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National Clinical Guideline Centre (UK). Sedation in Children and Young People: Sedation for Diagnostic and Therapeutic Procedures in Children and Young People [Internet]. London: Royal College of Physicians (UK); 2010 Dec. (NICE Clinical Guidelines, No. 112.)

5Psychological preparation (narrative review)

5.1. Introduction

This narrative review provided material to inform the GDG and to enable consensus decisions leading to recommendations on how children and young people should be prepared prior to their sedation experience. The nature of the evidence base in this area lends itself to this approach.

A full literature search was conducted for psychological preparation for sedation in children. The search was not limited by study design. The resulting 1455 studies were double sifted by the research fellow and by the reviewer for this topic. Two hundred and eight studies were ordered and quality assured by the reviewer.

The benefits of a systematic narrative review of the clinical evidence are highlighted by Oxman176 and colleagues. Applying the quality assurance principles advocated by Oxman176, a valid review article can provide the best possible source of information that can lay a foundation for clinical decisions to be made. There is an argument that focused narrative reviews for these important areas of preparation and assessment of the child prior to sedation are more likely to provide valid results that are useful for clinicians. Having provided the background and context for this review, we begin by defining psychological preparation and stating its aims and factors that affect its exact nature and content. This is followed by summarising the evidence for the efficacy of psychological preparation for anaesthesia induction and other medical procedures. Following this, the literature regarding parental and children's desire for information is reviewed. Next, the evidence regarding the effects of parental presence during anaesthesia induction and other medical procedures is discussed, along with the role that parents play when present. The review concludes by summarising the existing evidence and good clinical practice and making recommendations for the preparation of children and their parents for sedation.

5.2. What is psychological preparation

Psychological preparation includes specific interventions to provide information and reduce anxiety. Providing three types of information is central: (a) information is provided about the procedure itself (that is, steps that children must perform and steps that healthcare professionals will perform); (b) the sensations the patient can expect to feel (for example, sharp scratch, numbness); and (c) about how to cope with the procedure142.

The aim of pre-sedation and/or preprocedure psychological preparation in children and young people is to

  • reduce anxiety for patients and their parents
  • improve patient cooperation
  • enhance patient recovery
  • increase self-control for patients and their parents
  • improve long-term emotional and behavioural adjustment in patients and their parents.

The factors affecting pre-sedation and/or preprocedure preparation are (Kain and Caldwell-Andrews, 2005)103

  • the developmental stage of the child or young person
  • previous medical experiences
  • timing relative to the procedure
  • temperament, current anxiety levels and coping style
  • role of parents.

There is limited evidence regarding the best way to prepare children and young people for sedation; therefore, the extensive related literature on preparation for painful medical procedures and anaesthesia was reviewed and the results of this body of knowledge informed the present recommendations. Overall, published evidence supports the view that good preparation results in improved sedation outcomes (e.g. less distress and improved adjustment for the parent and patient139,158. A number of studies have shown that adequate preprocedural preparation can also reduce anxiety and procedural pain for a range of medical events, including venipuncture130, dental procedures166, surgery103 and voiding cystourethrography209.

5.3. Psychological preparation for anaesthesia induction

Children have numerous concerns related to anaesthesia and surgery including fear of separation, fear of physical harm, fear of the unknown, fear of death, fear of losing control and uncertainty of the limits of acceptable behaviour79,195. It has been estimated that 50% - 75% of children undergoing surgery will develop extreme anxiety and distress during the perioperative period122. Anxiety experienced by children at induction is associated with distress on awakening in the recovering area and with later postoperative behavioural problems230. Younger age, behavioural problems with previous healthcare attendances, longer duration of procedure, having more than five previous hospital admissions and anxious parents at induction are associated with high anxiety at induction50. Interestingly, mother's prediction of uncooperative behaviour is a good predictor of anxiety during induction154. Of all children undergoing general anaesthesia and surgery, 54% exhibit new onset maladaptive behavioural responses including general anxiety, night-time crying, enuresis, separation anxiety, eating disturbances, sleep-related problems and temper tantrums at 2 weeks postoperatively105,113,121.

Behavioural preoperative preparation has been advocated in the psychological and medical literature as a way to ameliorate children's preoperative anxiety and facilitate post procedure recovery. An estimated 78% of all major hospitals offer such programmes to children and their parents. These preparation programmes may provide narrative information, an orientation tour, role rehearsal using dolls, a puppet show, child life preparation or the teaching of coping and relaxation skills to children and their parents. Although there is a general consensus about the desirability of these programmes, recommendations regarding the content of preoperative preparation for children differ widely. O'Byrne and colleagues174 asked a panel of psychological experts to rate the effectiveness of behavioural preparation programs used in the United States prior to surgery. Experts rated each program on a 1 (least effective) to 9 (most effective) Likert scale. Coping skills instruction was ranked as the most effective preoperative intervention, followed by modelling, play therapy, operating theatre tours and printed materials.

Kain and Caldwell-Andrews103 suggest that a number of variables are important to consider when designing a preparation programme, including child age, timing relative to surgery and the child's previous hospitalisation history. For example, participation in a preparation programme more than 5-7 days prior to surgery has been found to be most beneficial for children 6 years and older, and the least the beneficial timing was when the program is given 1 day before surgery115,167,193. Previous hospitalisation history can also be a particular challenge for designing a preparation programme103. Information about what to expect on the day of surgery does not offer new knowledge to these children65 and it has also been demonstrated that simple modelling and play programmes are not beneficial for children with previous hospitalisations. Individualized coping skills training in combination with actual practice have been identified as strategies that are more helpful for these children116. Kain and Caldwell-Andrews103 suggest that the latter types of programs should be designed with the child's specific past experiences in mind.

