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

1 Inglis S, Farnill D. The effects of providing preoperativestatistical anaesthetic-risk information. Anaesth Intensive Care1993; 21: 799±805.

2 Kotiniemi LH, Ryhanen PT, Valanne J, et al. Postoperativesymptoms at home following day-case surgery in children.a multicentre survey of 551 children. Anaesthesia 1997; 52:963±969.

3 Chrousos GP, Gold PW. The concepts of stress and stresssystem disorders. Overview of physical and behavioral home-ostasis. Jama 1992; 267: 1244±1252.

4 Weissman C. The metabolic response to stress. An overviewand update. Anesthesiology 1990; 73: 308±327.

5 Kain ZN, Mayes LC, O'Connor TZ, et al. Preoperative anxietyin children. Predictors and outcomes. Arch Pediatr Adolesc Med1996; 150: 1238±1245.

108 H. KOINIG

Ó 2002 Blackwell Science Ltd, Paediatric Anaesthesia, 12, 107±109

6 Kain ZN, Caramico LA, Mayes LC, et al. Preoperative prepar-ation programs in children: a comparative examination. AnesthAnalg 1998; 87: 1249±1255.

7 Cassady JF Jr, Wysocki TT, Miller KM, et al. Use of apreanesthetic video for facilitation of parental education andanxiolysis before pediatric ambulatory surgery. Anesth Analg1999; 88: 246±250.

8 Bellew M, Atkinson KR, Dixon G, et al. The introduction of apaediatric anaesthesia lea¯et: An audit of its impact onparental anxiety and satisfaction.other authors. Paed Anaesth2002; 12: 124±130.

9 Kain ZN, Wang SM, Caramico LA, et al. Parental desire forperioperative information and informed consent: a two-phasestudy. Anesth Analg 1997; 84: 299±306.

10 Chan CSM, Molassiotis A. The effects of an educationalprogramme on the anxiety and satisfaction level of parentshaving parent present induction and visitation in a postanaes-thesia care unit. Paed Anaesth 2002; 12: 131±139.

11 Collins VJ. The anesthetist's second power. Anesthesiology 1948;9: 437±438.

12 Kain ZN, Ferris CA, Mayes LC, et al. Parental presenceduring induction of anesthesia: practice differences betweenthe United States and Great Britain. Paed Anaesth 1996; 6:187±193.

13 Gillerman RG, Hinkle AJ, Green HM, et al. Parental presenceplus oral midazolam decreases frequency of 5% halothaneinductions in children. J Clin Anesth 1996; 8: 480±485.

14 Kam PC, Voss TJ, Gold PD, et al. Behaviour of childrenassociated with parental participation during induction ofgeneral anaesthesia. J Paediatr Child Health 1998; 34: 29±31.

15 Kain ZN, Mayes LC, Caramico LA, et al. Parental presenceduring induction of anesthesia. A randomized controlled trial.Anesthesiology 1996; 84: 1060±1067.

16 Blesch P, Fisher ML. The impact of parental presence onparental anxiety and satisfaction. Aorn J 1996; 63: 761±768.

17 Kain ZN, Mayes LC, Wang SM, et al. Parental presence and asedative premedicant for children undergoing surgery: ahierarchical study. Anesthesiology 2000; 92: 939±946.

18 Kain ZN. Perioperative information and parental anxiety: thenext generation. Anesth Analg 1999; 88: 237±239.

19 Vessey JA, Bogetz MS, Caserza CL, et al. Parental upsetassociated with participation in induction of anaesthesia inchildren. Can J Anaesth 1994; 41: 276±280.

20 McCann ME, Kain ZN. The management of preoperativeanxiety in children: an update. Anesth Analg 2001; 93: 98±105.

Accepted 10 October 2001

EDITORIAL 109

Ó 2002 Blackwell Science Ltd, Paediatric Anaesthesia, 12, 107±109