British Journal of Anaesthesia, 121 (2): 438e444 (2018)

doi: 10.1016/j.bja.2018.02.067
Advance Access Publication Date: 4 May 2018
Paediatrics

PAEDIATRICS

The effectiveness of transport in a toy car for

reducing preoperative anxiety in preschool children:
a randomised controlled prospective trial
P. P. Liu1,2,#, Y. Sun1,2,#, C. Wu1,2, W. H. Xu1, R. D. Zhang1, J. J. Zheng1,2,
Y. Huang1,2, Y. Q. Chen1,2, M. Z. Zhang1,2,* and J. Z. Wu3,*
1
Department of Anaesthesiology, Shanghai Children’s Medical Centre, School of Medicine, Shanghai Jiao
Tong University, Shanghai, China, 2Paediatric Clinical Pharmacology Laboratory, Shanghai Children’s
Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China and 3Department of
Anesthesia and Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

*Corresponding authors. E-mails: zmzscmc@shsmu.edu.cn, junzheng.wu@cchmc.org

#
Co-first authors.

Abstract
Background: This study was designed to determine whether transport of a paediatric inpatient in a children’s ride-on toy
car has an effect on perioperative levels of anxiety compared with transport on a hospital gurney with or without oral
midazolam premedication.
Methods: In this prospective study, 108 children aged 2e5 yr with congenital heart disease and undergoing first surgical
correction were randomly allocated to one of three groups: Group C (transport in a children’s ride-on car), Group G
(transport on a gurney without premedication), or Group M (transport on a gurney and received premedication of oral
midazolam 0.5 mg kg
1). The modified Yale Preoperative Anxiety Scale-Short Form and parent-recorded anxiety VAS
were applied to evaluate anxiety in the following time points: pre-anaesthesia visit (the day before surgery), upon getting
in the ride-on car or on the gurney in the ward, upon arriving in the preoperative holding area, at the moment of leaving
from the holding area to the operating room (OR) (coincided with separation from parents), at the time after entering the
OR, and at the time just before anaesthesia induction.
Results: Children in Group C exhibited significantly lower levels of anxiety from the time they got into the ride-on car
until the time they entered the OR, compared with the other two groups (P<0.001). The subjects in Group C had similarly
low anxiety levels to those in the Group M at the time before induction (P¼0.914).
Conclusions: Transport in a ride-on toy car can relieve preoperative anxiety in preschool children undergoing surgery to
a comparable degree as midazolam.
Clinical trial registration: ChiCTR-IOR-17012791.