5.4. The benefit of preoperative anxiety reduction programmes – what the evidence says

  • Kain and colleagues110 in an RCT compared three types of behavioural preoperative preparation programmes including a tour of the OR (information based), an information-based + modelling-based programme (OR tour + commercially available videotape) or an information- + modelling- + coping-based programme (OR tour + videotape + child life preparation) with 75 children aged 2-12 years. Children and parents who received child life coping skills preparation exhibited less anxiety immediately following the preparation in the holding area on the day of surgery and on separation to the OR than children and parents who did not receive this preparation. There were no significant differences in anxiety levels across the groups during anaesthetic induction, in the recovery room or at 2 weeks following the operation.
  • Golan, Tighe, Dobija, Perel and Keidan78 found that the use of preoperative medically trained clowns for children undergoing surgery can significantly alleviate preoperative anxiety. In a randomised, controlled and blinded study conducted with 3-8 year olds undergoing GA for elective outpatient surgery, patients were assigned to three groups: Group 1 did not receive midazolam or clown presence (N=22), Group 2 received 0.5mg/kg oral midazolam 30min before surgery up to a maximum of 15mg (N=22), and Group 3 had two specially trained clowns (N=21) present upon arrival to the preoperative holding area and throughout operating theatre entrance and mask application for inhalation induction of anaesthesia. The intervention lasted approximately 20 minutes and the clowns used developmentally appropriate techniques, such as magic tricks, gags, music, games, puppets, word games and bubbles. In all groups parents were present. All children in the study were videotaped in the holding area until the induction of anaesthesia and blinded evaluators used the tapes to rate children's anxiety. The clown group had a statistically significant lower modified-Yale Preoperative Anxiety Scale score (m-YPAS; Kain, Mayes, Cicchetti et al., 1997117) in the preoperative holding area compared to a control and a midazolam group. The clowns' effect on anxiety reduction continued when the children entered the operating theatre but was equal at this point to the midazolam group. Upon application of the anaesthesia mask no statistically significant differences were detected between groups, but the clown group had the largest increase in m-YPAS score, which surpassed the other two groups' m-YPAS scores.
  • Kain, Caldwell-Andrews, Krivutza, Weinberg, Gaal and colleagues104 compared the effectiveness of an interactive music intervention and midazolam in alleviating preoperative anxiety in 123 children aged 3-7 years old. The results of this study suggested that interactive music therapy may be useful in alleviating preoperative anxiety on separation from parents and entrance to the OR, but that music therapy did not appear to alleviate children's anxiety at anaesthetic induction.
  • Kain and colleagues108 randomly assigned 408 children and their parents to one of four groups: (1) control, which received standard of care; (2) parental presence, which received standard parental presence during induction of anaesthesia; (3) ADVANCE: received standard-of-care treatment plus multicomponent family-centred behavioural preparation (anxiety-reduction, distraction, video modelling and education, adding parents, no excessive reassurance, coaching, and exposure/shaping); and (4) oral midazolam. Parents and children in the ADVANCE group exhibited significantly lower anxiety in the holding area as compared with all three other groups (34.4±16 vs. 39.7±15; p=0.007) and were less anxious during induction of anaesthesia as compared with the control and parental presence groups (44.9±22 vs. 51.6±25 and 53.6±25, respectively; p=0.006). Anxiety and compliance during induction of anaesthesia was similar for children in both the ADVANCE and midazolam groups (44.9±22 vs. 42.9±24; p=0.904). Children in the ADVANCE group exhibited a lower incidence of emergence delirium after surgery (p=0.038), required significantly less analgesia in the recovery room (p=0.016) and were discharged from the recovery room earlier (p=0.04) as compared with children in the three other groups.
  • A recent meta-analysis237 that assessed the effects of non-pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their cooperation concluded that non-pharmacological interventions, such as parental acupuncture, clown doctors, hypnotherapy, low sensory stimulation and handheld video games are promising and need to be investigated further. More specifically, six trials assessed interventions for children. Preparation with a computer package improved cooperation compared with parental presence36. Children playing hand-held video games before induction were significantly less anxious than controls or premedicated children179. Compared with controls, clown doctors reduced anxiety in children (modified Yale Preoperative Anxiety Scale (mYPAS): mean difference (MD) 30.75 95% CI 15.14 to 46.36; Vagnoli 2005220). In children undergoing hypnosis, there was a non-significant trend towards reduced anxiety during induction (mYPAS < 24: risk ratio (RR) 0.59 95% CI 0.33 to 1.04 - 39% versus 68%: Calipel 200534) compared with midazolam. A low sensory environment improved children's cooperation at induction (RR 0.66, 95% CI 0.45 to 0.95; Kain 2001121) and no effect on children's anxiety was found for music therapy104. Parental interventions were assessed in three trials. Children of parents having acupuncture compared with parental sham-acupuncture228 were less anxious during induction (mYPAS MD 17, 95% CI 3.49 to 30.51) and more children were co-operative (RR 0.63, 95% CI 0.4 to 0.99). Parental anxiety was also significantly reduced in this trial. In two trials162,240, a video viewed preoperatively did not show effects on child or parental outcomes.

