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Editorial
Preparing parents for their child's surgery:preoperative parental information and education
Perioperative preparation of paediatric patients and
their environment in order to prevent anxiety is an
important issue in paediatric anaesthesia. Anxiety in
paediatric patients may lead to immediate negative
postoperative responses such as nightmares, separ-
ation anxiety, eating disturbances and new-onset
enuresis (1,2). In addition, anxiety in children may
activate the human stress response (3), resulting in
catabolism, delayed wound healing and postopera-
tive immune suppression (4). Increased parental
anxiety has been demonstrated to result in increased
anxiety of their children (5). Considering the corre-
lation between a child's anxiety and its parent's
anxiety, preparing paediatric patients for anaesthe-
sia includes, besides queries regarding the current
medical conditions and history, perioperative infor-
mation and preparation of both, the child and the
parents.
As a means of preventing parental anxiety, pre-
operative preparation programmes have been prov-
en to be effective (6,7). However, high costs and
dif®cult administration of such extensive pro-
grammes have led to the search for cost-saving
alternative methods such as written information
lea¯ets. In addition, parental preoperative prepar-
ation programmes have yet to be assessed with
respect to how other considerations, particularly the
cultural and social background of different parents,
may or may not affect their effectiveness.
In the current issue of Paediatric Anaesthesia, two
articles focus on strategies to reduce parental anxiety
before surgery in their children. Bellew et al. (8)
report that the introduction of a paediatric anaes-
thesia information lea¯et improved parental satis-
faction regarding information compared with a
control group that received just oral instructions by
the anaesthesiologist and the nursing staff and no
written information. Con®rming the ®ndings of a
previous report (9), Bellew et al. (8) show that there
is a high expectation among parents that preopera-
tive information will provided them with know-
ledge of anaesthesia, the operating room,
postoperative care and postoperative pain relief.
The introduction of a written information lea¯et
signi®cantly improved parental information regard-
ing anaesthesia and the trip to the operating room.
Providing such an information lea¯et to the parents
during their child's preclinic appointment or when
the child was admitted to the ward before surgery
did not increase parental anxiety levels, thus indi-
cating the possibility of routine use of this method.
Since anaesthesiologists are obliged to follow the
process of informed consent, it is important to
mention that providing written information may
become part of this process. It is very likely that a
combination of written, pictorial, and verbal infor-
mation would improve the process of informed
consent and could therefore increase both patients
and parental satisfaction.
Also in this issue of the journal, Chan et al. (10)
present a study on the effects of a parental educa-
tional programme that includes a written informa-
tion pamphlet given before parental presence at
induction of anaesthesia and visitation in the pos-
tanaesthesia care unit. The authors report a signi®-
cant decrease of parental anxiety and an increase of
parental satisfaction after completion of an educa-
tional programme before their children underwent
surgery (10).
The issue of parental presence during induction of
anaesthesia has been a controversial topic for many
years. In the early days of anaesthesiology, parents
were excluded from the induction room (11).
Although there are differences along international
lines, since then parental presence at induction has
become relatively commonplace in some countries
(12). Potential bene®ts from parental presence at
induction of anaesthesia include reducing or avoid-
ing the fear and anxiety that might occur in both
the child and its parents while being separated as
Paediatric Anaesthesia 2002 12: 107±109
Ó 2002 Blackwell Science Ltd 107
the child is taken to the operating room, reducing
the need for preoperative sedatives, and improv-
ing the child's compliance during anaesthesia
induction. While some reports suggest that parental
presence during anaesthesia induction decreases the
anxiety of the child and its parents and improves the
cooperation of the child (13,14), others showed no
effects on the behavioural or psychological measures
of paediatric anxiety (15) and no effect on parental
anxiety and satisfaction (16). A recent study showed
no additive effect of a combination of oral preme-
dication with midazolam and parental presence at
induction on the anxiety of children undergoing
surgery but did report reduced parental anxiety and
increased parental satisfaction (17). These contra-
dictory results may be explained by an imperfect
randomization technique leading to false-positive
results. It is possible that parents with an avoidance
coping style (i.e. those who try to avoid unclear and
unpleasant situations) may have declined participa-
tion in the study (18), thus leaving only those
parents with a monitoring coping style (i.e. those
who actively seek available information) to take part
in both this study and in other studies concerning
parental presence during induction. As the authors
themselves mention, it is also plausible that gender-
speci®c differences (more mothers than fathers
participated in the study) in¯uenced the results
and limited the validity.
Potential disadvantages of parental presence at
induction include parental anxiety resulting in poss-
ible adverse reactions of the parents. Vessey et al.(19) reported that parents are often upset by events
that take place around the time of induction,
including seeing their child upset before induction,
seeing their child go limp when anaesthetized, and
being separated from their child after induction.
Adverse parental reactions may result in a pro-
longed anaesthesia induction and may put addi-
tional stress on the anaesthesiologist, which may
result in possible negative consequences (20). Al-
lowing a parent into an operating room may have
negative consequences such as parental criticism,
commands and increased distress for the parents
and the anaesthesiologist. Since it has not been
de®nitively proven that parental presence at induc-
tion decreases a child's anxiety before surgery, the
question arises as to whether or not an additional
risk to the child is created by allowing parents into
the operating room for what might only result in
increased parental satisfaction. Given the current
emphasis on patient (parental) satisfaction as a
measure for health care quality, perhaps we must
accept parental presence during induction in the
operating room. However, to gain the maximum
bene®t out of parental presence in the operating
room (both for the parents themselves and for the
child) and to reduce possible negative consequences,
the parents must be provided with adequate preop-
erative information and education. Such preopera-
tive information and education provides the
anaesthesiologist with the opportunity to inform
the general public about the role of anaesthesia, both
during surgery and in the recovery room and to
facilitate adequate postoperative pain therapy.
In conclusion, both studies in this issue of
Paediatric Anaesthesia are of particular clinical inter-
est because they focus on interventions that are
speci®cally designed to inform parents before their
children undergo surgery. Distribution of informa-
tion lea¯ets to parents or enrolment of parents in
speci®c preoperative educational programs may
reduce parental anxiety and increase parental sat-
isfaction, which in turn may help ease the fear and
anxieties of their children and thus help to ensure
that their children's operations proceed as smoothly
as possible.
H. KOINIGOINIG MDMD
Department of Anaesthesiology and
General Intensive Care
University of Vienna
Waehringer Guertel 18±20
A-1090 Vienna, Austria
References
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Accepted 10 October 2001
EDITORIAL 109
Ó 2002 Blackwell Science Ltd, Paediatric Anaesthesia, 12, 107±109
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