Keywords: anxiety; child; hospitalised; preschool; preoperative period

Editorial decision: 13 February 2018; Accepted: 13 February 2018

© 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

438

Editor’s key points
 Anxiety is common among children about to undergo
anaesthesia and surgery.
 Children being transported to the operating theatres
are often made to lie on a transport gurney.
 The authors compared the anxiolytic effect of allowing
children to use a ride-on toy car during transfer to that
of oral midazolam.
 Anxiety scores were reduced by riding on the toy car
compared with those in children transferred on a gur-
ney; the anxiolytic effect of the car ride was comparable
to that of oral midazolam premedication.
Significant anxiety was reported in up to 60% of all young chil-
dren undergoing anaesthesia and surgery.1 Preoperative anxiety
has been associated with short- and long-term traumatic con-
sequences, including risks of emergence delirium and mal-
adaptive postoperative behaviours such as separation anxiety
disorders and eating disorders.2e4 Several previous studies
indicated that preschool children were at increased risk for
development of pre-surgical anxiety.5 In addition, unfamiliar
environments and people and negative anticipation of surgical
procedure further distress young children.6
Three categories of interventions have been used to reduce
preoperative anxiety: sedatives premedication, parental pres-
ence during induction of anaesthesia, and hospital-based pre-
operative preparation programs. Midazolam premedication is
regarded as a reliable strategy in reducing preoperative anxiety,
but it can be associated with a number of untoward conse-
quences, such as paradoxical reaction, delayed patient discharge
in ultrashort procedures, and some operational drawbacks.7
Parental presence with the child until the completion of anaes-
thesia inhalation induction is popular in the UK and USA, and it
increases the parents’ satisfaction and the child’s cooperation.
But clinically, it is less practical in overpopulated Asian countries.
And some research has shown that parental presence is not
reliable for reducing preoperative anxiety.8,9 There are a variety of
hospital-based preoperative preparation programs applicable
to paediatric patients for relieving their anxieties, such as
clown doctors, video games,10e15 ADVANCE (Anxiety-reduction,
Distraction, Video modeling and education, Adding parents, No
excessive reassurance, Coaching, and Exposure/shaping; see
Kain and colleagues16 for a description of the intervention) pro-
gram, comical information leaflet, etc.16,17
In China, the model of same-day surgery is at a fledging
stage and most surgical patients are still admitted to hospital 1
or 2 days before the day of surgery. On the day of surgery,
children are transported from the ward to the holding area on
a hospital gurney 30 min before anaesthesia induction. More
often, both parents and children have shown significant anx-
iety when patients are placed on the gurney. Some children
even refuse to lie down on it. Recently, in our hospital, a
children’s ride-on toy car (Fig. 1) was used for transport and
attracted public attention. This non-motorised ride-on toy car
lets children enjoy ‘driving’ on the way from the ward to the
operating room (OR). In some preschoolers, enjoying riding in
this type of car is part of their daily routine. Thus, the ride-on
cars could open a new alternative avenue for alleviating pre-
operative anxiety in children.
Few investigations have been done to study the effect of
different transport modes on preoperative anxiety. Therefore,
the purpose of this study was to determine whether riding
Anxiolytic effects of transport in ride-on cars - 439
in ride-on cars from the ward to the OR is capable of alleviating
preoperative anxiety in preschool children in comparison
with midazolam premedication and transport on a hospital
gurney.
Methods
This prospective, randomised study was carried out over the
period from September to December, 2017. It was approved by
the Institutional Review Board of Shanghai Children’s Medical
Centre (SCMCIRB-K2016041) and was registered at Chinese
Clinical Trial Registry (ChiCTR-IOR-17012791). Written
informed consent was obtained from the parents or legal
guardians of each subject before the day of surgery.
Study population
Children with congenital heart disease, aged between 2 and 5
yr, ASA Physical Status (ASA-PS) 2 or 3, and undergoing the
first surgical correction were recruited in this study. Patients
having emergency surgery and those with a neuropsychiatric
disease, previous anaesthetic experience, taking psychoactive
medications, or with a history of significant hearing or visual
impairments and severe sleep apnoea were excluded from
participation.
Randomisation and preoperative management
According to a computer-generated randomisation list, pa-
tients were assigned in blocks of three with a sealed envelope
technique to one of three groups:
 Group C: participants were transported on a toy children’s
ride-on car and did not receive premedication.
 Group G: participants were transported on a hospital gurney
and did not receive premedication.
 Group M: participants were transported on a hospital gurney
and received premedication of oral midazolam (0.5 mg kg
1
up to a maximum of 15 mg upon arriving in the preoperative
holding area 30 min before surgery).
One of the anaesthesiologists from the research team visited
the thoracic cardiovascular ward to conduct preoperative in-
terviews and the baseline anxiety evaluation the day before
surgery. Patient characteristics and temperament [emotion-
ality, activity, sociability, and impulsivity (EASI)] of the child
were collected from the parents and the medical charts.
All operations were performed in morning sessions.
Eutectic mixture of local anaesthetics (EMLA) cream was
applied about 1 h before venipuncture. All patients arrived in
the preoperative holding area about 30 min before surgery.
Children in Group C were transported from the thoracic car-
diovascular ward to the OR on the ride-on car, while children
in Groups G and M were transported on a hospital gurney.
Upon arriving in the preoperative holding area, the patients in
Group M were administered oral midazolam 0.5 mg kg
1 by a
nurse. One parent was allowed to accompany the child in the
preoperative holding area. When the OR called, the children
were taken away from their parents via the standard practice
and transported to the OR (Fig. 2). The parents were escorted
out of the holding area after separation.
Anaesthesia induction and tracheal intubation
Once the patient was positioned on the operating table, the
monitors of ECG, pulse oximetry, and non-invasive blood
 440 - Liu et al.