5.5. Psychological preparation/interventions for other medical procedures - what the evidence says

  • Megel et al.165 examined how parents prepared their children before preschool immunisations. Five types of preprocedural preparation/discussion were postulated: information sharing (what will happen), sensory information (how it will feel), justifying the procedure (explaining why the procedure is necessary), teaching relaxation strategies and role playing. The results suggested that parents used a mixture of various types of preparation. Seventy-five percent of children received informational preparation from their parents, typically involving a description of the events that would occur. Of the 25% of children who received no information, nine children were <3 years of age. Forty-two percent of parents also used some sensory information in their description. Forty percent of parents offered a rationale for receiving the injection. Relatively few parents (10%) offered the children any strategies for how to cope with the procedure (for example, relaxation, breathing or distraction). Unfortunately, the relationship between the type of preparation and the child's subsequent distress was not reported by the researchers.
  • Uman et al.219 assessed the efficacy of cognitive-behavioural psychological interventions for needle-related procedural pain and distress in children and young people. Only randomised controlled trials (RCTs) with at least five participants in each study group comparing a psychological intervention group with a control or comparison group were eligible for inclusion. Twenty-eight trials with 1951 participants were included. Together, these studies included 1039 participants in treatment conditions and 951 in control conditions. The most commonly studied needle-procedures were immunisations and injections. The largest effect sizes for treatment improvement over control conditions exist for distraction37,62,186 (self-reported pain: SMD = -0.24, 95% CI = -0.45 to -0.04), hypnosis143,144,146,147 (self-reported pain: SMD = -1.47, 95% CI = -2.67 to - 0.27; self-reported distress: SMD = -2.20, 95% CI = -3.69 to -0.71; and behavioural measures of distress: SMD = -1.07, 95% CI = -1.79 to -0.35), and combined cognitive-behavioural interventions29,40,41,143 (other-reported distress: SMD = -0.88, 95% CI = -1.65 to -0.12; and behavioural measures of distress: SMD = -0.67, 95% CI = -0.95 to -0.38). The authors commented that while there may be preliminary evidence to support the efficacy of information/preparation there is not enough evidence at this time to make strong conclusions. More specifically, Harrison88 and Tak et al.211 reported that information/preparation was effective in reducing observer-reported distress (SMD = -0.77, 95% CI = -0.17 to -0.38) and pulse rates (SMD = -0.47, 95% CI = -0.87 to -0.07). Although SMDs for self-reported pain and observer-reported distress both fell in the negative range (-0.22 and -0.15), their CIs passed into the positive range, indicating that while there may be preliminary evidence to support the efficacy of information/preparation on these outcomes, there is not enough evidence at this time to make strong conclusions. Information/preparation did not appear to be effective in reducing distress as assessed by behavioural measures (SMD = 0.24, 95% CI = -0.30 to 0.78), as the SMD fell in the positive range.
  • Sinha et al. (2006)206 assessed the effectiveness of distraction techniques in reducing the sensory and affective components of pain among paediatric patients undergoing laceration repair in the ED. In total, 240 children between 6 and 18 years of age were randomly assigned to an intervention or control group. Those assigned to the intervention group were given a choice of age-appropriate distracters during laceration repair. Quantitative measures of pain intensity, situational anxiety and pain distress (as perceived by the parent) were assessed by using the 7-point Facial Pain Scale, State Trait Anxiety Inventory for Children, and a visual analogue scale, respectively, before and after laceration repair. The State-Trait Anxiety Inventory for Children was performed in children ≥ 10 years of age. There was no difference in mean change in Facial Pain Scale scores between the control and the intervention groups in children < 10 years of age. Multivariate analysis in this same age group showed that the intervention was independently associated with a reduction in pain distress as perceived by parents based on the mean change in visual analogue scale scores. In older children, the intervention was independently associated with reduction in situational anxiety but not in pain intensity or in parental perception of pain distress.
  • Haeberli et al. (2008)86 examined whether a psychoeducational intervention might reduce the need for anaesthesia during radiotherapy (RT). A total of 223 consecutive paediatric cancer patients receiving 4141 RT fractions during 244 RT courses were studied. Whereas in 154 RT courses corresponding with 2580 RT fractions patients received no psychoeducational intervention (group A), 90 RT courses corresponding with 1561 RT fractions were accomplished by using psychoeducational intervention (group B). This tailored psychoeducational intervention in group B included a play programme and interactive support by a trained nurse according to age to get familiar with staff, equipment and the procedure of radiotherapy. Group A did not differ significantly from group B in age, gender, diagnosis, localisation of RT and positioning during RT. Whereas 33 (21.4%) patients in group A got anaesthesia, only 8 (8.9%) patients in group B needed anaesthesia. The median age of cooperating patients without anaesthesia decreased from 3.2 to 2.7 years. In both uni- and multi-variate analyses the psychoeducational intervention significantly and independently reduced the need for anaesthesia.
  • Train et al. (2006)216 evaluated the effect of a psychological approach on distress and sedation rates in children undergoing dimer captosuccinic acid-labelled with technetium-99 (99mTc) (DMSA imaging). Baseline data, on a retrospective consecutive sample of children examined using DMSA over a 6-month period (n = 81), were collected via medical note search and postal questionnaire. A further consecutive sample of 40 children was recruited prospectively to the intervention, which consisted of distraction during medical procedures and environmental manipulation. In addition half of the intervention group were provided with a photo-booklet depicting a coping child model, together with a letter offering advice to parents on how to prepare their child for the procedure. Sedation rates were lower (p=0.003) and service satisfaction ratings higher (p=0.002) in the intervention group as compared with the baseline group. Within the intervention condition, children who received the photo-booklet displayed less distress before the procedure (p=0.01) than those who did not. Also, families who received the photo-booklet were more likely to attend the appointment (p=0.024).

5.6. Psychological preparation for dental procedures

In dentistry, the American Academy of Pediatric Dentistry (AAPD) recognises that, in providing oral healthcare for young patients, a continuum of both non-pharmacological and pharmacological behaviour guidance techniques may be used by dental healthcare providers and recommends behavioural guidance to be used in combination with pharmacological interventions for the management of the young dental patient15. Techniques recommended include:

  • Tell-show-do is a technique of behaviour shaping first described by Addelston11 that involves verbal explanations of procedures in phrases (what, why and how a procedure will be performed) appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, non-threatening setting (show); and then smoothly with no break in time and without deviating from the explanation and demonstration, completion of the procedure (do). The tell-show-do technique is used with communication skills (verbal and non-verbal) and positive reinforcement66,95.
  • Voice control is a controlled alteration of voice volume, tone or pace to influence and direct the patient's behaviour.
  • Positive reinforcement involves the reward of desired behaviours with social reinforcers, such as positive voice modulation, facial expression, verbal praise, and appropriate physical demonstrations of affection by all members of the dental team, and non-social reinforcers such as tokens and toys.

5.7. Parental desire for information

Parents are frequently dissatisfied with the lack of information they are offered and express a strong desire for perioperative information. Many healthcare professionals may withhold information because of a belief that details will induce anxiety in parents, which in turn will be communicated and increase the anxiety of children. Empirical evidence does not support this view.

