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Research Article| Volume 68, P35-43, January 2023

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The effect of active distraction compared to midazolam in preschool children in the perioperative setting: A randomized controlled trial

  • Michelle M. Levay, MSN, RN, CPN
    Michelle M. Levay
    Correspondence
    Corresponding author at: Office of Nursing Research & Innovation, USA.
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    Office of Nursing Research & Innovation, USA

    Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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  • Megan K. Sumser, BSN, RN, CPN
    Megan K. Sumser
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    Office of Nursing Research & Innovation, USA

    Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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  • Kristen M. Vargo, DNP, RN, NE-BC
    Kristen M. Vargo
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    Neurological & Orthopaedic and Rheumatology Institutes, USA

    Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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  • Alina Bodas, MD
    Alina Bodas
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    Department of Pediatric Anesthesiology, USA

    Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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  • James F. Bena, MS
    James F. Bena
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    Department of Quantitative Health Sciences, Lerner Research Institute, USA

    Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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  • Cynthia A. Danford, PhD, CRNP, PPCNP-BC, CPNP-PC, FAAN
    Cynthia A. Danford
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    Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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  • Sandra L. Siedlecki, PhD, RN, APRN-CNS, FAAN
    Sandra L. Siedlecki
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    Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Published:October 31, 2022DOI:https://doi.org/10.1016/j.pedn.2022.09.021
The effect of active distraction compared to midazolam in preschool children in the perioperative setting: A randomized controlled trial
Previous ArticleExploring outcomes from an innovative, pediatric-focused intervention with undergraduate nursing students
Next ArticlePostoperative opioid administration and post-traumatic stress symptoms in preschool children after cardiac surgery
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      Highlights

      • •
        Preschool children are at high risk for preoperative anxiety.
      • •
        Tablet is equally effective at reducing preoperative anxiety compared to midazolam.
      • •
        Active distraction resulted in shorter length of stay.
      • •
        Parents prefer their children have less medicine preoperatively.

      Abstract

      Purpose

      The primary purpose of this study was to compare the effect of active distraction to midazolam as a non-pharmacological method of reducing preoperative anxiety in preschool children. A secondary purpose was to compare emergence delirium, sedation/agitation, and length of stay between groups.

      Design and methods

      Preschool children (N = 99) scheduled for elective surgery participated in this 2-group randomized controlled trial: the active distraction (tablet) group (n = 52) had unlimited playtime with a tablet and the midazolam group (n = 47) were medicated approximately 10 min before mask induced anesthesia. Data were collected using the modified Yale Preoperative Anxiety Scale, Pediatric Anesthesia Emergence Delirium scale, and Richmond Agitation Sedation Score. Length of stay (LOS) was measured in minutes from PACU admission to discharge. Wilcoxon rank sum, Pearson's chi square, and Fischer's exact tests were used in analysis.

      Results

      Preschool children (3–5 years old), predominantly male (61%) and White (85%) presented for ear, nose, throat, ophthalmology, urology, and general surgery at a pediatric surgical center within a large Midwestern hospital. There was no significant difference in anxiety, emergence delirium, or sedation/agitation scores between midazolam and tablet groups. Children assigned to the tablet group had shorter LOS (p = 0.021).

      Conclusion

      Active distraction with a tablet as an anxiolytic was as effective as midazolam for pre-school aged children with no side effects and reduced length of stay.

      Practice implications

      Preoperatively, non-pharmacological methods such as active distraction with a tablet should be considered for preschool children as an alternative to medication.

      Keywords

      • Anxiety
      • Distraction
      • Emergence delirium
      • Pediatric
      • Perioperative

      Introduction

      Preoperative anxiety in children has been identified at rates as high as 75% (
      Getahun, Endalew, Mersha and Admass, 2020
      • Getahun A.B.
      • Endalew N.S.
      • Mersha A.T.
      • Admass B.A.
      Magnitude and factors associated with preoperative anxiety among pediatric patients: Cross-sectional study.
      Pediatric Health, Medicine and Therapeutics. 2020; 11: 485
      https://doi.org/10.2147/PHMT.S288077
      • Crossref
      • PubMed
      • Google Scholar
      ). Young children exhibit separation anxiety and display negative behaviors, such as crying and temper tantrums (
      Kain, Mayes, O'Connor and Cicchetti, 1996
      • Kain Z.N.
      • Mayes L.C.
      • O’Connor T.Z.
      • Cicchetti D.V.
      Preoperative anxiety in children: Predictors and outcomes.
      Archives of Pediatrics & Adolescent Medicine. 1996; 150: 1238-1245
      https://doi.org/10.1001/archpedi.1996.02170370016002
      • Crossref
      • PubMed
      • Scopus (516)
      • Google Scholar
      ;
      Kain et al., 2004
      • Kain Z.N.
      • Caldwell-Andrews A.A.
      • Maranets I.
      • McClain B.
      • Gaal D.
      • Mayes L.C.
      • Zhang H.
      Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors.
      Anesthesia & Analgesia. 2004; 99: 1648-1654
      https://doi.org/10.1213/01.ANE.0000136471.36680.97
      • Crossref
      • PubMed
      • Scopus (429)
      • Google Scholar
      ). In addition, preoperative anxiety may cause a neuroendocrine response presenting as maladaptive behaviors that can impact the initial postoperative recovery period and may persist for up to 6 months or longer (
      Kain, Mayes, Wang and Hofstadter, 1999
      • Kain Z.N.
      • Mayes L.C.
      • Wang S.M.
      • Hofstadter M.B.
      Postoperative behavioral outcomes in children: Effects of sedative premedication.
      The Journal of the American Society of Anesthesiologists. 1999; 90: 758-765
      https://doi.org/10.1097/00000542-199903000-00018
      • Crossref
      • PubMed
      • Scopus (186)
      • Google Scholar
      ;
      Kain et al., 2000
      • Kain Z.N.
      • Hofstadter M.B.
      • Mayes L.C.
      • Krivutza D.M.
      • Alexander G.
      • Wang S.M.
      • Reznick J.S.
      Midazolam: Effects on amnesia and anxiety in children.
      The Journal of the American Society of Anesthesiologists. 2000; 93: 676-684
      https://doi.org/10.1097/00000542-200009000-00016
      • Crossref
      • PubMed
      • Scopus (147)
      • Google Scholar
      ).
      Causes of preoperative anxiety in preschool children include the unfamiliar preoperative environment, encounters with doctors and nurses, wearing a hospital gown, obtaining vital signs, being weighed, or simply placing a name band on their wrist. To minimize preoperative anxiety many approaches, both pharmacologic and non-pharmacologic, have been implemented. Midazolam, a pharmacologic agent, is commonly used as an anxiolytic in the pediatric population (
      Heikal and Stuart, 2020
      • Heikal S.
      • Stuart G.
      Anxiolytic premedication for children.
      British Journal of Anaesthesia Education. 2020; 20: 220
      https://doi.org/10.1016/j.bjae.2020.02.006
      • Scopus (5)
      • Google Scholar
      ;
      Kain et al., 2000
      • Kain Z.N.
      • Hofstadter M.B.
      • Mayes L.C.
      • Krivutza D.M.
      • Alexander G.
      • Wang S.M.
      • Reznick J.S.
      Midazolam: Effects on amnesia and anxiety in children.
      The Journal of the American Society of Anesthesiologists. 2000; 93: 676-684
      https://doi.org/10.1097/00000542-200009000-00016
      • Crossref
      • PubMed
      • Scopus (147)
      • Google Scholar
      ;
      Kain et al., 1997
      • Kain Z.N.
      • Mayes L.C.
      • Bell C.
      • Weisman S.
      • Hofstadter M.B.
      • Rimar S.
      Premedication in the United States: A status report.
      Anesthesia & Analgesia. 1997; 84: 427-432
      • Crossref
      • PubMed
      • Google Scholar
      ). Non-pharmacologic distraction techniques have shown promise in minimizing anxiety in children and include listening to music (
      Aytekin, Doru and Kucukoglu, 2016
      • Aytekin A.
      • Doru Ö.
      • Kucukoglu S.
      The effects of distraction on preoperative anxiety level in children.
      Journal of Perianesthesia Nursing. 2016; 31: 56-62
      https://doi.org/10.1016/j.jopan.2014.11.016
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (31)
      • Google Scholar
      ;
      McGraw, 1994
      • McGraw T.
      Preparing children for the operating room: Psychological issues.
      Canadian Journal of Anaesthesia. 1994; 41: 1094-1103
      • Crossref
      • PubMed
      • Scopus (73)
      • Google Scholar
      ), using humor (
      Berger, Wilson, Potts and Poliyka, 2014
      • Berger J.
      • Wilson D.
      • Potts L.
      • Poliyka B.
      Wacky Wednesday: Use of distraction through humor to reduce preoperative anxiety in children and their parents.
      Journal of PeriAnesthesia Nursing. 2014; 29: 285-291
      https://doi.org/10.1016/j.jopan.2013.06.003
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (16)
      • Google Scholar
      ), and playing games (
      Kim, Chiesa, Raazi and Wright, 2019
      • Kim J.
      • Chiesa N.
      • Raazi M.
      • Wright K.D.
      A systematic review of technology-based preoperative preparation interventions for child and parent anxiety.
      Canadian Journal of Anesthesia. 2019; 66: 966-986
      https://doi.org/10.1007/s12630-019-01387-8
      • Crossref
      • PubMed
      • Scopus (28)
      • Google Scholar
      ). Several researchers found active distraction as an effective preoperative anxiolytic in children (
      Marechal et al., 2017
      • Marechal C.
      • Berthiller J.
      • Tosetti S.
      • Cogniat B.
      • Desombres H.
      • Bouvet L.
      • Kassai B.
      • Chassard D.
      • de Queiroz Siqueira M.
      Children and parental anxiolysis in paediatric ambulatory surgery: A randomized controlled study comparing 0.3 mg kg− 1 midazolam to tablet computer based interactive distraction.
      British Journal of Anaesthesia. 2017; 118: 247-253
      https://doi.org/10.1093/bja/aew436
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (25)
      • Google Scholar
      ;
      Patel et al., 2006
      • Patel A.
      • Schieble T.
      • Davidson M.
      • Tran M.C.
      • Schoenberg C.
      • Delphin E.
      • Bennett H.
      Distraction with a hand-held video game reduces pediatric preoperative anxiety.
      Pediatric Anesthesia. 2006; 16: 1019-1027
      https://doi.org/10.1111/j.1460-9592.2006.01914.x
      • Crossref
      • PubMed
      • Scopus (195)
      • Google Scholar
      ;
      Uyar, Polat, Bolat and Donmez, 2021
      • Uyar B.S.
      • Polat R.
      • Bolat M.
      • Donmez A.
      Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomized trial.
      European Journal of Anaesthesiology. 2021; 38: 744-750
      https://doi.org/10.1097/EJA.0000000000001384
      • Crossref
      • PubMed
      • Scopus (6)
      • Google Scholar
      ). Three researchers found active distraction was significantly better at reducing anxiety compared to midazolam (
      Lee et al., 2013
      • Lee J.H.
      • Jung H.K.
      • Lee G.G.
      • Kim H.Y.
      • Park S.G.
      • Woo S.C.
      Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
      Korean Journal of Anesthesiology. 2013; 65: 508
      https://doi.org/10.4097/kjae.2013.65.6.508
      • Crossref
      • PubMed
      • Scopus (46)
      • Google Scholar
      ;
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      ;
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      ). When exploring the effectiveness of distraction as an anxiolytic, the studies reviewed consisted of children from toddlerhood through adolescence; no studies focused on children from only one specific developmental stage, such as preschool. Since children respond differently than adults, and younger children are developmentally different from older children, previous studies should not be generalized to younger children. Thus, our study sought to determine the effectiveness of using tablets as a preoperative anxiolytic in preschool children ages 3 to 5.

