Effectiveness of two distraction strategies in reducing preoperative anxiety in children in China: A randomized controlled trial

Published:November 16, 2022DOI:


      • Effective interventions to reduce pre-operative anxiety in children is an urgent need.
      • The effect of two distraction strategies (music or animation) on preoperative anxietyin children is unknown.
      • The music or animation strategies can significantly reduce preoperative anxiety of children.
      • Both strategies are easy to operate in clinical practice.
      • Animation intervention was welcomed by most children.



      Music and animation are the most common and affordable distraction strategies to reduce preoperative anxiety in children; however, their effects are inconsistent. This study aimed to examine the effectiveness of two distraction strategies (music or animation) in reducing preoperative anxiety in children.

      Design and methods

      In this randomized controlled trial, 183 children who underwent surgery were divided into music, animation, and control groups using a single-blind block randomized design. Children in the control group underwent routine preoperative visits. Meanwhile, the children in the intervention groups could choose their favorite music and cartoons as intervention content. Study outcomes included anxiety levels, degree of cooperation, heart rate, and blood pressure. Data were collected before entering the operating room, entering the operating room, and before the induction of anesthesia; only the degree of cooperation was collected before the induction of anesthesia.


      Only animation significantly reduced preoperative anxiety in the children (P < 0.05) upon entering the operating room. Both music and animation reduced the level of preoperative anxiety before induction of anesthesia; however, there was no significant difference between them (P > 0.05). The induction compliance score was significantly lower in the music and animation groups than in the control group (P < 0.05). Heart rates differed significantly between the three groups from before entering the operating room to before induction of anesthesia. Children in the control group had the highest systolic blood pressure upon entering the operating room (P < 0.05).


      Music and animation strategies can significantly reduce preoperative anxiety in children and improve surgical cooperation during anesthesia induction.
      Trial Registration: NCT05285995.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


