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

Non-pharmacological interventions to reduce anxiety among children undergoing surgery: A systematic review

A hospitalized child experiences anxiety more frequently as compared to non-hospitalized children. Surgery can be emotionally distressing for children, and subsequently their parents and caregivers, this distress can cause profound adverse impacts on children. We aimed to identify the effect of non-pharmacological interventions on children's (1-18 years) anxiety undergoing surgery. The following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Proquest, Web" of Science, and Cochrane Central Register of Controlled Trials were systematically searched for full-text articles. The review included 15 randomized controlled trials. The risk of bias was assessed using Cochrane Risk of Bias tool. The interventions included in the study were preoperative education, puppet play, therapeutic play, distraction activities, parental presence, and clown therapy. The review presents a narrative reporting of the findings. This review identifies that non-pharmacological interventions are effective in reducing anxiety among children undergoing surgery. There are a limited number of studies from developing countries. Further research is required to underpin the use of these interventions with children before surgery.

Prospective, randomized, double-blind, double-dummy, active-controlled, phase 3 clinical trial comparing the safety and efficacy of intranasal dexmedetomidine to oral midazolam as premedication for propofol sedation in pediatric patients undergoing magnetic resonance imaging: the MIDEX MRI trial

BACKGROUND

Children under 6 years who need magnetic resonance imaging usually require sedation to obtain best quality images, but the optimal sedation protocol remains to be determined. In 2018, we showed a 22% interruption in image acquisition during magnetic resonance imaging when performing a propofol-based sedation using a bolus approach. As non-pharmacological premedication is often insufficient to reduce the anxiety of children related to parental separation, pharmacological premedication may be useful to facilitate the induction of anesthesia. In our institution, effective premedication is obtained oral intake of midazolam, though its administration relies on patients' compliance and could also lead to paradoxical reaction. Dexmedetomidine has a safe profile in the pediatric population and can therefore represent an interesting alternative. The primary objective of this trial is to demonstrate the superiority of intranasal dexmedetomidine compared to oral midazolam as premedication in reducing the occurrence of any event requiring temporary or definitive interruption of the examination to allow anesthesiologist intervention in children undergoing magnetic resonance imaging under propofol sedation.

METHODS

In this single-center, prospective, randomized, double-blind, double-dummy, active comparator-controlled, superiority trial, we planned to include 250 patients, aged 6 months to 6 years, undergoing a scheduled magnetic resonance imaging requiring the presence of an anesthesiologist. After informed consent, the patients will be randomized to receive either oral midazolam or intranasal dexmedetomidine as premedication. The data will be analyzed in intention to treat, using Kolmogorov-Smirnov Z, chi-square, Wilcoxon, and Mann-Whitney U tests. A P-value < 0.05 will be considered statistically significant.

DISCUSSION

The MIDEX MRI study will assess the efficacy of intranasal dexmedetomidine compared to oral midazolam to improve the quality of a propofol-based sedation prior to magnetic resonance imaging, without negative repercussion on the postoperative period.

TRIAL REGISTRATION

ClinicalTrial.gov NCT05192629 . Registered on 14 January 2022. Protocol version 2.1.

Effects of virtual reality on preoperative anxiety in children: A systematic review and meta-analysis of randomised controlled trials

AIMS

To synthesise and evaluate the effectiveness of virtual reality interventions in preoperative children.

BACKGROUND

Children consider operations as a predictable threat and stressful event. Children's anxiety before an operation increases as the time draws closer. Children could understand the operating room environment and process before the operation using virtual reality, which may reduce their anxiety before an operation.

DESIGN

A systematic review and meta-analysis of randomised controlled trials following the Cochrane method were conducted.

METHOD

CINAHL, Cochrane Library, Embase, Joanna Briggs Institute, MEDLINE and PubMed databases were searched for randomised controlled trials published before February 2021. A random-effects model meta-analysis to calculate pooled prevalence and 95% confidence intervals was performed. Conduction of the review adheres to the PRISMA checklist.

