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PEDIATRIC ANESTHESIA

Predicting Which Child-Parent Pair Will Benefit from Parental Presence During Induction of Anesthesia: A Decision-Making Approach

Zeev N. Kain, MD, MBA^*, Alison A. Caldwell-Andrews, PhD^*, Inna Maranets, MD, William Nelson, MD, and Linda C. Mayes, MD^*

*Center for the Advancement of Perioperative Health, and the Departments of Anesthesiology, Pediatrics & Child Psychiatry, and Child Study Center, Yale University School of Medicine, New Haven, Connecticut

	Abstract

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Using a multiply matched, concurrent cohort analysis, with 568 subjects matched from data obtained by our laboratory over the past 7 yr, we examined whether parental presence during induction of anesthesia (PPIA) reduces children’s anxiety depending on the interaction between child and parent’s baseline anxiety. Children’s and parents’ baseline anxiety was assessed preoperatively; children’s anxiety was again assessed during induction of anesthesia. We found that anxious children who received PPIA from a calm parent were significantly less anxious during induction of anesthesia as compared with anxious children who did not receive PPIA (P = 0.03). In contrast, calm children who received PPIA from an overly anxious parent were significantly more anxious as compared with calm children who were not accompanied by a parent (P = 0.002). We found no effect of PPIA on children’s anxiety during induction of anesthesia when calm parents accompanied calm children into the operating room (P = 0.15) or when overly anxious parents accompanied anxious children (P = 0.49). We conclude that the presence of a calm parent does benefit an anxious child during induction of anesthesia and the presence of an overly anxious parent has no benefit.

	Introduction

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Several randomized controlled trials indicate that parental presence during induction of anesthesia (PPIA) does not reduce child anxiety (1–4). Many clinicians believe, however, that randomized control trials do not reflect actual clinical practice and that the impact of PPIA also depends on variables such as the interaction between parental anxiety and the child’s anxiety. That is, children who are calm and whose parents are overly anxious may respond differently to PPIA as compared to anxious children with calm parents, calm children with calm parents, or anxious children with overly anxious parents.

Examining these four clinical scenarios within the context of PPIA while controlling for baseline variables requires an extremely large number of subjects and is thus impractical to be conducted as a randomized controlled trial. We suggest an alternative method: using a large, detailed, technical database with many hundreds of subjects to identify child-parent dyads that adhere to predefined criteria. Thus, the purpose of this analysis was to identify specific child-parent dyads that will benefit from PPIA.

	Methods

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Over the past 8 yr our research group has conducted multiple prospective and randomized studies involving PPIA. Data from all these studies were combined in a central database of more than 1500 patients. Subjects in these studies included parents and children aged 2–12 yr with a physical class of ASA I–II and who were undergoing elective outpatient surgery with general anesthesia. The IRB approved all studies, and assent (if appropriate) and informed consent was obtained from participants. No subject had a history of chronic illness, prematurity, psychiatric illness, or developmental delay.

Subjects eligible for the present multiply matched, concurrent cohort analysis were identified from the above database. "Matching" refers to a selection method that pairs subjects in "comparison" groups (no-PPIA) with those in an "index" group (PPIA). Matching controls for potential confounding variables such as children’s baseline temperament. The index group included children assigned to receive PPIA and the comparison group included children who were assigned not to receive PPIA. Both groups were matched based on age, gender, and baseline temperament as measured by emotionality level and activity level. No child in either group received a preoperative sedative.

Data obtained using the following measures were included in the present investigation. Trained psychologists administered all psychological instruments to children and parents. It is important to note that the same investigators performed all data collection using the same tools with the same population of children.

The State-Trait Anxiety Inventory (STAI) is a parental self-report measuring state and trait anxiety. This measure has excellent reliability and validity (5).

The EASI Scale of child temperament (EASI) assesses child’s baseline temperament and yields subscales including emotionality, and activity level. This instrument has good reliability and validity (6).

Modified Yale Preoperative Anxiety Scale (mYPAS) is an observation measure of anxiety previously developed by our laboratory. This measure has good reliability and validity (7,8).