      Review of literature

      Anxiety

      Children exhibit anxiety prior to surgery (
      Fortier and Kain, 2015
      • Fortier M.A.
      • Kain Z.N.
      Treating perioperative anxiety and pain in children: A tailored and innovative approach.
      Pediatric Anesthesia. 2015; 25: 27-35
      https://doi.org/10.1111/pan.12546
      • Crossref
      • PubMed
      • Scopus (86)
      • Google Scholar
      ;
      Kain, Mayes, O'Connor and Cicchetti, 1996
      • Kain Z.N.
      • Mayes L.C.
      • O’Connor T.Z.
      • Cicchetti D.V.
      Preoperative anxiety in children: Predictors and outcomes.
      Archives of Pediatrics & Adolescent Medicine. 1996; 150: 1238-1245
      https://doi.org/10.1001/archpedi.1996.02170370016002
      • Crossref
      • PubMed
      • Scopus (516)
      • Google Scholar
      ) with younger children exhibiting more preoperative anxiety than older children (
      Getahun, Endalew, Mersha and Admass, 2020
      • Getahun A.B.
      • Endalew N.S.
      • Mersha A.T.
      • Admass B.A.
      Magnitude and factors associated with preoperative anxiety among pediatric patients: Cross-sectional study.
      Pediatric Health, Medicine and Therapeutics. 2020; 11: 485
      https://doi.org/10.2147/PHMT.S288077
      • Crossref
      • PubMed
      • Google Scholar
      ;
      Lee et al., 2013
      • Lee J.H.
      • Jung H.K.
      • Lee G.G.
      • Kim H.Y.
      • Park S.G.
      • Woo S.C.
      Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
      Korean Journal of Anesthesiology. 2013; 65: 508
      https://doi.org/10.4097/kjae.2013.65.6.508
      • Crossref
      • PubMed
      • Scopus (46)
      • Google Scholar
      ;
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      ). Preoperative anxiety has been associated with adverse side effects such as postoperative pain and emergence delirium (ED) (
      Kain, Mayes, Caldwell-Andrews, Karas and McClain, 2006
      • Kain Z.N.
      • Mayes L.C.
      • Caldwell-Andrews A.A.
      • Karas D.E.
      • McClain B.C.
      Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery.
      Pediatrics. 2006; 118: 651-658
      https://doi.org/10.1542/peds.2005-2920
      • Crossref
      • PubMed
      • Scopus (456)
      • Google Scholar
      ). Analgesics are typically given to treat these side effects, which can result in nausea, vomiting, and drowsiness. Non-pharmacologic anxiolytic interventions may be beneficial to control anxiety and minimize the side effects of medications.
      In nine randomized controlled trials, researchers explored differences in anxiety between children who received non-pharmacologic distraction compared to those who received a pharmacologic intervention (
      Al-Yateem, Brenner, Shorrab and Docherty, 2016
      • Al-Yateem N.
      • Brenner M.
      • Shorrab A.A.
      • Docherty C.
      Play distraction versus pharmacological treatment to reduce anxiety levels in children undergoing day surgery: A randomized controlled non-inferiority trial.
      Child: Care, Health and Development. 2016; 42: 572-581
      https://doi.org/10.1111/cch.12343
      • Crossref
      • PubMed
      • Scopus (33)
      • Google Scholar
      ;
      Kerimoglu, Neuman, Paul, Stefanov and Twersky, 2013
      • Kerimoglu B.
      • Neuman A.
      • Paul J.
      • Stefanov D.G.
      • Twersky R.
      Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.
      Anesthesia & Analgesia. 2013; 117: 1373-1379
      https://doi.org/10.1213/ANE.0b013e3182a8c18f
      • Crossref
      • PubMed
      • Scopus (64)
      • Google Scholar
      ;
      Lee et al., 2013
      • Lee J.H.
      • Jung H.K.
      • Lee G.G.
      • Kim H.Y.
      • Park S.G.
      • Woo S.C.
      Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
      Korean Journal of Anesthesiology. 2013; 65: 508
      https://doi.org/10.4097/kjae.2013.65.6.508
      • Crossref
      • PubMed
      • Scopus (46)
      • Google Scholar
      ;
      Marechal et al., 2017
      • Marechal C.
      • Berthiller J.
      • Tosetti S.
      • Cogniat B.
      • Desombres H.
      • Bouvet L.
      • Kassai B.
      • Chassard D.
      • de Queiroz Siqueira M.
      Children and parental anxiolysis in paediatric ambulatory surgery: A randomized controlled study comparing 0.3 mg kg− 1 midazolam to tablet computer based interactive distraction.
      British Journal of Anaesthesia. 2017; 118: 247-253
      https://doi.org/10.1093/bja/aew436
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (25)
      • Google Scholar
      ;
      Patel et al., 2006
      • Patel A.
      • Schieble T.
      • Davidson M.
      • Tran M.C.
      • Schoenberg C.
      • Delphin E.
      • Bennett H.
      Distraction with a hand-held video game reduces pediatric preoperative anxiety.
      Pediatric Anesthesia. 2006; 16: 1019-1027
      https://doi.org/10.1111/j.1460-9592.2006.01914.x
      • Crossref
      • PubMed
      • Scopus (195)
      • Google Scholar
      ;
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      ;
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      ;
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      ;
      Uyar, Polat, Bolat and Donmez, 2021
      • Uyar B.S.
      • Polat R.
      • Bolat M.
      • Donmez A.
      Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomized trial.
      European Journal of Anaesthesiology. 2021; 38: 744-750
      https://doi.org/10.1097/EJA.0000000000001384
      • Crossref
      • PubMed
      • Scopus (6)
      • Google Scholar
      ) (Table 1). Five researchers used non-pharmacologic interventions that were active distraction with tablets, video games, or smartphone games (
      Lee et al., 2013
      • Lee J.H.
      • Jung H.K.
      • Lee G.G.
      • Kim H.Y.
      • Park S.G.
      • Woo S.C.
      Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
      Korean Journal of Anesthesiology. 2013; 65: 508
      https://doi.org/10.4097/kjae.2013.65.6.508
      • Crossref
      • PubMed
      • Scopus (46)
      • Google Scholar
      ;
      Marechal et al., 2017
      • Marechal C.
      • Berthiller J.
      • Tosetti S.
      • Cogniat B.
      • Desombres H.
      • Bouvet L.
      • Kassai B.
      • Chassard D.
      • de Queiroz Siqueira M.
      Children and parental anxiolysis in paediatric ambulatory surgery: A randomized controlled study comparing 0.3 mg kg− 1 midazolam to tablet computer based interactive distraction.
      British Journal of Anaesthesia. 2017; 118: 247-253
      https://doi.org/10.1093/bja/aew436
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (25)
      • Google Scholar
      ;
      Patel et al., 2006
      • Patel A.
      • Schieble T.
      • Davidson M.
      • Tran M.C.
      • Schoenberg C.
      • Delphin E.
      • Bennett H.
      Distraction with a hand-held video game reduces pediatric preoperative anxiety.
      Pediatric Anesthesia. 2006; 16: 1019-1027
      https://doi.org/10.1111/j.1460-9592.2006.01914.x
      • Crossref
      • PubMed
      • Scopus (195)
      • Google Scholar
      ;
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      ;
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      ). Three researchers used passive distraction with storytelling, watching cartoons via DVD player or video glasses (
      Al-Yateem, Brenner, Shorrab and Docherty, 2016
      • Al-Yateem N.
      • Brenner M.
      • Shorrab A.A.
      • Docherty C.
      Play distraction versus pharmacological treatment to reduce anxiety levels in children undergoing day surgery: A randomized controlled non-inferiority trial.
      Child: Care, Health and Development. 2016; 42: 572-581
      https://doi.org/10.1111/cch.12343
      • Crossref
      • PubMed
      • Scopus (33)
      • Google Scholar
      ;
      Kerimoglu, Neuman, Paul, Stefanov and Twersky, 2013
      • Kerimoglu B.
      • Neuman A.
      • Paul J.
      • Stefanov D.G.
      • Twersky R.
      Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.
      Anesthesia & Analgesia. 2013; 117: 1373-1379
      https://doi.org/10.1213/ANE.0b013e3182a8c18f
      • Crossref
      • PubMed
      • Scopus (64)
      • Google Scholar
      ;
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      ). Only one study compared both active and passive distraction (
      Uyar, Polat, Bolat and Donmez, 2021
      • Uyar B.S.
      • Polat R.
      • Bolat M.
      • Donmez A.
      Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomized trial.
      European Journal of Anaesthesiology. 2021; 38: 744-750
      https://doi.org/10.1097/EJA.0000000000001384
      • Crossref
      • PubMed
      • Scopus (6)
      • Google Scholar
      ).
      Table 1Summary of reviewed studies.
      Author/ YearNon-pharmacologic InterventionIntervention groupsAge range (years)

      mean (SD)
      Anxiety

      (mYPAS)
      Emergence Delirium (PAED)Length of Stay
      Al-Yateem, Brenner, Shorrab and Docherty, 2016
      • Al-Yateem N.
      • Brenner M.
      • Shorrab A.A.
      • Docherty C.
      Play distraction versus pharmacological treatment to reduce anxiety levels in children undergoing day surgery: A randomized controlled non-inferiority trial.
      Child: Care, Health and Development. 2016; 42: 572-581
      https://doi.org/10.1111/cch.12343
      • Crossref
      • PubMed
      • Scopus (33)
      • Google Scholar
      Storytelling with educational coloring book **Midazolam (n = 84)

      Play (n = 84)
      3–8

      5.23 (1.06)

      5.25 (0.98)
      No differenceNANA
      Kerimoglu, Neuman, Paul, Stefanov and Twersky, 2013
      • Kerimoglu B.
      • Neuman A.
      • Paul J.
      • Stefanov D.G.
      • Twersky R.
      Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.
      Anesthesia & Analgesia. 2013; 117: 1373-1379
      https://doi.org/10.1213/ANE.0b013e3182a8c18f
      • Crossref
      • PubMed
      • Scopus (64)
      • Google Scholar
      Video glasses with cartoons**Midazolam (n = 32)

      Video glasses (n = 32)

      Combined (n = 32)
      4–9

      Mean

      not reported
      No differenceNANA
      Lee et al., 2013
      • Lee J.H.
      • Jung H.K.
      • Lee G.G.
      • Kim H.Y.
      • Park S.G.
      • Woo S.C.
      Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
      Korean Journal of Anesthesiology. 2013; 65: 508
      https://doi.org/10.4097/kjae.2013.65.6.508
      • Crossref
      • PubMed
      • Scopus (46)
      • Google Scholar
      Video games*Midazolam (n = 40)

      Video games (n = 40)

      Combined (n = 40)
      1–10

      5.7 (2.2)

      4.5 (1.8)

