Parental Presence and a Sedative Premedicant for Children Undergoing Surgery: A Hierarchical Study

ZEEV N. KAIN, LINDA C. MAYES, SHU-MING WANG, LISA A. CARAMICO, DAWN M. KRIVUTZA AND MAURA B. HOFSTADTER Departments of Anesthesiology, Pediatrics, and Child Psychology, Yale University School of Medicine, New Haven, Connecticut Anesthesiology, 92: 939–946, 2000 Some anesthesiologists use both sedative premedication and parental presence during induction of anesthesia (PPIA) to treat anxiety in children undergoing surgery and general anesthesia. Although recent studies indicate that PPIA alone is not an effective intervention, it may further reduce anxiety when combined with oral midazolam. This study sought to determine whether the combination of parental presence and sedative premedication is more effective than sedation alone in reducing anxiety in children and increasing parental satisfaction. A group of 103 children aged 2 to 8 yr took part in the study. All were scheduled for elective, outpatient surgery, and none had a history of chronic illness. Children randomized to sedative premedication alone received oral midazolam syrup (0.5 mg/kg) at least 20 min before surgery. In addition to premedication, the remaining children had a parent present throughout the anesthesia induction process. The effects of these interventions on children and parents were evaluated using standardized measures of anxiety and satisfaction. The two intervention groups were similar in children’s age and gender, distribution of surgical procedures, and parental trait anxiety. All children showed increasing anxiety from time in the holding area to introduction of the anesthesia mask, but the intervention groups did not differ in level of observed anxiety. Parents who accompanied their children into the operating room, however, were significantly less anxious after separation than those who did not accompany their children. Results of a questionnaire completed 2 wk after surgery revealed parental satisfaction with overall care to be significantly higher in the sedative plus PPIA group than in the sedative alone group. Children who received sedative premedication before surgery did not have their anxiety reduced by the addition of parental presence during induction of anesthesia. But PPIA did reduce parental anxiety and increase parental satisfaction with the overall hospital experience. Comment: The effect of the presence of parents during induction of anesthesia in their children remains an issue of almost religious fervor to some, as is pointed out in an editorial accompanying this article. As with most issues of dogmatic belief, the reasons behind this agitated discussion remain unclear to me. Nevertheless, let’s discuss this article. This study compared the anxiolytic value (to both children and parents) of oral midazolam premedication (0.5 mg/kg, a routine dose) vs. midazolam premedication plus parental presence during induction of anesthesia. In a change from the general view of previous studies, the authors emphasize the effects on patient (including parental) satisfaction rather than just effects on morbidity. It is truly a kinder and gentler world in which we live. Patients and parents were given a variety of psychometric instruments that this group at Yale has previously reported upon and validated. Patient and parental anxiety and satisfaction were rated at a variety of perioperative times. Here are the main findings. If children have been premedicated, parental presence neither improved children’s anxiety nor offered additional improvement in children’s compliance during induction. This is probably not completely surprising to those of us who delight in the cooperative behavior of children after they are given oral midazolam. Parents in the parental presence group, however, were less anxious after separation and more satisfied with the separation process, the operating room, and the hospital. This article is the latest in a series from these authors and others that have shown that parental presence, although appreciated by parents, offers no advantage to the children. Two previous studies by this same Yale group have reported that there were no differences in parental anxiety whether they were or were not present during induction. As such, the current study is at variance, and may be related to the use of routine premedication in the current study. At least that is what is suggested as a hypothesis by the authors. In fact, however, it would seem that the results should be opposite. If parents see their children well sedated on separation one would expect them overall to have lower anxiety, and therefore one wouldn’t expect as pronounced a difference with parents who are present at induction. Parental presence at induction is to some extent a local sociocultural phenomenon. Some parents may not wish to be present, but feel it is somehow required if offered. Others may insist on it if they know it is a local option. Outcome data from parental presence clearly need to identify whether routine premedication is used. If it is used, then parental presence is useful only for parent, not for patient or physician. If sedation is not routinely used, then, based on my practice, I feel strongly (but not to the point of religious fervor, mind you) that parental presence is very useful, particularly for young children above the age of stranger anxiety (approximately 10 months of age). Certainly, the availability of induction rooms immediately adjacent to the operating rooms makes this a much simpler practice. I had never used these before I came to my current hospital and would never give them up. Victor C. Baum M.D.