RESULTS

Of 257 articles screened, six interventions involving 529 participants aged 4-12 years were included in the analysis. All study evidence levels were B2/Level 2, the quality was medium to high on the modified Jadad scale, with a low risk of bias. The results revealed that virtual reality significantly reduced preoperative anxiety in children (SMD: -0.91, 95% CI: -1.43 to -0.39, p = .0006). Furthermore, virtual reality significantly improved children's compliance with anaesthesia (SMD: 3.49, 95% CI: 1.32 to 9.21, p = .01).

CONCLUSION

Children who used virtual reality before an operation felt more familiar with the operating room environment and understood the preoperative preparation procedures. Virtual reality effectively reduced children's anxiety and improved their compliance with anaesthesia.

RELEVANCE TO CLINICAL PRACTICE

This systematic review and meta-analysis investigated the effect of virtual reality on preoperative anxiety in children and the findings supported its positive effects. The results could provide a reference for incorporating virtual reality into preoperative preparation guidelines.

Interventions and methods to prepare, educate or familiarise children and young people for radiological procedures: a scoping review

Children attending hospital for radiological procedures can experience uncertainty, anxiety and distress; this can result in sub-optimal experiences for children, poor scan quality and the need for radiological procedures to be rescheduled or sedation to be used. The preparation and education of children before clinical procedures has been shown to have a positive influence on procedural outcomes. This scoping review aimed to locate and examine the evidence relating to non-invasive interventions and methods to prepare, educate and familiarise children for radiological procedures within a healthcare setting. A comprehensive search strategy identified 36 articles. A narrative synthesis approach was adopted to make sense of the key findings. Studies investigated a range of radiological procedures (MRI, plain radiographs, CT, fluoroscopy and Micturating cystourethrogram) using a wide range of interventions (smartphone applications, storybooks, videos, mock scanners) which varied by method, mode of delivery and target audience. The outcomes used to evaluate the value and impact of the interventions are wide, varied and inconsistently applied making it difficult to judge which interventions offer the optimal impact on scan quality, scan completion and children’s experiences. This review highlights that there is a need to further understand which specific elements of the non-invasive interventions ‘work best’ for children. There is a need for consistency on the outcomes measured and for these measures to include child-centred outcomes alongside scan quality and length of radiological procedure.

Play-Based Activities with a CoderBot Robot on a Pediatric Ward: A Case Study

Being hospitalized is a threatening and stressful experience for many children. From a psychological point of view, children may experience increased feelings of anxiety and fear that can negatively influence their behavioral, cognitive, and emotional outcomes. To mitigate such adverse effects on children’s mental health and well-being, interventions that might contribute to protecting the emotional domain of hospitalized children are welcome. The present case study of a single-setting intervention allowed us to evaluate the impact, on children admitted to a pediatric short-term recovery ward (N = 61), of participating in play-based activities with a CoderBot robot. The methodology spanned multiple data sources (children, parents, nurses), field observation, and a sequential (quantitative–qualitative) mixed-method approach to data analysis. We found that robot-based activities are associated with enhanced well-being (particularly positive emotions). Both the participating children and their caregivers reported that the activity was enjoyable and interesting, especially thanks to its technologically innovative nature. We critically discuss these positive findings in relation to the strengths of our pilot study, as well as its contextual and methodological limitations, and outline possible future lines of development for this kind of project.

Adultification of Black Children in Pediatric Anesthesia

BACKGROUND

Unconscious racial bias in anesthesia care has been shown to exist. We hypothesized that black children may undergo inhalation induction less often, receive less support from child life, have fewer opportunities to have a family member present for induction, and receive premedication with oral midazolam less often.

METHODS

We retrospectively collected data on those <18 years of age from January 1, 2012 to January 1, 2018 including age, sex, race, height, weight, American Society of Anesthesiologists (ASA) physical status, surgical service, and deidentified anesthesiology attending physician. Outcome data included mask versus intravenous induction, midazolam premedication, child life consultation, and family member presence. Racial differences between all outcomes were assessed in the cohort using a multivariable logistic regression model.

