Child life specialists (CLS) are individuals, working in a pediatric hospital setting, who are specialized in child psychology and development. Their goal is to provide emotional and spiritual support, educate and advocate children in a manner appropriate for the development of the child [8]. Along with other team members, they help to build rapport with the patient and the family and help in strengthen the role of parents in a family centered care model [8-10]. The admitted children may be exposed to two kinds of trauma which could impact their welfare- trauma of sickness and the trauma of hospitalization [11]. CLS help in reducing fear and allay anxiety by employing unique strategies tapered to the needs of the child. It may be as simple as giving a box of Lego to a 6-year-old to divert his attention during a physical examination or as complicated as to extract history from a sexually abused 5-year-old girl using play therapy. They also form an integral part of pediatric palliative care team – by identifying non-verbal pain, recognizing the needs and emotions at the end of life, conveying them to the palliative care teams and help in building legacy [8]. Interdisciplinary CLS teams work together focusing on the quality of life, addressing the psychosocial needs, while respecting the traditional cultures and religious customs [10-12]. They work at times that are convenient for the child, help restructure the day, and prepare children for medical procedures [10,13]. They may decorate the hospital room to make it as comfortable and familiar as the home environment and have traditional ‘‘Friday family game nights.’’ They play board games; bring in movies, and electronic gadgets, helping children stay in touch with their classmates. They encourage patients and families to continue to maintain a semblance of normal life in the hospital setting [8,12,14]. The CLS work in both out-patient and inpatient pediatric settings including in the pediatric intensive care units, behavioral and rehabilitation facilities [15]. Most hospitals have a ratio of 1 CLF for every 10-15 patients, but the ratio may vary depending on the severity of illness and the emotional state of each patient [8,12].

Art and health have been at the center of human interest since early times [12]. Creative art therapy is the use of expressive media including music, dance, poetry and fine arts which blend together in providing support during medical interventions [8,14,16]. It is well known that music can provide analgesia in painful procedures [13,17]. In addition, creative art therapy assists patients to express thoughts, feelings, and access the subconscious when words are difficult [14,17].

Art therapy is especially effective in pediatrics where primary communication is non-verbal [10,14]. It is well known that, the prefrontal cortex and anterior cingulate cortex are under-activated and amygdala is over-activated in children with mental trauma resulting from chronic debilitating medical illness, death of parents or abuse [18].　 Self-expression through art therapy allows the creator to depict emotional experiences by creation of images and provides insight into how these experiences affect thoughts and behaviors [10,12,14,17]. These acti-vities assist in making mind and body connections such as creating a map which can depict their emotions using shapes and colors [14,19]. Creative art therapists provide comfort and support at the community meetings through active listening at times of emotional distress [14,17]. The pediatric psychiatric unit implements a behavioral modification plan that is facilitated by creative art therapists which consists of earning points on a scale of 0-4. Most children are motivated to maintain positive behavior to earn privileges, such as not wearing a hospital gown or getting a special treat [19]. It is often seen that many sick children are more open to the creative art therapists as opposed to their physicians or nurses [19,20]. There is evidence that patients taking part in visual and performing arts interventions, had earlier discharges compared to those not doing so [12,14]. Furthermore, it also shows that complimentary medicine is effective in decreasing the incidence of apnea in premature infants, shortening length of stay in NICU by 3 days [21]. A study in 29 children found that that those receiving music therapy coped better with immunization procedures than those receiving traditional care [22]. One group was randomly assigned to have a music therapist present during immunization, while the second group received traditional care [22]. It has also been reported that music significantly increases levels of oxygen saturation and salivary IgA [23]. Studies show that parent’s participation in music therapy helped in improving their interactions with their child. However more studies are needed to explore the type and duration of art-based therapies that are effective in specific conditions.

The first written records of massage therapy (MT) were found in China and Egypt, as long back as 2700 BC. In United States, MT became popular in the hospitals in the 1850’s [24]. Many studies have shown that MT can relieve both emotional and physical discomforts by decreasing anxiety, fear and stress associated with chronic conditions such cancer, asthma, sickle cell disease in children [25]. Pediatric massage therapy (PMT) decreases cortisol level, reduces anxiety and improves the pulmonary function in patients with cystic fibrosis [25]. PMT increases the ability of children with ADHD to focus, helps the autistic child to tolerate touch, and relieves post-traumatic stress disorder [25,26]. The therapists offer their services in a variety of settings like NICU, oncology units, and adolescents clinics [26,27]. Growing evidence has shown that neonates feel the same pain intensity as older children and adults. The lack of verbal skills and cognitive limitation to recognize pain such as in vaccination (commonest source of iatrogenic pain in children) among infant and younger children is more challenging compared to older children. One interes-ting study found that massage therapy reduced vacci-nation pain (mean pain scores of 3.05 ± 0.13 and 5.03 ± 0.03 in the study and control groups, respectively) [27]. More studies are needed to understand the frequency, style, and duration that have maximal benefits in children.

Aromatherapy is the use of aromatic plant extracts and essential oils in massage or baths, which potentially induces self-healing in hospitalized children by reducing stress and promoting relaxation. The use of　such essential oils　for therapeutic, spiritual, hygienic, and ritualistic purposes dates back to ancient civilizations in Chinese, Indian, Egyptian, Greek, and Romans who used them in cosmetics, perfumes and drugs [28]. Variable effectiveness has been seen in pediatric cancer patients [29]. On the other hand, a systematic review found that aromatherapy had superior results in reducing anxiety and improving quality of life compared to massage therapy [30].

