| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
 
|
|
|
||
|
|
Anesth Analg 2006;102:1070-1072 © 2006 International Anesthesia Research Society doi: 10.1213/01.ane.0000198332.51475.50
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
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.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Emotional distress experienced by children undergoing in-hospital procedures has been recognized since at least 1941 (1). The incidence of clinically significant anxiety during the preoperative period has been reported to be as frequent as 40%–60% (2–4). Treating and addressing this anxiety, which may lead to adverse psychological and physiological outcomes, is important (3–5). Kain et al. (6) have reported that pediatric anxiety is associated with increased incidence of nightmares, separation anxiety, eating disorders, and increased fear of physicians at 2-wk follow-up. Anxiety in the preoperative holding area may be expressed by facial expressions of fear, trembling, panic, crying, or even combativeness.
Several interventional techniques are available to reduce preoperative anxiety in children. Pharmacological regimens such as oral midazolam are effective and are used with great frequency (7). The administration of oral premedication to children is often met with apprehension, reluctance, or refusal. The purpose of the present study was to determine whether giving a small toy to a child would decrease anxiety and apprehension associated with taking oral premedication.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
This study was approved by our IRB. A parent or guardian provided informed signed consent for participation of each child. The study population consisted of 100 ASA physical status I–II children aged 3 to 6 yr. They were undergoing elective ambulatory surgery such as tonsillectomy, hernia repair, or minor urogenital procedures under general anesthesia. The children were randomized into two equal groups, and the types of surgery did not differ between groups. The sample size of 50 per group was determined by using 28 ± 8 as the mean ± sd values of the Modified Yale Preoperative Anxiety Scale (mYPAS) scores reported for children (9) and by assuming that a reduction of 5 U in the anxiety score would be significant at <0.05 with 0.8 as the power of analysis to evaluate the difference between 2 groups using analysis of variance. Children who came on even numbered dates of the month were included in the toy group and given a toy at a designated time preoperatively. Children who came on odd numbered dates of the month were included in the no-toy group and were not given a toy preoperatively but received a toy postoperatively to keep them happy. Randomization and giving the toy were performed by the anesthesiologist.
The anxiety scores were recorded for each child by trained research assistants who were not familiar with the aim or other details of the study. This assured a level of blinding in anxiety data collection. We used the mYPAS, which was shown to be an excellent and reliable tool for assessing children’s anxiety during the perioperative period (9). The mYPAS included scores for general activity (1 to 4), vocalization (1 to 6), emotional expressivity (1 to 4), state of apparent arousal (1 to 4), and need of parent (1 to 4). These scores were taken by the research assistant in the preoperative holding area, where the child was in the company of the parent or guardian.
In the toy group, the first mYPAS scores were recorded at baseline. Within 3 min after the baseline recording, the child was given a toy by the anesthesiologist, who simply stated "I have a toy for you to keep." Three minutes after the toy was given, the research assistant came back to record the second mYPAS scores. Within 5 min after the second score, the child was offered oral midazolam and the third mYPAS scores were recorded. In the no-toy group, the mYPAS scores were recorded at the same intervals as in the toy group, except that the toy was not given before the second score. We did not collect these or any other data during the induction of anesthesia or in the postoperative period. The midazolam was given as oral syrup at a dose of 0.5 mg/kg by a nurse who was not involved in the study and was instructed to give the same care to the child whether a toy was given or not. The toys used in this study consisted of several different bendable animal figures at a price of approximately 34 cents per toy (Fig. 1).
|
The data were analyzed using SigmaStat software (Systat Software Inc., Point Richmond, CA). The "adjusted mYPAS total score" for each child at a given time was computed as the sum of the weighted scores for the 5 different anxiety variables multiplied by 100/5 (9). The adjusted mYPAS total score ranges from 0 to 100, with higher scores indicating greater anxiety. Significance of differences in the median values of the adjusted mYPAS total scores at different time periods between the toy and no-toy groups were evaluated using Friedman repeated-measures analysis of variance on ranks. All pairwise multiple comparisons were performed using the Tukey test.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
At baseline, the median mYPAS score was 28 in the no-toy group and 33 in the toy group, but the values in the two groups were not significantly different (Table 1). The second score, taken 3 min after the first score, was 28 in the no-toy group and 23 in the toy group; again the difference in values between groups was not significant (Table 1). The third score, taken during administration of midazolam, was 42 in the no-toy group and 23 in the toy group, with the value in toy group being significantly lower (P < 0.05) (Table 1).
|
A comparison within the no-toy group showed that the third mYPAS score taken during the administration of midazolam was significantly higher (P < 0.05) than the first score taken at baseline or the second score take 3 min after the baseline score (Table 1). A comparison within the toy group showed that the second mYPAS score taken 3 min after giving the toy was significantly lower (P < 0.05) than the baseline score (Table 1). There was no further reduction in the third score compared with the second score in the toy group (Table 1).
