Association of Temperament With Preoperative Anxiety in Pediatric Patients Undergoing Surgery: A Systematic Review and Meta-analysis

Effect of video distraction on preoperative anxiety scores in pediatric patients undergoing general anesthesia in ophthalmic daycare procedures: A randomized controlled trial

Background and Aims

Parental separation, fear, and exposure to the operating room environment lead to stress and anxiety in pediatric patients. This study aims to identify the research gaps in the effect of video distraction on pediatric patients of Indian origin. We hypothesized that video distraction along with parental presence would reduce preoperative anxiety in pediatric patients undergoing ophthalmic procedures under general anesthesia compared with parental presence alone.

Material and Methods

In this prospective randomized trial, 145 patients aged 2-8 years, ASA I-II, with at least one functional eye undergoing elective ophthalmic daycare procedures were enrolled. They were randomly allocated to two Groups: Group V had distraction by watching a video/playing a video game together with parental presence, whereas control Group C had parental presence alone without any video distraction. The primary objective of the study was to compare preoperative anxiety using the Modified Yale Preoperative Anxiety score (mYPAS) and heart rate (HR), whereas the secondary objective was to compare child fear, emergence delirium, and parental satisfaction between the two groups. The three time points for intergroup comparisons were the preoperative holding area 10 min before induction (T0), transport of the child to the operating room (T1), and face mask introduction (T2).

Results

There was a statistically significant difference between mYPAS score in groups V and C at all time points (P = 0.036, P = 0.0001, P = 0.0000), parental satisfaction score at all three time points (P = 0.0049, P = 0.0000, P = 0.0000), and Child Fear Score at T1 and T2 (P = 0.0001, P = 0.0001, respectively). However, there was no statistically significant difference in the emergence of delirium between the two groups.

Conclusions

Video distraction together with parental presence has a promising role for implementation in hospitals with heavy workload settings where pharmacological intervention would not be feasible, to alleviate preoperative anxiety in children. However, preoperative anxiety may not translate into increased postoperative emergence delirium as was earlier believed.

Developing the pediatric surgery patient satisfaction scale and assessment of its validity and reliability

Aim of this study was to develop a patient satisfaction scale for needs and expectations of pediatric surgery patients and to propose a new measurement tool in this field. Population of study consisted of all patients between May 2018 and February 2020 at a pediatric surgery service of a university hospital in Turkey. A pool of 70 items was prepared for scale. Two items were removed in line with expert opinions and suggestions. As a result of content validity and test application, 36 items were removed, and scale was revised. Data were transferred to SPSS Statistics 23 and AMOS 22 program. After evaluating scope validity of scale, Content Validity, Structural Validity, Exploratory Factor Analysis, and finally Reliability Analysis were examined. As a result of the analyses, 32 items with eight sub-dimensions were obtained from scale. Eight-factor scale explained 60.42% of total variance. Cronbach Alpha internal consistency of scale was found to be 0.88. Item factor loads of scale were created and the reliability of scale were obtained at desired level. The scale is suitable for patients aged 6 to 18 years old.

Predictors of parental anxiety in a paediatric emergency department

BACKGROUND

Children experience significant anxiety in the paediatric ED. Although research from preoperative and primary care samples indicates that parents experience anxiety surrounding their children's medical procedures, less is known about parental anxiety and factors that contribute to higher parental anxiety in the ED. This study aimed to assess parental anxiety in families presenting to a paediatric ED with a variety of presenting concerns and examine demographic and psychological factors associated with parental anxiety.

METHODS

This cross-sectional study included parents of children <18 years old presenting to a paediatric ED in Orange County, California, USA, for a non-psychiatric complaint between 20 January 2021 and 26 March 2021. Parents were, on average, 34.76±9.10 years old, 87.5% were mothers, 59.2% identified as non-Latinx and parents reported average levels of mental health (T-score=51.21±9.84). Parent state anxiety was assessed via the State-Trait Anxiety Inventory and validated instruments were used to measure child temperament (ie, emotionality, activity, sociability, shyness), previous medical anxiety, and parent physical and mental health. Data were analysed using multiple linear regression models.

RESULTS

Out of 201 families screened, 150 were eligible, and 120 enrolled. In the sample, 42.5% of parents endorsed clinically significant levels of anxiety in the ED. Regression analyses indicated that lower child activity temperament (ie, tendency to be less active/energetic; B=-3.20, 95% CI -5.70 to -0.70, p=0.012) and poorer parent mental health (B=-0.31, 95% CI -0.52 to -0.09, p=0.006) were independently associated with higher parent anxiety (F(5, 99)=6.77, p=0.004).

