Effects of psychological preparation on children hospitalized for dental operations

Systematic review of the development and effectiveness of digital health information interventions, compared with usual care, in supporting patient preparation for paediatric hospital care, and the impact on their health outcomes

Background and aim

Elective surgery can be overwhelming for children, leading to pre-operative anxiety, which is associated with adverse clinical and behavioural outcomes. Evidence shows that paediatric preparation digital health interventions (DHIs) can contribute to reduced pre-operative anxiety and negative behavioural changes. However, this evidence does not consider their design and development in the context of behavioural science. This systematic review used the Theoretical Domains Framework (TDF) to evaluate the design and development of DHIs used to support children up to 14 years of age and their parents, prepare for hospital procedures, and determine any correlation to health outcomes. It also considered whether any behavioural frameworks and co-production were utilised in their design.

Methods

A search of the MEDLINE, EMBASE, PsycINFO, and HMIC databases was carried out, looking for original, empirical research using digital paediatric preparation technologies to reduce pre-operative anxiety and behavioural changes. Limitations for the period (2000-2022), English language, and age applied.

Results

Seventeen studies were included, sixteen randomised control trials and one before and after evaluation study. The results suggest that paediatric preparation DHIs that score highly against the TDF are (1) associated with improved health outcomes, (2) incorporate the use of co-production and behavioural science in their design, (3) are interactive, and (4) are used at home in advance of the planned procedure.

Conclusion

Paediatric preparation DHIs that are co-produced and designed in the context of behavioural science are associated with reduced pre-operative anxiety and improved health outcomes and may be more cost-effective than other interventions.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022274182.

State of the Art: Immersive Technologies for Perioperative Anxiety, Acute, and Chronic Pain Management in Pediatric Patients

Purpose of Review

This review summarizes and provides a comprehensive narrative synthesis of the current evidence on immersive technology’s (i.e., virtual and augmented Reality) use for perioperative anxiety, acute, and chronic pain in pediatrics.

Recent Findings

Researchers have increasingly studied immersive technology as a non-pharmacological alternative for perioperative anxiety, acute, and chronic pain management. We found several research studies published over the last 3 years: almost all studies examined the use of virtual reality for perioperative anxiety and pain; only one case report was about the use of augmented reality for preoperative anxiety. Most studies showed that virtual reality intervention is effective and safe for perioperative anxiety, acute, and chronic pain. However, the studies are heterogeneous with relatively small sample sizes.

Summary

This review shows that more high-quality studies (i.e., randomized controlled trials with larger sample sizes and standardized methods for measuring and reporting outcomes) are needed to examine the effectiveness and adverse effects of virtual reality intervention on perioperative anxiety, acute, and chronic pain in pediatrics.

Oncological Children and Well-Being: Occupational Performance and HRQOL Change after Fine Motor Skills Stimulation Activities

Cancer children experience long periods of hospitalization, which are associated with limited performance in several developmental domains and participation restrictions in age appropriate occupations. Fine motor abilities represent building blocks in performing daily life skills and have been found to be closely connected with later academic success. Moreover, medical and psychological sequelae for cancer inpatients may result in diminished daily activities functioning, poor perceived health related quality of life (HRQOL), and increase the likelihood of long-term impairments. This study examines the variations in the occupational performance of children hospitalized for acute lymphoblastic leukemia (ALL) after their participation to a stimulation program designed to enhance fine motor skills. Parents reported significant gains in children's motor functioning, a slight improvement in overall occupational performance related to an increase in the area of productivity and self-care, and a better quality of life perception following the stimulation activities. Feasibility of the stimulation program in a health care setting are discussed evaluating its benefits for cancer children and their families.

Participation of paediatric patients in primary dental care before and after a dental general anaesthetic

Purpose

The aim of this retrospective study is to determine children’s attendance and experience of preventative interventions and operative treatment (restorations and extractions) with their primary care dentist (PCD) in the 12 months before and after their caries management under dental general anaesthetic (DGA).

Methods

A record of all children who had an elective DGA in 2016 across two hospital sites was retrospectively obtained (n = 1308). A representative sample of 300 was randomly selected encompassing 114 dental practices. An online questionnaire to the children’s PCDs collated quantitative and qualitative data regarding participation in the pre- and post-DGA period.

Results

Data was collated and analysed for 80 children (mean age: 6 years 10 months [SD = 2.49; range: 2 years 1 month – 14 years 3 months]; equal sex distribution) with 43 responding PCDs. Attendance for examination declined significantly from 85% (n = 68) pre-DGA to 57.5% (n = 46) post-DGA (p ≤ 0.001). Attendance at emergency appointments pre-DGA was high (33.75% [n = 27]); a significant reduction post-DGA was recorded (p ≤ 0.001). Over one third of children (37.5% [n = 30]) did not receive any form of preventative intervention over 24 months. A non-significant reduction in the provision of operative treatment was observed post-DGA (p = 0.06 [fill, primary]; p = 0.78 [fill, permanent]; p = 0.66 [ext, primary]). No statistical difference between age and treatment experience was found. Qualitative analysis revealed challenges in providing care included behavioural difficulties and poor attendance.