Although specific procedures for each subject included in this investigation may have differed in some minor ways, all shared the following basic protocol:

In the preoperative waiting area, children were assigned to receive either PPIA or no PPIA. State anxiety of the child (mYPAS) and trait and state anxiety of the parent (STAI) were evaluated. Parents completed the EASI. No child received midazolam or any other behavioral intervention.

In the operating room, child’s state anxiety (mYPAS) was evaluated upon introduction of the anesthesia mask. Next, a Spo₂ probe was placed on the child’s hand and a scented anesthesia mask was introduced. Child’s state anxiety was evaluated again and anesthesia was induced using an O₂/N₂O/sevoflurane technique.

A database search identified 513 children who were eligible for inclusion in the PPIA group and 426 children who were eligible for inclusion in the non-PPIA group (total N = 939). Matching on variables of age, gender, and baseline temperament yielded 568 subjects (284 pairs).

We classified children as high or low in anxiety based on mYPAS scores in the preoperative waiting area. After examining items and the distribution of mYPAS scores for 1000 patients, we defined children as "calm" children if they scored <30 and "anxious" if they scored over 40. Similarly, we used state anxiety scores (STAI) to classify parental anxiety as overly anxious (upper 50%) or calm (lower 50%). We then defined four groups of child-parent pairs: calm parent-calm child; overly anxious parent-calm child; calm parent-anxious child; overly anxious parent-anxious child. We used one-way analysis of variance to examine group differences on mYPAS scores during induction of anesthesia; independent sample Student’s t-tests compared scores from each group. Descriptive statistics describe baseline demographic characteristics of each group. Data are presented as mean ± sd.

	Results

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We identified a total of 568 children and parents for this multiply matched concurrent cohort analysis. Baseline characteristics of both PPIA and no-PPIA groups are shown in Table 1. No differences were found between the two groups studied.

We first compared groups that received PPIA to groups that did not receive PPIA (Table 2). We found that anxious children who received PPIA from a calm parent were significantly less anxious during induction of anesthesia as compared with anxious children who did not receive PPIA (P = 0.03). In contrast, calm children who received PPIA from an overly anxious parent were significantly more anxious as compared with calm children who were not accompanied by a parent (P = 0.002). We found no effect of PPIA on children’s anxiety when calm parents accompanied calm children into the operating room (OR) (P = 0.15) or when overly anxious parents accompanied anxious children into the OR (P = 0.49). Next, we stratified the data by age and created 2 groups, children aged 2–6 yr old and children aged 7–12 yr old. The results of this stratified analysis were identical to the results of the whole group analysis.

We next used one-way analysis of variance to compare anxiety during induction of anesthesia across all groups that received PPIA (Table 2). Post hoc tests showed that the calm children who received PPIA from a calm parent were significantly less anxious as compared with the other 3 groups (P < 0.01 in all cases). Also, anxious children who received PPIA from an overly anxious parent were significantly more anxious as compared with all 3 other groups (P < 0.01 in all cases).

Similarly, when we compared anxiety across all groups that did not receive PPIA, anxious children who did not receive PPIA from either an overly anxious or a calm parent were significantly more anxious during induction of anesthesia than calm children who did not receive PPIA from either a calm or an overly anxious parent (P < 0.0001 in. both cases) (Table 2).

	Discussion

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In this analysis, we examined four parental presence clinical scenarios that present daily to the practicing anesthesiologist. We found that letting an overly anxious parent into the OR does not appear to benefit an anxious child and increases anxiety in a calm child. Thus, it seems that the practicing anesthesiologist should not allow overly anxious parents into the OR if the primary interest is reduction of child anxiety. In contrast, letting calm parents in the OR will benefit anxious children and will not change the anxiety level of children who were calm in the preoperative holding area.

