Letter to: The Potential of Structured Active Play for Social and Personal Development in Preschoolers During Cancer Treatment: A Qualitative RePlay Study

We read with great interest the study on structured active play and its role in supporting the social and personal development of preschool children undergoing cancer treatment. Using a hermeneutic–phenomenological approach, the researchers seek to understand how engagement in active play promotes confidence in movement, encourages social interactions and fosters personal development (Pouplier et al. 2024). Several methodological and conceptual aspects of the study warrant closer examination to refine the interpretation of the findings and strengthen the evidence base.

The reliance on participant observation introduces interpretive limitations. While the researchers documented children's engagement through facial expressions and behavioural cues, these observations remain subjective. The study does not include validated quantitative assessments of motor skills or psychosocial development, leaving room for ambiguity in measuring actual developmental progress. A more rigorous methodology would include objective assessments such as validated gross motor function tests, structured behavioural coding systems and standardised parent questionnaires to corroborate findings from participant observations. In addition, the study identifies familiarity, recognition and fun as key motivators for participation in structured active play but does not account for potential confounding variables that may influence engagement. The extent to which medical conditions such as fatigue, pain or neuropathy affect participation remains unclear. Some children may have been more likely to participate due to better baseline physical function or milder treatment side effects. Without detailed stratification of participant characteristics, it is difficult to determine whether the observed benefits of structured active play apply broadly to all preschool children with cancer or only to a subset with specific physical abilities.

Parental involvement plays a critical role in children's participation, but the study does not examine variations in parental support. Parents' socio-economic background, educational level and psychological well-being may significantly influence their ability to facilitate structured active play at home. Parents experiencing emotional distress or caregiving burdens may have difficulty maintaining consistency in facilitating active play. Future research should examine how parental stress and resilience affect the implementation of structured active play interventions, and whether additional support mechanisms for parents could improve intervention adherence and effectiveness. In addition, the study suggests that structured active play contributes to preschoolers' confidence in movement and social interactions, but the mechanistic pathways underlying these improvements remain speculative. The intervention design assumes that active play directly improves social skills but does not disentangle whether improvements are due to increased physical activity, the presence of social facilitators (e.g. parents and healthcare professionals) or a combination of both. More detailed analysis, such as tracking specific social behaviours before, during and after the intervention, could help clarify the precise mechanisms by which structured active play influences social and personal development.

The integration of structured active play into clinical practice requires more detailed analysis of feasibility and long-term sustainability. The study focuses on short-term observations within a hospital setting, leaving uncertainty as to whether the observed benefits are sustained after discharge. Understanding whether structured active play can be effectively sustained in the home environment, particularly for families with limited resources or competing caregiving demands, is critical for its broader application in paediatric oncology care. Future research should examine strategies to optimise adherence and long-term engagement, possibly incorporating digital tools or remote coaching to support parents in maintaining active play routines.

In conclusion, this study advances the understanding of structured active play in paediatric oncology but leaves several critical questions unanswered. More precise methods, comprehensive participant stratification and deeper exploration of parental roles and mechanistic pathways are needed to refine the intervention and maximise its clinical relevance. Addressing these gaps will improve the applicability of structured active play to support the social and personal development of preschool children undergoing cancer treatment.