Conclusion

Improvements are required in strategies employed to support high caries risk children pre- and post-DGA to facilitate a higher incidence of attendance and preventative intervention with PCDs.

"Doc McStuffins: Doctor for a Day" Virtual Reality (DocVR) for Pediatric Preoperative Anxiety and Satisfaction: Pediatric Medical Technology Feasibility Study

Background

Preoperative anxiety is a common occurrence among children and is associated with a host of maladaptive postoperative behaviors. Consequently, increased attention has been placed on interventions to reduce preoperative anxiety and its associated outcomes. Child Life preparation prior to surgery includes evidence-based practices such as age-appropriate distraction and therapeutic play. Virtual reality (VR) is a promising addition to the Child Life toolbox to address anxiety prior to surgery. The current study evaluates the implementation and feasibility of a VR experience, “Doc McStuffins: Doctor for a Day Virtual Reality Experience” (DocVR), developed by Disney Junior in collaboration with Children’s Hospital Los Angeles, to target pediatric preoperative anxiety.

Objective

The primary aim of this study was to examine the feasibility and efficacy of DocVR for preoperative anxiety. A secondary aim was to improve patient, caregiver, and health care provider satisfaction with the preoperative experience.

Methods

In this study, 51 patients (age 6-14 years) scheduled for surgery in the ambulatory surgery center and the main operating room at Children’s Hospital Los Angeles were approached to participate in Disney’s DocVR experience. The patients played the DocVR experience for an average of 18 minutes (3-55 minutes). Irrespective of surgical procedure, patients and their families were eligible, as long as they had no known marked cognitive or visual impairments that would interfere with completing the survey and engaging in the DocVR experience.

Results

Patients who tried the DocVR experience (n=51) responded overwhelmingly positively to both the VR technology and to the game itself. Patients experienced a statistically significant decrease in anxiety following DocVR game play (Z=–3.26, P=.001). On the Facial Affective Scale, the percentage of patients who chose the face with the most positive facial expression to represent their affect increased from 23% (12/51) pre-VR to 49% (25/47) post-VR. Furthermore, 97% (38/39) of patients reported feeling more comfortable at the hospital, and 74% (28/38) reported feeling less scared at the hospital after playing the game. The game was enjoyed by 94% (46/49) of patients, and 88% (30/34) of patients reported feeling both “Interested” and “Involved” in the game.

Conclusions

DocVR is a feasible and beneficial VR experience to relieve pediatric preoperative anxiety and improve satisfaction in the preoperative area. The VR experience resulted in a decrease in overall anxiety and an increase in overall positive affect during the preoperative time. Patients also responded positively to the game, confirming their interest in the content and affirming the quality of the DocVR experience. The positive response to the game indicates that DocVR has the potential to make the overall preoperative experience less anxiety-producing and more comfortable, which leads to improved patient satisfaction. Naturally, improved patient outcomes lead to improved caregiver and health care provider satisfaction.

Dental anxiety: An understudied problem in youth

Dental anxiety and dental phobia typically emerge during childhood; the associated avoidance of dental care can result in oral health problems and is associated with lower quality of life. In this review, we discuss the definition of dental phobia and dental anxiety and issues related to their differentiation. We then review the literature on dental anxiety and dental phobia, including its prevalence, assessment, and sequalae. Moreover, we provide a synthesis of findings on the etiology and maintenance of dental phobia and propose a comprehensive cognitive behavioral model to guide further study. We also present a systematic qualitative and a quantitative review of the treatment literature, concluding that although we have made strides in learning how to prevent dental anxiety in youth, the methods effective in preventing anxiety may not be equally effective in treating youth with dental phobia. We propose a multidisciplinary approach, including those with expertise in pediatric anxiety as well as pediatric dentistry, is likely required to move forward.

Therapeutic play to prepare children for invasive procedures: a systematic review

OBJECTIVE

To analyze the available evidence regarding the efficacy of using therapeutic play on behavior and anxiety in children undergoing invasive procedures.

DATA SOURCE

The systematic review search was performed in the MEDLINE, LILACS, CENTRAL and CINAHL databases. There was no limitation on the year or language.