      5.0 (2.4)
      Non-pharmacologic intervention superior

      (p < 0.01)
      NANA
      Marechal et al., 2017
      • Marechal C.
      • Berthiller J.
      • Tosetti S.
      • Cogniat B.
      • Desombres H.
      • Bouvet L.
      • Kassai B.
      • Chassard D.
      • de Queiroz Siqueira M.
      Children and parental anxiolysis in paediatric ambulatory surgery: A randomized controlled study comparing 0.3 mg kg− 1 midazolam to tablet computer based interactive distraction.
      British Journal of Anaesthesia. 2017; 118: 247-253
      https://doi.org/10.1093/bja/aew436
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (25)
      • Google Scholar
      Video games*Midazolam (n = 55)

      Video games (n = 60)
      4–11

      6.8 (1.8)

      6.7 (1.9)
      No differenceNANA
      Patel et al., 2006
      • Patel A.
      • Schieble T.
      • Davidson M.
      • Tran M.C.
      • Schoenberg C.
      • Delphin E.
      • Bennett H.
      Distraction with a hand-held video game reduces pediatric preoperative anxiety.
      Pediatric Anesthesia. 2006; 16: 1019-1027
      https://doi.org/10.1111/j.1460-9592.2006.01914.x
      • Crossref
      • PubMed
      • Scopus (195)
      • Google Scholar
      Video games*Midazolam (n = 38)

      Parent (n = 36)

      Video games (n = 38)
      4–12

      6.9 (0.4)

      6.6 (0.4)

      7.0 (0.4)
      No differenceNANA
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      Video games*Midazolam (n = 51)

      Video games (n = 57)
      1–11

      5 (2.9)

      5 (3.0)
      Non-pharmacologic superior (p < 0.001)No differenceNon-pharmacologic superior

      (p = 0.03)
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      Cartoons**Midazolam (n = 45)

      Cartoons (n = 45)

      Combined (n = 45)
      2–12

      5.8 (3.1)

      6 (2.8)

      6.1 (3)
      No differenceNo differenceNA
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      Video games*Midazolam (n = 51)

      Video games (n = 51)
      4–12

      6.9 (2.5)

      6.8 (2.4)
      Non-pharmacologic intervention superior

      (p ≤ 0.001)
      Non- pharmacologic superior

      (p = 0.001)
      Non-pharmacologic superior

      (p = 0.03)
      Uyar, Polat, Bolat and Donmez, 2021
      • Uyar B.S.
      • Polat R.
      • Bolat M.
      • Donmez A.
      Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomized trial.
      European Journal of Anaesthesiology. 2021; 38: 744-750
      https://doi.org/10.1097/EJA.0000000000001384
      • Crossref
      • PubMed
      • Scopus (6)
      • Google Scholar
      Video games *

      Cartoon**
      Midazolam (n = 46)

      Video games (n = 46)

      Cartoon (n = 46)
      5–8

      6.5 (1.1)

      6.7 (1.0)

      6.6 (1.0)
      No differenceNANA
      mYPAS = modified Yale Preoperative Anxiety Scale; PAED = Pediatric Anesthesia Emergence Delirium; NA = not assessed; p = p-value; * = active intervention; ** = passive intervention.
      • Open table in a new tab
      Lee et al., 2013
      • Lee J.H.
      • Jung H.K.
      • Lee G.G.
      • Kim H.Y.
      • Park S.G.
      • Woo S.C.
      Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
      Korean Journal of Anesthesiology. 2013; 65: 508
      https://doi.org/10.4097/kjae.2013.65.6.508
      • Crossref
      • PubMed
      • Scopus (46)
      • Google Scholar
      ,
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      , and
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      found that active distraction (tablet or smartphone) was superior to midazolam for reducing preoperative anxiety in children.
      Marechal et al., 2017
      • Marechal C.
      • Berthiller J.
      • Tosetti S.
      • Cogniat B.
      • Desombres H.
      • Bouvet L.
      • Kassai B.
      • Chassard D.
      • de Queiroz Siqueira M.
      Children and parental anxiolysis in paediatric ambulatory surgery: A randomized controlled study comparing 0.3 mg kg− 1 midazolam to tablet computer based interactive distraction.
      British Journal of Anaesthesia. 2017; 118: 247-253
      https://doi.org/10.1093/bja/aew436
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (25)
      • Google Scholar
      and
      Patel et al., 2006
      • Patel A.
      • Schieble T.
      • Davidson M.
      • Tran M.C.
      • Schoenberg C.
      • Delphin E.
      • Bennett H.
      Distraction with a hand-held video game reduces pediatric preoperative anxiety.
      Pediatric Anesthesia. 2006; 16: 1019-1027
      https://doi.org/10.1111/j.1460-9592.2006.01914.x
      • Crossref
      • PubMed
      • Scopus (195)
      • Google Scholar
      found no difference in anxiolytic effects between active distraction and midazolam. Similarly,
      Al-Yateem, Brenner, Shorrab and Docherty, 2016
      • Al-Yateem N.
      • Brenner M.
      • Shorrab A.A.
      • Docherty C.
      Play distraction versus pharmacological treatment to reduce anxiety levels in children undergoing day surgery: A randomized controlled non-inferiority trial.
      Child: Care, Health and Development. 2016; 42: 572-581
      https://doi.org/10.1111/cch.12343
      • Crossref
      • PubMed
      • Scopus (33)
      • Google Scholar
      ,
      Kerimoglu, Neuman, Paul, Stefanov and Twersky, 2013
      • Kerimoglu B.
      • Neuman A.
      • Paul J.
      • Stefanov D.G.
      • Twersky R.
      Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.
      Anesthesia & Analgesia. 2013; 117: 1373-1379
      https://doi.org/10.1213/ANE.0b013e3182a8c18f
      • Crossref
      • PubMed
      • Scopus (64)
      • Google Scholar
      , and
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      found no difference between passive distraction and midazolam.
      Uyar, Polat, Bolat and Donmez, 2021
      • Uyar B.S.
      • Polat R.
      • Bolat M.
      • Donmez A.
      Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomized trial.
      European Journal of Anaesthesiology. 2021; 38: 744-750
      https://doi.org/10.1097/EJA.0000000000001384
      • Crossref
      • PubMed
      • Scopus (6)
      • Google Scholar
      compared active and passive distraction with midazolam and found no differences.
      All studies reviewed assessed anxiety using the modified Yale Preoperative Anxiety Scale (mYPAS). The mYPAS is a valid/reliable observational tool used to evaluate patients' anxiety preoperative and during induction of anesthesia (
      Kain et al., 1997
      • Kain Z.N.
      • Mayes L.C.
      • Cicchetti D.V.
      • Bagnall A.L.
      • Finley J.D.
      • Hofstadter M.B.
      The Yale preoperative anxiety scale: How does it compare with a “gold standard”?.
      Anesthesia & Analgesia. 1997; 85: 783-788
      • Crossref
      • PubMed
      • Google Scholar
      ). Differences in findings specific to anxiety may be attributed to the timing of the measurement. Most researchers measured anxiety at the time of mask induction of anesthesia (
      Al-Yateem, Brenner, Shorrab and Docherty, 2016
      • Al-Yateem N.
      • Brenner M.
      • Shorrab A.A.
      • Docherty C.
      Play distraction versus pharmacological treatment to reduce anxiety levels in children undergoing day surgery: A randomized controlled non-inferiority trial.
      Child: Care, Health and Development. 2016; 42: 572-581
      https://doi.org/10.1111/cch.12343
      • Crossref
      • PubMed
      • Scopus (33)
      • Google Scholar
      ;
      Kerimoglu, Neuman, Paul, Stefanov and Twersky, 2013
      • Kerimoglu B.
      • Neuman A.
      • Paul J.
      • Stefanov D.G.
      • Twersky R.
      Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.
      Anesthesia & Analgesia. 2013; 117: 1373-1379
      https://doi.org/10.1213/ANE.0b013e3182a8c18f
      • Crossref
      • PubMed
      • Scopus (64)
      • Google Scholar
      ;
      Marechal et al., 2017
      • Marechal C.
      • Berthiller J.
      • Tosetti S.
      • Cogniat B.
      • Desombres H.
      • Bouvet L.
      • Kassai B.
      • Chassard D.
      • de Queiroz Siqueira M.
      Children and parental anxiolysis in paediatric ambulatory surgery: A randomized controlled study comparing 0.3 mg kg− 1 midazolam to tablet computer based interactive distraction.
      British Journal of Anaesthesia. 2017; 118: 247-253
      https://doi.org/10.1093/bja/aew436
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (25)
      • Google Scholar
      ;
      Patel et al., 2006
      • Patel A.
      • Schieble T.
      • Davidson M.
      • Tran M.C.
      • Schoenberg C.
      • Delphin E.
      • Bennett H.
      Distraction with a hand-held video game reduces pediatric preoperative anxiety.
      Pediatric Anesthesia. 2006; 16: 1019-1027
      https://doi.org/10.1111/j.1460-9592.2006.01914.x
      • Crossref
      • PubMed
      • Scopus (195)
      • Google Scholar
      ;
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      ;
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      ;
      Uyar, Polat, Bolat and Donmez, 2021
      • Uyar B.S.
      • Polat R.
      • Bolat M.
      • Donmez A.
      Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomized trial.
      European Journal of Anaesthesiology. 2021; 38: 744-750
      https://doi.org/10.1097/EJA.0000000000001384
      • Crossref
      • PubMed
      • Scopus (6)
      • Google Scholar
      ), while some measured anxiety upon entry into the operating room (
      Lee et al., 2013
      • Lee J.H.
      • Jung H.K.
      • Lee G.G.
      • Kim H.Y.
      • Park S.G.
      • Woo S.C.
      Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
      Korean Journal of Anesthesiology. 2013; 65: 508
      https://doi.org/10.4097/kjae.2013.65.6.508
      • Crossref
      • PubMed
      • Scopus (46)
      • Google Scholar
      ) or at the time of parental separation (
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      ).
      Sample characteristics, age, and duration of the non-pharmacologic interventions varied from study to study. The studies reviewed included children across a variety of developmental stages.
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      stratified children by age but did not report the number of children in each subgroup and reported mYPAS results in aggregate.
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      and
      Lee et al., 2013
      • Lee J.H.
      • Jung H.K.
      • Lee G.G.
      • Kim H.Y.
      • Park S.G.
      • Woo S.C.
      Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
      Korean Journal of Anesthesiology. 2013; 65: 508
      https://doi.org/10.4097/kjae.2013.65.6.508
      • Crossref
      • PubMed
      • Scopus (46)
      • Google Scholar
      examined different age groups and reported mYPAS scores but did not report the number of children.
      Patel et al., 2006
      • Patel A.
      • Schieble T.
      • Davidson M.
      • Tran M.C.
      • Schoenberg C.
      • Delphin E.
      • Bennett H.
      Distraction with a hand-held video game reduces pediatric preoperative anxiety.
      Pediatric Anesthesia. 2006; 16: 1019-1027
      https://doi.org/10.1111/j.1460-9592.2006.01914.x
      • Crossref
      • PubMed
      • Scopus (195)
      • Google Scholar
      was the only study to report changes in mYPAS score by age (4–5, 6–9, >10), yet there were no significant differences between groups for any age subgroup, possibly due to small sample sizes. Since children may respond differently to stressful situations and interventions (pharmacologic and non-pharmacologic), based on their age and developmental stage, it is unclear if distraction as an intervention would be appropriate, feasible, or beneficial for preschool children.
      In the studies reviewed, duration of intervention (playtime) varied from 1 min to 60 min, with one study not reporting the intervention duration (
      Kerimoglu, Neuman, Paul, Stefanov and Twersky, 2013
      • Kerimoglu B.
      • Neuman A.
      • Paul J.
      • Stefanov D.G.
      • Twersky R.
      Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.
      Anesthesia & Analgesia. 2013; 117: 1373-1379
      https://doi.org/10.1213/ANE.0b013e3182a8c18f
      • Crossref
      • PubMed
      • Scopus (64)
      • Google Scholar
      ). None of the studies allowed children unlimited playtime nor controlled for variations in timing of the intervention. Thus it remains unknown if duration of playtime had any influence on children's preoperative anxiety. It was also unclear how duration of playtime was defined and whether the timing of the intervention continued during transfer to the OR and mask induction of anesthesia. Therefore, comparison of intervention duration between studies were difficult.

