiography? and [2] What is the role of nurses in reducing stress in children under angiography and what effective interventions they can implement?
The initial search revealed 60 studies that were reviewed for eligibility by 2 researchers in terms of relevancy and quality. Eventually, 12 studies were included in the narrative review. The quality of the studies was examined based on the critical appraisal checklist for articles. In this study, the checklist presented by Downs and Black [7] was used for critical appraisal of the studies. The final studies were reviewed by 2 researchers. Then, the name of the author, year of the study, country, sample size, study design, type of intervention, anxiety measuring instrument, and overall study results were extracted using a standard form.
3. Results
From 60 studies in the initial search, 12 studies were maintained. The articles were collected in English, except for two articles, which were done in Thai due to the small number of articles in this field. These two articles were translated into English and studied. Publications included in the review are listed and described in Table 1 which provides a descriptive snapshot of the methods, findings, and participant groups.
Before performing any process, the conditions of the family and the child should be evaluated, including the amount of growth and development, the speed of dealing with the stressful conditions created, previous experiences, especially undesirable ones from the hospital, and cultural and spiritual factors to supply the most effective intervention for them. Understanding the stages of cognitive development in children is a key to understanding children’s perceptions of health-related events and information-processing abilities. Previous hospital experiences play a crucial role in determining child and adolescent responses to invasive medical procedures, particularly when those experiences are perceived negatively. Studies suggest that naive children demonstrate decreased anxiety after viewing hospital-relevant audiovisual materials, whereas children with previous hospital experiences may have increased levels of tension or remain unaffected [10, 12, 13]. Nurses can also play a role in the recovery and treatment of children under angiography with effective intervention [14-19] (Table 2).
Research regarding the efficacy of procedure preparation generally indicates that outcomes are enhanced by [1] active participation by children and family members/caregivers; [2] personal interaction with health professionals (compared with only watching a videotape or reading a pamphlet); [3] developmentally appropriate timing and content; and [4] comprehensive stress management programs that provide information, supportive counseling, and coping skills training. Issues about intensity, rehearsal, reinforcement, and timing require further investigation. In younger children (age 3 to 5 years), anxiety levels are managed most effectively with preparation the night before surgery, whereas older children (aged 5-12 y) respond optimally when the knowledge is presented 1 week before surgery. Pre-procedure interventions attempted within 24 hours of surgery may very well increase school-age children’s anxiety levels. When only limited preparation time is out there, refocusing techniques or distraction could also be more practical than other methods [20-22].
Information is provided by a range of methods including [1] verbal discussions with the physician, nurse, child life specialist, and other health care team members; [2] videotapes of hospitalization or procedure; [3] written information or picture books; [4] preoperative classes; [5] hospital tours; [6] structured-play sessions or puppet shows; and/or [7] via computer/Internet. It is important to recollect that informatics is stricken by multiple factors including anxiety as well as developmental/cognitive level; thus, ongoing validation of the child’s and parents’ understanding is required. Verbal information should be simple, realistic, and honest. When communicating with children, it is necessary to supply concrete information using child-sensitive language and avoid words that will be threatening or misinterpreted [10, 23-26].
The play could be a primary kind of communication for kids and provides a good method for the presentation and exploration of medical concepts while permitting insight into the child’s understanding of matters and level of coping. Play may be spontaneous or recreational, expressive, or therapeutic. The spontaneous or recreational play could be a play activity within which the kids choose the things and activities that can distract them from stressful circumstances. Expressive play provides a method for the expression of feelings, the discharge of energy, and relaxation. Medical play combines spontaneous and therapeutic play to organize children for medical or nursing procedures through the employment of hospital-related props like syringes, masks, and dolls with intravenous lines, incisions, and chest tubes. This stuff is used to convey information and provide children with opportunities for hands-on learning. During the play session, concrete simple explanations are offered, and misperceptions are corrected. Medical play employing a beloved doll or stuffed animal often works well, because it allows the kid to be in the very position of control as the doctor or nurse playing or acting accordingly [19, 21, 24].

Medical play sessions offer a perfect opportunity for assessment of children’s current level of coping, medical information, and areas of misperceptions. The rising popularity of video games has seen a recent push towards the application of significant games, that is, video game-based technologies to teaching and learning, medical education, and training. Besides the popularity of the utilization of virtual simulation, serious gaming, and immersive technologies in medical education from an instructor-trainee point of view, they can also have an excellent impact on patient education, and more specifically, improve the patient’s experience and awareness [26, 27]. Also, by imitating fictional characters that are defined to adapt children to stressful situations, they can confront reality and influence their stress. This imitation of real-world processes is widely used for the practice of skills, problem-solving, and decision-making that mirrors real-world situations and environments [28].