Acupuncture, originating in China in 100 BC, is a form of alternative medicine in which thin needles are inserted into the body [31]. It is still not clear whether acupuncture works through release of neurochemicals such as endorphins or through direct effect on the sympathetic and parasympathetic nervous system [10]. One study showed that it is effective and well tolerated in acute post-operative pain as well as in chronic pain [32]. Further, acupuncture promotes relaxation and sleep [32], thereby decreasing the stress of hospitalization. The biggest challenge in pediatric acupuncture is addressing children’s fear of needles. To deal with this issue, the acupuncturist may spend hours with their first-time patients and families to make them completely comfortable with the procedure. They explain and demonstrate the process on their own hands or on the child’s toy animal.

Overall, studies have shown good results regarding the efficacy of acupuncture, especially in reduction of pain and vomiting in the pediatric oncology population [33]. It is worthwhile to mention that, acupuncture is safe with less than 0.05% serious adverse event rate [34]. However, more studies need to be done to establish its role in pediatric patients.

Pet therapy involves bringing domestic animals into the hospital to interact with patients. Pet therapy was first reported in 1792, to help people with mental illnesses at York Retreat in England, while the first documented use of animal therapy was in a convalescent hospital in New York in 1942 [35,36]. It is not clear when pet therapy was introduced in the pediatric patients. Many studies have shown that pet therapy has an important role in hospitalized children by improving satisfaction, decreasing stress, boosting the morale of patients and their parents as well as reducing post-operative pain, improving pleasure in pediatric palliative　care patients [37,38]. The commonly used animals in pet therapy are dogs, which are trained for interacting in medical settings. However, there are concerns regarding risks of potential allergic reactions and occasional aggressive-ness of pets in hospital settings. More studies need to be done to explore type, time and preconditions of pet therapy in the pediatric population.

Hypnosis is the induction of a state of consciousness in which a person apparently loses the power of voluntary action and is highly responsive to suggestions or direc-tions [40]. It is not clear when hypnosis was used for the first time in the pediatric population, but it has been used in the treatment of a wide variety of childhood disorders. A systematic review done in 2010 suggested that hypnosis works by changing the perception and sensation [41]. Another study showed that hypnosis may activate certain brain areas resulting in changes in arousal, visual imagery perception and reinterpretation [42]. To measure the sensitivity of the child to hypnosis, many scales have emerged, with ‘The Shorter stanford clinical scale’ being the most commonly used [43]. According to studies, hypnosis has a positive impact in pediatric cancer patients in reducing anxiety, pain, nausea, vomiting and stress. Studies have also indicated that hypnosis is superior to standard therapy of controlled breathing, games or distraction [44,45].

Hospital school program provides hospitalized children with their educational needs to enable a smooth transition back to school [46]. The teachers of the hospital school program are state certified. They are provided with curriculum and instructional materials aligned to the common core learning standards [46,47]. The children have a choice of attending the class in a group or may opt for individual bedside teaching, Science and Maths are taught in a large class setting. Along with academics, children are also taught coping skills and how to work with small peer groups in art projects [47]. They are given incentives like scented pencils, erasers, and highligh-ters　for completing the educational tasks. Attending home school, while being hospitalized, helps children maintain their academic standing, especially during prolonged absence from school [46-48]. In addition, the children may take the examinations required for promotion. Thus, the hospital school program ensures children feel comfortable and less stressed, brightens their spirits during the hospital stay, and facilitates a smoother return to school.

Hospital clowning is a program where specially trained　clowns visit health care facilities with an aim to bring some joy and brighten up the everyday life of the otherwise mundane hospital environment [48]. Since its introduction in the US in 1986, by professional clown Michael Christensen, medical clowning has been widely used in hospitals worldwide [48].

Hospitalization can be a frightening experience for both parents their children. Thus, the so called ‘red nose doctors’ pitch in to help alleviate family fears and anxiety [10,48]. The Nonprofit organization ‘Red Noses’ founded in 2003, comprising of ‘red nose doctors’ or the ‘clown doctors’ serve the inpatient, intensive care, out-patient units and acute care waiting areas, touching the lives of hundreds of children and their families every year. The clowns use performances such as ‘red nose transplants’, ‘kitty cat scans’, funny bone exams, music, and magic tricks to demystify even the most complicated medical treatments, and support the emotional wellbeing of children and their families [48,49]. They reduce the children’s pre-operative anxiety and the pain during an invasive procedures like venous blood draws, allergy skin prick tests, and aid in healing respiratory infections [48-50]. According to a recent meta-analysis, clowning was found to be as effective in reducing children’s preope-rative anxiety as midazolam or the presence of parents [48].

The invaluable role of ancillary services in managing a hospitalized child cannot be overemphasized. They improve patient satisfaction and have a positive outcome on the quality of life, which can be translated in to measu-rable outcomes such as reducing time for procedures, less doctor’s visits, fewer symptoms, early discharge and fewer medications. These services help in conserving staff time and energy thereby increasing productivity, staff retention and decreasing burnout [50].

The services can be implemented depending on the geographic location, hospital tier, and availability of the providers. All services need not be available in one facility, but they may be shared between different hospitals within a commutable range. As more free-standing children’s hospitals emerge, the ancillary services will gain more recognition and popularity to give the best patient care experience.

Acknowledgements: Ms Larissa Hall (Art Therapist) and Ms. Jessica Indarte (NYS Department of health school educator) for their contributions.

Contributors: MA: did literature search, wrote, edited and approved the final version of the manuscript; AY: did literature search, wrote, edited and approved the final version of the manuscript; RBB: conceptualized, did literature search, wrote, edited and approved the final version of the manuscript.

Funding: None; Competing interest: None stated.

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