        • Abbas M.
        • Liard A.
        • Elbaz F.
        • Bachy B.
        Outcome of surgical management of concealed penis.
        Journal of Pediatric Urology. 2007; 3: 490-494
        • Atak M.
        • Ozyazicioglu N.
        The effect of different audio distraction methods on Children’s postoperative pain and anxiety.
        Journal of Perianesthesia Nursing. 2021; 36: 75-80
        • Aydin T.
        • Sahin L.
        • Algin C.
        • Kabay S.
        • Yucel M.
        • Hacioglu A.
        • Kilicoglu A.
        Do not mask the mask: Use it as a premedicant.
        Paediatric Anaesthesia. 2008; 18: 107-112
        • Aytekin A.
        • Doru O.
        • Kucukoglu S.
        The effects of distraction on preoperative anxiety level in children.
        Journal of Perianesthesia Nursing. 2016; 31: 56-62
        • Beizaee Y.
        • Rejeh N.
        • Heravi-Karimooi M.
        • Tadrisi S.D.
        • Griffiths P.
        • Vaismoradi M.
        The effect of guided imagery on anxiety, depression and vital signs in patients on hemodialysis.
        Complementary Therapies in Clinical Practice. 2018; 33: 184-190
        • Bozkurt P.
        Premedication of the pediatric patient - anesthesia for the uncooperative child.
        Current Opinion in Anaesthesiology. 2007; 20: 211-215
        • Bradt J.
        • Dileo C.
        • Shim M.
        Music interventions for preoperative anxiety.
        Cochrane Database of Systematic Reviews. 2013; 6: D6908
        • Brans K.
        • Koval P.
        • Verduyn P.
        • Lim Y.L.
        • Kuppens P.
        The regulation of negative and positive affect in daily life.
        Emotion. 2013; 13: 926-939
        • Chow C.H.
        • Van Lieshout R.J.
        • Schmidt L.A.
        • Dobson K.G.
        • Buckley N.
        Systematic review: Audiovisual interventions for reducing preoperative anxiety in children undergoing elective surgery.
        Journal of Pediatric Psychology. 2016; 41: 182-203
        • Dai Y.
        • Zheng X.L.
        • Shu L.L.
        • Zheng Q.Y.
        • Xu X.L.
        • Ouyang R.X.
        Study on translation of the modified Yale preoperative anxiety scale – Short form and its reliability and validity.
        Nursing Research. 2019; 33 (In Chinese): 2596-2599
        • Deng K.X.
        Effect of funny nursing on anesthesia induction cooperation for preschool children.
        The Journal of Nursing. 2016; 31 ([In Chinese]): 56-58
        • Ding M.S.
        • Yu X.Y.
        • Wang D.D.
        The effectiveness of diversified interventions on preoperative anxiety in preschool children.
        Chinese Nursing Education. 2015; 12 (In Chinese): 619-622
        • Dinleyici M.
        • Carman K.B.
        • Ozturk E.
        • Sahin-Dagli F.
        Media use by children, and Parents’ views on Children’s media usage.
        Interactive Journal of Medical Research. 2016; 5e18
        • Dwairej D.A.
        • Obeidat H.M.
        • Aloweidi A.S.
        Video game distraction and anesthesia mask practice reduce children’s preoperative anxiety: A randomized clinical trial.
        Journal for Specialists in Pediatric Nursing. 2020; 25e12272
        • Eijlers R.
        • Dierckx B.
        • Staals L.M.
        • Berghmans J.M.
        • van der Schroeff M.P.
        • Strabbing E.M.
        • Utens E.M.W.J.
        Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial.
        European Journal of Anaesthesiology. 2019; 36: 728-737
        • Gao X.L.
        • Liu Y.
        • Tian S.
        • Zhang D.Q.
        • Wu Q.P.
        Effect of interested play on reducing children’s preoperative anxiety.
        Chinese Journal of Nursing. 2013; 48 (In Chinese): 27-29
        • van der Heijden M.J.
        • Oliai A.S.
        • van Dijk M.
        • Jeekel J.
        • Hunink M.G.
        The effects of perioperative music interventions in pediatric surgery: A systematic review and Meta-analysis of randomized controlled trials.
        PLoS One. 2015; 10e133608
        • Jallo N.
        • Ruiz R.J.
        • Elswick R.J.
        • French E.
        Guided imagery for stress and symptom management in pregnant african american women.
        Evidence-based Complementary and Alternative Medicine. 2014; 2014: 840923
        • Jenkins B.N.
        • Fortier M.A.
        • Kaplan S.H.
        • Mayes L.C.
        • Kain Z.N.
        Development of a short version of the modified Yale preoperative anxiety scale.
        Anesthesia and Analgesia. 2014; 119: 643-650
        • 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 and Analgesia. 2004; 99: 1648-1654
        • Kain Z.N.
        • MacLaren J.
        • McClain B.C.
        • Saadat H.
        • Wang S.M.
        • Mayes L.C.
        • Anderson G.M.
        Effects of age and emotionality on the effectiveness of midazolam administered preoperatively to children.
        Anesthesiology. 2007; 107: 545-552
