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Access this article online Quick Response Code: Website: www.ijhas.in DOI: 10.4103/ijhas.IJHAS_76_16





Department of Child Health Nursing, Yenepoya Nursing College, Yenepoya University, 1 Department of Medical Surgical Nursing, Laxmi Memorial College of Nursing, 2 Department of Paediatrics, Yenepoya Medical College, Mangalore, Karnataka, India

Address for correspondence:

Mrs. Priya Reshma Aranha, Yenepoya University, Mangalore - 575 018, Karnataka, India. E-mail: priyaresh. menezes@gmail.com

Submission: 31-05-2016 Accepted: 21-01-2017

Preoperative preparation of children

Priya Reshma Aranha, Larissa Martha Sams 1 , Prakash Saldanha 2


Surgery is a stressful and anxiety provoking experience for children. Millions of children undergo surgery every year. The majority of children experience significant preoperative anxiety which intern can affect their recovery. Preoperative anxiety may bring about physical and physiological changes in children, which can be particularly evident in terms of increased heart rate and blood pressure. To identify various strategies used to minimize the preoperative anxiety of children and update their clinical effectiveness among children undergoing surgery, the authors searched PubMed, MEDLINE, CINAHL, ScienceDirect, Google Scholar, Scopus, and Cochrane Library for identifying the relevant studies and retrieved available literature. It is concluded that utilization of the strategies available to reduce the preoperative anxiety of children will be a promising intervention to reduce anxiety, to promote relaxation, satisfaction, and speedy recovery. Many of these techniques are simple, cost‑effective and can be easily carried out by nurses. It is essential to use the age appropriate and individualized methods in preparing children for surgery. Further research is required to strengthen the evidence.

Key words:

Children, evidence‑based practice, preoperative preparation

H ospitalization and surgery are stressful events in the life of a child and parents.

When a child undergoes surgery, it often becomes a very significant and memorable event in the life of the entire family. Unlike other significant events in the child’s life, it has an element of threat, and the fear of the unknown can be overwhelming. [1]

and the fear of the unknown can be overwhelming. [ 1 ] It has been seen

It has been seen that 75% of children undergoing surgery experience anxiety. [2] In a study, it was observed that 67% of children developed postoperative negative behavioral changes. [3] Physiological changes such as elevated pulse rate and blood pressure are also anticipated when there is a painful procedure as well as preoperative anxiety. [4,5]

Preoperative anxiety is a distressing feeling which results in adverse physiological and psychological reactions in children. With a high level of anxiety, they are more likely to exhibit signs of the emergence of delirium and develop maladaptive behavior postoperatively. They may need additional postoperative pain control medications. [6]

Parents also may be anxious regarding anesthesia and associated risks, how the child would respond to the surgical experience and their own inadequacy in taking care of their child after the

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discharge from the hospital. [7] Well prepared parents, in turn, will be able to support their children and help them to prepare well for the upcoming surgery.

Importance of this review The child is different from an adult. Therefore, it is essential to have a tailored approach to their preoperative preparation. Adequate preoperative psychological preparation of children is the responsibility of the health‑care workers. The aim of the preparation is to reduce the anxiety of children and family, improve cooperation, enhance recovery, and increase self‑control, improve long‑term emotional, and behavioral adjustments.

The factors to be considered while planning preoperative preparation of children are – developmental stage of child, previous medical experiences, duration of the procedure, temperament, current anxiety levels, coping skills, and parental involvement.

Many strategies have been developed for the alleviation of preoperative anxiety of children and their parents and implemented in pediatric surgical settings. These strategies are based on rigorous research evidence and can be implemented in the nursing care during the preoperative preparation of children and their parents. Nurses and other health‑care providers should be able to identify an

How to cite this article: Aranha PR, Sams LM, Saldanha P. Preoperative preparation of children. Int J Health Allied Sci 2017;6:1-4.

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Aranha, et al.: Preoperative preparation of children undergoing surgery

appropriate strategy based on individualized child and parent’s needs.


We searched PubMed, MEDLINE, CINAHL, ScienceDirect, Google Scholar, Scopus, and Cochrane Library for identifying the relevant studies and available literature. Different combinations of search terms were used to collect available literature and retrieved relevant research studies. Search terms included were preoperative anxiety of children, preoperative fear of children, pharmacological and nonpharmacological interventions to manage the preoperative anxiety of children, preoperative preparation of children, and postoperative outcomes. The descriptive synthesis was adapted to report the findings.

that nursing interventions can be used as effective techniques to reduce the preoperative anxiety in school‑age children. Both the quality of the preoperative program and the preparation and support for the hospitalization/surgery provided by parents to their children are essential to help both child and parents find strategies to overcome their anxiety, stress, and anguish caused by the situations. Cost effectiveness and feasibility of the interventions to be considered. Another systematic review [14] revealed that nonpharmacological interventions for assisting the induction of anesthesia in children were studied. Evidence showed that the presence of parents during induction of general anesthesia does not reduce the child’s anxiety. Promising nonpharmacological interventions such as parental acupuncture, clown doctor, hypnotherapy, low sensory stimulation, and hand‑held video games proved to be effective.

Pharmacological and nonpharmacological interventions for preparing children for surgery While pharmacological measures used to reduce the preoperative anxiety, a wide range of nonpharmacological techniques being successfully used for the children. These techniques can be used as a single measure or in combination or complementing with the pharmacological measure. The literature reveals that preparation programs such as role rehearsals with dolls, [1518] puppet shows [19,20] the teaching of coping and relaxation skills [21,22] orientation tours of the operating room [16,17] as well as educational videos. [2325] Some programs focus exclusively on preparing the child. [2628] The evidence [29] shows that when the oral midazolam and clowns were used to reduce the preoperative anxiety of children, the children in the clown group exhibited statistically significant lower anxiety score in comparison with the children in the midazolam group. Thus, it is evident that psychological preparation techniques can be used to manage the preoperative anxiety of children.