  • Kain et al.120 explored parents' desire for perioperative and anaesthetic information at a pre-surgical assessment clinic visit or on the day of their children's outpatient surgery. Almost all parents (95%; n = 317) wished to receive comprehensive information concerning their child's anaesthetic, including information about all possible complications.
  • Waisel and Troug227 evaluated parents' perceived understanding and anxiety related to the discussion of the general anaesthesia risks for children that occurred during the preoperative interview with the anaesthetist, immediately prior to surgery. Approximately half the sample (N=55) was most concerned about the anaesthetic aspects of surgery (N=25), and 39% (N=21) were equally concerned about anaesthesia and surgery. Over 90% (N=50) of parents reported that the discussion of anaesthetic risks was desirable and that they understood the information. Half of the sample (N=25) felt the discussion did not change their anxiety, whereas 25% (N=13) felt it decreased anxiety and 24% (N=12) felt it increased anxiety.
  • Litman et al.148 examined parental knowledge and desire for information regarding risk of death from anaesthesia in 115 parents of healthy children undergoing elective surgery. The majority (87%) wanted to know the chance of death after anaesthesia and over half of parents (68%) had accurate knowledge of risk of death from anaesthesia. Most parents (75%) also wanted to know all possible risks, however, this was greater for mothers than fathers. A separate group of parents (N=121) were surveyed after participating in a pre-anaesthetic discussion with the anaesthetist. In 60% of cases, risk of death from anaesthesia was mentioned or implied and the proportion of parents who said they had wanted this information was similar to the previous survey. No demographic factors influenced the responses. However, several parents did not want the risk of death discussed in front of the children, who were sometimes present during the discussions.
  • Franck and Spencer70 critically analysed the published research literature (six descriptive and five intervention studies) on providing information about children's anaesthesia to parents. The intervention studies tested different methods of providing information, including verbal, video or written modalities, and showed some improvements in knowledge, anxiety and satisfaction. The authors concluded that parents want detailed information about the specifics of anaesthetic procedures, risks and personnel roles.

5.8. Children's desire for information

There is widespread agreement that children should be given information prior to anaesthesia, surgery and medical procedures but continuing debate about the most appropriate form and content of that information. There is little research evidence about children's concerns, fears and misconceptions about hospitals, anaesthesia and medical procedures and paucity of data regarding children's desire for perioperative information207.

Fortier et al.68 studied the perioperative information children want to receive from the medical staff. On the day of surgery, 143 children aged 7-17 years (ASA I or II) completed a 40-item assessment of desired surgical information and the State-Trait Anxiety Inventory for Children. Parents completed a measure assessing their child's temperament (Emotionality, Activity, Sociability and Impulsivity Survey) and the State-Trait Anxiety Inventory. The vast majority of children had a desire for comprehensive information about their surgery, including information about pain and anaesthesia, and procedural information and information about potential complications. The most highly endorsed items by children involved information about pain, including whether they would experience pain, how long it would last and how bad it would be. Children who were more anxious endorsed a stronger desire for pain information and a lesser tendency to avoid information. Younger children wanted to know what the perioperative environment would look like more than adolescent children. There were no significant correlations among child age, gender, and temperament on desire for information. Interestingly, children with a history of surgery did not require less perioperative information as compared with children who never had surgery.

5.9. Parental presence in anaesthesia induction

Permitting parental presence during anaesthesia induction varies widely between and within hospitals and countries111 and is surrounded in controversy. While parental presence is routine in some hospitals and actively discouraged in others, in many cases it is based on parental advocacy balanced with the preference of individual anaesthetists carrying out the induction. Supporters of parental presence during induction of anaesthesia argue that the trauma of separation is avoided, it increases child cooperation, minimises the need for premedication, decreases the child's anxiety during induction, facilitates the long term behavioural sequelae of surgery and enhances parental satisfaction. Arguments against parental presence include the potentially unpredictable response of the parent to the situation, increased parental anxiety and distress levels, the logistics of moving parents in and out of the induction area, the extra stress on the anaesthetist due to the presence of an emotionally involved observer and potential legal ramifications of having a parent present32,74,87,123,204,240.

The question of whether parents should stay with their child during a medical procedure has been empirically studied in many contexts apart from induction of anaesthesia, including venipuncture and immunisation, dental procedures, burn debridement, lumbar puncture, bone marrow aspirations and minor emergency procedures. In all of these contexts empirical evidence is inconclusive.