CONCLUSION

Over 40% of parents sampled endorsed clinically significant anxiety in the paediatric ED. Child temperament, specifically lower activity temperament, and poorer parental mental health were identified as contributors to parent anxiety, whereas clinical condition or severity did not influence parent anxiety. Current results may help identify families in need of additional intervention and may improve patient outcomes.

Children's Shyness, Frontal Brain Activity, and Anxiety in the Perioperative Context

Although preoperative anxiety affects up to 75% of children undergoing surgery each year and is associated with many adverse outcomes, we know relatively little about individual differences in how children respond to impending surgery. We examined whether patterns of anterior brain electrical activity (i.e., a neural correlate of anxious arousal) moderated the relation between children's shyness and preoperative anxiety on the day of surgery in 70 children (36 girls, Mage = 10.4 years, SDage = 1.7, years, range 8 to 13 years) undergoing elective surgery. Shyness was assessed using self-report approximately 1 week prior to surgery during a preoperative visit (Time 1), preoperative anxiety was assessed using self-report, and regional EEG (left and right frontal and temporal sites) was assessed using a dry sensory EEG headband on the day of surgery (Time 2). We found that overall frontal EEG alpha power moderated the relation between shyness and self-reported preoperative anxiety. Shyness was related to higher levels of self-reported anxiety on the day of surgery for children with lower average overall frontal alpha EEG power (i.e., higher cortical activity) but not for children with higher average overall frontal alpha EEG power (i.e., lower cortical activity). These results suggest that the pattern of frontal brain activity might amplify some shy children's affective responses to impending surgery. Findings also extend prior results linking children's shyness, frontal brain activity, and anxiety observed in the laboratory to a real-world, ecologically salient environment.

Non-pharmacological interventions to reduce anxiety among children undergoing surgery: A systematic review

A hospitalized child experiences anxiety more frequently as compared to non-hospitalized children. Surgery can be emotionally distressing for children, and subsequently their parents and caregivers, this distress can cause profound adverse impacts on children. We aimed to identify the effect of non-pharmacological interventions on children's (1-18 years) anxiety undergoing surgery. The following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Proquest, Web" of Science, and Cochrane Central Register of Controlled Trials were systematically searched for full-text articles. The review included 15 randomized controlled trials. The risk of bias was assessed using Cochrane Risk of Bias tool. The interventions included in the study were preoperative education, puppet play, therapeutic play, distraction activities, parental presence, and clown therapy. The review presents a narrative reporting of the findings. This review identifies that non-pharmacological interventions are effective in reducing anxiety among children undergoing surgery. There are a limited number of studies from developing countries. Further research is required to underpin the use of these interventions with children before surgery.

Incidence and risk factors associated with negative postoperative behavioral changes in children undergoing painless gastroscopy

OBJECTIVE

To investigate the incidence of and risk factors associated with negative postoperative behavioral changes (NPOBCs) in children undergoing painless gastroscopy.

METHODS

Inclusion criteria: ASA I-II and outpatients aged 6-12 years undergoing painless gastroscopy.

EXCLUSION CRITERIA

history of surgery or anesthesia, children with developmental or intellectual abnormalities, refusal to participate, preoperative abdominal pain score > 3 points, history of chronic abdominal pain of > 3 months duration, and serious intraoperative complications. On the 1st, 14th, and 30th day after the gastroscopy, the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS) was used to assess NPOBCs in children.

RESULTS

A total of 1,670 children were included in this prospective observational cohort study. The incidence rates of NPOBCs were 14.13%, 4.55%, and 2.14% on the 1st, 14th, and 30th day after gastroscopy, respectively. The risk factors for the first day were female sex (OR 1.34, 95% CI 1.00-1.79), parental anxiety (OR 2.23, 95% CI 1.75-3.12), and severe anxiety in children (OR 2.83, 95% CI 1.96-4.07). The risk factors on the 14th day were parental anxiety (OR 3.71, 95% CI 2.19-6.29), a parental educational level above high school (OR 1.65, 95% CI 1.00-2.70), and severe anxiety in children (OR 11.87, 95% CI 5.85-24.07). The risk factors on the 30th day were female sex (OR 2.99, 95% CI 1.41-6.34), being an only child (OR 4.42, 95% CI 2.18-8.95), a parental educational level above high school (OR 2.66, 95% CI 1.27 NPOBCs 5.56), and severe anxiety in children (OR 6.84, 95% CI 2.84-16.49).

