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Meta-Analysis
. 2015 Jul 14;2015(7):CD006447.
doi: 10.1002/14651858.CD006447.pub3.

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

Anne Manyande  1 , Allan M Cyna, Peggy Yip, Cheryl Chooi, Philippa Middleton
Affiliations
Meta-Analysis

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

Anne Manyande et al. Cochrane Database Syst Rev. .

Abstract

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.

PubMed Disclaimer

Conflict of interest statement

Anne Manyande: none known

Allan M Cyna: Payment for lectures including service on speakers bureaus: South Australian Society of Hypnosis (Course teaching). Travel and accomodation and meeting expenses unrelated to this research: AAGBI London Jan 2011; MSA Kuala Lumpar 2011; Wellington NZ Haemophilia nurses meeting 2012; Birth International 2013

Peggy Yip: none known

Cheryl S Chooi: none known

Philippa Middleton: none known

Figures

1
1
Study flow diagram of literature search results for this review UPDATE only (results not available for earlier version of the review Yip 2009). We reran the search in August 2014. *We will deal with the single study of interest found when we update the review.
2
2
Risk of bias graph, authors' decision of each included study (review plus update).
3
3
Risk of bias summary for each included study in both the review and update.
1.1
1.1. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 1 anxiety during induction.
1.3
1.3. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 3 anxiety during induction (parental anxiety subgroup).
1.5
1.5. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 5 anxiety/distress before induction.
1.6
1.6. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 6 parental anxiety (on day of surgery).
1.7
1.7. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 7 parental anxiety (physiological signs).
1.8
1.8. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 8 parental anxiety during induction (parental anxiety subgroup).
1.9
1.9. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 9 parental anxiety postop.
1.11
1.11. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 11 emergence delirium.
1.13
1.13. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 13 time taken for induction (minutes).
1.14
1.14. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 14 negative behaviour postop.
1.15
1.15. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 15 negative behaviour postop.
1.16
1.16. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 16 parental satisfaction.
1.17
1.17. Analysis
Comparison 1 Parental presence versus no parental presence, Outcome 17 parental satisfaction.
2.2
2.2. Analysis
Comparison 2 Two parents versus one parent, Outcome 2 co‐operation during induction.
2.3
2.3. Analysis
Comparison 2 Two parents versus one parent, Outcome 3 parental anxiety after leaving OR.
3.1
3.1. Analysis
Comparison 3 Parental presence versus midazolam, Outcome 1 anxiety during induction.
3.3
3.3. Analysis
Comparison 3 Parental presence versus midazolam, Outcome 3 cooperation during induction.
3.5
3.5. Analysis
Comparison 3 Parental presence versus midazolam, Outcome 5 parental anxiety.
3.6
3.6. Analysis
Comparison 3 Parental presence versus midazolam, Outcome 6 time taken for induction (minutes).
3.7
3.7. Analysis
Comparison 3 Parental presence versus midazolam, Outcome 7 emergence delirium.
3.9
3.9. Analysis
Comparison 3 Parental presence versus midazolam, Outcome 9 negative behaviour postop.
3.10
3.10. Analysis
Comparison 3 Parental presence versus midazolam, Outcome 10 parental satisfaction.
4.1
4.1. Analysis
Comparison 4 Parental presence + midazolam versus no parental presence, Outcome 1 parental anxiety.
4.2
4.2. Analysis
Comparison 4 Parental presence + midazolam versus no parental presence, Outcome 2 parental anxiety.
5.1
5.1. Analysis
Comparison 5 Video 'fairytale', Outcome 1 co‐operation.
5.2
5.2. Analysis
Comparison 5 Video 'fairytale', Outcome 2 parental anxiety (STAI ≥ 46).
5.3
5.3. Analysis
Comparison 5 Video 'fairytale', Outcome 3 parental anxiety (APAIS ≥ 13).
5.4
5.4. Analysis
Comparison 5 Video 'fairytale', Outcome 4 parental anxiety (STAI).
5.5
5.5. Analysis
Comparison 5 Video 'fairytale', Outcome 5 parental anxiety (APAIS).
6.1
6.1. Analysis
Comparison 6 Low sensory stimulation versus control, Outcome 1 co‐operation at induction.
6.2
6.2. Analysis
Comparison 6 Low sensory stimulation versus control, Outcome 2 parental anxiety.