  • Three studies have focused on parental presence during anaesthesia induction in relation to parents' anxiety. In a prospective study, Bevan et al.27 examined parents of children aged 2–10 years (ASA physical status I or II) undergoing ear, nose and throat, plastic, dental, eye or urologic surgery. Of the 134 children enrolled in the study, 67 had parents present during induction (treatment group) and 67 did not (control group). Group assignment was determined by day of surgery. Parents' in-hospital anxiety was assessed in the reception and induction areas with the VAS, a 100 mm linear scale ranging from 0 to 100 (“no fear” to “great anxiety”). Parents in the treatment group had a mean VAS score of 42.8 ± 32.2 in the reception area compared to 41.9 ± 28.9 in the control group. In the induction area, the treatment group had a mean VAS score of 54.1 ± 36.4 compared to 52.3 ± 33.1 in the control group. Neither of these between-group differences were significant. Subgroups of “calm” and “anxious” parents were identified by a median split of their preoperative VAS scores. Children in the “calm treatment” “calm control” and “anxious control” subgroups were similarly upset at induction. Children in the “anxious-treatment” subgroup were the most disturbed at induction and significantly more than those in the “anxious control” subgroup. Preoperative parental anxiety levels also correlated with the child's fears (measured with the Hospital Fears Inventory199) and behaviours (measured with the Behavioural Questionnaire225) one week after surgery.
  • Blesch and Fisher28 carried out a RCT of parents of children aged 10 years or younger undergoing elective myringotomy with tube insertion, tonsillectomy and/or adenoidectomy. Of the 75 parents in the study, based on the week that their children were scheduled for surgery, 41 were assigned to be present for induction (treatment group) and 34 were not (control group). Parents' blood pressure and pulse rates were obtained as measures of anxiety at the following intervals: after consenting to the study, after separation from their children and before discharge. The state scale of the State-Trait Anxiety Inventory (STAI) was used to measure parents' subjective anxiety. After consent, the treatment group's mean blood pressure was 115/76 ± 13.7/9.8 mmHg compared to 112/72 ± 13.4/8.8 mmHg in the control group. After consent, the treatment group's mean pulse rate was 77 ± 10.2/min compared to 73 ± 10.5/min in the control group. After separation from children, the treatment group's mean blood pressure and pulse rate were 132/78 ± 19/10.9 mmHg and 81 ± 12.7/min, respectively, compared to 125/80 ± 15.4/11.5 mmHg and 75 ± 14.9/min, respectively, in the control group. Before discharge, the treatment group's mean blood pressure was 118/73 ± 12.8/11 mmHg compared to 110/71 ± 9.2/7.9 mmHg in the control group. Before discharge, the treatment group's mean pulse rate was 73 ± 7.3/min compared to 74 ± 12.6/min in the control group. The only significant differences found between the treatment and control groups were between time after consent and time after separation from their children mean diastolic blood pressures (−2.49 ± 10.63 vs. −8.24 ± 11.01, respectively; p = 0.025) and time after separation from their children and time before discharge mean pulse rates (7.66 ± 10.30 vs. 2.00 ± 9.07, respectively; p = 0.016). Subjective anxiety was not significantly different between the treatment and control group (39.05 ± 11.53 vs. 44.61 ± 14.51, respectively; P = 0.077).
  • In a RCT Palermo et al.177 assessed parents of infants aged 1-12 months (ASA class I and II), undergoing outpatient surgery. Of the 73 parents in the study, 37 were present during induction and 36 were not. Parental anxiety was measured with the STAI before and after surgery. There were no significant differences in anxiety between the two groups. Before surgery, parents of accompanied children had a mean STAI score of 57.6 ± 5.4 compared to 56.9 ± 6.4 for parents of unaccompanied children. After surgery, parents of accompanied children had a mean STAI score of 47.2 ± 4.8 compared to 45.2 ± 5.2 for parents of unaccompanied children. Interestingly, parents who were present during induction demonstrated comparable healthcare attitudes (measured with the Health Care Attitudes Questionnaire85) before and after surgery, as well as comparable levels of satisfaction with the surgical experience (measured with a modified version of the Perception of Procedures Questionnaire127) compared to parents who were absent during induction.
  • Four studies have examined parental presence during anaesthesia induction in relation to children's anxiety. Hickmott et al.93 undertook a RCT of children aged 1–9 years undergoing general anaesthesia for minor elective surgery. Of 49 children in the study, 26 had their mothers present during induction and 23 did not. Allocation to each group was determined by the week in which the children's surgery took place. A recovery room or ward nurse, not involved in the anaesthetic procedure, was responsible for observing and measuring children's anxiety levels in the anaesthesia room. Time in the anaesthesia room was separated into the ‘waiting period’ (time from the children's arrival until the anaesthetist arrived) and the ‘induction period’ (time from the anaesthetist's arrival). Children's anxiety was measured using a pre-determined scale ranging from 0 (no anxiety) to 2 (marked anxiety) during the waiting period and 0 (calm) to 4 (screaming and uncontrollable) during the induction period. During the waiting period in the mother-present group, five children scored 0 and two children scored 2; whereas, in the mother-absent group, seven children scored 0 and one each scored 1 and 2. During the induction period in the mother-present group, 13 children scored 0, nine scored 1, and two each scored 2 and 3; whereas, in the mother-absent group, 15 children scored 0, four scored 1, three scored 2, and one scored 3. Children's anxiety levels did not differ significantly between the two groups during either the waiting or the induction period (Mann–Whitney U test).
  • In a RCT, Amanor-Boadu14 assessed 118 children aged 1–12 years undergoing inguinal surgery as day cases. Children undergoing surgery were randomly assigned to be accompanied or unaccompanied. Of the 118 children in the study, 52 were accompanied by a parent and 66 were not. Children were evaluated according to their age group, that is, aged 5 years or less and more than 5 years. Heart rates using a stethoscope were taken both on the ward and before induction as a measure of anxiety. For children 5 years or less, unaccompanied children had a mean heart rate of 109 ± 13/min on the ward compared to 111 ± 12/min for accompanied children. For children more than 5 years, unaccompanied children had a mean heart rate of 101 ± 11/min on the ward compared to 100 ± 10/min for accompanied children. These two differences were not significant. Mean heart rates before induction, for children 5 years or less, was 128 ± 20/min for unaccompanied children compared to 118 ± 16/min for accompanied children. For children more than 5 years, it was 108 ± 10/min for unaccompanied children compared to 97 ± 19/min for accompanied children. Both of these differences were significant at p = 0.001.
  • In a retrospective study using a multiple matched concurrent cohort, Kain et al.106 examined children's anxiety in relation to parents'. The participants were selected from a database of children from a number of previous prospective and randomized studies that the authors conducted comparing parental presence with no parental presence. Of the 568 children included in the study (aged 2–12 years undergoing general anaesthesia for elective outpatient surgery), 284 had their parent present during induction and 284 did not. For children, anxiety was measured with the modified Yale Preoperative Anxiety Scale (mYPAS) and children were categorized as “anxious” if they scored >40 on the mYPAS, and as “calm” if they scored <30 on the mYPAS. For parents, anxiety was measured with the STAI and parents were categorized as “anxious” if they scored in the upper 50% on the STAI, and as “calm” if they scored in the lower 50% on the STAI. Four groups of child-parent pairs were then retrospectively compared for the parent-present and parent-absent groups: calm parent-calm child, anxious parent-calm child, calm parent-anxious child and anxious parent-anxious child. Anxious children with calm parents present were significantly less anxious during induction than anxious children with no calm parents present (mean mYPAS = 51.9 ± 24 vs. 64.6 ± 26, respectively; P = 0.03). Calm children with anxious parents present were significantly more anxious during induction than calm children with no anxious parents present (mean mYPAS = 52.4 ± 28 vs. 39.4 ± 21, respectively; p = 0.002). On the other hand, there was no significant difference in anxiety during induction between calm children with calm parents present and calm children with no calm parents present (mean mYPAS = 39.9 ± 22 vs. 34.7 ± 20, respectively; p = 0.15), and no significant difference in anxiety during induction between anxious children with anxious parents present and anxious children with no anxious parents present (mean mYPAS = 71.0 ± 23 vs. 66.6 ± 27, respectively; p = 0.49). The authors concluded that the presence of a calm parent does benefit an anxious child during induction of anaesthesia and the presence of an overly anxious parent has no benefit.