SYNTHESIS OF DATA

The literature search found 1892 articles and selected 22 for full reading. Eight articles were excluded, as they did not address the objectives assessed in this review. Twelve studies, representing 14 articles, were included. The studies were conducted between 1983 and 2015, five in Brazil, one in the United States, five in China, one in Lebanon, one in Taiwan, and one in Iran. Most studies showed that intervention with therapeutic play promotes reduction in the level of anxiety and promotes collaborative behavior and acceptance of the invasive procedure.

CONCLUSIONS

Evidence related to the use of therapeutic play on anxiety and behavior of children undergoing invasive procedures is still questionable. The absence, in most studies, of the creation of a random sequence to assign the subjects to either the control or the experimental group, as well as allocation concealment, are factors that contribute to these questions. Another issue that characterizes an important source of bias is the absence of blinded evaluators. It is necessary to perform further studies that will take into account greater methodological stringency.

Prevention and Intervention Strategies to Alleviate Preoperative Anxiety in Children

Preoperative anxiety (anxiety regarding impending surgical experience) in children is a common phenomenon that has been associated with a number of negative behaviors during the surgery experience (e.g., agitation, crying, spontaneous urination, and the need for physical restraint during anesthetic induction). Preoperative anxiety has also been associated with the display of a number of maladaptive behaviors postsurgery, including postoperative pain, sleeping disturbances, parent-child conflict, and separation anxiety. For these reasons, researchers have sought out interventions to treat or prevent childhood preoperative anxiety and possibly decrease the development of negative behaviors postsurgery. Such interventions include sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, and acupuncture. The present article reviews the existing research on the various modes of intervention for preoperative anxiety in children. Clinical implications and future directions are discussed.

Non-pharmacological interventions for assisting the induction of anaesthesia in children

BACKGROUND

Induction of general anaesthesia can be distressing for children. Non-pharmacological methods for reducing anxiety and improving co-operation may avoid the adverse effects of preoperative sedation.

OBJECTIVES

To assess the effects of non-pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their co-operation.

SEARCH METHODS

In this updated review we searched CENTRAL (the Cochrane Library 2012, Issue 12) and searched the following databases from inception to 15 January 2013: MEDLINE, EMBASE, PsycINFO and Web of Science. We reran the search in August 2014. We will deal with the single study found to be of interest when we next update the review.

SELECTION CRITERIA

We included randomized controlled trials of a non-pharmacological intervention implemented on the day of surgery or anaesthesia.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed risk of bias in trials.

MAIN RESULTS

We included 28 trials (2681 children) investigating 17 interventions of interest; all trials were conducted in high-income countries. Overall we judged the trials to be at high risk of bias. Except for parental acupuncture (graded low), all other GRADE assessments of the primary outcomes of comparisons were very low, indicating a high degree of uncertainty about the overall findings. Parental presence: In five trials (557 children), parental presence at induction of anaesthesia did not reduce child anxiety compared with not having a parent present (standardized mean difference (SMD) 0.03, 95% confidence interval (CI) -0.14 to 0.20). In a further three trials (267 children) where we were unable to pool results, we found no clear differences in child anxiety, whether a parent was present or not. In a single trial, child anxiety showed no significant difference whether one or two parents were present, although parental anxiety was significantly reduced when both parents were present at the induction. Parental presence was significantly less effective than sedative premedication in reducing children's anxiety at induction in three trials with 254 children (we could not pool results). Child interventions (passive): When a video of the child's choice was played during induction, children were significantly less anxious than controls (median difference modified Yale Preoperative Anxiety Scale (mYPAS) 31.2, 95% CI 27.1 to 33.3) in a trial of 91 children. In another trial of 120 children, co-operation at induction did not differ significantly when a video fairytale was played before induction. Children exposed to low sensory stimulation were significantly less anxious than control children on introduction of the anaesthesia mask and more likely to be co-operative during induction in one trial of 70 children. Music therapy did not show a significant effect on children's anxiety in another trial of 51 children. Child interventions (mask introduction): We found no significant differences between a mask exposure intervention and control in a single trial of 103 children for child anxiety (risk ratio (RR) 0.59, 95% CI 0.31 to 1.11) although children did demonstrate significantly better co-operation in the mask exposure group (RR 1.27, 95% CI 1.06 to 1.51). Child interventions (interactive): In a three-arm trial of 168 children, preparation with interactive computer packages (in addition to parental presence) was more effective than verbal preparation, although differences between computer and cartoon preparation were not significant, and neither was cartoon preparation when compared with verbal preparation. Children given video games before induction were significantly less anxious at induction than those in the control group (mYPAS mean difference (MD) -9.80, 95% CI -19.42 to -0.18) and also when compared with children who were sedated with midazolam (mYPAS MD -12.20, 95% CI -21.82 to -2.58) in a trial of 112 children. When compared with parental presence only, clowns or clown doctors significantly lessened children's anxiety in the operating/induction room (mYPAS MD -24.41, 95% CI -38.43 to -10.48; random-effects, I² 75%) in three trials with a total of 133 children. However, we saw no significant differences in child anxiety in the operating room between clowns/clown doctors and sedative premedication (mYPAS MD -9.67, 95% CI -21.14 to 1.80, random-effects, I² 66%; 2 trials of 93 children). In a trial of hypnotherapy versus sedative premedication in 50 children, there were no significant differences in children's anxiety at induction (RR 0.59, 95% CI 0.33 to 1.04). Parental interventions: Children of parents having acupuncture compared with parental sham acupuncture were less anxious during induction (mYPAS MD -17, 95% CI -30.51 to -3.49) and were more co-operative (RR 1.59, 95% CI 1.01 to 2.53) in a single trial of 67 children. Two trials with 191 parents assessed the effects of parental video viewing but did not report any of the review's prespecified primary outcomes.