      Pharmacologic management of anxiety in children

      Midazolam, a benzodiazepine with anxiolytic and amnesic properties, is routinely given to children to manage anxiety (
      Kain, Mayes, Wang and Hofstadter, 1999
      • Kain Z.N.
      • Mayes L.C.
      • Wang S.M.
      • Hofstadter M.B.
      Postoperative behavioral outcomes in children: Effects of sedative premedication.
      The Journal of the American Society of Anesthesiologists. 1999; 90: 758-765
      https://doi.org/10.1097/00000542-199903000-00018
      • Crossref
      • PubMed
      • Scopus (186)
      • Google Scholar
      ;
      Kain et al., 2000
      • Kain Z.N.
      • Hofstadter M.B.
      • Mayes L.C.
      • Krivutza D.M.
      • Alexander G.
      • Wang S.M.
      • Reznick J.S.
      Midazolam: Effects on amnesia and anxiety in children.
      The Journal of the American Society of Anesthesiologists. 2000; 93: 676-684
      https://doi.org/10.1097/00000542-200009000-00016
      • Crossref
      • PubMed
      • Scopus (147)
      • Google Scholar
      ;
      Taketomo, Hodding and Kraus, 2019
      • Taketomo C.
      • Hodding J.
      • Kraus D.
      Lexicomp pediatric & neonatal dosage handbook: An extensive resource for clinicians treating pediatric and neonatal patients.
      26th ed. Wolters Kluwer Health, 2019
      • Google Scholar
      ). Midazolam is administered as an oral agent (syrup), but due to its bitter taste, children are often reluctant to take the medication (
      Salman et al., 2018
      • Salman S.
      • Tang E.K.Y.
      • Cheung L.C.
      • Nguyen M.N.
      • Sommerfield D.
      • Slevin L.
      • Von Ungern Sternberg B.S.
      A novel, palatable paediatric oral formulation of midazolam: Pharmacokinetics, tolerability, efficacy and safety.
      Anaesthesia. 2018; 73: 1469-1477
      https://doi.org/10.1111/anae.14318
      • Crossref
      • PubMed
      • Scopus (14)
      • Google Scholar
      ;
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      ). Administering medication to uncooperative pediatric patients is both challenging and stressful. As with most pharmaceutical agents, midazolam is not without side effects. The most serious side effects of midazolam include respiratory depression, excess sedation, hypotension, paradoxical reaction, emergence delirium (ED), and agitation (
      Taketomo, Hodding and Kraus, 2019
      • Taketomo C.
      • Hodding J.
      • Kraus D.
      Lexicomp pediatric & neonatal dosage handbook: An extensive resource for clinicians treating pediatric and neonatal patients.
      26th ed. Wolters Kluwer Health, 2019
      • Google Scholar
      ). Anatomical and physiological differences predispose preschool children to respiratory distress if they become over sedated (
      Ferrari, 2021
      • Ferrari L.R.
      The pediatric airway: Anatomy, challenges, and solutions.
      in: Mason K.P. Pediatric sedation outside of the operating room. Springer International Publishing, 2021: 125-139
      https://doi.org/10.1007/978-30-30-58406-1
      • Crossref
      • Scopus (1)
      • Google Scholar
      ). Although administration of midazolam is common practice, exploring non-pharmacologic interventions that do not have serious side effects warrants attention.

      Emergence delirium

      Emergence delirium (ED) is a condition occurring post general anesthesia, characterized by hallucinations, delusions, and confusion. Children with ED exhibit restlessness, screaming, and involuntary thrashing in bed and are therefore at risk for disrupting surgical wounds, dislodging medical equipment, and causing injury to themselves or others (
      Sikich and Lerman, 2004
      • Sikich N.
      • Lerman J.
      Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale.
      The Journal of the American Society of Anesthesiologists. 2004; 100: 1138-1145
      https://doi.org/10.1097/00000542-200405000-00015
      • Crossref
      • PubMed
      • Scopus (507)
      • Google Scholar
      ). Not only is it difficult for nurses to manage ED in children, but it is also distressing for parents to witness. It has been noted that preschool children experience higher rates of ED when compared to older children (
      Dahmani, Delivet and Hilly, 2014
      • Dahmani S.
      • Delivet H.
      • Hilly J.
      Emergence delirium in children: An update.
      Current Opinion in Anesthesiology. 2014; 27: 309-315
      https://doi.org/10.1097/ACO.0000000000000076
      • Crossref
      • PubMed
      • Scopus (124)
      • Google Scholar
      ). The higher incidence of ED in preschool children is most notable following surgeries involving ear, nose and throat, ophthalmology, and circumcisions (
      Eckenhoff, Kneale and Dripps, 1961
      • Eckenhoff J.E.
      • Kneale D.H.
      • Dripps R.D.
      The incidence and etiology of postanesthetic excitement a clinical survey.
      The Journal of the American Society of Anesthesiologists. 1961; 22: 667-673
      https://doi.org/10.1097/00000542-196109000-00002
      • PubMed
      • Google Scholar
      ;
      Mason, 2017
      • Mason K.P.
      Paediatric emergence delirium: A comprehensive review and interpretation of the literature.
      British Journal of Anaesthesia. 2017; 118: 335-343
      https://doi.org/10.1093/bja/aew477
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (102)
      • Google Scholar
      ;
      Voepel-Lewis, Malviya and Tait, 2003
      • Voepel-Lewis T.
      • Malviya S.
      • Tait A.R.
      A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit.
      Anesthesia & Analgesia. 2003; 96: 1625-1630
      https://doi.org/10.1213/01.ANE.0000062522.21048.61
      • Crossref
      • PubMed
      • Scopus (346)
      • Google Scholar
      ).
      Cole, Murray, McAllister and Hirshberg, 2002
      • Cole J.W.
      • Murray D.J.
      • McAllister J.D.
      • Hirshberg G.E.
      Emergence behaviour in children: Defining the incidence of excitement and agitation following anaesthesia.
      Pediatric Anesthesia. 2002; 12: 442-447
      https://doi.org/10.1046/j.1460-9592.2002.00868.x
      • Crossref
      • PubMed
      • Scopus (182)
      • Google Scholar
      found children who received midazolam preoperatively experienced a higher incidence of ED compared to children who did not receive the medication. This is consistent with the evidence that lists ED as a side effect of midazolam (
      Taketomo, Hodding and Kraus, 2019
      • Taketomo C.
      • Hodding J.
      • Kraus D.
      Lexicomp pediatric & neonatal dosage handbook: An extensive resource for clinicians treating pediatric and neonatal patients.
      26th ed. Wolters Kluwer Health, 2019
      • Google Scholar
      ).
      Strategies to prevent ED remain controversial, but rapid identification of ED is imperative to reduce injury and lessen associated ill effects. Emergence delirium in the pediatric population is typically assessed with the Pediatric Anesthesia Emergence Delirium (PAED) scale (
      Ringblom, Wåhlin and Proczkowska, 2018
      • Ringblom J.
      • Wåhlin I.
      • Proczkowska M.
      A psychometric evaluation of the pediatric anesthesia emergence delirium scale.
      Pediatric Anesthesia. 2018; 28: 332-337
      https://doi.org/10.1111/pan.13348
      • Crossref
      • PubMed
      • Scopus (23)
      • Google Scholar
      ). Out of the nine studies reviewed (Table 1), only
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      ,
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      , and
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      measured the incidence of ED. None of these studies found a significant difference between the non-pharmacologic intervention and midazolam during “emergence from anesthesia” post-surgery. However,
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      found a significant difference at 15 min post-emergence from anesthesia, with less ED in the non-pharmacologic group compared to the midazolam group (p = 0.001). Conflicting findings may be attributed to variations in the timing of the assessment.

      Sedation/agitation

      The sedative and anxiolytic properties of midazolam are beneficial, as it increases cooperation during mask induction (
      Kain, Mayes, Wang, Caramico and Hofstadter, 1998
      • Kain Z.N.
      • Mayes L.C.
      • Wang S.M.
      • Caramico L.A.
      • Hofstadter M.B.
      Parental presence during induction of anesthesia versus sedative premedication: Which intervention is more effective?.
      The Journal of the American Society of Anesthesiologists. 1998; 89: 1147-1156
      https://doi.org/10.1097/00000542-199811000-00015
      • Crossref
      • PubMed
      • Scopus (276)
      • Google Scholar
      ;
      Kain et al., 2000
      • Kain Z.N.
      • Hofstadter M.B.
      • Mayes L.C.
      • Krivutza D.M.
      • Alexander G.
      • Wang S.M.
      • Reznick J.S.
      Midazolam: Effects on amnesia and anxiety in children.
      The Journal of the American Society of Anesthesiologists. 2000; 93: 676-684
      https://doi.org/10.1097/00000542-200009000-00016
      • Crossref
      • PubMed
      • Scopus (147)
      • Google Scholar
      ). A rare unintended side effect occurs when children experience a paradoxical reaction in which children become delirious and combative, requiring medication reversal to prevent injury (
      Jackson, Beck and Losek, 2015
      • Jackson B.F.
      • Beck L.A.
      • Losek J.D.
      Successful flumazenil reversal of paradoxical reaction to midazolam in a child.
      The Journal of Emergency Medicine. 2015; 48: e67-e72
      https://doi.org/10.1016/j.jemermed.2014.09.062
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (12)
      • Google Scholar
      ). Excessive sedation and agitation, side effects of midazolam, may also influence length of stay (LOS) in the postoperative recovery area (
      Dahmani, Delivet and Hilly, 2014
      • Dahmani S.
      • Delivet H.
      • Hilly J.
      Emergence delirium in children: An update.
      Current Opinion in Anesthesiology. 2014; 27: 309-315
      https://doi.org/10.1097/ACO.0000000000000076
      • Crossref
      • PubMed
      • Scopus (124)
      • Google Scholar
      ;
      Parnis, Foate, Van der Walt, Short and Crowe, 1992
      • Parnis S.J.
      • Foate J.A.
      • Van der Walt J.H.
      • Short T.
      • Crowe C.E.
      Oral midazolam is an effective premedication for children having day-stay anaesthesia.
      Anaesthesia and Intensive Care. 1992; 20 (https://doi.org/10.1177%2F0310057X9202000102): 9-14
      • Crossref
      • PubMed
      • Google Scholar
      ;
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      ). None of the studies reviewed measured sedation or agitation, and it is unknown if either pharmacologic or non-pharmacologic interventions influence sedation and agitation postoperatively.