RESULTS

A total of 33,717 Caucasian and 3901 black children were eligible for the study. For the primary outcome, black children 10-14 years were 1.3 times more likely than Caucasian children to receive mask induction (adjusted odds ratio [AOR], 1.3; 95% confidence interval [CI], 1.1-1.6; P = .001). Child life consultation was poorly documented (<0.5%) and not analyzed. Black children <15 years of age were at least 31% less likely than Caucasians to have a family member present for induction (AOR range, 0.4-0.6; 95% CI range, 0.31-0.84; P < .010). Black children <5 years of age were 13% less likely than Caucasians to have midazolam given preoperatively (AOR, 0.9; 95% CI, 0.8-0.9; P = .012).

CONCLUSIONS

This study suggests that disparities in strategies for mitigating anxiety in the peri-induction period exist and adultification may be 1 cause for this bias. Black children 10 to 14 years of age are 1.3 times as likely as their Caucasian peers to be offered inhalation induction to reduce anxiety. However, black children are less likely to receive premedication with midazolam in the perioperative period or to have family members present at induction. The cause of this difference is unclear, and further prospective studies are needed to fully understand this difference.

Psychological preparation reduces preoperative anxiety in children. Randomized and double-blind trial

OBJECTIVE

To verify the effect of psychological preparation on the relief of preoperative anxiety in children and to correlate parents' and children's levels of anxiety.

METHOD

After the approval of the institutional Research Ethics Committee and written consent of the children's parents or guardians, 118 children of both genders were prospectively selected, aged between 2 and 8 years, physical condition classification ASA I, who were treated in the pre-anesthetic evaluation ambulatory of the University Hospital and who underwent ambulatory surgeries at the same hospital. Two controlled groups of 59 children were randomized: control group basic preparation and psychological preparation group. On the day of surgery, all selected children were evaluated regarding their level of anxiety using the modified Yale Preoperative Anxiety Scale and their parents were evaluated regarding their level of anxiety through the Visual Analog Scale. The evaluator was blinded to which study group the child and family member belonged to.

RESULTS

Nine children and their family members were excluded per group when the results were analyzed. Children from the prepared group showed significant reductions in their level of anxiety in relation to the control group (p=0.04). There was no correlation between the level of anxiety of children and their parents' levels (p=0.78).

CONCLUSION

The psychological preparation was effective in reducing the level of anxiety of children. However, there was no relation between the level of anxiety of children and their parents' level.

Effects of repeated exposure to different concentrations of sevoflurane on the neonatal mouse hippocampus

Background and objectives

Developing brain is more vulnerable to environmental risk than is the developed brain. We evaluated the effects of repeated exposure to different concentrations of sevoflurane on the neonatal mouse hippocampus using stereological methods.

Methods

Eighteen neonatal male mice were randomly divided into three groups. Group A, inhaled sevoflurane at a concentration of 1.5%; Group B, inhaled sevoflurane at a concentration of 3%; and Group C (control group), inhaled only 100% oxygen. Treatments were applied for 30 min a day for 7 consecutive days. The hippocampal volume, dendrite length, number of neurons, and number of glial cells were evaluated in each group using stereological estimations.

Results

We identified a ∼2% reduction in the volume of the hippocampus in Group A compared to Group C. Mean hippocampal volume was ∼11% smaller in Group B than it was in Group C. However, these differences in hippocampal volume between the groups were not statistically significant (p > 0.05 for all). As for the number of neurons, we found significantly fewer neurons in Group A (∼29% less) and Group B (∼43% less) than we did in Group C (p < 0.05 for both). The dendrite length was ∼8% shorter in Group A and ∼11% shorter in Group B than it was in Group C.

Conclusions

Repeated exposure to sevoflurane, regardless of the concentration, reduced the volume of the neonatal mouse hippocampus, as well as the number of neurons and dendrite length.