Fig 1. Photographs of (A) the children’s toy ride-on car and (B) the hospital gurney used for the transport of children from the cardiac ward
to the operating room.

pressure measurement were placed, and then an i.v. line was
established. Induction was performed with etomidate 0.3 mg
kg
1, sufentanil 2 mg kg
1, and rocuronium 0.6 mg kg
1. After
tracheal intubation, anaesthesia was maintained with propo-
fol, sufentanil, and rocuronium, in combination with sevo-
flurane as clinically indicated.
Preoperative anxiety measurements
Children’s anxiety levels were evaluated using the modified
Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF) and
the parent-recorded anxiety VAS (VAS-C). The mYPAS-SF is
the short version of the mYPAS, which has shown good-to-
excellent inter- and intra-observer reliabilities and validity
for measuring children’s anxiety in children aged 2e12 yr.18
The mYPAS measurement includes 22 items in five behav-
ioural categories: activity, state of apparent arousal, vocal-
isation, emotional expression, and the use of parents.
Considering the absence of parents after the transportation to
the OR, the short version of mYPAS (mYPAS-SF) was proposed
by Jenkins and colleagues.19 The item of ‘use of parents’ was
removed. The accuracy of mYPAS-SF was retained and it was
more easily used in clinical research settings. The mYPAS-SF
scores are obtained by summing the scores of 18 items in the

Fig 2. Study flow diagram. EASI, emotionality, activity, sociability and impulsivity; Group C, transport in children’s ride-on cars; Group G,
transport on a gurney without premedication; Group M, transport on a gurney and received premedication of oral midazolam 0.5 mg kg
1.
mYPAS-SF, modified Yale Preoperative Anxiety Scale-Short Form; OR, operating room; VAS-C, Visual Analog Scale of children; VAS-P,
Visual Analog Scale of parents.
 Anxiolytic effects of transport in ride-on cars - 441