      Length of stay

      Research findings on LOS and midazolam are conflicting (
      Banchs and Lerman, 2014
      • Banchs R.J.
      • Lerman J.
      Preoperative anxiety management, emergence delirium, and postoperative behavior.
      Anesthesiology Clinics. 2014; 32: 1-23
      https://doi.org/10.1016/j.anclin.2013.10.011
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (74)
      • Google Scholar
      ;
      Hudek, 2009
      • Hudek K.
      Emergence delirium: A nursing perspective.
      AORN Journal. 2009; 89: 509-520
      https://doi.org/10.1016/j.aorn.2008.12.026
      • Crossref
      • PubMed
      • Scopus (31)
      • Google Scholar
      ;
      Lepouse, Lautner, Liu, Gomis and Leon, 2006
      • Lepouse C.
      • Lautner C.A.
      • Liu L.
      • Gomis P.
      • Leon A.
      Emergence delirium in adults in the post-anaesthesia care unit.
      British Journal of Anaesthesia. 2006; 96: 747-753
      https://doi.org/10.1093/bja/ael094
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (229)
      • Google Scholar
      ). Length of stay may or may not be associated with medications administered during the perianesthesia period. LOS was only addressed in two of the studies we reviewed.
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      and
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      reported that LOS was shorter in the non-pharmacologic group compared to the pharmacologic group.

      Preschool development

      Characterized by Erikson's psychosocial stage of initiative versus guilt, preschool children benefit from asserting control and exploring the world around them to create a sense of accomplishment and mastery (
      Kyle and Carman, 2021
      • Kyle T.
      • Carman S.
      Growth and development of the preschooler.
      in: Essentials of pediatric nursing. 4th ed. Wolters Kluwer, 2021: 119-137
      • Google Scholar
      ). Children in this age group like to participate in activities with purpose. Thus, based on their developmental abilities, using an interactive tablet-like device with age-appropriate games might be useful as an alternative to pharmacologic interventions.

      Purpose

      The primary purpose of this study was to compare tablet-based active distraction versus midazolam as a method of managing preoperative anxiety in preschool children ages 3 to 5. The secondary purpose was to compare the two groups on the frequency of side effects of ED, frequency of sedation and agitation, and the difference in length of stay (Fig. 1).
      Fig. 1
      Fig. 1Study Design.
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      The study design and research questions are based upon the conceptual model found in Fig. 1. In this model, we posit no difference in anxiolytic effects between pharmacological and non-pharmacologic interventions. However, pharmacologic interventions have side effects, such as sedation and agitation, which will impact length of stay.

      Methods

      Design

      A 2-group randomized controlled clinical trial was used to address the specific aims of the study. Data were collected from April 2017 to March 2019.

      Specific aims

      In this study of preschool children ages 3 to 5 who received the tablet versus those who received oral midazolam, we sought to compare preoperative anxiety scores as measured by the mYPAS; postoperatively compare the frequency of ED, as measured by the PAED; preoperative and postoperatively compare the presence of sedation and agitation, as measured by the RASS; and compare Post Anesthesia Care Unit (PACU) length of stay, as measured in minutes (Table 2).
      Table 2Time points when subjects were assessed.
      Induction Operating RoomAdmission to PACUEmergence from anesthesia
      AnxietymYPAS
      Sedation/AgitationRASSRASS
      Emergence DeliriumPAED
      PACU = Post Anesthesia Care Unit; mYPAS = Modified Yale Preoperative Anxiety Scale; RASS = Richmond Agitation Sedation Scale; PAED = Pediatric Anesthesia Emergence Delirium scale.
      • Open table in a new tab

      Sample size and setting

      To achieve a moderate effect, the desired sample for this study was 36 per group with an alpha of 0.05 and power of 0.80. Oversampling was used to accommodate for possible attrition.
      This study was conducted in a 10-bed pediatric PACU at a large Magnet® designated quaternary care medical center in Midwest USA. Preschool children ages 3 to 5 scheduled for elective surgery under general anesthesia with mask induction were included in the study. Anesthesia providers classify children according to the American Society of Anesthesiologists (ASA), which is a subjective grading system to rate a patient's preoperative comorbidity. Children were included in the study if classified as ASA I or II (Table 3).
      Table 3American Society of Anesthesiologists physical status classification system:
      ASA classificationDescription
      IHealthy
      IIMild systemic disease; has a controlled disease of one body system
      IIISevere systemic disease; has a controlled disease of more than one body system or major system
      IVSevere systemic disease that is constant threat to life; or severe disease that is poorly controlled or end stage
      VPatient with catastrophic injuries not expected to survive without an operation
      VIBrain death
      Committee on Economics. (2020, December 13). ASA Physical Status Classification System. American Society of Anesthesiologists.
      Committee on Economics, 2020
      • Committee on Economics
      ASA Physical Status Classification System.
      American Society of Anesthesiologists, 2020
      https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
      • Google Scholar
      .
      • Open table in a new tab
      Excluded from this study were children with ASA classification of III or higher, children with an allergy to midazolam, or children with documented cognitive and developmental delays. In addition, children were excluded if the anesthesiologist determined it would be in the child's best interest to be pre-medicated with midazolam prior to surgery.

      Recruitment procedures

      Researchers regularly reviewed the surgery schedule to identify eligible participants. A research team member contacted parents primarily by phone and sometimes by email within the week prior to surgery to discuss the study and answer questions. On the day of surgery, parents were again asked if they had any additional questions and if they would be interested in their child participating. Once parents agreed to participate, informed consent was obtained from the parent, and assent was obtained from the child. Playing games with the tablet was deemed as assent by the child.

      Protection of human subjects

      The study was approved by the Institutional Review Board. To minimize threats to confidentiality, no identifying data were recorded, and all study results were reported in aggregate. Data were maintained in a password-protected file on an encrypted computer, and only the study team had access to the data.

      Random assignment

      Preschool children were randomly assigned to the midazolam or tablet group. Randomization occurred when the parent or child selected a sealed envelope representing group assignment (Fig. 2).
      Fig. 2
      Fig. 2CONSORT 2010 Flow Diagram.
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      Midazolam group

      Preschool children assigned to the midazolam group received a dose of oral midazolam as prescribed by the anesthesia provider (usual and customary care) approximately 15–20 min prior to arrival in the operating room. The usual single oral dose for children prior to general anesthesia is 0.5 mg/kg (
      Taketomo, Hodding and Kraus, 2019
      • Taketomo C.
      • Hodding J.
      • Kraus D.
      Lexicomp pediatric & neonatal dosage handbook: An extensive resource for clinicians treating pediatric and neonatal patients.
      26th ed. Wolters Kluwer Health, 2019
      • Google Scholar
      ).

      Tablet group

      Preschool children in the experimental group were given a tablet with age-appropriate games. Children were able to select games of their choice. Child Life Specialists served as consultants on game selections utilizing knowledge of developmental milestones for preschool children ages 3 to 5. Children had unlimited playtime, which varied from child to child, and continued through mask induction of anesthesia.

      Measurement tools

      To address the first three study aims, data were collected on anxiety, ED, sedation, and agitation using three measures: the modified Yale Preoperative Anxiety Scale (mYPAS), the Pediatric Anesthesia Emergence Delirium (PAED) scale, and the Richmond Agitation Sedation Scale (RASS) (Fig. 3). After training, the mYPAS and RASS were measured by the pre-operative RN during mask induction and the RASS and PAED were measured by the post-operative RN in PACU (Table 2).
      Fig. 3
      Fig. 3Study measures (with abbreviated descriptors).
      Show full caption
      mYPAS = Modified Yale Preoperative Anxiety Scale (
      Kain et al., 1997
      • Kain Z.N.
      • Mayes L.C.
      • Cicchetti D.V.
      • Bagnall A.L.
      • Finley J.D.
      • Hofstadter M.B.
      The Yale preoperative anxiety scale: How does it compare with a “gold standard”?.
      Anesthesia & Analgesia. 1997; 85: 783-788
      • Crossref
      • PubMed
      • Google Scholar
      ); RASS = Richmond Agitation Sedation Scale (
      Kerson et al., 2016
      • Kerson A.G.
      • DeMaria R.
      • Mauer E.
      • Joyce C.
      • Gerber L.M.
      • Greenwald B.M.
      • Traube C.
      Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children.
      Journal of Intensive Care. 2016; 4: 1-6
      https://doi.org/10.1186/s40560-016-0189-5
      • Crossref
      • PubMed
      • Scopus (62)
      • Google Scholar
      ); PAED = Pediatric Anesthesia Emergence Delirium (
      Sikich and Lerman, 2004
      • Sikich N.
      • Lerman J.
      Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale.
      The Journal of the American Society of Anesthesiologists. 2004; 100: 1138-1145
      https://doi.org/10.1097/00000542-200405000-00015
      • Crossref
      • PubMed
      • Scopus (507)
      • Google Scholar
      ).
      • View Large Image
      • Figure Viewer
      • Download Hi-res image
      • Download (PPT)

      Modified Yale Preoperative Anxiety Scale (mYPAS)

      The mYPAS assesses the child's anxiety using a 22-item weighted observational scale with five domains (activity, vocalizations, emotional expressivity, state of apparent arousal, use of parents) (
      Kain et al., 1997
      • Kain Z.N.
      • Mayes L.C.
      • Cicchetti D.V.
      • Bagnall A.L.
      • Finley J.D.
      • Hofstadter M.B.
      The Yale preoperative anxiety scale: How does it compare with a “gold standard”?.
      Anesthesia & Analgesia. 1997; 85: 783-788
      • Crossref
      • PubMed
      • Google Scholar
      ). Scores range from 23 to 100, with higher scores indicating more anxiety. A categorical variable was created using a cut-off score of 30 or more to indicate anxiety versus no anxiety. No reliability estimates were found in the literature for the mYPAS, which included “use of parents.” However,
      Kühlmann, Lahdo, Staals and Van Dijk, 2019
      • Kühlmann A.Y.
      • Lahdo N.
      • Staals L.M.
      • Van Dijk M.
      What are the validity and reliability of the modified Yale preoperative anxiety scale-Short form in children less than 2 years old?.
      Pediatric Anesthesia. 2019; 29: 137-143
      https://doi.org/10.1111/pan.13536
      • Crossref
      • PubMed
      • Scopus (7)
      • Google Scholar
      and
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      reported internal consistency of >0.90 for the mYPAS-SF, which excluded “use of parents.” Two preoperative nurses were trained to use the mYPAS and achieved high inter-rater reliability (percent agreement 0.96).

      Pediatric anesthesia emergence delirium (PAED)

      The PAED scale was used to assess the presence of ED in the PACU.
      Bajwa, Costi and Cyna, 2010
      • Bajwa S.A.
      • Costi D.
      • Cyna A.M.
      A comparison of emergence delirium scales following general anesthesia in children.
      Pediatric Anesthesia. 2010; 20: 704-711
      https://doi.org/10.1111/j.1460-9592.2010.03328.x
      • Crossref
      • PubMed
      • Scopus (125)
      • Google Scholar
      compared the PAED scale to the Watcha and Cravero scale for the presence of ED in children recovering from general anesthesia (including surgical and non-surgical cases).
      Bajwa, Costi and Cyna, 2010
      • Bajwa S.A.
      • Costi D.
      • Cyna A.M.
      A comparison of emergence delirium scales following general anesthesia in children.
      Pediatric Anesthesia. 2010; 20: 704-711
      https://doi.org/10.1111/j.1460-9592.2010.03328.x
      • Crossref
      • PubMed
      • Scopus (125)
      • Google Scholar
      , reported the sensitivity of the PAED was 1.00 and specificity was 94.5 for scores >12. Additionally,
      Ringblom, Wåhlin and Proczkowska, 2018
      • Ringblom J.
      • Wåhlin I.
      • Proczkowska M.
      A psychometric evaluation of the pediatric anesthesia emergence delirium scale.
      Pediatric Anesthesia. 2018; 28: 332-337
      https://doi.org/10.1111/pan.13348
      • Crossref
      • PubMed
      • Scopus (23)
      • Google Scholar
      reported a Cronbach's alpha of 0.96. The PAED scale contains five items assessing behavior (makes eye contact, actions are purposeful, aware of surroundings, restless, inconsolable). The scale utilizes a 5-point Likert scale with total scores ranging from 0 to 20 (
      Sikich and Lerman, 2004
      • Sikich N.
      • Lerman J.
      Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale.
      The Journal of the American Society of Anesthesiologists. 2004; 100: 1138-1145
      https://doi.org/10.1097/00000542-200405000-00015
      • Crossref
      • PubMed
      • Scopus (507)
      • Google Scholar
      ). Similar to the study by
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      , we used a cut-off score of 12 to indicate the presence of ED. A categorical variable was created to reflect the presence of ED or no ED. Two postoperative nurses were trained to use the PAED scale in PACU and achieved high inter-rater reliability (percent agreement 0.92).