The conclusions of this report validate and extend previous work done by Bevan et al. (3) that indicated that the presence of a calm parent benefited a child during induction of anesthesia, while the presence of an anxious parent did not. Similarly, Messeri et al. (9) have recently indicated, in a nonrandomized and noncontrolled study that anxious parents increase the stress of anesthetic induction in children, even those who have been premedicated. Interestingly, although these reports were hindered by methodological issues such as small sample size, lack of reliability and validity of assessment instruments and the presence of confounding variables such as premedication, their conclusions are valid.

Although this present report provides valid empirical data that are aimed to predict which child-parent pairs will benefit from PPIA, this report does not address the question of anxiety assessment in busy perioperative settings. Indeed, because administering structured anxiety instruments is not practical in the clinical settings, it is best for the practitioner to use their clinical judgment with regard to the anxiety of the child and parent in the holding area. Also, indicating to a parent that it is best if they would not accompany their child during induction of anesthesia can pose a challenge. The authors of this report suggest that the practitioner can indicate to these parents that their presence will indeed result in increasing the child’s anxiety and alternatively offer to administer the child a sedative premedication.

Several methodological issues related to this report have to be noted. First, although anesthesiologists in our institutions have the option to administer sedatives preoperatively, children included in this report were all part of an experimental protocol that did not allow the administration of any sedatives. Second, we have defined parents as overly anxious if they scored high on the STAI, indicating that many parents are typically anxious during the perioperative period. Hence, for the purpose of this report we wanted to identify a population of parents who are overly anxious.

We conclude that the practicing anesthesiologist should consider both the anxiety of the child and the parent in the holding area when considering PPIA. Indeed, this report suggests that overly anxious parents should not be present during induction of anesthesia. Also, the presence of a calm parent does benefit an anxious child during induction of anesthesia.

	Footnotes

 
Supported, in part, by a grant from the National Institutes of Health (NICHD, R01HD37007–01), Bethesda, Maryland.

Accepted for publication July 26, 2005.

Address correspondence and reprint requests Zeev N. Kain, MD, MBA, Department of Anesthesiology, Yale University School of Med, 333 Cedar Street, New Haven, Connecticut 06510. Address e-mail to zeev.kain{at}yale.edu.

	References

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1. Kain ZN, Mayes LC, Caramico LA, et al. Parental presence during induction of anesthesia: a randomized controlled trial. Anesthesiology 1996;84:1060–7.[Web of Science][Medline]
2. Kain Z, Mayes L, Wang S, et al. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study. Anesthesiology 2000;92:939–46.[Web of Science][Medline]
3. Bevan JC, Johnston C, Haig MJ, et al. Preoperative parental anxiety predicts behavioral and emotional responses to induction of anesthesia in children. Can J Anaesth 1990;37:177–82.[Web of Science][Medline]
4. Hickmott KC, Shaw EA, Goodyer I, Baker RD. Anaesthetic induction in children: the effect of maternal presence on mood and subsequent behaviour. Eur J Anaesthesiol 1989;6:145–55.[Web of Science][Medline]
5. Spielberger CD. Manual for the State-Trait Anxiety Inventory (STAI: Form Y). Palo Alto, CA: Consulting Psychologists Press, 1983:4–26.
6. Buss AH, Plomin R. Theory and measurement of EAS. In: Temperament: early developing personality traits. Hillsdale, NJ: L. Erlbaum Associates, 1984:98–130.
7. Kain Z, Mayes L, Cicchetti D, et al. The Yale preoperative anxiety scale: how does it compare to a gold standard? Anesth Analg 1997;85:783–8.[Abstract]
8. Kain Z, Mayes L, Cicchetti D, et al. Measurement tool for pre-operative anxiety in children: The Yale Preoperative Anxiety Scale. Child Neuropsychol 1995;1:203–10.
9. Messeri A, Caprilli S, Busoni P. Anaesthesia induction in children: a psychological evaluation of the efficiency of parents’ presence. Paediatr Anaesth 2004;14:551–6.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (5) Citing Articles via Google Scholar Google Scholar Articles by Kain, Z. N. Articles by Mayes, L. C. Search for Related Content PubMed PubMed Citation Articles by Kain, Z. N. Articles by Mayes, L. C. Related Collections Preoperative Evaluation Pediatrics