  • In a RCT, Patel et al.179 examined 112 children aged 4–12 years undergoing outpatient surgery. Children's change in anxiety was assessed from baseline to introduction of the anaesthesia mask using the mYPAS. Children were randomly assigned to one of three groups using sealed envelopes: parental presence (n = 36), parental presence plus 0.5 mg/kg oral midazolam (n = 38), or parental presence plus a hand-held video game (n = 38). Children who received parental presence plus a hand-held video game experienced a statistically significant decrease in anxiety from baseline to introduction of the anaesthesia mask compared to children who received parental presence alone (median change in mYPAS = −3.3 vs. +11.8, respectively; p = 0.04). Children who received parental presence plus midazolam did not experience a statistically significant change in anxiety from baseline to introduction of the anaesthesia mask compared to the other two groups (median change in mYPAS = +7.3).
  • Seven studies examined both parents' and children's anxiety in relation to parental presence during anaesthesia induction. Johnston et al.102 carried out a prospective study of parents and their children aged 2–8 years undergoing day surgery. Of the 134 children in the study, 67 had their parent present and 67 did not. Parents and children were assigned to each group based on the day of the week that surgery was scheduled. Anxiety was measured before induction. For parents, the VAS, a 10 cm line ranging from 0 (“no anxiety”) to 10 (“most anxiety”), was used to measure anxiety. For children, the Global Mood Scale (GMS), an observation scale ranging from 1 (child attentive and happily active) to 7 (child screaming), was used. Overall, there were no differences in parents' or children's anxiety between parent-present and parent-absent groups. To conduct further analysis, the authors separated parents into low-anxiety and high-anxiety groups based on their VAS scores; that is, those who scored ≤3 on the VAS were considered low-anxiety, and those who scored ≥6 on the VAS were considered high-anxiety. The authors found that high-anxiety parents who were present for induction were more anxious than high-anxiety parents who were not present for induction. Low-anxiety parents who were present for induction were less anxious than low-anxiety parents who were not present for induction. Children with high-anxiety parents who were present were more anxious than children with high-anxiety parents who were not present. Children with low-anxiety parents experienced the same level of anxiety whether they were in the parent-present or parent-absent group.
  • In a non-randomised prospective study Cameron et al.35 assessed 74 parents and their children aged 1–8 years undergoing day surgery. Parents were only allowed to be present for induction if the anaesthetist carrying out the induction granted them permission. The treatment group consisted of 38 parents who were granted permission and decided to be present. The control group consisted of 36 parents who were either not permitted or decided not to be present. In the control group, 22 parents chose to separate from their children in the theatre holding bay area and 14 parents chose to separate from their children in the day surgery ward. Parents' anxiety was measured immediately upon separation from their children using a VAS with scores ranging from 1 (“no anxiety at all”) to 10 (“most anxiety anyone could have”). A five-point scale with scores ranging from 1 (cheerful and attentive) to 5 (very distressed and uncontrollable) was used by parents to assess their children's anxiety right before separation from them. Parents in the treatment group were significantly less anxious, as measured by the VAS, than parents in the control group (mean = 3.4 ± 1.6 vs. 6.5 ± 2.2, respectively; p < 0.001). Parents who were present for induction reported their children to be significantly less anxious than parents who were not present for induction (mean = 1.9 ± 1.1 vs. 2.8 ± 1.1, respectively; p < 0.001).
  • In a RCT, Kain et al.116 examined parents and their children aged 1–6 years undergoing general anaesthesia for elective outpatient surgery. Of the 84 children in the study, using a random numbers table generated by a computer, 43 were randomised to have their parent present during induction (intervention group) and 41 did not (control group). For children, anxiety was measured with the Yale Preoperative Anxiety Scale (YPAS), Clinical Anxiety Rating Scale (CARS), VAS and cortisol. For parents, anxiety was measured with the STAI, VAS, heart rates and blood pressure. The VAS, a 100-mm line ranging from 0 (“not anxious”) to 100 (“extremely anxious”), was used as an observational measure for children and a self-report measure for parents. Using these measures, no significant differences were found between the two groups for either children's or parents' anxiety. For children, anxiety was reported as medians and 25–75% interquartile ranges for the holding area, induction 1 (entering the induction room) and/or induction 2 (introduction of anaesthesia mask). On the VAS, children in the control group compared to those in the intervention group scored the following: holding area = 11 (0–28) vs. 6 (0–33), respectively; induction 1 = 38 (0–89) vs. 37 (0–82), respectively; and induction 2 = 43 (5–78) vs. 45 (8– 86), respectively. On the YPAS, children in the control group compared to those in the intervention group scored the following: induction 1 = 34 (24–41) vs. 30 (25– 41), respectively, and induction 2 = 38 (24–65) vs. 42 (30–62), respectively. On the CARS, children in the control group compared to those in the intervention group scored the following: induction 1 = 0 (0–1) vs. 0 (0–1), respectively, and induction 2 = 1 (0–4) vs. 1 (0–4), respectively. With respect to cortisol (μg/ml) for induction 2, the results for children in the control group compared to those in the intervention group were 73 (51–100) vs. 76 (48–91), respectively. For parents, anxiety was reported as means and standard deviations or as medians and 25–75% interquartile ranges for the holding area and/or post-induction (after parents left their children). State-Trait Anxiety Inventory scores for the control and intervention group parents were 46 ± 12 vs. 43 ± 12, respectively, post-induction. VAS scores for the control group parents compared to the intervention group parents were 43 (20–58) vs. 38 (13–49), respectively, in the holding area and 49 (18–73) vs. 41 (5–66), respectively, post-induction. Systolic blood pressure (mmHg) for the control group parents compared to the intervention group parents was 114 ± 11 vs. 116 ± 17, respectively, in the holding area and 122 ± 12 vs. 121 ± 13, respectively, post-induction. Diastolic blood pressure (mmHg) for the control group parents compared to the intervention group parents was 71 ± 8 vs. 67 ± 10, respectively, in the holding area and 77 ± 9 vs. 75 ± 7, respectively, post-induction. Heart rates (beats/minute) for the control group parents compared to the intervention group parents were 81 ± 9 vs. 78 ± 8, respectively, in the holding area and 85 ± 10 vs. 84 ± 8, respectively, post-induction. The authors concluded that only children who were older than 4 years, had a parent with a low trait anxiety level or a low baseline level of activity as assessed by temperament ratings benefited from parental presence during induction of anaesthesia. In contrast, there was a trend among children younger than 4 years to be more anxious during induction in the presence of their parent.
