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Preoperative preparation of children
Priya Reshma Aranha, Larissa Martha Sams1, Prakash Saldanha2

Surgery is a stressful and anxiety provoking experience for children. Millions of children undergo surgery every
year. The majority of children experience significant preoperative anxiety which intern can affect their recovery.
Preoperative anxiety may bring about physical and physiological changes in children, which can be particularly
evident in terms of increased heart rate and blood pressure. To identify various strategies used to minimize the
DOI: preoperative anxiety of children and update their clinical effectiveness among children undergoing surgery, the
10.4103/ijhas.IJHAS_76_16 authors searched PubMed, MEDLINE, CINAHL, ScienceDirect, Google Scholar, Scopus, and Cochrane Library
for identifying the relevant studies and retrieved available literature. It is concluded that utilization of the strategies
available to reduce the preoperative anxiety of children will be a promising intervention to reduce anxiety, to
promote relaxation, satisfaction, and speedy recovery. Many of these techniques are simple, cost‑effective and
can be easily carried out by nurses. It is essential to use the age appropriate and individualized methods in
preparing children for surgery. Further research is required to strengthen the evidence.
Key words:
Children, evidence‑based practice, preoperative preparation

H ospitalization and surgery are stressful

events in the life of a child and parents.
When a child undergoes surgery, it often
discharge from the hospital.[7] Well prepared
parents, in turn, will be able to support their
children and help them to prepare well for the
becomes a very significant and memorable upcoming surgery.
event in the life of the entire family. Unlike other
significant events in the child’s life, it has an Importance of this review
element of threat, and the fear of the unknown The child is different from an adult. Therefore, it
can be overwhelming.[1] is essential to have a tailored approach to their
preoperative preparation. Adequate preoperative
It has been seen that 75% of children undergoing psychological preparation of children is the
surgery experience anxiety.[2] In a study, it responsibility of the health‑care workers. The
was observed that 67% of children developed aim of the preparation is to reduce the anxiety
postoperative negative behavioral changes.[3] of children and family, improve cooperation,
Physiological changes such as elevated pulse enhance recovery, and increase self‑control,
Department of Child rate and blood pressure are also anticipated improve long‑term emotional, and behavioral
Health Nursing, when there is a painful procedure as well as adjustments.
Yenepoya Nursing preoperative anxiety.[4,5]
College, Yenepoya The factors to be considered while planning
University, 1Department Preoperative anxiety is a distressing feeling preoperative preparation of children
of Medical Surgical which results in adverse physiological and are – developmental stage of child, previous
Nursing, Laxmi psychological reactions in children. With a high medical experiences, duration of the procedure,
Memorial College of level of anxiety, they are more likely to exhibit temperament, current anxiety levels, coping
Nursing, 2Department signs of the emergence of delirium and develop skills, and parental involvement.
of Paediatrics, maladaptive behavior postoperatively. They
Yenepoya Medical may need additional postoperative pain control Many strategies have been developed for
College, Mangalore, medications.[6] the alleviation of preoperative anxiety of
Karnataka, India children and their parents and implemented
Parents also may be anxious regarding anesthesia in pediatric surgical settings. These strategies
Address for and associated risks, how the child would are based on rigorous research evidence and
correspondence: respond to the surgical experience and their own can be implemented in the nursing care during
Mrs. Priya Reshma Aranha, inadequacy in taking care of their child after the the preoperative preparation of children and
Yenepoya University, their parents. Nurses and other health‑care
Mangalore ‑ 575 018, This is an open access article distributed under the terms of the Creative
providers should be able to identify an
Karnataka, India. Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which
E‑mail: priyaresh. allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under How to cite this article: Aranha PR, Sams LM,
the identical terms.
Saldanha P. Preoperative preparation of children. Int
Submission: 31‑05‑2016 J Health Allied Sci 2017;6:1-4.
Accepted: 21‑01‑2017 For reprints contact:

© 2017 International Journal of Health & Allied Sciences | Published by Wolters Kluwer ‑ Medknow 1

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Aranha, et al.: Preoperative preparation of children undergoing surgery