other four behavioural categories. The score range is 22.9e100, decrease in mYPAS-SF was considered to be 15 points.13 A
with a score of >30 indicating the presence of significant sample size of 26 participants in each group was calculated by
anxiety. A single assessor who was assigned to evaluate the one-way ANOVA to show a difference in mean mYPAS-SF scores
mYPAS-SF score had received training by reviewing video- of 15 for an expected SD of 15 with a significance level of 0.05
tapes before the study and this individual was considered as (a¼0.05), and a power of 90% (b¼0.10). To allow for attrition,
qualified until his/her scoring skill reached at least 80% sample size was enlarged to 108.
agreement with the psychologist’s criteria, as suggested by
Sadhasivam and colleagues.20 The parent-recorded anxiety
VAS measures children’s anxiety assessed by the accompa- Results
nying parents using a 10-cm scale.21 General characteristics of subjects
In the present study, the mYPAS-SF scores were assessed at
A total of 108 children participated in this randomised study
six time points (Fig. 2), that is, during the pre-anaesthesia visit
and 36 subjects were randomised into each group initially. Six
the day before surgery (T0; baseline), upon getting inside the
children were excluded because of withdrawal of consent,
ride-on car or onto the gurney in the ward (T1), upon arriving in
incomplete data, or non-compliance with our protocol. Four of
the preoperative holding area (T2), at the time of leaving the
these patients refused to get on the gurney, and two patients’
holding area for OR (coincided with separation from parents,
surgery was postponed. Thus, 102 participants completed the
T3), once entering the OR (T4), and at the time after monitor
study, and they were included in the data analysis. There were
placement and ready for anaesthesia induction (T5). The
no significant intergroup differences observed in subject
parent-recorded anxiety VAS scores were measured from T0 to
characteristics, temperament (EASI), or surgical characteris-
T3 before children were separated from parents. At the same
tics (Table 1).
time, parental anxiety was also determined by the VAS-P
scale.
Subject anxiety
Statistical analysis At T0, the baseline median mYPAS-SF scores were compa-
Outcome analysis rably lower than 30 (P¼0.324), and there was no significant
difference in the number of children exhibiting baseline
The primary end point of this study was to analyse children’s anxiety (an mYPAS-SF score >30) among groups (P¼0.750).
anxiety manifested just before the induction of anaesthesia. Children in Group C exhibited lower mYPAS-SF scores
The second end point was to evaluate the separation anxiety compared with the other two groups at T1 (P<0.001 vs both
at the moment of leaving from the holding area to the OR by groups), T2 (P<0.001 vs both groups), T3 (P<0.001 vs Group G
using the mYPAS-SF score and VAS-C. The parental anxiety and P¼0.005 vs Group M), and T4 (P<0.001 vs Group G and
evaluated by VAS-P was the additional outcome. P¼0.012 vs Group M). At T5, children in Group C displayed
Outcome data were analysed in the intention-to-treat (ITT) similar mYPAS-SF scores with Group M (P¼0.984), and both
population. The ShapiroeWilk and AndersoneDarling tests were significantly lower than Group G (P<0.001). Children in
were used to test the assumption of normal distribution.
Normally distributed data were reported as mean [standard
deviation (SD)]. Non-normally distributed and ordinal data
were reported as median (inter-quartile range), and categori- Table 1 Subject and surgical characteristics. Values are mean
cal data were presented as the number (percentage). The (SD), range, or actual numbers unless otherwise stated. Group
normally distributed continuous variables were compared C, transport in children’s ride-on toy cars; Group G, transport
using one-way analysis of variance (ANOVA). Non-normally on a gurney without premedication; Group M, transport on a
gurney and received premedication of oral midazolam 0.5 mg
distributed continuous variables, such as mYPAS-SF scores
kg
1. ASD, atrial septal defect; VSD, ventricular septal defect.
at each time point, were compared using the non-parametric Others included tetralogy of Fallot, partial anomalous pul-
KruskaleWallis test. When significant differences were monary venous connection, double outlet right ventricle, etc.
found, the test was followed by pairwise comparison using the
ManneWhitney U-test, with Bonferroni adjustment for mul- Group C Group G Group M
tiple tests (three comparisons). A Bonferroni-adjusted P value (n¼34) (n¼34) (n¼34)
<0.017 (0.05/3) was considered statistically significant. The
Age (yr) 3.6 (0.9) 3.5 (1.2) 3.4 (1.0)
change in mYPAS-SF scores over time among the three groups
Age range (yr), 2.1e5.0 2.0e5.0 2.1e5.0
was compared using the repeated measures ANOVA. Categorical
(minimume
variables were analysed using the c2 test or the Fisher’s exact maximum)
test. Correlations between mYPAS-SF score and VAS-C or VAS- Gender (M/F) 19/15 16/18 17/17
P before transport to the OR were assessed using the Weight (kg) 15.5 (2.8) 14.9 (4.1) 15.3 (2.7)
Spearman rank correlation coefficients. Height (cm) 98.4 (8.1) 96.6 (10.4) 98.1 (7.0)
ASA PS (2/3) 13/21 12/22 13/21
Statistical analysis was performed with SAS 9.4 (SAS
Guardian (father 8/26/0 9/23/2 8/25/1
Institute Inc., Cary, NC, USA). A P value <0.05 was considered
/mother/grandparent)
to be statistically significant. The Bonferroni adjustment was Time from ward to 3.87 (0.69) 3.85 (0.64) 3.84 (0.63)
made to control type I error for multiple testing. holding area (min)
Time from holding 58.6 (7.1) 59.3 (8.0) 59.1 (8.3)
area to OR (s)
Sample size calculation Type of surgery, n (%)
In a pilot study of 27 children, the mean (SD) mYPAS-SF scores ASD/VSD 24 (70.6) 24 (70.6) 23 (67.6)
Others 10 (29.4) 10 (29.4) 11 (32.4)
just before induction were 56.0 (5.8), 69.0 (12.2), and 52.8 (13.7)