  • Kain et al.118 in a RCT studied 88 parents and their children aged 2–8 years undergoing general anaesthesia for elective outpatient surgery. The children were randomized into one of three groups according to a random numbers table: (a) parental presence (n = 29); (b) premedication with 0.5 mg/kg oral midazolam mixed in 10 mg/kg acetaminophine syrup at least 20 minutes before surgery (n = 33); (c) no parental presence and no sedative premedication (n = 26). Anxiety was measured for parents with the STAI and for children with the Procedural Behavior Rating Scale (PBRS126). There were no significant differences between the three groups regarding children's anxiety in the preoperative holding area. Upon separation from their parents, children in the midazolam group were significantly less anxious than children in the other two groups (PBRS = 0 (0–1) vs. 4 (0–5); p = 0.02). Children in the midazolam group were also significantly less anxious than children in the other two groups at both entrance to the operating room (p = 0.0171) and introduction of the anaesthesia mask (p = 0.0176). Parents in the midazolam group were significantly less anxious after separation than parents in the parental presence group and parents in the control group (mean STAI score = 43 ± 12 vs. 50 ± 10 vs. 47 ± 10, respectively; p = 0.048). The percentage of inductions in which compliance of the child was poor was significantly greater in the control group compared with the parental presence and midazolam groups (25% vs. 17% vs 0%; p= 0.013)
  • Kain et al.119 in a RCT assessed 103 parents and their children aged 2–8 years. Parents and their children were randomly assigned to each group using a random numbers table. The intervention group had parental presence and received premedication with oral midazolam syrup (0.5 mg/kg at least 20 minutes before surgery. The control group received premedication with oral midazolam syrup (0.5 mg/kg) at least 20 minutes before surgery only. Anxiety was measured for children with the mYPAS and for parents with the STAI. Children's anxiety was not significantly different between the two study groups (p = 0.49). Parents' anxiety, on the other hand, was significantly lower after separation for those who were present compared to those who were not present (mean = 43 ± 11 vs. 48 ± 12, respectively; p = 0.037). Parental satisfaction with the overall care provided and with the separation process was significantly higher among the premedication and parental presence group compared with the premedication only group.
  • Kain et al.107 undertook a RCT of parents and their children undergoing general anaesthesia and elective outpatient surgery. Of the 80 children in the study, 29 had their parent present, 27 had their parent present and received oral midazolam (0.5 mg/ kg) about 30 minutes before induction, and 24 did not have their parent present (control group). They were randomly assigned to the three groups based on a random number table. For children, anxiety was measured with the mYPAS and for parents with the STAI. Heart rates, skin conductance levels (SCL) and blood pressure levels were also used to measure parents' anxiety. Children in the parental presence plus midazolam group were less anxious than children in either the control group or the parental presence only group (p = 0.023). At different time points, parents in both parental presence groups had higher anxiety, as measured by heart rates, than the control group (p < 0.05). However, there was no significant difference in heart rates between the parental presence and parental presence plus midazolam groups. Skin conductance level was higher in the two parental presence groups than in the control group (p < 0.05). However, there was no significant difference in SCL between the two parental presence groups. The SCLs were not provided by the authors. There were no significant differences between the parental presence, parental presence plus midazolam and control groups with regards to systolic blood pressure (123 ± 21 vs. 128 ± 16 vs. 126 ± 19, respectively; p = 0.59) and diastolic blood pressure (82 ± 14 vs. 85 ± 13 vs. 81 ± 15, respectively; p = 0.88) after induction. In addition, there were no significant differences in parents' self-reported anxiety, as measured by the STAI, between the three groups (STAI scores and p values were not provided).
  • Kain et al.109 undertook a prospective study of parents and their children (mean age = 4.9 years) who were part of a previous investigation by the authors at their initial surgery and were undergoing a subsequent surgery. At their initial surgery, the children had been assigned to the following preoperative intervention: parental presence (n = 27), oral midazolam (n = 13), parental presence plus oral midazolam (n = 10) and no intervention (n = 33). The authors allowed parents to choose their preoperative intervention group at the subsequent surgery. The parents of the 83 children in the study chose the following preoperative intervention: parental presence (n = 46), oral midazolam (n = 8), parental presence plus oral midazolam (n = 21) and no intervention (n = 8). Anxiety was measured for children with the mYPAS and for parents with the STAI. There were no significant differences between the groups regarding children's anxiety upon entering the operating room (median mYPAS score [range]: parental presence = 45.8 [22.9–91.7], oral midazolam = 54.2 [22.9–95.8], parental presence plus oral midazolam = 35.4 [22.9–100.0], and no intervention = 23.2 [22.9–45.8; p = 0.31) or during induction (median mYPAS score [range]: parental presence = 45.8 [22.9–100.0], oral midazolam = 65.5 [22.9–95.8], parental presence plus oral midazolam = 34.2 [22.9–100.0], and no intervention = 24.5 [22.9–50.0]; p = 0.15). There was also no significant difference in parents' anxiety at separation (mean STAI score: parental presence = 42.8 ± 11.1, oral midazolam = 49 ± 6.5, parental presence plus oral midazolam = 43.3 ± 13.0 and no intervention = 37.8 ± 6.5; p = 0.28). Children in the midazolam group experienced significantly higher anxiety in the preoperative holding area than children in the other groups (median mYPAS score [range]: parental presence = 23.3 [23.3–70.0], oral midazolam = 37.5 [23.3–68.8], parental presence plus oral midazolam = 45.8 [23.3–96.7], and no intervention = 23.3 [23.3–55.0]; p = 0.03). Parents of children in the midazolam group were also significantly more anxious than parents of children in the other groups in the preoperative holding area (mean STAI score: parental presence = 38.6 ± 9.1, oral midazolam = 47.3 ± 8.4, parental presence plus oral midazolam = 42.5 ± 12.2 and no intervention = 36.8 ± 5.1; p = 0.09). Interestingly, of parents whose children received parental presence at the initial surgery, 70% chose to be present during induction again. In contrast, only 23% of the patients who received midazolam at the initial surgery requested midazolam at the subsequent surgery and only 15% of the patients who received no intervention at the initial surgery requested no intervention at the subsequent surgery. Parents' intervention preferences at the subsequent surgery were influenced by children's anxiety at the initial surgery.
  • Arai et al.18, in 22 pairs of mothers and children (1-3 years old) scheduled for minor plastic surgery under general anaesthesia found that higher parental anxiety pre-surgery, as indicated by higher amounts of maternal salivary amylase activity, was significantly correlated with higher children's anxiety during induction (rs = -0.667, p < 0.0001) and severer children's emergence agitation (rs= 0.705, p < 0.0001). Both children's anxiety and agitation were rated by a blind observer.
  • In another study17 the same authors randomised, using computer-generated random numbers, 58 children, aged 1-3 years, classified as ASA I, undergoing minor plastic surgery under general anaesthesia to one of three groups: (a) a sedative group (0.5 mg/kg oral midazolam) (n= 19); (b) parental presence (20); (c) a sedative and parental presence (19). Children in the midazolam group showed a better quality of mask induction compared with those on the parental presence group but the addition of parental presence to oral midazolam did not provide additional improvement of mask induction. In contrast, the children in the midazolam and parental presence group were less agitated than those in the other groups at emergence from anaesthesia.
  • A recent meta-analysis237 that assessed the effects of non-pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their cooperation concluded that the presence of parents during induction of general anaesthesia does not reduce their child's anxiety. However, the authors commented further that calm parents may be helpful and parental presence should be considered on an individual basis.