appropriate strategy based on individualized child and that nursing interventions can be used as effective techniques to
parent’s needs. reduce the preoperative anxiety in school‑age children. Both the
quality of the preoperative program and the preparation and
Methods support for the hospitalization/surgery provided by parents
to their children are essential to help both child and parents
We searched PubMed, MEDLINE, CINAHL, ScienceDirect, find strategies to overcome their anxiety, stress, and anguish
Google Scholar, Scopus, and Cochrane Library for identifying caused by the situations. Cost effectiveness and feasibility
the relevant studies and available literature. Different of the interventions to be considered. Another systematic
combinations of search terms were used to collect available review[14] revealed that nonpharmacological interventions for
literature and retrieved relevant research studies. Search terms assisting the induction of anesthesia in children were studied.
included were preoperative anxiety of children, preoperative Evidence showed that the presence of parents during induction
fear of children, pharmacological and nonpharmacological of general anesthesia does not reduce the child’s anxiety.
interventions to manage the preoperative anxiety of children, Promising nonpharmacological interventions such as parental
preoperative preparation of children, and postoperative acupuncture, clown doctor, hypnotherapy, low sensory
outcomes. The descriptive synthesis was adapted to report stimulation, and hand‑held video games proved to be effective.
the findings.
Pharmacological and nonpharmacological interventions for
Outcomes of systematic reviews preparing children for surgery
Systematic reviews and meta‑analyses of studies have While pharmacological measures used to reduce the
established the beneficial effects of various preoperative preoperative anxiety, a wide range of nonpharmacological
preparation strategies on the children undergoing surgery. techniques being successfully used for the children. These
A systematic review [8] analyzed the use of sedative techniques can be used as a single measure or in combination
premedications, parental presence during induction of or complementing with the pharmacological measure. The
anesthesia and various behavioral preparation techniques. literature reveals that preparation programs such as role
Evidence indicates that the role of sedative premedication is rehearsals with dolls,[15‑18] puppet shows[19,20] the teaching
firmly established while behavioral techniques are gaining of coping and relaxation skills[21,22] orientation tours of the
wider acceptance. Routine parental presence does not confer operating room[16,17] as well as educational videos.[23‑25] Some
a benefit to the child although parental satisfaction is enabled. programs focus exclusively on preparing the child.[26‑28] The
There is little evidence comparing preinduction techniques for evidence[29] shows that when the oral midazolam and clowns
children with chronic illness requiring repeated visits to the were used to reduce the preoperative anxiety of children, the
operation theater. Review by National Clinical Guidelines[9] children in the clown group exhibited statistically significant
showed that preoperative psychological preparation is effective
lower anxiety score in comparison with the children in the
in reducing anxiety of children undergoing surgery and their
midazolam group. Thus, it is evident that psychological
parents. Evidence shows that psychological preparation
preparation techniques can be used to manage the preoperative
for anesthesia induction, perioperative anxiety reduction
anxiety of children.
programs, psychological preparations/interventions for other
medical procedures, dental procedures is effective. To know
the desire of children and parents regarding the need for Discussion
preoperative information is essential. Parental presence during
anesthesia induction can also help children. Another review[10] The review of literature suggests that the use of toys and
has identified that the preparation programs, although relevant, preoperative visit[30] can reduce the preoperative anxiety in
are not the only form to soothe preoperative anxiety in children. children. Along with the children, the parents too were involved
The methods should be tailored for each child and can be in a study, and there was a high level of satisfaction among
supplemented by preoperative sedative medications. The the parents who underwent this intervention. Performing
literature shows various well‑tried methods of preoperative preoperative preparation program for children is essential. It
management can be applied before hospitalization. The crucial was seen that when the children received therapeutic play[31]
elements of such a strategy are to dissipate the emerging consisting of operation room tour, demonstration and return
doubts by providing children and parents with relevant demonstration of procedures on the mannequins had a better
and understanding information. It was also reviewed that impact. Having encountered with clown and developmentally
audiovisual interventions[11] appear potentially useful in appropriate techniques such as magic tricks, gags, music,
reducing preoperative anxiety and its associated outcomes in games, puppets, word games, and bubbles can also reduce
children undergoing elective surgery. The systematic review the preoperative anxiety in children.[32] It is well studied that
suggested that videos, multifaceted programs, and interactive children who are viewing animated cartoon and playing with
games appear to be most effective, whereas music therapy a favorite toy,[33] working on cartoon coloring book,[34] picture
and internet programs are less effective. A literature survey[12] book[35] are effective methods, whereas video distraction and
was done to review and analyze the studies on the effect of parental presence and combination of both is also effective in
perioperative music in pediatric surgery for children from minimizing preoperative anxiety of children.[36]
day 1 to 18 years of age. The evidence indicates that music
interventions may have a statistically significant effect in It was a promising result of a study which concluded that
reducing postoperative pain, anxiety, and distress in children video glasses are not inferior to midazolam for preoperative
undergoing surgical procedure and music therapy may be anxiolysis and provide a safe, noninvasive nonpharmacological
considered for clinical use. An integrative review[13] showed and pleasant alternative.[37]

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Aranha, et al.: Preoperative preparation of children undergoing surgery

While various activities such as video and toys being effective Acknowledgments
in reducing preoperative anxiety of children, evidences also We greatly acknowledge all the authors of the original research
suggest that surgery virtual tour offered on a website,[38] articles that have been found useful to write this review
orientation tours,[39] providing conventional verbal information article and extend our thanks to the central library, Yenepoya
including role play,[17] operation room tours, information, University for providing facilities to retrieve relevant studies
modeling, coping‑based programs could also effectively reduce from various online databases.
the preoperative anxiety of children.[18]
Financial support and sponsorship
Researchers have also compared many such interventions Nil.
to rule out the best for children. One such study where the
family‑centered behavioral preparation including – anxiety Conflicts of interest
reduction, distraction, video modeling and education, adding There are no conflicts of interest.
parents, no excessive reassurance, coaching, and exposure
is more effective over providing standard care, parental References
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