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Studies have shown that oral midazolam reduced preoperative anxiety in pediatric patients (7). However, no studies have evaluated the ways to reduce the anxiety related to the administration of midazolam itself. In the present study, we tested whether giving a toy to children before preoperative administration of midazolam would reduce the anxiety associated with taking this medication. We assessed the anxiety of children using the modified mYPAS score, which has proven to be a reliable measure of anxiety in children (9).
In our study, the median mYPAS scores taken at baseline varied from 28 to 33, which were within the range reported by Kain et al. (9) in children at the holding area before induction. It is interesting to note that children in the no-toy group had a significant increase (P < 0.05) in the median mYPAS score from 28 at baseline to 42 during the administration of midazolam, clearly demonstrating that administration of the medication itself is very stressful to children during the preoperative period. In the toy group the mYPAS score was significantly (P < 0.05) reduced from baseline values of 33 to 23 soon after giving the toy. In the toy group, giving the toy also eliminated the spike in anxiety during administration of oral midazolam, which occurred in the no-toy group (Table 1). Thus, the study demonstrated that giving a toy reduces preoperative anxiety in children and enables them to easily accept the administration of midazolam. Another possible benefit of giving the toy may be a reduction of the necessary dose of midazolam secondary to decreased anxiety levels. This would require further investigation.
Although our study clearly showed the beneficial effects of giving a toy to reduce preoperative anxiety in children, some of the experimental limitations of the study need explanation. Because the child was playing with the given toy, it was hard to make the study blinded. However, we minimized the bias of the research persons who collected the anxiety scores by not explaining to them the primary aim of the study or why some children had a toy and others did not. They were simply told how to take the anxiety scores. Another limitation may be that giving a toy is not a pharmacological means of reducing the anxiety in a well controlled dose- and time-dependent manner. However, the toy would not have any adverse side effects as many drugs do, and parental presence, which is also non-pharmacological, has been shown to be effective in reducing preoperative anxiety in children (8). Another consideration may be that the types of surgery were not exactly the same in the two groups of children enrolled in the study. However, the mYPAS score of children was reported to have no significant correlation with the type of surgery (9). Based on these considerations, we suggest that giving a toy to children is an easy, safe, and economical means of reducing preoperative medication anxiety.
|
Footnotes |
|---|
Accepted for publication October 31, 2005.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
- Pearson G. Effect of operative procedures on the emotional life of the child. Am J Dis Child 1941;62:716–29.
- Corman H, Hornick E, Kritchman M. Terestman N. Emotional reactions of surgical patients to hospitalization, anesthesia and surgery. Am J Surg 1958;96:646–53.[Web of Science][Medline]
- Vermon D, Foley J, Sipowicz R, Shutman J. The psychological responses of children to hospitalization and illness. Springfield, Massachusetts: Thomas Books, 1965:1–5.
- Melamed BG, Siegel LJ. Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling. J Consult Clin Psychol 1975;43:511–21.[Web of Science][Medline]
- Schwartz BH, Albino JE Tedesco LA. Effects of psychological preparation on children hospitalized for dental operations. J Pediatr 1983;102:634–8.[Web of Science][Medline]
- Kain ZN, Mayes LC, O’Conner Cicchetti DV. Preoperative anxiety in children: predictors and outcomes. Arch Pediatr Adolesc Med 1996;150:1238–43.
[Abstract/Free Full Text] - Feld LH, Negus JB, White PF. Oral midazolam preanesthetic medication in pediatric outcomes. Anesthesiology 1990;73:831–4.[Web of Science][Medline]
- Kain ZN, Mayes LC, Caramico LA, et al. Parental presence during induction of anesthesia: a randomized controlled trail. Anesthesiology 1996;84:1060–7.[Web of Science][Medline]
- Kain ZN, Mayes LC, Cicchetti DV, et al. The Yale preoperative scale: how does it compare with a "gold standard"? Anesth Analg 1997;85:783–8.[Abstract]
This article has been cited by other articles:
|
|
 |
|
  J. E. MacLaren and Z. N. Kain Prevalence and Predictors of Significant Sleep Disturbances in Children Undergoing Ambulatory Tonsillectomy and Adenoidectomy J. Pediatr. Psychol., April 1, 2008; 33(3): 248 - 257. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