      Richmond agitation sedation scale (RASS)

      Sedation and agitation were assessed using the RASS. The RASS is a 10-item observational tool. Scores on the RASS range from negative 5 (unarousable) to positive 4 (combative/violent). The RASS tool has demonstrated reliability (
      Kerson et al., 2016
      • Kerson A.G.
      • DeMaria R.
      • Mauer E.
      • Joyce C.
      • Gerber L.M.
      • Greenwald B.M.
      • Traube C.
      Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children.
      Journal of Intensive Care. 2016; 4: 1-6
      https://doi.org/10.1186/s40560-016-0189-5
      • Crossref
      • PubMed
      • Scopus (62)
      • Google Scholar
      ). For this study, we categorized the RASS scores as agitated, calm, or sedated. Scores of 2 or higher indicated agitation, scores of +1 to −1 indicated calm, and scores of −2 and lower indicated sedation. Inter-rater reliability on the RASS was high following training with two preoperative nurses in the OR (percent agreement 1.00) and two nurses in PACU (percent agreement 0.85).

      Statistical methods

      Categorical variables were described using frequencies and percentages. Comparisons between groups were made with Pearson's chi-square tests or Fisher's exact tests. Normally distributed continuous variables were presented with means and standard deviations, and comparisons were made with independent sample t-tests. Continuous variables with a non-normal distribution were described using medians and quartiles and compared using Wilcoxon Rank Sum tests. Ordered categorical variables also used Wilcoxon Rank Sum tests to make comparisons between groups. Analyses were performed using SAS® Software (version 9.4; Cary, NC).

      Results

      Initial recruitment for our study included 184 eligible preschool children (Fig. 2). Several children were excluded due to parents or children changing their minds or physicians' preferences. This resulted in 137 preschool children randomly assigned to the midazolam or tablet group. Attrition in the midazolam group (n = 27; 36%) and tablet group (n = 11; 17%) occurred for multiple reasons, such as the children refusing to participate or on reassessment, the anesthesia team determining the patient did not meet inclusion criteria. Additionally, attrition in the midazolam group occurred when parents opted out of the study because they preferred the tablet group (n = 21; 28%). Three children were lost to follow-up when the study team became busy with other patients and could not assess children in PACU. The final sample included 99 preschool children (midazolam group n = 47; tablet group n = 52).
      Most children in the sample were White, with a total mean age (months) of 50.14 (SD 10.293), midazolam group mean age (months) of 48.28 (SD 9.019) and tablet group mean age (months) of 51.83 (SD 11.140). There were no significant differences between age, sex, race, and ethnicity (Table 4). However, there was a significant difference in the types of surgical procedures between groups (p = 0.035), with more children (n = 50, 51%) undergoing ear, nose, and throat procedures (Table 5) than ophthalmology, urology, and general surgery.
      Table 4Demographics.
      Midazolam

      n = 47
      Tablet

      n = 52
      Total

      n = 99
      n%n%n%
      Age
       3 years old2451%2242%4646%
       4 years old1634%1529%3131%
       5 years old715%1529%2222%
      Gender
       Male3268%2854%6061%
       Female1532%2446%3939%
      Race
       Black24%24%44%
       White3983%4587%8485%
       Other613%510%1111%
      Type of surgery
       Ear Nose Throat2043%3058%5051%
       Ophthalmology1328%1835%3131%
       Urology1021%24%1212%
       General surgery49%24%66%
      Child Life Specialist
       Services provided4391%4485%8788%
      • Open table in a new tab
      Table 5Surgery procedure by age and intervention.
      3 years old4 years old5 years oldTotal
      MidazolamTabletMidazolamTabletMidazolamTablet(n)
      Ear Nose Throat13(54%)11(50%)5(50%)10(67%)2(29%)9(60%)50
      Urology5(21%)1(5%)3(19%)1(7%)2(29%)0(0%)12
      Ophthalmology5(21%)9(41%)6(38%)3(20%)2(29%)6(40%)31
      General Surgery1(4%)1(5%)2(13%)1(7%)1(14%)0(0%)6
      TOTALS (n,%)24(52%)22(48%)16(52%)15(48%)7(32%)15(68%)99
      n (column %).
      • Open table in a new tab
      For both groups, anxiety was low with a median score of less than the cut point of 30. In addition, there were few cases of ED, with a median score of less than the cut-off score of 12. There was no significant difference in anxiolytic effects of midazolam versus the tablet intervention in this study. There was also no significant difference between groups for ED or sedation and agitation. However, the tablet intervention resulted in a significantly shorter length of stay compared to the midazolam intervention (Table 6).
      Table 6Differences in primary outcomes by group.
      FactorMidazolam

      (n = 47)
      Tablet

      (n = 52)
      DFTest Statisticp-value
      m-YPAS Anxiety Score28.0 [23.0, 65.0]25.0 [23.0, 42.5]N/A2456.50.44
      Length of stay88.0 [78.0, 101.0]75.5 [59.5, 98.0]N/A26860.021
      PAED final score8.0 [6.0, 10.0]8.0 [5.0, 10.5]N/A2420.50.62
      OR RASS codeN/A22670.31
       Sedated1 (2.1)0 (0.00)
       Calm42 (89.4)45 (86.5)
       Agitated4 (8.5)7 (13.5)
      PACU RASS codeN/A23110.52
       Sedated45 (95.7)48 (92.3)
       Calm0 (0.00)3 (5.8)
       Agitated2 (4.3)1 (1.9)
      Statistics presented as Median [P25, P75], n (column %).
      p-values
      Total n = 99.
      • Open table in a new tab

      Discussion

      Children's behavior, emotions, and coping strategies are influenced by their psychosocial development. Previous research on preoperative anxiety comparing active distraction techniques to midazolam lacked focus on one stage of development. We explored whether there were differences in anxiety, ED, sedation/agitation, and LOS when comparing active distraction to midazolam in preschool children ages 3 to 5 in the psychosocial stage of initiative versus guilt (
      Kyle and Carman, 2021
      • Kyle T.
      • Carman S.
      Growth and development of the preschooler.
      in: Essentials of pediatric nursing. 4th ed. Wolters Kluwer, 2021: 119-137
      • Google Scholar
      ). We found no significant differences between groups in preoperative anxiety, which was consistent with previous research (
      Al-Yateem, Brenner, Shorrab and Docherty, 2016
      • Al-Yateem N.
      • Brenner M.
      • Shorrab A.A.
      • Docherty C.
      Play distraction versus pharmacological treatment to reduce anxiety levels in children undergoing day surgery: A randomized controlled non-inferiority trial.
      Child: Care, Health and Development. 2016; 42: 572-581
      https://doi.org/10.1111/cch.12343
      • Crossref
      • PubMed
      • Scopus (33)
      • Google Scholar
      ;
      Kerimoglu, Neuman, Paul, Stefanov and Twersky, 2013
      • Kerimoglu B.
      • Neuman A.
      • Paul J.
      • Stefanov D.G.
      • Twersky R.
      Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.
      Anesthesia & Analgesia. 2013; 117: 1373-1379
      https://doi.org/10.1213/ANE.0b013e3182a8c18f
      • Crossref
      • PubMed
      • Scopus (64)
      • Google Scholar
      ;
      Marechal et al., 2017
      • Marechal C.
      • Berthiller J.
      • Tosetti S.
      • Cogniat B.
      • Desombres H.
      • Bouvet L.
      • Kassai B.
      • Chassard D.
      • de Queiroz Siqueira M.
      Children and parental anxiolysis in paediatric ambulatory surgery: A randomized controlled study comparing 0.3 mg kg− 1 midazolam to tablet computer based interactive distraction.
      British Journal of Anaesthesia. 2017; 118: 247-253
      https://doi.org/10.1093/bja/aew436
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (25)
      • Google Scholar
      ;
      Patel et al., 2006
      • Patel A.
      • Schieble T.
      • Davidson M.
      • Tran M.C.
      • Schoenberg C.
      • Delphin E.
      • Bennett H.
      Distraction with a hand-held video game reduces pediatric preoperative anxiety.
      Pediatric Anesthesia. 2006; 16: 1019-1027
      https://doi.org/10.1111/j.1460-9592.2006.01914.x
      • Crossref
      • PubMed
      • Scopus (195)
      • Google Scholar
      ;
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      ;
      Uyar, Polat, Bolat and Donmez, 2021
      • Uyar B.S.
      • Polat R.
      • Bolat M.
      • Donmez A.
      Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomized trial.
      European Journal of Anaesthesiology. 2021; 38: 744-750
      https://doi.org/10.1097/EJA.0000000000001384
      • Crossref
      • PubMed
      • Scopus (6)
      • Google Scholar
      ). Similar to studies by
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      and
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      , we found no significant difference in ED. Previous studies did not include assessment of sedation/agitation (Table 1). This study improved upon other studies by assessing sedation/agitation. However, we found no significant differences between groups.
      One significant finding was the difference in LOS, with the tablet group being discharged 12.5 min sooner than the midazolam group. This is consistent with findings reported by
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      and
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      . In our study, we allowed children unlimited play- time with the tablet. This contrasts with other studies that allowed children to play between 1 and 60 min (
      Al-Yateem, Brenner, Shorrab and Docherty, 2016
      • Al-Yateem N.
      • Brenner M.
      • Shorrab A.A.
      • Docherty C.
      Play distraction versus pharmacological treatment to reduce anxiety levels in children undergoing day surgery: A randomized controlled non-inferiority trial.
      Child: Care, Health and Development. 2016; 42: 572-581
      https://doi.org/10.1111/cch.12343
      • Crossref
      • PubMed
      • Scopus (33)
      • Google Scholar
      ;
      Lee et al., 2013
      • Lee J.H.
      • Jung H.K.
      • Lee G.G.
      • Kim H.Y.
      • Park S.G.
      • Woo S.C.
      Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
      Korean Journal of Anesthesiology. 2013; 65: 508
      https://doi.org/10.4097/kjae.2013.65.6.508
      • Crossref
      • PubMed
      • Scopus (46)
      • Google Scholar
      ;
      Marechal et al., 2017
      • Marechal C.
      • Berthiller J.
      • Tosetti S.
      • Cogniat B.
      • Desombres H.
      • Bouvet L.
      • Kassai B.
      • Chassard D.
      • de Queiroz Siqueira M.
      Children and parental anxiolysis in paediatric ambulatory surgery: A randomized controlled study comparing 0.3 mg kg− 1 midazolam to tablet computer based interactive distraction.
      British Journal of Anaesthesia. 2017; 118: 247-253
      https://doi.org/10.1093/bja/aew436
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (25)
      • Google Scholar
      ;
      Patel et al., 2006
      • Patel A.
      • Schieble T.
      • Davidson M.
      • Tran M.C.
      • Schoenberg C.
      • Delphin E.
      • Bennett H.
      Distraction with a hand-held video game reduces pediatric preoperative anxiety.
      Pediatric Anesthesia. 2006; 16: 1019-1027
      https://doi.org/10.1111/j.1460-9592.2006.01914.x
      • Crossref
      • PubMed
      • Scopus (195)
      • Google Scholar
      ;
      Seiden et al., 2014
      • Seiden S.C.
      • McMullan S.
      • Sequera-Ramos L.
      • De Oliveira Jr G.S.
      • Roth A.
      • Rosenblatt A.
      • Suresh S.
      Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
      Pediatric Anesthesia. 2014; 24: 1217-1223
      https://doi.org/10.1111/pan.12475
      • Crossref
      • PubMed
      • Scopus (44)
      • Google Scholar
      ;
      Sola et al., 2017
      • Sola C.
      • Lefauconnier A.
      • Bringuier S.
      • Raux O.
      • Capdevila X.
      • Dadure C.
      Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
      Pediatric Anesthesia. 2017; 27: 827-834
      https://doi.org/10.1111/pan.13180
      • Crossref
      • PubMed
      • Scopus (27)
      • Google Scholar
      ;
      Stewart, Cazzell and Pearcy, 2019
      • Stewart B.
      • Cazzell M.A.
      • Pearcy T.
      Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
      Journal of Perianesthesia Nursing. 2019; 34: 567-575
      https://doi.org/10.1016/j.jopan.2018.08.004
      • Abstract
      • Full Text
      • Full Text PDF
      • PubMed
      • Scopus (11)
      • Google Scholar
      ;
      Uyar, Polat, Bolat and Donmez, 2021
      • Uyar B.S.
      • Polat R.
      • Bolat M.
      • Donmez A.
      Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomized trial.
      European Journal of Anaesthesiology. 2021; 38: 744-750
      https://doi.org/10.1097/EJA.0000000000001384
      • Crossref
      • PubMed
      • Scopus (6)
      • Google Scholar
      ). Overall, our findings support using an active distraction intervention with unlimited playtime as an alternative to pharmacological means as an anxiolytic agent.