CONCLUSION

In children undergoing painless gastroscopy, the incidence rates of NPOBCs on the 1st, 14th, and 30th day were 14.13%, 4.55%, and 2.14%, respectively. The risk factors for NPOBCs were severe anxiety in children, female sex, parental anxiety, and a parental educational level above high school. In particular, severe preoperative anxiety in children was a persistent risk factor for NPOBCs within 30 days.

Assessment of potential predictors affecting preoperative anxiety in Indian children- A prospective observational study

Background and Aims

Preoperative anxiety is a common problem among children undergoing surgery. The aim of the study was to assess the incidence and identify various predictors of preoperative anxiety in Indian children.

Material and Methods

A prospective, observational study was conducted on 60 children of the American Society of Anesthesiologists Physical status 1/2, aged 2-6 years and scheduled for elective surgery under general anesthesia in a tertiary care teaching hospital. Preoperative parental anxiety was assessed using the State-Trait Anxiety Inventory questionnaire. The children's anxiety was assessed in the preoperative room, at the time of parental separation, and at the induction of anesthesia using modified Yale Preoperative Anxiety Scale (mYPAS) scoring by an anesthesiologist and a psychologist. Sedative premedication was employed prior to parental separation. Logistic regression analysis was carried out to identify the possible predictors of anxiety.

Results

The incidence of high preoperative anxiety among the studied children was 76% in the preoperative room, 93% during parental separation, and 96% during anesthetic induction. Among the nine possible predictors identified on univariate regression, the presence of siblings was found to be a significant independent predictor on multivariate regression analysis (P = 0.04). The inter-rater agreement was excellent for the assessment of preoperative anxiety using mYPAS by the anesthesiologist and psychologist (weighted Kappa, k = 0.79).

Conclusion

The incidence of preoperative anxiety in Indian children in the age group of 2-6 years is very high. The preop anxiety escalates progressively at parental separation and induction of anesthesia despite sedative premedication. The presence of siblings is a significant predictor of preoperative anxiety.

Development and validation of a prediction model for preoperative anxiety in children aged 2-12 years old

BACKGROUND

Children with preoperative anxiety are at risk of perioperative adverse events, such as reflux aspiration, prolonged induction time, wake agitation, and delirium. Identifying children at high risk of severe preoperative anxiety may help anesthesiologists intervene and manage them in advance.

AIM

The authors hypothesized that the risk of developing serious preoperative anxiety in children is predictable by variables related to basic information about the parent and child. We developed a clinical prediction model to identify patients vulnerable to severe preoperative anxiety among children aged 2-12 years.

METHODS

We enrolled patients aged 2-12 years who underwent elective surgery under general anesthesia and divided them into derivation (n = 340, 70.8%) and validation (n = 140, 29.2%) groups. Preoperative anxiety was assessed using the modified Yale Preoperative Anxiety Scale, and a high level of preoperative anxiety was defined as a score of >30. The following predictors were collected preoperatively: gender, age, weight, children's education level, only child, history of surgery, waiting time in the anesthesia waiting area, parental education level, parental anxiety, whether venous access had been established in the ward, and whether they had received anti-anxiety interventions. A prediction model was built using binary logistic regression analysis; bootstrap was applied for internal validation, and external validation was performed using the validation datasets.

RESULTS

The prediction model had good discrimination, with an area under the receiver operator characteristic curve (AUC) of 0.961 (95% CI = 0.943-0.979) and 0.896 (95% CI = 0.842-0.950) in the derivation and validation cohorts, respectively. The predictive variables included in the final clinical model were pharmacological intervention (OR = 0.008, 95% CI = 0.002-0.025), nonpharmacological intervention (OR = 0.342, 95% CI = 0.104-1.127), parental education level (OR = 0.211, 95% CI = 0.108-0.411), parental anxiety (OR = 6.15, 95% CI = 2.396-15.786), only child (OR = 2.417, 95% CI = 1.065-5.488), history of surgery (OR = 3.513, 95% CI = 1.137-10.860), and age (OR = 0.692, 95% CI = 0.500-0.957).

CONCLUSIONS

In this study, a clinical prediction model was developed and validated for the first time. The proposed clinical prediction model can help doctors identify children most likely to develop a high level of preoperative anxiety.

CLINICAL TRIAL REGISTRATION IDENTIFIER

ChiCTR2100054409 (https://www.chictr.org.cn/index.aspx).

Children's perioperative multidimensional anxiety scale: Turkish cross-cultural adaptation

RATIONALE

The number of pediatric surgeries is constantly increasing. Evaluating anxiety levels in pediatric surgical patients is highly important in terms of preventing complications.