Children may perceive increased control over their environment by being given a choice of their favorite music tapes, compact disks, and available relaxation tapes. Music can be the voice of a mother or father singing a story or lullaby to their child. Comprehensive coping skills training is effective in children undergoing cardiac catheterization [24]. However, no program has been developed for the adaptation of children under angiography in Iran, and nurses do not use programs such as play therapy, music therapy, etc. in their interventions.
4. Discussion
Children under angiography and their families need education. Silvio Simeone et al. stated that educating parents before surgery about expectations before, during, and after a child’s heart surgery may improve parental knowledge and satisfaction and reduce anxiety. If the child feels pain, it may make the child move their legs and it may negatively affect their quality of life as well. Relieving the pain and distracting the child to keep the leg still may reduce the risk of hemorrhage. To relieve the pain of the child after angiography, non-pharmacological methods are used as well as pharmacological methods. These are distraction methods such as listening to music, art therapy, therapeutic touch, drawing pictures, reading books, and playing games. A game is the most important occupation of a child where the child participates and enjoys taking part. A game enables the child to define fears and worries without words and have fun. Therefore, it becomes easy for the child to cope with stressful situations. Farsi et al. stated that both methods of peer education and orientation tours decreased the anxiety levels in patients undergoing coronary artery angiography. Therefore, these approaches should be carried out according to the hospital’s condition and facilities [26].
Post-angiography children who play digital games have decreased pain levels and mobility states [25]. Smelling the scent of lavender significantly reduced anxiety and pain in our patients, before and after coronary angiography [3]. This method can be used to reduce pain and stress in infants and soothe the baby with the smell of breast milk. As Sajjadi et al. showed, olfactory stimulation with breast milk has a positive effect on reducing neonatal pain during hepatitis B vaccination [27]. A telephone-based orientation program could be used when patients are waiting to have the procedure as a strategy for reducing anxiety in patients undergoing coronary angiography [28]. Listening to music for 20 minutes before coronary artery angiography was reportedly effective in reducing the patients’ anxiety scores. This rapid systematic review revealed that complementary therapies, such as music therapy, reflexology, Benson’s relaxation technique, aromatherapy, guided imagery, and yoga could be used as effective interventions separately or in conjunction with nursing interventions for reducing the level of anxiety among the patients undergoing coronary artery angiography [29].
Nick Farjam et al. stated that nursing consultation and guided imagery interventions reduced the stress and anxiety of adult patients undergoing angiography. In future studies, these techniques can be employed by nurses, depending on their ease of use and conditions to reduce stress and anxiety in pediatric angiography [30]. Relaxation and guided imagery have been shown to impact the autonomic nervous system. Ball et al. stated that the use of relaxation along with guided imagery is an effective and safe treatment for childhood recurrent abdominal pain [31] Vagnoli et al. expressed children undergoing minor surgery received the relaxation-guided imagery before the induction of general anesthesia, which reduces preoperative anxiety and postoperative pain in children [32]. In an integrative review, Marcia Felix et al. stated that the knowledge synthesis resulting from this review indicates that evidence could be identified on the use of guided imagery associated with relaxation therapy for postoperative pain management [33]. This evidence, however, suggests that the quality of using this therapy is limited. The acknowledged benefits of guided imagery associated with relaxation therapy as a complementary approach to drug analgesia in postoperative pain control strengthen its indication for nursing practice [33]. Although information education using a comic book did not affect anxiety in these children, nurses should find another way to provide information to reduce their anxiety [25]. Ying Tsao et al. recommend that the picture book be routinely read and used during venipunctures to decrease procedural distress in preschool‐aged children [34]. As an effective nursing intervention presenting no side effects, listening to pleasant natural sounds can be helpful in the management of anxiety [2]. Discharge planning designed according to the care needs of children and their parents improved the quality of life of children undergoing heart surgery [35, 36].
Pediatric angiography is one of the specialized sections in which appropriate nursing interventions are one of the important factors in improving the quality of care [37]. Given that no intervention has been performed for children undergoing angiography in Iran and their families, it is suggested that future research be conducted to investigate the impact of effective interventions on children undergoing angiography as a high-risk group that needs more attention. In addition, the development of a guideline for nursing interventions in pediatric angiography is essential.
5. Conclusions
Significant advances in the treatment of cardiovascular diseases in the young have greatly expanded the therapeutic options available to children and families. These therapies often require invasive medical procedures, and some involve a staged approach with numerous surgical procedures and/or heart catheterizations during childhood. A significant body of scientific literature supports the efficacy of psychological preparation for this population, but the implementation of this knowledge requires an ongoing set of guidelines. We hope that these guidelines will facilitate the development, implementation, and evaluation of pre-procedure programs for children and adolescents who must undergo angiography procedures.
Ethical Considerations
Compliance with ethical guidelines
There were no ethical considerations to be considered in this research.
Funding
This research received no specific grant from any funding agency, commercial, or non-profit sectors.
Authors' contributions
All authors equally contributed to preparing this article.
Conflict of interest
The authors declared no conflict of interest.