Taken in combination the results of the above randomised studies indicate that current evidence shows that there is no apparent benefit of parental presence during anaesthesia induction in relation to decreasing parents' and children's anxiety39. In many cases, midazolam or distraction techniques appear to be a suitable substitute. Overall, positive effects for parental presence, including lower levels of child anxiety and distress, have been reported in studies in which parents were not randomly assigned to condition but were permitted to self-select presence or absence. In terms of child characteristics, a prospective cohort study has demonstrated that children who benefit from parental presence are older, have lower levels of activity in their temperament and have parents who are calmer and who value preparation and coping skills for medical situations114.

5.10. Parental presence during medical procedures

Piira et al.183 conducted a systematic review, of controlled studies investigating parental presence in the paediatric treatment room at the time of their child's medical procedure. A total of 28 studies met the inclusion criteria, which were as follows: the studies evaluated the effects of parental presence on child, parent or health professional outcomes; concurrent control groups were used; only primary data were used to avoid bias resulting from the use of duplicate results. The age of the children participating in the studies ranged from 2 weeks to 18 years. 1256 children had a parent present and 1025 children did not have a parent present. The medical experiences included routine immunisations, venipunctures, dental procedures, lumbar punctures, burns treatments, intubation, central line placement, chest tube placement and anaesthesia induction, with some studies including a number of different painful contexts. There were mixed findings regarding the effect of parental presence on measures of child distress and affect; however, studies of lower levels of evidence were more likely to report significant results. Parents who were present during their child's medical intervention were either better off or no different from parents who were absent with regard to their levels of distress and satisfaction. There was no evidence of increased technical complications nor elevated staff anxiety for health professionals attending to children with a parent present as compared to attending to children without their parents.

5.11. The role of the parents during medical procedures and/or anaesthesia induction

In the paediatric pain literature a number of studies point to the role that parents play in shaping their child's pain perception and distress response. Certain parental behaviours are associated with child coping and others with child distress when children undergo painful medical procedures. Parenting behaviours such as agitation, provision of reassurance, empathic comments, giving control, excessive explanations and apologies to their children have been shown to be associated with (and indeed precede) elevated distress and increased pain intensity during medical procedures30,31,48. Humour, commands to use coping strategies and non-procedural talk are associated with increases in child's coping. Dahlquist and colleagues47 demonstrated the influence of speech function on pain distress. Their results showed that vague commands by caregivers were positively associated with child distress during painful procedures. Liossi and colleagues145 showed that parental expectancies are highly predictive of experienced pain in children undergoing lumbar punctures.

Parents are often anxious not only about their child's distress but also about their own ability to support and comfort their child through a painful experience. Thus, parents need to be included in interventions and helped to control their own anxiety, which in turn will ensure less anxiety being communicated to the child. Simple educational leaflets can give useful information and more extensive training programmes can teach parents what to do185.

5.12. Summary - preparation for sedation

In summary, current evidence from the literature dealing with patient preparation, that is, preparation for anaesthesia and medical procedures suggests:

  • that preparation for sedation is important for young people and their parents
  • there is some helpful direction informing what this should and should not include and how it is performed.

For children, the extensiveness and style of preparation should be guided by each child's age and developmental level

In general, specific discussion about the sedation and procedure has more relevance for children >2 years of age. The outcome from this narrative review suggests that preparation should have at least three components, namely:

  • what will happen (where, how long it will last and what will be done)
  • how it will feel (pressure, temperature and level of discomfort to be expected)
  • strategies to cope with the stressor (which may be related to the sedation technique and/or procedure57,182,210.

Given this, children can be asked what strategies they think will help them to cope and, if possible, those strategies should be incorporated into the sedation administration. In addition, given the strong data supporting distraction, distraction techniques should be used during the induction of sedation. Evidence supporting the use of behavioural strategies, such as teaching children coping techniques to alleviate their preoperative anxiety, has emerged throughout the literature236. Teaching children coping skills allows them to learn how to calm themselves in times of stress and thus may be useful not just at the time of the procedure in question but at subsequent procedures as well.

For parents, there is inconclusive evidence indicating whether parents should be encouraged or discouraged to be present at their child's induction. The offer to be present is therefore based on negotiation with the care team. Although parental presence may not have a clear, direct influence on child distress and behavioural outcomes, there are potential advantages for parents and children; offering the option of parental presence is clearly in line with a paradigm shift to family-centred care during hospitalisation112. Parental inclusion in supporting interventions may also help their own anxiety, lessening the potential for this to be communicated to their child.

Copyright © 2010, National Clinical Guideline Centre.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

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Cover of Sedation in Children and Young People
Sedation in Children and Young People: Sedation for Diagnostic and Therapeutic Procedures in Children and Young People [Internet].
NICE Clinical Guidelines, No. 112.
National Clinical Guideline Centre (UK).

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