      Practice implications

      In our study, medicating children prior to surgery versus using active distraction resulted in no difference in anxiety. Collaboration with parents, nurses and anesthesia providers is needed to consider the best method to reduce preoperative anxiety in the preschool child. Non-pharmacological methods of distraction, such as the tablet, should be considered as an alternative to medication. In addition, the tablet resulted in a reduced length of stay, which is an important consideration for optimal efficiency in busy surgical centers.

      Strengths and limitations

      The major strength of our study was the randomized control trial design and homogenous sample of children in the preschool stage of development. Extensive training of co-investigators to maintain inter-rater reliability estimates of 0.80 for the intervention and data collection assured intervention and data fidelity.
      As this study was conducted at a single site with a predominantly White sample, findings should be generalized with caution. A major study limitation was the number of patients lost to attrition after randomization: 32% (n = 24) midazolam group and 13% (n = 8) tablet group. Most of the attrition in the midazolam group was due to parental preference (n = 21, 28%), with parents preferring the non-pharmacologic intervention. In addition, two children (3%) in the midazolam group and four children (6%) in the tablet group were excluded per anesthesia after randomization. Attrition may have resulted in a biased sample. Another study limitation is that nurses and the anesthesia team were not blinded to the intervention.
      Anecdotally, many parents expressed a preference for their children to have less medicine throughout their surgical experience. At the same time, a change in practice was noted during the study, with physicians ordering pharmacologic interventions less frequently.

      Conclusion

      The use of tablets as an anxiolytic option appears to be as effective as midazolam for pre-school aged children preoperatively. It also seems to be well received and preferred by many parents. There is potential that the use of the tablet, as compared to midazolam, may result in a shorter LOS. Future researchers should consider replicating this study with different developmental age groups.

      Funding statement

      NuRF Research Grant from Office of Nursing Research and Innovation, Cleveland Clinic.

      CRediT authorship contribution statement

      Michelle Levay: Conceptualization, Investigation, Writing – original draft, Project administration, Funding acquisition. Megan Sumser: Investigation, Writing – review & editing. Kristen Vargo: Supervision. Alina Bodas: Supervision, Resources. James F. Bena: Formal analysis. Cynthia A. Danford: Writing – review & editing. Sandra L. Siedlecki: Methodology, Validation, Writing – review & editing.

      Conflict of interest statement

      The authors have no known conflict of interest, financial or other, to disclose.

      Acknowledgments

      The authors wish to express our deepest appreciation to the following co-investigators for their dedication to the study and our patients: V. Seward, RN, CPN, J. Dingenary, RN, CPN, J. Mason, BSN, RN, CPN, E. Kampman, RN, CPN, M. Romanak, BSN, RN, CPN, T. Billingsley, MSN, RN, CPNP-AC, and A. Sammon, MS, CCLS. We would also like to acknowledge the Cleveland Clinic pediatric surgeons for graciously allowing us to enroll their patients. A special thank you goes to the Pediatric Anesthesia Staff and CRNA team including D. Markakis, MD, FAAP, Chair, Department of Pediatric Anesthesiology. Finally, we would also like to express our gratitude to the Office of Nursing Research & Innovation and Associate Chief Nursing Officer, Dr. N. Albert, PhD, CCRN, FAAN.