AUTHORS' CONCLUSIONS

This review shows that the presence of parents during induction of general anaesthesia does not diminish their child's anxiety. Potentially promising non-pharmacological interventions such as parental acupuncture; clowns/clown doctors; playing videos of the child's choice during induction; low sensory stimulation; and hand-held video games need further investigation in larger studies.

Preoperative anxiety management, emergence delirium, and postoperative behavior

Preoperative anxiolysis is important for children scheduled for surgery. The nature of the anxiety depends on several factors, including age, temperament, past hospitalizations, and socioeconomic and ethnic backgrounds. A panoply of interventions effect anxiolysis, including parental presence, distraction, and premedication, although no single strategy is effective for all ages. Emergence delirium (ED) occurs after the use of sevoflurane and desflurane in preschool-aged children in the recovery room. Symptoms usually last approximately 15 minutes and resolve spontaneously. The Pediatric Anesthesia Emergence Delirium scale is used to diagnose ED and evaluate therapeutic interventions for ED such as propofol and opioids.

A comparison of inhalational inductions for children in the operating room vs the induction room

BACKGROUND

There has been debate about the use of an induction room (IR) compared with an operating room (OR) for inhalational induction in children. The quality of the anesthesia induction between these two physical environments has not been studied previously. We sought to compare child distress, OR utilization and efficiency, and parental satisfaction and safety, between an IR and an OR.

METHODS

In a prospective observational study, we studied 501 developmentally appropriate children ages 1-14 years, American Society of Anesthesiologists (ASA) physical status I-III, presenting for the inhalational induction of anesthesia, undergoing outpatient or outpatient-admit ENT surgery. Inductions were performed in an IR (IR group) or OR (OR group) with parent(s) present. Child behavioral compliance was assessed using the Induction Compliance Checklist (ICC), a validated observational scale from 0 to 10 consisting of 10 behaviors; an ICC score ≥4 was considered poor behavioral compliance. Times for transport, anesthesia start, ready for surgery, surgery finish, out of OR, and total case process times were recorded. OR utilization and OR efficiency was derived using these times. Data on number and experience of clinical providers were also collected. Parent satisfaction with the induction was measured using a satisfaction survey. Safety was measured by recording respiratory complications during induction. The chi-squared test was conducted to determine whether induction location was associated with level of behavioral compliance. A multivariable proportional odds model was used to control for risk factors. OR utilization and efficiency were analyzed using the Wilcoxon-Mann-Whitney test.

RESULTS

There were no significant differences in ICC scores between the groups (P-value = 0.12). Anesthesia, nonoperative, and transport time were statistically less in the OR group when compared with the IR group, although total case process times were similar in both groups. While OR efficiency was significantly higher for the OR group (P-value = 0.0096), OR utilization did not differ between groups (P-value = 0.288). The OR group had a significantly higher number of anesthesia providers and a more experienced surgical team. Parents in the two groups were equally satisfied with their experience during induction, and none of the subjects had respiratory complications during the anesthesia induction.

CONCLUSIONS

We found no differences in child distress, parent satisfaction, and respiratory complications between inductions conducted in the IR vs the OR. Differences in utilization, efficiency, and turnover were minimal and not operationally significant. Capital equipment, space, and staffing strategies should be key drivers in considerations for the use of IRs, and in the design of ORs with IRs.

The impact of emotional intelligence and intelligence quotient (IQ) on child anxiety and behavior in the dental setting

OBJECTIVE

The aim of this study was to evaluate the impact of IQ and EQ on child's anxiety and behavior in the dental setting.

MATERIALS AND METHODS

One hundred and seven children (age range 7-12 years) were selected. BarOn Emotional Quotient Inventory: Youth Version (Baron EQ-I: YV) and the Raven's Colored Progressive Matrices (RCPM) tests were administered on the first examination session. Children's anxiety and behavior were evaluated using the modified child dental anxiety scale (MCDAS) and the sound, eye and motor (SEM) scales, respectively, during the second session.