[Effects of repeated exposure to different concentrations of sevoflurane on the neonatal mouse hippocampus]

BACKGROUND AND OBJECTIVES

Developing brain is more vulnerable to environmental risk than is the developed brain. We evaluated the effects of repeated exposure to different concentrations of sevoflurane on the neonatal mouse hippocampus using stereological methods.

METHODS

Eighteen neonatal male mice were randomly divided into three groups. Group A, inhaled sevoflurane at a concentration of 1.5%; Group B, inhaled sevoflurane at a concentration of 3%; and Group C (control group), inhaled only 100% oxygen. Treatments were applied for 30min a day for 7 consecutive days. The hippocampal volume, dendrite length, number of neurons, and number of glial cells were evaluated in each group using stereological estimations.

RESULTS

We identified a ∼2% reduction in the volume of the hippocampus in Group A compared to Group C. Mean hippocampal volume was ∼11% smaller in Group B than it was in Group C. However, these differences in hippocampal volume between the groups were not statistically significant (p>0.05 for all). As for the number of neurons, we found significantly fewer neurons in Group A (∼29% less) and Group B (∼43% less) than we did in Group C (p<0.05 for both). The dendrite length was ∼8% shorter in Group A and ∼11% shorter in Group B than it was in Group C.

CONCLUSIONS

Repeated exposure to sevoflurane, regardless of the concentration, reduced the volume of the neonatal mouse hippocampus, as well as the number of neurons and dendrite length.

Anxiety during inhalation induction in paediatrics: Sitting versus supine position, a randomised trial

STUDY OBJECTIVE

We evaluated if the sitting or supine positions affect anxiety levels induced by the application of a facemask in children.

DESIGN

Prospective, randomised study.

SETTING

Paediatric hospital, operating room.

PATIENTS

Two to twelve years old children, 1-3 ASA status, undergoing inhalation anaesthesia for elective surgery.

INTERVENTION

Children were randomly assigned to a sitting or supine position. After monitoring equipment was established, inhalation was inducted by the application of the mask.

MEASUREMENTS

Child anxiety was then assessed with the modified Yale Preoperative Anxiety Scale (mYPAS) before the application of the facemask and following mask application.

MAIN RESULTS

Overall, 99 children in the sitting group and 103 in the supine group were analysed. The mYPAS score was not different in both groups before the application of facemask (40 [28-51] versus 40 [28-53]; P=0.99). It increased (P=0.005) to a similar extent in both groups following mask application without difference between groups (48 [38-60] versus 48 [35-63]; P=0.95). Side effects were not different between both groups.

CONCLUSION

In children undergoing inhalation induction, sitting or supine positions did not modify anxiety induced by the application of a facemask, nor adverse effects; therefore, children should be allowed to choose their preferred position.

Clowning in Health Care Settings: The Point of View of Adults

Within the past decade, there has been a surge of interest in investigating the effects of clown intervention in a large variety of clinical settings. Many studies have focused on the effects of clown intervention on children. However, few studies have investigated clowning effects on adults. This paper presents an overview of the concept of medical clowning followed by a literature review conducted on the empirical studies drawn from three data bases (PubMed, PsycINFO, and Google Scholar), with the aim of mapping and discussing the evidence of clowning effects on non-children, namely adults. The following areas were investigated: Adult and elderly patients (mainly those with dementia), observers of clowning, namely non-hospitalized adults who are at the hospital as relatives of patients or health-care staff, and finally clowns themselves. The main results are that 1) clown intervention induces positive emotions, thereby enhancing the patient's well-being, reduces psychological symptoms and emotional reactivity, and prompts a decrease in negative emotions, such as anxiety and stress; 2) clown doctors are also well-perceived by relatives and healthcare staff and their presence appears to be useful in creating a lighter atmosphere in the health setting; 3) few pilot studies have been conducted on clown doctors and this lacuna represents a subject for future research.