in Groups C, G, and M, respectively. A clinically significant
 442 - Liu et al.
Group M exhibited similar mYPAS-SF scores with Group G at
T2 (P¼0.914), and were less anxious than Group G at T3, T4,
and T5 (all P<0.001).
In all groups, there was an upward trend of anxiety levels
from baseline to the preoperative holding area and to the
moment of just before inductsion (Fig. 3). However, the
mYPAS-SF scores in children of all groups increased sharply at
T1 (upon getting on the gurney or in the ride-on car) compared
with baseline (T0) and then, decreased at T2 (arriving in the
holding area). Likewise, the mYPAS-SF of children in Group G
increased sharply at T3 (the time of transport to the OR) and
relatively decreased at T4 (when arriving in the OR) (Table 2).
VAS-C scores for different time points among three groups are
presented in Table 2.
Parent anxiety
Parent anxiety was assessed using VAS-P before separation
from children (T3). The baseline VAS-P scores were not
different in the three groups (P¼0.740). There was a significant
difference at T1 (P¼0.036), with the lowest median anxiety
scores recorded in the Group C (Table 2). However, no pairwise
comparisons were found to be significant after Bonferroni
correction for multiple testing. Parent anxiety in Group C
was lower than in Group M at T2 (P¼0.004) and VAS-P in
Group C was lower than the other two groups at T3 (P¼0.007 vs
Group G, P¼0.008 vs Group M). Results showed that the
changes of parent anxiety scores were weakly correlated with
Fig 3. Box plot of scores for the modified Yale Preoperative
Anxiety Scale-Short Form (mYPAS-SF) by study groups across
different study times: T0¼baseline during pre-anaesthesia visit;
T1¼upon getting in the ride-on cars or on the gurney in the
ward; T2¼upon arriving in holding area; T3¼leaving from hold-
ing area for the operating room (OR) coincided with separation
from parents; T4¼entrance to the OR; T5¼before anaesthesia
induction. *Bonferroni-adjusted P<0.017 vs Group G after
ManneWhitney U-test. #Bonferroni-adjusted P<0.017 vs Group
M after ManneWhitney U-test. Group C, transport in ride-on
cars; Group G, transport on a gurney without premedication;
Group M, transport on a gurney and received premedication of
oral midazolam 0.5 mg kg
1. Median values shown as solid line.
Whiskers represent 5th and 95th percentile values, and dots
represent outliers.
the changes of mYPAS-SF scores from T0 to T3 (P¼0.0118,
r¼0.249).
Discussion
This study demonstrated that transport from the ward to the
OR by riding in a children’s toy car significantly reduced
preoperative anxiety. This transporting mode showed similar
anxiolytic effects at the time just before anaesthesia induc-
tion as oral midazolam.
In China today, hospital admission before surgeries re-
mains the main model of surgical practice. The routes from
the wards to the OR could be zigzagged and up-and-down
depending on the layout of a hospital, and could be rather
distant by striding buildings, which may add an extra layer of
distress to both parents and patients during transport. Our
results indicated both parents and children showed significant
anxiety when patients were placed on the gurney. Similar to
children who are undergoing ambulatory surgery, inpatients
also have to face the separation anxiety from their parents.
The sharp increase in mYPAS-SF scores at T1 and at T3 of
Group G indicated the two sources of preoperative anxiety in
hospitalised preschool children.
Even though similar and reduced pre-induction anxiety
levels were found both in children of Groups C and M, trans-
port in the ride-on cars did show several advantages over
midazolam premedication in clinical practice. The ride-on car
transport appears to be easy-to-use, highly accepted, cost-
effective, and devoid of side-effects and it is a good tool to
mitigate pre-surgical anxiety in children. Midazolam pre-
medication needs a nurse to check, prepare, and administer,
and could be problematic if children are resistant and refuse to
take it.22 The time of onset for midazolam varies greatly
among individual children, and the paradoxical response and
delayed discharge cannot be neglected.22,23 In the current
study, children riding in the cars exhibited lower anxiety than
the other two groups from the beginning of transportation to
entering the OR. The reduction in anxiety can be attributed to
the following factors. First, children were captivated by the
colourful and stylish ride-on cars and were imagining them-
selves driving when holding the steering wheels. Secondly, the
children were sitting in the ride-on car naturally, and enjoying
the views of surroundings and feeling relaxed. However,
transport on a gurney requires patients’ restraint with a strap,
which increased the patients’ fear and uncooperativeness.
That was why some children refused to stay on it.
The effect of different distraction tools on reducing pre-
operative anxiety in children has been reported in a variety of
settings. Seiden and colleagues24 found that a tablet-based
interactive distraction tool was superior to midazolam pre-
medication in minimising the preoperative anxiety at
parental separation, and was not inferior to oral midazolam
during induction of anaesthesia for children aged 1e11 yr
undergoing outpatient surgery. In addition, several studies
demonstrated that video distraction was an effective method
of reducing preoperative anxiety in comparison with oral
midazolam or parental presence.11,12,14,15 Unlike studies
mentioned above, our research intended to intervene in an
earlier stage and the results showed that children’s transport
in a ride-on car is an effective way to ease children’s anxiety
in the preoperative period. Indeed, there is evidence indi-
cating that children who experience high levels of distress
and anxiety at one point are less cooperative when under-
going procedures later.25 From this point of view, the
 Anxiolytic effects of transport in ride-on cars - 443