RESULTS

The mean (SD) age of subjects was 8.48 (1.41) years old. The result revealed a significant negative correlation between children's behavior and total EQ score (p < 0.01) but there was no relationship found between children's behavior and IQ score. A significant positive correlation was found between anxiety scores on MCDAS and SEM (p < 0.01), but no relationship was found between EQ and MCDAS scores. Both anxiety (p < 0.01) and EQ score (p < 0.01) were effective variables in predicting the child's SEM score.

CONCLUSION

The major finding of this research suggested that a high EQ may be more effective than a low EQ in moderating the level of cooperation during dental treatment of children. IQ scores, on the other hand, were related to the child's EQ score (r = 0.20) and age (r = - 0.29).

Factors affecting preoperative anxiety in children undergoing general anaesthesia for dental rehabilitation

AIM

The primary aim was to examine anxiety levels, and to identify factors affecting preoperative anxiety among healthy children undergoing general anaesthesia for dental rehabilitation. A secondary aim was to assess parental distress and attitude to accompanying their children during this procedure.

STUDY DESIGN

Observational cross sectional study.

METHODS

Anxiety levels of 118 children admitted to the Day Case unit of King Abdullah teaching hospital in Irbid, Jordan, for dental rehabilitation under general anaesthesia (GA) were assessed at different phases (before and during induction of GA) using the Global Mood Score (GMS) with parental presence. The effect of certain variables such as age, sex, reason for referral, past GA experience, accompanying parent, and parental distress, on children's anxiety during this procedure were assessed using multivariate analysis. The level of significance was <0.05. Parental distress and attitudes to accompanying their children were assessed using a structured questionnaire.

RESULTS

There was a significant increase of child anxiety on GMS reaching its highest level in phase three (induction phase). A multivariate test (MANOVA) showed that previous experience of the child with GA, and reason for referral to dental rehabilitation under GA, significantly predicted child anxiety (P-value of 0.019 and 0.012) respectively. However, parental distress, accompanying person, age, and sex of the child, did not affect child anxiety. Parental distress was at its highest level in phase three, mothers were significantly more stressed than fathers and parental distress was significantly increased when a child was <5 years of age.

CONCLUSION

Factors contributing to increased child anxiety during induction of GA for dental rehabilitation were age, previous GA experience, and referral for GA at a very young age. Most parents, especially mothers, were distressed during the induction phase, therefore sufficient preoperative preparation of those children and parents is necessary to achieve best patient management.

Non-pharmacological interventions for assisting the induction of anaesthesia in children

BACKGROUND

Induction of general anaesthesia can be distressing for children. Non-pharmacological methods for reducing anxiety and improving co-operation may avoid the adverse effects of preoperative sedation.

OBJECTIVES

To assess the effects of non-pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their co-operation.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2009, Issue 1). We searched the following databases from inception to 14th December 2008: MEDLINE, PsycINFO, CINAHL, DISSERTATION ABSTRACTS, Web of Science and EMBASE.

SELECTION CRITERIA

We included randomized controlled trials of a non-pharmacological intervention implemented on the day of surgery or anaesthesia.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed risk of bias in trials.

MAIN RESULTS

We included 17 trials, all from developed countries, involving 1796 children, their parents or both. Eight trials assessed parental presence. None showed significant differences in anxiety or co-operation of children during induction, except for one where parental presence was significantly less effective than midazolam in reducing children's anxiety at induction. Six trials assessed interventions for children. Preparation with a computer package improved co-operation compared with parental presence (one trial). Children playing hand-held video games before induction were significantly less anxious than controls or premedicated children (one trial). 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; one trial). In children undergoing hypnosis, there was a nonsignificant trend towards reduced anxiety during induction (mYPAS < 24: risk ratio (RR) 0.59 95% CI 0.33 to 1.04 - 39% versus 68%: one trial) compared with midazolam. A low sensory environment improved children's co-operation at induction (RR 0.66, 95% CI 0.45 to 0.95; one trial) and no effect on children's anxiety was found for music therapy (one trial).Parental interventions were assessed in three trials. Children of parents having acupuncture compared with parental sham-acupuncture 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 trials, a video viewed preoperatively did not show effects on child or parental outcomes.

AUTHORS' CONCLUSIONS

This review shows that the presence of parents during induction of general anaesthesia does not reduce their child's anxiety. Promising non-pharmacological interventions such as parental acupuncture; clown doctors; hypnotherapy; low sensory stimulation; and hand-held video games needs to be investigated further.