User Evaluation of Neonatology Ward Design

Objective:

The object of this article is to identify the set of affective and emotional factors behind users’ assessments of a space in a neonatology unit and to propose design guidelines based on these.

Background:

The importance of the neonatology service and the variety of users place great demands on the space at all levels. Despite the repercussions, the emotional aspects of the environment have received less attention.

Methods:

To avoid incurring limitations in the user mental scheme, this study uses two complementary methodologies: focus group and semantic differential. The (qualitative) focus group methodology provides exploratory information and concepts. The (quantitative) semantic differential methodology then uses these concepts to extract the conceptual structures that users employ in their assessment of the space. Of the total 175 subjects, 31 took part in focus groups and 144 in semantic differential.

Results:

Five independent concepts were identified: privacy, functionality and professional nature, spaciousness, lighting, and cleanliness. In relation to the importance of the overall positive assessment of the space, the perception of privacy and sensations of dominance and pleasure are fundamental. Six relevant design aspects were also identified: provide spacious surroundings, facilitate sufficient separation between the different posts or cots, use different colors from those usually found in health-care centers, as some aversion was found to white and especially green, design areas with childhood themes, use warm artificial light, and choose user-friendly equipment.

Conclusions:

Results provide design recommendations of interest and show the possibilities offered by combining both systems to analyze user response.

The Effects of Distraction on Preoperative Anxiety Level in Children

PURPOSE

The purpose of this study was to investigate the effects of distraction on the preoperative anxiety levels of pediatric patients.

DESIGN

A prospective, two-group experimental design was used.

METHODS

This study was conducted in the clinic of pediatric surgery of a university hospital in Turkey between November 20, 2013 and January 25, 2014. The population of the study was composed of a total of 83 children (40 in the study group and 43 in the control group) who met the inclusion. The data were collected using the "Personal Information Form," "Separation Scoring," and "State-Trait Anxiety Inventory for Children-State Form." Distraction was performed on the children in the study group during the preoperative period. No intervention was applied to the children in the control group.

FINDING

The results of this study demonstrated that the separation scores and State-Trait Anxiety Inventory for Children-State scores of the children in the study group, on whom distraction was applied, were lower than those of the control group.

CONCLUSIONS

Distraction applied to children in the preoperative period significantly reduced anxiety and separation anxiety.

Preoperative Education and Decreasing Preoperative Anxiety Among Children Aged 8 - 10 Years Old and Their Mothers

BACKGROUND

Preoperative anxiety is associated with adverse clinical, behavioral, and psychological outcomes. Various effective interventions targeting preoperative anxiety in children exist.

OBJECTIVES

The aim of this study was to evaluate the educational intervention by residents on children and maternal anxiety and their satisfaction from anxiety management.

PATIENTS AND METHODS

After obtaining the institutional ethics committee approval and written informed parental consent, 36 ASA-I, II children (age range, 8 - 10 years) underwent small operations were included in this prospective randomized study. The participants were allocated into the intervention (n =18) and control (n =18) groups. Children in the first group were prepared routinely. In the second group children and their mothers received data about anesthesia and operation by the booklet. Children-maternal anxiety was assessed using the anxiety level form, at the night and in the morning before surgery. Few days after surgery mothers, residents, and children experiences and satisfaction from anxiety management were assessed in the focus group discussion.

RESULTS

Mean scores and standard deviations of state anxiety in the intervention group before and after training were 33.1 ± 5.5 and 30.8 ± 6, respectively (P = 0.06). In the control group it was 32 ± 6.5 on the night and 34.1 ± 6.7 in the morning before surgery (P = 0.00). Comparison between groups was not significant (P = 0.6) and (P = 0.1). The mean levels of anxiety in the control group mothers on the night before and in the morning of surgery were 39.2 ± 13.1 and 42.8 ± 14 (P = 0.00), respectively. In the intervention group, mothers' anxiety before education was 41 ± 12.7 and after education it was 35.6 ± 9.5 (P = 0.04). Comparison between groups was not significant (P = 0.7) and (P = 0.1). According to the focus group discussions, booklet study, provided education, sympathy of medical team, spiritual issues and beliefs reduced anxiety and fear of surgery. Anesthesia and lack of knowledge of what will happen, crying and restlessness of children increased preoperative anxiety.