AIMS AND OBJECTIVES

The purpose of this study is to cross-culturally adapt to the Turkish version, and to test the validity and reliability of Children's Perioperative Multidimensional Anxiety Scale (CPMAS).

METHOD

This methodological study was carried out with 50 children aged 7-10 years who underwent surgery at Bartın Obstetrics and Pediatrics Hospital between September 2021 and May 2022. The self-reported CPMAS and Children's Anxiety Meter-State (CAM-S) were administered before the surgery, on the day of the surgery, and 1 month after the surgery to collect data. The internal consistency, test-retest reliability, parallel forms reliability, content validity, and construct validity of CPMAS were tested.

RESULTS

Children's Perioperative Multidimensional Anxiety Scale showed a high level of internal consistency (Cronbach's alpha = 0.858, 0.916, 0.864). The item-total correlation values of CPMAS were found to be 0.58-0.71 before the surgery, 0.77-0.83 on the day of the surgery, and 0.60-0.80 1 month after the surgery. CPMAS was found to be a single-factor scale explaining 65% of the variance in the examined variable. The correlations between CPMAS and CAM-S (parallel forms) were found to be 0.474 before the surgery, 0.528 on the day of the surgery, and 0.599 1 month after the surgery.

CONCLUSION

The CPMAS, which was developed by Chow et al. in English, had high validity and reliability levels for Turkey. It is recommended that the scale be used by healthcare professionals in Turkey in the assessment of surgery-related anxiety in children.

Correlation of temperament characteristics and early functional exercise compliance in school-age children with limb fractures: Implication for clinical nursing care

Early functional exercise plays a very important role in the rehabilitation and nursing care of children with fractures. We aimed to evaluate the role of temperament characteristics in the early functional exercise compliance in school-age children with limb fractures, to provide evidence to clinical nursing care. School-age children with limb fractures admitted to our hospital from January 1, 2021 to June 30, 2022 were selected. We collected the general information, evaluated the temperament characteristics and their functional exercise compliance in school-age children. Correlation and regression analyses were conducted to assess the correlation of temperament characteristics and early functional exercise compliance. A total of 126 school-age children with limb fractures were finally included. There were 68, 36, and 22 children that were rated as easy-going, troublesome and initiate slow temperament, respectively. The children with easy-going temperament had the best early functional exercise compliance, followed by children with initiate slow temperament, and compliance of children with troublesome temperament was the worst. The reaction intensity factor in the temperament characteristics of school-age children with fracture was negatively correlated with early functional exercise compliance (P = .007). Reaction intensity was a risk factor for early functional exercise compliance in school-age children with fractures (P = .004). Health care providers must consider the influence of temperament characteristics on compliance in school-age children with fractures, and take targeted nursing measures according to different temperament characteristics of children to improve early functional exercise compliance in school-age children with fractures, so as to improve the functional recovery and prognosis of children.

Research Progress on Risk Factors of Preoperative Anxiety in Children: A Scoping Review

Preoperative anxiety has adverse effects on children and negative impacts on postoperative rehabilitation. Anesthesiologists can accurately identify children with preoperative anxiety, and individualized intervention can effectively improve their psychological state and clinical prognosis. However, a comprehensive summary of the current available evidence has yet to be conducted. Searches were conducted in Medline databases from inception to March 2022. Primary studies that reported preoperative anxiety in children and its attendant effects on postoperative recovery and prognosis were screened and included. Among the 309 publications identified, 12 related studies (n = 3540 patients) met the eligibility criteria. The incidence of preoperative anxiety in children in the included studies ranged from 41.7% to 75.44%. While 16 influencing factors were identified, only 5 factors had a significant impact on preoperative anxiety in children: younger age (n = 8), parental anxiety (n = 7), negative previous hospitalizations (n = 3), less sociableness (n = 2), and surgical setting (n = 1). The current scoping review identified risk factors for preoperative anxiety in children. Healthcare workers should identify and manage preoperatively anxious children. There are still some factors that are controversial, and large-scale clinical studies are needed.

Compliance of functional exercises in school-age children with limb fractures: implication for nursing countermeasures

Background

Functional exercises is very essential to the recovery of patients with fracture. We aimed to evaluate the compliance of functional exercises in school-age children with limb fracture, to provide evidence to the clinical management and nursing care of children with limb fracture.

Methods

School-age children with limb fractures treated in our hospital from January 1, 2020 to June 30, 2021 were selected. The characteristics and postoperative functional exercise compliance of included children were analyzed. Pearson correlation and Logistic regression analysis were conducted to analyze the influencing factors of compliance to functional exercises.