Pretend play as a resource for children: implications for pediatricians and health professionals

Pretend play relates to many areas of adaptive functioning in child development including creativity, coping, and emotion regulation. Though pretend play interventions have been employed in medical settings for decades, there are few empirical studies of such interventions in the literature. A review of literature involving pretend play in medical settings indicates that pretend play interventions are effective in inpatient and outpatient settings for preventing and reducing anxiety and distress. Pretend play also has effects on pain, externalizing behavior, and adaptation to chronic illness. Such effects have been demonstrated in the short term; however they have not been shown to be stable in the long term, indicating that intermittent refresher sessions may be necessary. The sparse empirical literature regarding pretend play in medical settings spans a large number of journals and years, and conclusions are limited by methodological issues including measurement, treatment fidelity, research design, statistical procedures, and potential confounding variables. Despite these limitations, existing evidence suggests that play is a helpful intervention and that future research that addresses these limitations is warranted.

Giving Toys to Children Reduces Their Anxiety About Receiving Premedication for Surgery

Children have increased anxiety during the preoperative period. The administration of oral premedication to children is often met with apprehension, reluctance, or refusal. We sought to determine whether giving a small toy to the children would decrease the anxiety associated with taking oral premedication. This was a prospective study involving 100 children 3-6 yr of age randomized into two equal groups. The anxiety of each child was assessed using the Modified Yale Preoperative Anxiety Scale. The results showed significantly less anxiety in children who received a toy before oral administration of midazolam.

Dental anxiety, distress at induction and postoperative morbidity in children undergoing tooth extraction using general anaesthesia

OBJECTIVE

To report on the prevalence of postoperative morbidity in children undergoing tooth extraction under chair dental general anaesthetic (CDGA) in relation to pre-operative dental anxiety and anaesthetic induction distress.

DESIGN

A prospective national study.

SETTING

Twenty-five Scottish DGA centres in 2001.

SUBJECTS AND METHOD

Four hundred and seven children (mean age 6.6 years; range: 2.3 to 14.8 years; 52% male). Before CDGA, the Modified Child Dental Anxiety (MCDAS) and Modified Dental Anxiety (MDAS) Scales were completed for children and accompanying adult respectively; the latter also returned a morbidity questionnaire 24 hours and one week post-operatively. Anaesthetic induction distress was scored immediately before CDGA induction using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS).

RESULTS

The mean MCDAS score was 24.2 (population norm 18.2); 21% of adults were anxious. Forty-two per cent of children had induction distress; this related to their MCDAS scores (r=0.43, p<0.001, Pearson Product Moment Correlation Coefficient). Morbidity at 24 hours and seven days was 63% and 24% respectively; this related to MCDAS scores (r=0.15, p=0.029 and r=0.17, p=0.009, Pearson Product Moment Correlation Coefficient) and to induction distress (chi2=7.14, p=0.007 and chi2=11.70, p=0.001).

CONCLUSION

The majority of children suffered next day morbidity and many still had symptoms a week later. Most children were dentally anxious; this related to induction distress and postoperative morbidity.

Pediatric anxiety: child life intervention in day surgery

Although many hospitals offer a surgical preparation program to children and families, minimal research has been conducted specifically on preparation by child life specialists. The purpose of this double-blind intervention study was to determine if children prepared for day surgery by a child life specialist exhibited less anxiety than those who received routine standard of care. One hundred forty-two children, aged between 5 and 11 years old, undergoing elective otolaryngology surgery completed the study. The "Child Drawing: Hospital" instrument developed by Clatworthy, Simon, and Tiedeman [Clatworthy, S., Simon, K., & Tiedeman, M. E. (1999). Child Drawing: Hospital - An instrument designed to measure the emotional status of hospitalized school-aged children. Journal of Pediatric Nursing, 14, 2-9] was used to determine children's anxiety levels preintervention and postintervention. Eighty children received formal preparation for their surgeries by a child life specialist and 62 received no intervention. The data were analyzed using a repeated-measures model with intervention, age, sex, and level of surgery for main effects. The anxiety score change was significantly better for the patients in the child life intervention group than for those in the nonintervention group, F(1,135) = 4.24, p = .04. The increase in anxiety scores in the nonintervention group suggests that children could benefit from preoperative preparation. Health professionals, including nurses, may impact children's abilities to cope with a surgical process. The information in this study will be useful in deciding whether all children, not just those with a perceived need, should be prepared prior to an elective day surgery.

Facilitating coping behavior in children prior to dental general anesthesia: a randomized controlled trial

BACKGROUND

The aim of this study was to establish the efficacy of two different preparation packages, a paper-based cartoon and an interactive computer, at facilitating coping behavior in children undergoing dental general anesthetic (DGA) tooth extraction.