CONCLUSIONS

In this study, the preoperative anxiety was reduced by explaining anesthesia and surgery to the mothers and children (in mothers it was significant P < 0.05). Since there is a direct relation between mothers' and their children's anxiety, using an effective method to reduce anxiety in children and their mothers together at the same time would be very useful for children and their mothers.

Preoperative anxiety management, emergence delirium, and postoperative behavior

Preoperative anxiolysis is important for children scheduled for surgery. The nature of the anxiety depends on several factors, including age, temperament, past hospitalizations, and socioeconomic and ethnic backgrounds. A panoply of interventions effect anxiolysis, including parental presence, distraction, and premedication, although no single strategy is effective for all ages. Emergence delirium (ED) occurs after the use of sevoflurane and desflurane in preschool-aged children in the recovery room. Symptoms usually last approximately 15 minutes and resolve spontaneously. The Pediatric Anesthesia Emergence Delirium scale is used to diagnose ED and evaluate therapeutic interventions for ED such as propofol and opioids.

Preoperative evaluation, premedication, and induction of anesthesia in infants and children

PURPOSE OF REVIEW

Preparation for and induction of anesthesia in children has evolved significantly over the last decade, with particular reference to the reduction of perioperative anxiety reduction by nonpharmacologic and pharmacologic means. Several new large population studies and meta-analyses further scrutinize the current techniques.

RECENT FINDINGS

Many nonpharmacologic methods to reduce anxiety are effective λU similar to sedative premedications, with the exception of parent present induction of anesthesia. Healthcare providers can be taught to increase anxiety-reducing behaviors through an educational intervention. Clonidine and dexmedetomidine have many similar or superior qualities to midazolam.

SUMMARY

Larger studies still need to be conducted before wide-scale application of many nonpharmalogical interventions such as parental acupuncture. Similarly, more investigation should be done on outcomes such as onset, emergence, and discharge times, as well as the postoperative response with reference to emergence delirium and postoperative nausea and vomiting prevention to outline the differences among sedative premedications such as midazolam, clonidine, and dexmedetomidine.

Text Watch

The BJMT Text Watch appears in the second issue of each volume. It aims to raise awareness of music therapy writing outside the principal English language music therapy journals, and to act as a guide to the proliferating literature of our profession. It seeks to draw attention to relevant material from publications that may be less accessible to music therapists, and which therefore might otherwise be overlooked.1

Text Watch includes music therapy and related publications in English that have been published in the current or previous calendar year2- books, chapters, articles, published conference papers and other published media (CD-ROMs, videos, etc).

Please note that articles published in English language music therapy journals are listed in Journal Watch (included in the first issue of each volume).

Paediatric MRI under sedation: is it necessary? What is the evidence for the alternatives?

To achieve diagnostic images during MRI examinations, small children need to lie still to avoid movement artefact. To reduce patient motion, obviate the need for voluntary immobilisation or breath-holding and therefore obtain high-quality images, MRI of infants is frequently carried out under sedation or general anaesthesia, but this is not without risk and expense. However, many other techniques are available for preparing children for MRI, which have not been fully evaluated. Here, we evaluate the advantages and disadvantage of sedation and anaesthesia for MRI. We then evaluate the alternatives, which include neonatal comforting techniques, sleep manipulation, and appropriate adaptation of the physical environment. We summarize the evidence for their use according to an established hierarchy. Lastly, we discuss several factors that will influence the choice of imaging preparation, including patient factors, imaging factors and service provision. The choice of approach to paediatric MRI is multi-factorial, with limited scientific evidence for many of the current approaches. These considerations may enable others to image children using MRI under different circumstances.