Outcomes of systematic reviews Systematic reviews and meta‑analyses of studies have established the beneficial effects of various preoperative

preparation strategies on the children undergoing surgery.

A systematic review [8] analyzed the use of sedative

premedications, parental presence during induction of anesthesia and various behavioral preparation techniques. Evidence indicates that the role of sedative premedication is firmly established while behavioral techniques are gaining wider acceptance. Routine parental presence does not confer

wider acceptance. Routine parental presence does not confer a benefit to the child although parental satisfaction

a benefit to the child although parental satisfaction is enabled. There is little evidence comparing preinduction techniques for children with chronic illness requiring repeated visits to the operation theater. Review by National Clinical Guidelines [9] showed that preoperative psychological preparation is effective


parents. Evidence shows that psychological preparation for anesthesia induction, perioperative anxiety reduction programs, psychological preparations/interventions for other medical procedures, dental procedures is effective. To know the desire of children and parents regarding the need for preoperative information is essential. Parental presence during

anesthesia induction can also help children. Another review [10] has identified that the preparation programs, although relevant,

are not the only form to soothe preoperative anxiety in children.

The methods should be tailored for each child and can be supplemented by preoperative sedative medications. The literature shows various well‑tried methods of preoperative management can be applied before hospitalization. The crucial elements of such a strategy are to dissipate the emerging doubts by providing children and parents with relevant and understanding information. It was also reviewed that audiovisual interventions [11] appear potentially useful in reducing preoperative anxiety and its associated outcomes in children undergoing elective surgery. The systematic review suggested that videos, multifaceted programs, and interactive games appear to be most effective, whereas music therapy and internet programs are less effective. A literature survey [12] was done to review and analyze the studies on the effect of perioperative music in pediatric surgery for children from day 1 to 18 years of age. The evidence indicates that music interventions may have a statistically significant effect in reducing postoperative pain, anxiety, and distress in children undergoing surgical procedure and music therapy may be considered for clinical use. An integrative review [13] showed

reducing anxiety of children undergoing surgery and their


The review of literature suggests that the use of toys and preoperative visit [30] can reduce the preoperative anxiety in children. Along with the children, the parents too were involved in a study, and there was a high level of satisfaction among the parents who underwent this intervention. Performing preoperative preparation program for children is essential. It was seen that when the children received therapeutic play [31] consisting of operation room tour, demonstration and return demonstration of procedures on the mannequins had a better impact. Having encountered with clown and developmentally appropriate techniques such as magic tricks, gags, music, games, puppets, word games, and bubbles can also reduce the preoperative anxiety in children. [32] It is well studied that children who are viewing animated cartoon and playing with a favorite toy, [33] working on cartoon coloring book, [34] picture book [35] are effective methods, whereas video distraction and parental presence and combination of both is also effective in minimizing preoperative anxiety of children. [36]

It was a promising result of a study which concluded that video glasses are not inferior to midazolam for preoperative anxiolysis and provide a safe, noninvasive nonpharmacological and pleasant alternative. [37]

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Aranha, et al.: Preoperative preparation of children undergoing surgery

While various activities such as video and toys being effective in reducing preoperative anxiety of children, evidences also suggest that surgery virtual tour offered on a website, [38] orientation tours, [39] providing conventional verbal information including role play, [17] operation room tours, information, modeling, coping‑based programs could also effectively reduce the preoperative anxiety of children. [18]

Acknowledgments We greatly acknowledge all the authors of the original research articles that have been found useful to write this review article and extend our thanks to the central library, Yenepoya University for providing facilities to retrieve relevant studies from various online databases.

Financial support and sponsorship Nil.

Conflicts of interest There are no conflicts of interest.


Researchers have also compared many such interventions to rule out the best for children. One such study where the family‑centered behavioral preparation including – anxiety reduction, distraction, video modeling and education, adding parents, no excessive reassurance, coaching, and exposure is more effective over providing standard care, parental presence, and oral midazolam was used in preparing children for surgery [40] and it showed a significant result in reduction of preoperative anxiety of parents and their children.

On the other hand, when the effectiveness of interactive music intervention and midazolam was investigated, it was seen that music therapy did not appear to alleviate children’s anxiety at anesthesia induction. [41]

Structured preoperative preparation has a significant effect on the anxiety of the child and parent, child’s behavioral changes and parent satisfaction. [42] Internet preparation program can also help adolescents to get well prepared for their surgery. [43] Preadmission visits can help to increase the parents and their child’s knowledge on hospital experience and help them to reduce their anxiety [44] On the other hand, it was proved that home based preparation of children for cardiac surgery is effective when compared to the hospital based preparation. [45]

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Implications for clinical practice Preoperative preparation of children and their parents is an important aspect of nursing care where psychological preparation should be more emphasized. Studies have shown that many nonpharmacological methods are effective in reducing preoperative anxiety of children and their parents. Therefore, it is the need of the hour to utilize these study findings in clinical practice, thereby prepare the children and their parents well for surgery. However, the techniques to be used should be age appropriate, according to the developmental stage of the child. It is also important to have further research on preoperative preparation of children to focus on target interventions to promote physical, psychological wellbeing as well as to enhance speedy recovery among children undergoing surgery.


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