METHOD

A total of 198 children were allocated randomly to computer, cartoon or control groups. A Visual Analog Scale (VAS) and Modified Child Dental Anxiety Scale (MCDAS) were used to compare preoperative anxiety levels between the three study groups. Blinded observers then scored behavior at both anesthesia induction and upon recovery using a VAS for each (0 = coped/no distress and 10 = no coping/high distress).

RESULTS

The children's median age was 5 (range 3-10) years, 57% were boys, a median of seven teeth were extracted (range 1-20). Preoperative anxiety was similar for all preparation groups; with 24% of all children categorized 'phobic' using MCDAS. The median induction (coping) VAS level for both the computer and the cartoon groups was '1' (range 0-10), compared with the control group level of '3' (range 0-10). The median recovery (coping) VAS levels were: computer group: 0 (range 0-10), cartoon group: 4 (range 0-10) and control group: 2.5 (range 0-10). The Mann-Whitney U-test showed that the computer group coped significantly better than the control group at induction (P = 0.014) and significantly better than the cartoon group upon recovery (P = 0.016). The statistical power for detecting differences between groups (computer/cartoon versus control) was calculated to be 90%, based on pilot study data.

CONCLUSIONS

The computer preparation package facilitated coping behavior in children undergoing DGA induction.

Premedication in children: hypnosis versus midazolam

BACKGROUND

The main objectives of premedication in children are to facilitate the separation from the parents, to reduce preoperative anxiety, to smooth the induction of anesthesia and to lower the risk of postoperative behavioral disorders. The most common technique is sedative premedication with midazolam. Hypnosis enables a state of relaxation to be achieved and has never been evaluated as a premedication technique. The aim of the present study was to evaluate the efficacy of hypnosis on anxiety and perioperative behavioral disorders versus midazolam.

METHODS

Fifty children from 2 to 11 years of age were randomized into two groups: group H received hypnosis as premedication; group M were given 0.5 mg x kg(-1) midazolam orally, 30 min before surgery. Preoperative anxiety was evaluated using the Modified Yale Preoperative Anxiety Scale (mYPAS) score when arriving in the department (T1), when entering the operating room (T2), and when fitting the facemask (T3). Postoperative behavioral disorders were evaluated using the Posthospitalization Behavioral Questionnaire (PHBQ) at days 1, 7 and 14.

RESULTS

The two groups showed no significant difference preoperatively with the PHBQ: (M) 21 (17-25) vs (H) 20 (8-25) and mYPAS score: (M) 28 (23-75) vs (H) 23 (23-78). The number of anxious children was less during induction of anesthesia in the hypnosis group (T3: 39% vs 68%) (P < 0.05). Postoperatively, hypnosis reduced the frequency of behavior disorders approximately by half on day 1 (30% vs 62%) and day 7 (26% vs 59%).

CONCLUSIONS

Hypnosis seems effective as premedication in children scheduled for surgery. It alleviates preoperative anxiety, especially during induction of anesthesia and reduces behavioral disorders during the first postoperative week.

Predictors of preoperative anxiety in children

This study aimed to identify factors contributing to anxiety at induction of anaesthesia in children. One hundred and twenty children aged five to twelve years and scheduled for surgery requiring general anaesthesia were included. Children were interviewed and assessed prior to surgery. Parents completed anxiety measures prior to surgery and were interviewed after the induction of anaesthesia. The level of children's anxiety was determined at the time of induction of anaesthesia by the modified Yale Preoperative Anxiety Scale. Factors associated with increased levels of anxiety in the children included increased number of people in the room at induction of anaesthesia; longer waiting time between admission at the hospital and induction of anaesthesia; negative memories of previous hospital experiences; and having a mother who does not practise a religion. Suggestions for implementation of the findings and for future research are provided.

Social adaptability, cognitive abilities, and other predictors for children's reactions to surgery

STUDY OBJECTIVE

To examine the relationship between social adaptability, cognitive abilities, and other personality characteristics to perioperative anxiety.

STUDY DESIGN

Prospective cohort investigation.

PATIENTS

60 children ASA physical status I and II, age 3 to 10 years.

SETTING

Tertiary care children's hospital.

MEASUREMENTS

Temperament (EASI), cognitive abilities (KABC), and adaptive behavior (Vineland) were evaluated in a group of children undergoing surgery. Parental coping style (MBBS) and parental state (STAI-S) and trait (STAI-T) anxiety were assessed as well. On the day of surgery, anxiety of the child was measured at the preoperative holding area and during induction of anesthesia (m-YPAS).