7.1
7.1. Analysis
Comparison 7 Mask introduction/exposure, Outcome 1 anxiety.
7.2
7.2. Analysis
Comparison 7 Mask introduction/exposure, Outcome 2 co‐operation (ICC): number of children compliant.
7.3
7.3. Analysis
Comparison 7 Mask introduction/exposure, Outcome 3 parental anxiety (STAI: trait).
11.1
11.1. Analysis
Comparison 11 Video game versus control, Outcome 1 anxiety during induction.
11.2
11.2. Analysis
Comparison 11 Video game versus control, Outcome 2 negative behaviour postop.
12.1
12.1. Analysis
Comparison 12 Video game versus midazolam, Outcome 1 anxiety during induction.
12.2
12.2. Analysis
Comparison 12 Video game versus midazolam, Outcome 2 negative behaviour postop.
13.1
13.1. Analysis
Comparison 13 Clowns/clown doctors versus parental presence, Outcome 1 anxiety.
13.2
13.2. Analysis
Comparison 13 Clowns/clown doctors versus parental presence, Outcome 2 co‐operation at induction.
13.3
13.3. Analysis
Comparison 13 Clowns/clown doctors versus parental presence, Outcome 3 parental anxiety.
13.4
13.4. Analysis
Comparison 13 Clowns/clown doctors versus parental presence, Outcome 4 negative behaviour postop.
14.1
14.1. Analysis
Comparison 14 Clowns/clown doctors versus midazolam, Outcome 1 anxiety.
14.2
14.2. Analysis
Comparison 14 Clowns/clown doctors versus midazolam, Outcome 2 parental anxiety.
15.1
15.1. Analysis
Comparison 15 Hypnosis versus midazolam, Outcome 1 anxiety during induction.
15.2
15.2. Analysis
Comparison 15 Hypnosis versus midazolam, Outcome 2 negative behaviour postop.
16.1
16.1. Analysis
Comparison 16 Acupuncture for parents, Outcome 1 anxiety during induction.
16.2
16.2. Analysis
Comparison 16 Acupuncture for parents, Outcome 2 co‐operation during induction.
16.3
16.3. Analysis
Comparison 16 Acupuncture for parents, Outcome 3 parental anxiety.
17.1
17.1. Analysis
Comparison 17 Videos for parents, Outcome 1 parental anxiety.
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

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Kain 2001 {published data only}
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Kain 2003 {published data only}
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Kain 2004 {published data only}
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Kain 2007 {published data only}
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Kazak 2010 {published data only}
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MacLaren 2008 {published data only}
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McEwen 2007 {published data only}
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Meisel 2009 {published data only}
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Mifflin 2012 {published data only}
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Palermo 2000 {published data only}
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Patel 2006 {published data only}
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Vagnoli 2005 {published data only}
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Vagnoli 2010 {published data only}
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Wang 2004 {published data only}
    1. Wang SM, Maranets I, Weinberg ME, Caldwell‐Andrews AA, Kain ZN. Parental auricular acupuncture as an adjunct for parental presence during induction of anesthesia. Anesthesiology 2004;100(6):1399‐404. [PUBMED: 15166558 ] - PubMed
Wright 2010 {published data only}
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Zuwala 2001 {published data only}
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References to studies excluded from this review

Agostini 2014 {published data only}
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Akin 2012 {published data only}
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Aydin 2008 {published data only}
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Cumino 2013 {published data only}
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Klemetti 2009 {published data only}
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Lardner 2010 {published data only}
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Sadideen 2012 {published data only}
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References to studies awaiting assessment

Kerimoglu 2013 {published data only}
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Additional references

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