Results

A total of 328 children with limb fracture were included, the incidence of compliance to functional exercise was only 35.98%. Pearson correlation analysis showed that age(r = 0.707), only child of family(r = 0.537), guardians(r = 0.642) and type of temperament(r = 0.635) were correlated with compliance to functional exercises in school-age children with limb fractures (all p < 0.05). Logistic regression analysis indicated that age ≤ 10y (OR2.913, 95%CI2.091 ~ 3.611), only child of family (OR2.006, 95%CI1.683 ~ 2.558), guarded by grandparents (OR1.512, 95%CI1.201 ~ 2.118), non-easy-going temperament (OR4.127, 95%CI3.811 ~ 4.902) were the influencing factors of non-compliance to functional exercises in children with limb fracture (all p < 0.05).

Conclusions

School-age children have poor compliance with functional exercises after limb fractures, and there are many influencing factors. For children with those risks, health care providers should actively intervene in nursing to improve children’s exercise compliance and the rehabilitation effect.

Association of Age and Temperamental Traits with Children's Behaviour during Dental Treatment

During paediatric dental treatment, cooperation by children is essential, and temperament can determine their behaviour style. This study aimed to associate temperamental traits and age with behaviour during paediatric dental treatment. This was an observational and cross-sectional study of patients aged 3-10 years. To determine the temperamental traits, an Emotionality Activity and Sociability Temperament Survey (EAS) was performed with the children's parents. The type of behaviour was determined with Frankl's criteria. The total scores for temperamental traits, means, and standard deviations were obtained. The chi-squared test, one-way ANOVA and Student's t-test were applied. A total of 140 patients, who were 5 ± 2.1 years old, participated in the study. Age was determinant for negative behaviour, with a greater frequency in children ≤5 years old (p < 0.05), and a significant negative correlation between age and behaviour (rho = -0.245, p = 0.001). Patients with higher emotionality and activity presented negative and definitely negative behaviours more frequently (p < 0.01). The values for sociability and shyness were similar for positive or negative behaviours. In conclusion, the temperamental traits of emotionality and activity were more frequent in children with disruptive behaviours; therefore, conducting a survey on temperamental traits can be useful for planning behavioural approaches in paediatric dentistry.

A systematic scoping literature review on the use of child life therapy (CLT) in the perioperative setting

BACKGROUND

Children and their caregivers often experience anxiety related to a perioperative admission. A systematic scoping review was conducted to map the evidence for child life therapy, including the professional background of treating clinicians.

METHODS

A scoping review was conducted using the Arksey and O'Malley methodology. Six databases: PubMed, CINAHL, PsychINFO, Cochrane Library, EMBASE and Web of Science were searched.

RESULTS

After reviewing 578 titles and abstracts, and 55 full texts, 11 studies were retained. Included studies were randomised controlled trials (n = 5), retrospective studies (n = 3), descriptive studies (n = 1) and clinical studies (n = 2). Child life therapy was effective for anxiety, anaesthetic induction quality, child cooperation and parental satisfaction. Professions delivering interventions included Child Life Therapists, nurses and a multidisciplinary team.

CONCLUSION

There is emerging evidence for child life therapy which may be used to guide delivery of paediatric procedural support in perioperative settings. Further studies are needed to inform practice.

The role of anxiety and related states in pediatric postsurgical pain

Background: Nearly 20% of children and adolescents have pain with disability 1 year after surgery, and they experience poor sleep, school absence, and decreased activities. Negative clinical, psychological, and developmental effects include greater pain medication use, longer recovery, and fear of future medical care. Research has found psychological and family influences (i.e., child and parental anxiety) on pediatric chronic postsurgical pain (CPSP), but a better understanding of the role of perioperative anxiety and its related states in predicting pediatric postsurgical pain is needed. The poor understanding of the causes of child CPSP can lead to misdiagnosis and inadequate treatment, with significant short- and long-term effects. Objectives: The aim of this review was to summarize the literature on children's perioperative anxiety and parental anxiety in relation to acute postsurgical pain, CPSP, and pain trajectories. We also examined other related psychological factors (i.e., anxiety sensitivity, catastrophizing, pain anxiety, and fear of pain) in relation to pediatric acute and chronic postsurgical pain. Lastly, we discuss the interventions that may be effective in reducing children's and parents' preoperative anxiety. Conclusions: Our findings may improve the understanding of the causes of CPSP and highlight the gaps in research and need for further study.