      References

        • Al-Yateem N.
        • Brenner M.
        • Shorrab A.A.
        • Docherty C.
        Play distraction versus pharmacological treatment to reduce anxiety levels in children undergoing day surgery: A randomized controlled non-inferiority trial.
        Child: Care, Health and Development. 2016; 42: 572-581
        https://doi.org/10.1111/cch.12343
        View in Article
        • Scopus (33)
        • PubMed
        • Crossref
        • Google Scholar
        • Aytekin A.
        • Doru Ö.
        • Kucukoglu S.
        The effects of distraction on preoperative anxiety level in children.
        Journal of Perianesthesia Nursing. 2016; 31: 56-62
        https://doi.org/10.1016/j.jopan.2014.11.016
        View in Article
        • Scopus (31)
        • PubMed
        • Abstract
        • Full Text
        • Full Text PDF
        • Google Scholar
        • Bajwa S.A.
        • Costi D.
        • Cyna A.M.
        A comparison of emergence delirium scales following general anesthesia in children.
        Pediatric Anesthesia. 2010; 20: 704-711
        https://doi.org/10.1111/j.1460-9592.2010.03328.x
        View in Article
        • Scopus (125)
        • PubMed
        • Crossref
        • Google Scholar
        • Banchs R.J.
        • Lerman J.
        Preoperative anxiety management, emergence delirium, and postoperative behavior.
        Anesthesiology Clinics. 2014; 32: 1-23
        https://doi.org/10.1016/j.anclin.2013.10.011
        View in Article
        • Scopus (74)
        • PubMed
        • Abstract
        • Full Text
        • Full Text PDF
        • Google Scholar
        • Berger J.
        • Wilson D.
        • Potts L.
        • Poliyka B.
        Wacky Wednesday: Use of distraction through humor to reduce preoperative anxiety in children and their parents.
        Journal of PeriAnesthesia Nursing. 2014; 29: 285-291
        https://doi.org/10.1016/j.jopan.2013.06.003
        View in Article
        • Scopus (16)
        • PubMed
        • Abstract
        • Full Text
        • Full Text PDF
        • Google Scholar
        • Cole J.W.
        • Murray D.J.
        • McAllister J.D.
        • Hirshberg G.E.
        Emergence behaviour in children: Defining the incidence of excitement and agitation following anaesthesia.
        Pediatric Anesthesia. 2002; 12: 442-447
        https://doi.org/10.1046/j.1460-9592.2002.00868.x
        View in Article
        • Scopus (182)
        • PubMed
        • Crossref
        • Google Scholar
        • Committee on Economics
        ASA Physical Status Classification System.
        American Society of Anesthesiologists, 2020
        https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
        View in Article
        • Google Scholar
        • Dahmani S.
        • Delivet H.
        • Hilly J.
        Emergence delirium in children: An update.
        Current Opinion in Anesthesiology. 2014; 27: 309-315
        https://doi.org/10.1097/ACO.0000000000000076
        View in Article
        • Scopus (124)
        • PubMed
        • Crossref
        • Google Scholar
        • Eckenhoff J.E.
        • Kneale D.H.
        • Dripps R.D.
        The incidence and etiology of postanesthetic excitement a clinical survey.
        The Journal of the American Society of Anesthesiologists. 1961; 22: 667-673
        https://doi.org/10.1097/00000542-196109000-00002
        View in Article
        • PubMed
        • Google Scholar
        • Ferrari L.R.
        The pediatric airway: Anatomy, challenges, and solutions.
        in: Mason K.P. Pediatric sedation outside of the operating room. Springer International Publishing, 2021: 125-139
        https://doi.org/10.1007/978-30-30-58406-1
        View in Article
        • Scopus (1)
        • Crossref
        • Google Scholar
        • Fortier M.A.
        • Kain Z.N.
        Treating perioperative anxiety and pain in children: A tailored and innovative approach.
        Pediatric Anesthesia. 2015; 25: 27-35
        https://doi.org/10.1111/pan.12546
        View in Article
        • Scopus (86)
        • PubMed
        • Crossref
        • Google Scholar
        • Getahun A.B.
        • Endalew N.S.
        • Mersha A.T.
        • Admass B.A.
        Magnitude and factors associated with preoperative anxiety among pediatric patients: Cross-sectional study.
        Pediatric Health, Medicine and Therapeutics. 2020; 11: 485
        https://doi.org/10.2147/PHMT.S288077
        View in Article
        • PubMed
        • Crossref
        • Google Scholar
        • Heikal S.
        • Stuart G.
        Anxiolytic premedication for children.
        British Journal of Anaesthesia Education. 2020; 20: 220
        https://doi.org/10.1016/j.bjae.2020.02.006
        View in Article
        • Scopus (5)
        • Google Scholar
        • Hudek K.
        Emergence delirium: A nursing perspective.
        AORN Journal. 2009; 89: 509-520
        https://doi.org/10.1016/j.aorn.2008.12.026
        View in Article
        • Scopus (31)
        • PubMed
        • Crossref
        • Google Scholar
        • Jackson B.F.
        • Beck L.A.
        • Losek J.D.
        Successful flumazenil reversal of paradoxical reaction to midazolam in a child.
        The Journal of Emergency Medicine. 2015; 48: e67-e72
        https://doi.org/10.1016/j.jemermed.2014.09.062
        View in Article
        • Scopus (12)
        • PubMed
        • Abstract
        • Full Text
        • Full Text PDF
        • Google Scholar
        • Kain Z.N.
        • Caldwell-Andrews A.A.
        • Maranets I.
        • McClain B.
        • Gaal D.
        • Mayes L.C.
        • Zhang H.
        Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors.
        Anesthesia & Analgesia. 2004; 99: 1648-1654
        https://doi.org/10.1213/01.ANE.0000136471.36680.97
        View in Article
        • Scopus (429)
        • PubMed
        • Crossref
        • Google Scholar
        • Kain Z.N.
        • Hofstadter M.B.
        • Mayes L.C.
        • Krivutza D.M.
        • Alexander G.
        • Wang S.M.
        • Reznick J.S.
        Midazolam: Effects on amnesia and anxiety in children.
        The Journal of the American Society of Anesthesiologists. 2000; 93: 676-684
        https://doi.org/10.1097/00000542-200009000-00016
        View in Article
        • Scopus (147)
        • PubMed
        • Crossref
        • Google Scholar
        • Kain Z.N.
        • Mayes L.C.
        • Bell C.
        • Weisman S.
        • Hofstadter M.B.
        • Rimar S.
        Premedication in the United States: A status report.
        Anesthesia & Analgesia. 1997; 84: 427-432
        View in Article
        • PubMed
        • Crossref
        • Google Scholar
        • Kain Z.N.
        • Mayes L.C.
        • Caldwell-Andrews A.A.
        • Karas D.E.
        • McClain B.C.
        Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery.
        Pediatrics. 2006; 118: 651-658
        https://doi.org/10.1542/peds.2005-2920
        View in Article
        • Scopus (456)
        • PubMed
        • Crossref
        • Google Scholar
        • Kain Z.N.
        • Mayes L.C.
        • Cicchetti D.V.
        • Bagnall A.L.
        • Finley J.D.
        • Hofstadter M.B.
        The Yale preoperative anxiety scale: How does it compare with a “gold standard”?.
        Anesthesia & Analgesia. 1997; 85: 783-788
        View in Article
        • PubMed
        • Crossref
        • Google Scholar
        • Kain Z.N.
        • Mayes L.C.
        • O’Connor T.Z.
        • Cicchetti D.V.
        Preoperative anxiety in children: Predictors and outcomes.
        Archives of Pediatrics & Adolescent Medicine. 1996; 150: 1238-1245
        https://doi.org/10.1001/archpedi.1996.02170370016002
        View in Article
        • Scopus (516)
        • PubMed
        • Crossref
        • Google Scholar
        • Kain Z.N.
        • Mayes L.C.
        • Wang S.M.
        • Caramico L.A.
        • Hofstadter M.B.
        Parental presence during induction of anesthesia versus sedative premedication: Which intervention is more effective?.
        The Journal of the American Society of Anesthesiologists. 1998; 89: 1147-1156
        https://doi.org/10.1097/00000542-199811000-00015
        View in Article
        • Scopus (276)
        • PubMed
        • Crossref
        • Google Scholar
        • Kain Z.N.
        • Mayes L.C.
        • Wang S.M.
        • Hofstadter M.B.
        Postoperative behavioral outcomes in children: Effects of sedative premedication.
        The Journal of the American Society of Anesthesiologists. 1999; 90: 758-765
        https://doi.org/10.1097/00000542-199903000-00018
        View in Article
        • Scopus (186)
        • PubMed
        • Crossref
        • Google Scholar
        • Kerimoglu B.
        • Neuman A.
        • Paul J.
        • Stefanov D.G.
        • Twersky R.
        Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.
        Anesthesia & Analgesia. 2013; 117: 1373-1379
        https://doi.org/10.1213/ANE.0b013e3182a8c18f
        View in Article
        • Scopus (64)
        • PubMed
        • Crossref
        • Google Scholar
        • Kerson A.G.
        • DeMaria R.
        • Mauer E.
        • Joyce C.
        • Gerber L.M.
        • Greenwald B.M.
        • Traube C.
        Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children.
        Journal of Intensive Care. 2016; 4: 1-6
        https://doi.org/10.1186/s40560-016-0189-5
        View in Article
        • Scopus (62)
        • PubMed
        • Crossref
        • Google Scholar
        • Kim J.
        • Chiesa N.
        • Raazi M.
        • Wright K.D.
        A systematic review of technology-based preoperative preparation interventions for child and parent anxiety.
        Canadian Journal of Anesthesia. 2019; 66: 966-986
        https://doi.org/10.1007/s12630-019-01387-8
        View in Article
        • Scopus (28)
        • PubMed
        • Crossref
        • Google Scholar
        • Kühlmann A.Y.
        • Lahdo N.
        • Staals L.M.
        • Van Dijk M.
        What are the validity and reliability of the modified Yale preoperative anxiety scale-Short form in children less than 2 years old?.
        Pediatric Anesthesia. 2019; 29: 137-143
        https://doi.org/10.1111/pan.13536
        View in Article
        • Scopus (7)
        • PubMed
        • Crossref
        • Google Scholar
        • Kyle T.
        • Carman S.
        Growth and development of the preschooler.
        in: Essentials of pediatric nursing. 4th ed. Wolters Kluwer, 2021: 119-137 (ISBN 978-1-9751-3984-1)
        View in Article
        • Google Scholar
        • Lee J.H.
        • Jung H.K.
        • Lee G.G.
        • Kim H.Y.
        • Park S.G.
        • Woo S.C.
        Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients.
        Korean Journal of Anesthesiology. 2013; 65: 508
        https://doi.org/10.4097/kjae.2013.65.6.508
        View in Article
        • Scopus (46)
        • PubMed
        • Crossref
        • Google Scholar
        • Lepouse C.
        • Lautner C.A.
        • Liu L.
        • Gomis P.
        • Leon A.
        Emergence delirium in adults in the post-anaesthesia care unit.
        British Journal of Anaesthesia. 2006; 96: 747-753
        https://doi.org/10.1093/bja/ael094
        View in Article
        • Scopus (229)
        • PubMed
        • Abstract
        • Full Text
        • Full Text PDF
        • Google Scholar
        • Marechal C.
        • Berthiller J.
        • Tosetti S.
        • Cogniat B.
        • Desombres H.
        • Bouvet L.
        • Kassai B.
        • Chassard D.
        • de Queiroz Siqueira M.
        Children and parental anxiolysis in paediatric ambulatory surgery: A randomized controlled study comparing 0.3 mg kg− 1 midazolam to tablet computer based interactive distraction.
        British Journal of Anaesthesia. 2017; 118: 247-253
        https://doi.org/10.1093/bja/aew436
        View in Article
        • Scopus (25)
        • PubMed
        • Abstract
        • Full Text
        • Full Text PDF
        • Google Scholar
        • Mason K.P.
        Paediatric emergence delirium: A comprehensive review and interpretation of the literature.
        British Journal of Anaesthesia. 2017; 118: 335-343
        https://doi.org/10.1093/bja/aew477
        View in Article
        • Scopus (102)
        • PubMed
        • Abstract
        • Full Text
        • Full Text PDF
        • Google Scholar
        • McGraw T.
        Preparing children for the operating room: Psychological issues.
        Canadian Journal of Anaesthesia. 1994; 41: 1094-1103
        View in Article
        • Scopus (73)
        • PubMed
        • Crossref
        • Google Scholar
        • Parnis S.J.
        • Foate J.A.
        • Van der Walt J.H.
        • Short T.
        • Crowe C.E.
        Oral midazolam is an effective premedication for children having day-stay anaesthesia.
        Anaesthesia and Intensive Care. 1992; 20 (https://doi.org/10.1177%2F0310057X9202000102): 9-14
        View in Article
        • PubMed
        • Crossref
        • Google Scholar
        • Patel A.
        • Schieble T.
        • Davidson M.
        • Tran M.C.
        • Schoenberg C.
        • Delphin E.
        • Bennett H.
        Distraction with a hand-held video game reduces pediatric preoperative anxiety.
        Pediatric Anesthesia. 2006; 16: 1019-1027
        https://doi.org/10.1111/j.1460-9592.2006.01914.x
        View in Article
        • Scopus (195)
        • PubMed
        • Crossref
        • Google Scholar
        • Ringblom J.
        • Wåhlin I.
        • Proczkowska M.
        A psychometric evaluation of the pediatric anesthesia emergence delirium scale.
        Pediatric Anesthesia. 2018; 28: 332-337
        https://doi.org/10.1111/pan.13348
        View in Article
        • Scopus (23)
        • PubMed
        • Crossref
        • Google Scholar
        • Salman S.
        • Tang E.K.Y.
        • Cheung L.C.
        • Nguyen M.N.
        • Sommerfield D.
        • Slevin L.
        • Von Ungern Sternberg B.S.
        A novel, palatable paediatric oral formulation of midazolam: Pharmacokinetics, tolerability, efficacy and safety.
        Anaesthesia. 2018; 73: 1469-1477
        https://doi.org/10.1111/anae.14318
        View in Article
        • Scopus (14)
        • PubMed
        • Crossref
        • Google Scholar
        • Seiden S.C.
        • McMullan S.
        • Sequera-Ramos L.
        • De Oliveira Jr G.S.
        • Roth A.
        • Rosenblatt A.
        • Suresh S.
        Tablet-based interactive distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: A noninferiority randomized trial.
        Pediatric Anesthesia. 2014; 24: 1217-1223
        https://doi.org/10.1111/pan.12475
        View in Article
        • Scopus (44)
        • PubMed
        • Crossref
        • Google Scholar
        • Sikich N.
        • Lerman J.
        Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale.
        The Journal of the American Society of Anesthesiologists. 2004; 100: 1138-1145
        https://doi.org/10.1097/00000542-200405000-00015
        View in Article
        • Scopus (507)
        • PubMed
        • Crossref
        • Google Scholar
        • Sola C.
        • Lefauconnier A.
        • Bringuier S.
        • Raux O.
        • Capdevila X.
        • Dadure C.
        Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
        Pediatric Anesthesia. 2017; 27: 827-834
        https://doi.org/10.1111/pan.13180
        View in Article
        • Scopus (27)
        • PubMed
        • Crossref
        • Google Scholar
        • Stewart B.
        • Cazzell M.A.
        • Pearcy T.
        Single-blinded randomized controlled study on use of interactive distraction versus oral midazolam to reduce pediatric preoperative anxiety, emergence delirium, and postanesthesia length of stay.
        Journal of Perianesthesia Nursing. 2019; 34: 567-575
        https://doi.org/10.1016/j.jopan.2018.08.004
        View in Article
        • Scopus (11)
        • PubMed
        • Abstract
        • Full Text
        • Full Text PDF
        • Google Scholar
        • Taketomo C.
        • Hodding J.
        • Kraus D.
        Lexicomp pediatric & neonatal dosage handbook: An extensive resource for clinicians treating pediatric and neonatal patients.
        26th ed. Wolters Kluwer Health, 2019 (ISBN 978-1-59195-380-7)
        View in Article
        • Google Scholar
        • Uyar B.S.
        • Polat R.
        • Bolat M.
        • Donmez A.
        Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomized trial.
        European Journal of Anaesthesiology. 2021; 38: 744-750
        https://doi.org/10.1097/EJA.0000000000001384
        View in Article
        • Scopus (6)
        • PubMed
        • Crossref
        • Google Scholar
        • Voepel-Lewis T.
        • Malviya S.
        • Tait A.R.
        A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit.
        Anesthesia & Analgesia. 2003; 96: 1625-1630
        https://doi.org/10.1213/01.ANE.0000062522.21048.61
        View in Article
        • Scopus (346)
        • PubMed
        • Crossref
        • Google Scholar

      Article info

      Publication history

      Published online: October 31, 2022
      Accepted: September 23, 2022
      Received in revised form: September 15, 2022
      Received: May 9, 2022

      Identification

      DOI: https://doi.org/10.1016/j.pedn.2022.09.021

      Copyright

      © 2022 Elsevier Inc. All rights reserved.

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