Table 2 Anxiety levels in children and parents in different groups. Values are median (inter-quartile range) for continuous variables
and number of patients (%) for categorical variables. T0¼baseline during pre-anaesthesia visit; T1¼upon getting in the ride-on cars or
on the gurney in the ward; T2¼upon arriving in holding area; T3¼leaving holding area for the OR coincided with separation from
parents; T4¼entrance to the OR; T5¼before anaesthesia induction.

Group C Group G Group M P-value

(n¼34) (n¼34) (n¼34)

Children’s anxiety
mYPAS-SF
T0 28.1 (22.9e33.3) 27.1 (22.9e33.3)¶ 22.9 (22.9e33.3)¶ 0.324x
T1 34.4 (22.9e45.8)* y z 51.0 (39.6e63.0)z ¶
50.0 (44.3e57.3)z ¶ <0.001x
T2 27.1 (22.9e41.1)* y 39.6 (32.3e50.5)z 39.6 (32.3e46.9)z <0.001x
T3 33.3 (27.1e46.9)* y z 65.6 (45.8e72.9)y z ¶
45.8 (33.3e51.6)* z <0.001x
T4 43.8 (27.1e46.9)* y z ¶ 58.3 (45.8e72.9)y z ¶
50.0 (44.3e53.1)* z <0.001x
T5 50.0 (45.8e58.9) * z ¶ 66.7 (56.3e84.9)y z ¶
50.0 (45.8e57.3)* z ¶ <0.001x
Baseline anxiety, [n(%)] 13 (38.2) 15 (44.1) 12 (35.3) 0.750jj
VAS-C
T0 1.0 (0e2.0) 1.0 (0e2.0)¶ 1.0 (0e2.0)¶ 0.558 x
y z
T1 1.5 (1.0e2.0)* 3.0 (2.0e4.0)z 3.0 (2.0e4.0)z ¶ <0.001x
T2 1.0 (0e2.0)* y 3.0 (2.0e4.0)z 2.0 (1.0e4.25)z <0.001x
z ¶
T3 2.0 (1.0e3.0)* 6.0 (3.0e8.0)y z ¶
3.0 (2.0e5.25)* z ¶
<0.001x
Parental anxiety
VAS-P
T0 4.0 (4.0e5.0)¶ 4.0 (4.0e5.0)¶ 4.0 (4.0e4.25)¶ 0.740x
T1 5.0 (5.0e6.0)z ¶ 6.0 (5.0e7.0)z ¶
6.0 (5.0e6.0)z ¶ 0.036x
T2 6.0 (5.0e7.25)y z 7.0 (6.0e8.0)z 7.0 (6.0e8.0)z 0.01x
T3 7.0 (6.0e8.0)* y z ¶
8.0 (7.0e9.0)z ¶
8.0 (7.75e9.0)z ¶ 0.012x