        • 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 and Analgesia. 1997; 85: 783-788
        • Kain Z.N.
        • Mayes L.C.
        • Cicchetti D.V.
        • Caramico L.A.
        • Rimar S.
        Measurement tool for preoperative anxiety in young children: The Yale preoperative anxiety scale.
        Child Neuropsychology. 1995; 1: 203-210
        • 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?.
        Anesthesiology. 1998; 89 (9A-10A): 1147-1156
        • Karakul A.
        • Bolışık Z.B.
        The effect of music listened to during recovery period after day surgery on anxiety state and vital signs of child and adolescent.
        The Journal of Pediatric Researc. 2018; 5
        • Kuhlmann A.
        • van Rosmalen J.
        • Staals L.M.
        • Keyzer-Dekker C.
        • Dogger J.
        • de Leeuw T.G.
        • van Dijk M.
        Music interventions in pediatric surgery (the music under surgery in children study): A randomized clinical trial.
        Anesthesia and Analgesia. 2020; 130: 991-1001
        • Kumar A.
        • Das S.
        • Chauhan S.
        • Kiran U.
        • Satapathy S.
        Perioperative anxiety and stress in children undergoing congenital cardiac surgery and their parents: Effect of brief intervention-a randomized control trial.
        Journal of Cardiothoracic and Vascular Anesthesia. 2019; 33: 1244-1250
        • Li Z.Q.
        • Xu Q.
        • Zhou T.
        • Wang L.
        Effect of music on induction of anesthesia on parental presence.
        Journal of Huazhong University of Science and Technology (Medical Edition). 2011; 40 (In Chinese): 750-752
        • Meletti D.P.
        • Meletti J.
        • Camargo R.
        • Silva L.M.
        • Mdolo N.
        Psychological preparation reduces preoperative anxiety in children. Randomized and double-blind trial.
        Jornal de Pediatria. 2019; 95: 545-551
        • Millett C.R.
        • Gooding L.F.
        Comparing active and passive distraction-based music therapy interventions on preoperative anxiety in pediatric patients and their caregivers.
        Journal of Music Therapy. 2018; 54: 460-478
        • Mitchell R.B.
        • Archer S.M.
        • Ishman S.L.
        • Rosenfeld R.M.
        • Coles S.
        • Finestone S.A.
        • Nnacheta L.C.
        Clinical practice guideline: Tonsillectomy in children (update)-executive summary.
        Otolaryngology and Head and Neck Surgery. 2019; 160: 187-205
        • Moseley S.L.
        • Heine C.
        • Valente T.
        • Stone D.
        • Levy D.A.
        • Downs J.B.
        • Clemmens C.
        Effects of parental presence during induction of anesthesia on operative and perioperative times in pediatric patients undergoing adenotonsillectomy.
        International Journal of Pediatric Otorhinolaryngology. 2021; 140110515
        • Sadhasivam S.
        • Cohen L.L.
        • Szabova A.
        • Varughese A.
        • Kurth C.D.
        • Willging P.
        • Gunter J.
        Real-time assessment of perioperative behaviors and prediction of perioperative outcomes.
        Anesthesia and Analgesia. 2009; 108: 822-826
        • Santiago A.E.
        • Issy A.M.
        • Sakata R.K.
        Effects of preoperative intravenous clonidine in patients undergoing cataract surgery: A double-blind, randomized trial.
        Journal of Ophthalmology. 2014; 2014: 346549
        • Schneemilch C.E.
        • Bachmann H.
        • Ulrich A.
        • Elwert R.
        • Halloul Z.
        • Hachenberg T.
        Clonidine decreases stress response in patients undergoing carotid endarterectomy under regional anesthesia: A prospective, randomized, double-blinded, placebo-controlled study.
        Anesthesia and Analgesia. 2006; 103: 297-302
        • Schulz K.F.
        • Altman D.G.
        • Moher D.
        CONSORT 2010 statement: Updated guidelines for reporting parallel group randomized trials.
        BMC Medicine. 2010; 8: 18
        • Takenaka S.
        • Hirose M.
        Preoperative anxiety and intraoperative nociception in patients undergoing thoracic surgery.
        The Journal of Surgical Research. 2020; 249: 13-17
        • Vagnoli L.
        • Bettini A.
        • Amore E.
        • De Masi S.
        • Messeri A.
        Relaxation-guided imagery reduces perioperative anxiety and pain in children: A randomized study.
        European Journal of Pediatrics. 2019; 178: 913-921
        • Wang W.J.
        • Zhou Y.Q.
        • He S.B.
        • Yang Q.S.
        • Yang Y.C.
        Application of specialized game intervention in perioperative nursing for preschool children patients in ophthalmology.
        Chinese Journal of Nursing. 2018; 53 (In Chinese): 1429-1433
        • Zutter A.
        • Frei F.J.
        Uncooperative children during induction of anesthesia: Theory and practice.
        Anaesthesist. 2011; 60: 743-750