MAIN RESULTS

Univariate correlational analysis demonstrated that young age (r = -0.27), poor social adaptability (Vineland) (r = -0.38), shy and inhibited personality (EASI; temperament) (r = -0.33), higher intelligence (KABC) (r = 0.29), increased parental anxiety (r = 0.44), and parental high-monitoring coping style (r = -0.25) are all associated with higher levels of perioperative anxiety. Stepwise multivariate regression analysis has demonstrated that controlling for the variables above, parental anxiety (p = 0.004), child's social adaptive capabilities (p = 0.04), and child's temperament (sociability) (p = 0.04) are independent predictors for increased perioperative anxiety (R(2) = 0.38, F = 5.5, p = 0.003).

CONCLUSIONS

Anesthesiologists need to pay close attention to the families of pediatric surgical children who are socially maladjusted, shy and inhibited, and have anxious parents.

Distress during the induction of anesthesia and postoperative behavioral outcomes

We determined whether children who are extremely anxious during the induction of anesthesia are more at risk of developing postoperative negative behavioral changes compared with children who appear calm during the induction process. Children (n = 91) aged 1-7 yr scheduled for general anesthesia and elective outpatient surgery were recruited. Using validated measures of preoperative anxiety and postoperative behaviors, children were evaluated during the induction of general anesthesia and on Postoperative Days 1, 2, 3, 7, and 14. Using a multivariate logistic regression model, in which the dependent variable was the presence or absence of postoperative negative behavioral changes and the independent variables included several potential predictors, we demonstrated that anxiety of the child, time after surgery, and type of surgical procedure were predictors for postoperative maladaptive behavior. The frequency of negative postoperative behavioral changes decreased with time after surgery, and the frequency of negative postoperative behavioral changes increased when the child exhibited increased anxiety during the induction of anesthesia. Finally, we found a significant correlation (r) of 0.42 (P = 0.004) between the anxiety of the child during induction and the excitement score on arrival to the postanesthesia care unit. We conclude that children who are anxious during the induction of anesthesia have an increased likelihood of developing postoperative negative behavioral changes. We recommend that anesthesiologists advise parents of children who are anxious during the induction of anesthesia of the increased likelihood that their children will develop postoperative negative behavioral changes such as nightmares, separation anxiety, and aggression toward authority.

IMPLICATIONS

Anesthesiologists who care for children who are anxious during the induction of anesthesia should inform parents that these children have an increased likelihood of developing postoperative negative behavioral changes.

Preoperative preparation programs in children: a comparative examination

We sought to determine whether an extensive behavioral preparation program for children undergoing surgery is more effective than a limited behavioral program. The primary end point was child and parent anxiety during the preoperative period. Secondary end points included behavior of the child during the induction of anesthesia and the postoperative recovery period. Several days before surgery, children (n = 75) aged 2-12 yr randomly received either an information-based program (OR tour), an information + modeling-based program (OR tour + videotape), or an information + modeling + coping-based program (OR tour + videotape + child-life preparation). Using behavioral and physiological measures of anxiety, we found that children who received the extensive program exhibited less anxiety immediately after the intervention, in the holding area on the day of surgery, and on separation to the operating room. These findings, however, achieved statistical significance only in the holding area on the day of surgery (44[10-72] vs 32[8-50] vs 9[6-33]; P = 0.02). Similarly, parents in the extensive program were significantly less anxious on the day of surgery in the preoperative holding area, as assessed by behavioral (P = 0.015) and physiological measures (P = 0.01). In contrast, no differences were found among the groups during the induction of anesthesia, recovery room period, or 2 wk postoperatively. We conclude that children and parents who received the extensive preoperative preparation program exhibited lower levels of anxiety during the preoperative period, but not during the intraoperative or postoperative periods.

IMPLICATIONS

The extensive behavioral preoperative program that we undertook had limited anxiolytic effects. These effects were localized to the preoperative period and did not extended to the induction of anesthesia or the postoperative recovery period.

Primary prevention mental health programs for children and adolescents: a meta-analytic review

Used meta-analysis to review 177 primary prevention programs designed to prevent behavioral and social problems in children and adolescents. Findings provide empirical support for further research and practice in primary prevention. Most categories of programs produced outcomes similar to or higher in magnitude than those obtained by many other established preventive and treatment interventions in the social sciences and medicine. Programs modifying the school environment, individually focused mental health promotion efforts, and attempts to help children negotiate stressful transitions yield significant mean effects ranging from 0.24 to 0.93. In practical terms, the average participant in a primary prevention program surpasses the performance of between 59% to 82% of those in a control group, and outcomes reflect an 8% to 46% difference in success rates favoring prevention groups. Most categories of programs had the dual benefit of significantly reducing problems and significantly increasing competencies. Priorities for future research include clearer specification of intervention procedures and program goals, assessment of program implementation, more follow-up studies, and determining how characteristics of the intervention and participants relate to different outcomes.