*
Bonferroni-adjusted P<0.017 vs Group G after ManneWhitney U-test.
y
Bonferroni-adjusted P<0.017 vs Group M after ManneWhitney U- test.
z
P<0.05 vs T0 within group.
¶
P<0.05 vs T2 within group.
x
KruskaleWallis test.
jj
c2 test. Group C, transport in ride-on cars; Group G, transport on a gurney without premedication; Group M, transport on a gurney and received
premedication of oral midazolam 0.5 mg kg
1; mYPAS-SF, modified Yale Preoperative Anxiety Scale-Short Form.

techniques to minimise preoperative anxiety should be
applied even before patients are leaving the ward and on the
way to the preoperative holding area.
With the rapid development of communication technolo-
gies, hospital-based preoperative preparation programs can be
conducted as early as the pre-anaesthesia visit or when chil-
dren are at home. Non-pharmacological techniques, such as
the ADVANCE program, the web-based education program
(e.g. I-PPP, WebTIPS), education leaflets, etc., have been vali-
dated to reduce preoperative anxiety,16,17,26e30 but they are
either complex with several components or time-consuming.
Parents need to start learning about the programs in
advance and to a large extent, the efficacy of the programs
depends on the parental adherence to them.31 What is more,
the cultural differences, education backgrounds, or charac-
teristics of the parents can also limit the generality of these
programs. In our study, parent anxiety in Group C was
significantly lower than the other two groups. One of the
possible reasons is that parents feel less worried when chil-
dren are enjoying playing with ride-on cars rather than being
restrained on the gurney. In addition, children’s crying and
refusing to take oral preoperative medication would also in-
crease parents’ nervousness.
There are a few limitations in our work. First, the study was
performed only in patients with congenital heart disease in the
heart centre of our hospital, and all the patients remained
intubated and were sent to the cardiac intensive care unit at
the end of surgery. Therefore, we were unable to observe the
effect of ride-on cars on the patients’ recovery during the
immediate postoperative period. Second, blinding was
impossible in this study because transport in ride-on cars or on
gurneys and midazolam premedication were visible to all in-
vestigators and participants.
In conclusion, our results support that transport on a ride-
on toy car can be a very sensible and practical addition to
preoperative anxiolytic applications in paediatric surgical
patients.
Authors’ contributions
Study design/planning: P.P.L, Y.S, M.Z.Z, J.Z.W.
Study conduct: P.P.L, Y.S, C.W, W.H.X, R.D.Z, Y. H, Y.Q.C.
Data analysis: P.P.L, Y.S, C.W, J.J.Z.
Writing the manuscript: P.P.L, Y.S, C.W, J.Z.W, M.Z.Z.
Acknowledgements
We thank Shanghai Alumni Association, China University of
Mining and Technology for donating ride-on cars to children
with congenital heart disease.
Declaration of interest
The authors declare no conflicts of interest.
Funding
Pudong New Area Science and Technology Development
Innovation Fund (PKJ2015-Y02).
 444 - Liu et al.
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Handling editor: A.R. Absalom