Many children undergoing surgery experience substantial anxiety in the preoperative holding area and the operating room (OR) before induction of anesthesia. In fact, approximately 50% of children experience anxiety regarding an impending surgical experience.1–3 Preoperative anxiety may be caused by separation from parents, unfamiliar environments and people, and negative anticipation of surgical procedures. Children’s preoperative anxiety has been observed to manifest in different ways, with many children appearing fearful and agitated, breathing deeply, shivering, crying, and stopping talking or playing. Children may protest, fight, or try to escape, which may be emotionally traumatic for the child and parents. Intense preoperative anxiety has been associated with difficulty in anesthetic induction and the development of postoperative agitation and negative behaviors.4–6 Common postoperative behavioral changes include separation anxiety, nightmares, aggression toward authority, and nocturnal enuresis.3,4 Kain et al.2 showed that 67% of children had behavior changes the day after surgery, and this persisted for 6 months in 20% and for 1 year in 7% of the children.
To reduce the incidence of preoperative anxiety in children, anesthesiologists have used a number of prevention strategies, including sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, hypnosis, and acupuncture.7 Some of these interventions are used fairly frequently, whereas others are used less frequently because of undesirable side effects, time constraints, or increased health care costs. Although premedication with oral midazolam is often used to alleviate childhood anxiety, its use has been associated with side effects.8–10
Preschool children generally enjoy watching animated cartoons, and they can become sufficiently engrossed to become oblivious to their surroundings and disregard verbal and tactile stimuli. Children may also be comforted by familiar toys. Therefore, viewing an animated cartoon or playing with a favorite toy seems likely to alleviate preoperative anxiety in children. There are no controlled trials that have investigated the effects of viewing animated cartoons on preoperative anxiety in children. This study was performed to determine the beneficial effects of viewing an animated cartoon or playing with a favorite toy on preoperative anxiety in children aged 3 to 7 years in the OR before anesthesia induction.
This prospective, randomized trial examined the effects of 2 behavioral interventions on preoperative anxiety in children undergoing general anesthesia for elective surgery. The study was approved by the IRB of Chonbuk National University Hospital in South Korea. Written informed parental consent was obtained for all participants.
One hundred and thirty children, aged 3 to 7 years, ASA physical status I or II, were enrolled. Children having emergency surgery and those with previous anesthetic experience, developmental delays, mental retardation, or chronic illnesses were excluded from the study. Subjects were randomly assigned by computer-generated random number to 1 of 3 groups: group 1 (control), group 2 (toy), and group 3 (animated cartoon).
Patients were admitted the evening before surgery. The research team anesthesiologist visited the pediatric ward to conduct preoperative interviews and measure baseline anxiety scores. The patients were allocated to 1 of 3 groups before preoperative assessment of baseline anxiety. Demographic data were collected from the parents and the medical charts. The children in group 2 were asked to bring their favorite toy with them to the preoperative holding room.
Children’s preoperative anxiety was determined by the modified Yale Preoperative Anxiety Scale (mYPAS) and the parent-recorded anxiety Visual Analog Scale (VAS). The mYPAS contains 22 items in 5 categories qualifying anxiety in young children: activity, emotional expressivity, state of arousal, vocalization, and use of parents. This observational measurement has shown good-to-excellent inter- and intraobserver reliabilities and validity for measuring children’s anxiety in the preoperative holding area, upon entrance to the OR, and during induction of anesthesia in children aged 2 to 12 years. The score range is 23.3 to 100, with a score of ltequ30 indicating that the subject does not have anxiety; a score mt30 indicates that the subject does have anxiety.11 The parent-recorded anxiety VAS measures children’s anxiety assessed by the accompanying parents using a 10-cm scale. In the current study, the mYPAS and parent-recorded anxiety VAS scores were used to measure the children’s anxiety levels the night before surgery, when they were in the preanesthetic holding room, and just before anesthesia induction.
All operations were performed in morning sessions. A 24-gauge catheter was inserted into a peripheral vein the night before surgery or the morning of surgery after EMLA (Eutectic Mixture of Local Anesthetics) cream application, and the time was recorded. When the children were transported from the pediatric ward to the preanesthetic holding room, the children in group 2 brought their favorite toys and were allowed to play with them until anesthesia induction. After the second measurement of anxiety scores, in the preanesthetic holding room, the children in group 3 chose 1 from a selection of 10 movies. The preselected 10 movies were 4 action movies (Beyblade®, Power Ranger®, Power Ranger Jungle Force®, and Robocar Poli®), 4 comics (Chiro®, Crayon Shin-chan®, Doraemon®, and Pororo®), 1 science fiction (Keroro®), and Cinderella. The children in group 3 watched their selected movie using a notebook or tablet personal computers (PCs) until anesthesia induction. When the children fell asleep after administration of IV anesthetics, the movie was stopped. When the patients were transported from the preanesthetic holding room to the OR, they were accompanied by their parent and a research team member. When they entered the OR, the parent was dressed in scrubs, hat, and mask. After monitor placement of electrocardiogram and pulse oximetry, the final mYPAS and parent-recorded anxiety VAS measurements were taken just before anesthesia induction. The mYPAS scores were measured by 1 anesthesiologist to exclude interrater bias.
Standard anesthetic regimens and techniques were used for all patients. IV anesthetic induction was performed using 4 to 6 mg/kg thiopental or 1 to 2 mg/kg ketamine, and patient arterial blood pressure was noninvasively monitored with an anesthesia workstation (Zeus®; Dräger Medical, Lübeck, Germany). For facilitation of tracheal intubation, the patients received 0.6 mg/kg rocuronium. After tracheal intubation, temperature was monitored at the nasopharynx or rectum. Anesthesia was maintained with 50% nitrous oxide in oxygen and 1.5% to 3.0% sevoflurane. Fresh gas flow rate was maintained at 3 L/min during the operation. End-tidal carbon dioxide partial pressure was maintained at 30 to 35 mm Hg. Arterial blood pressure and heart rate were kept within 20% of preanesthetic values. At the end of surgery, sevoflurane and nitrous oxide administration was discontinued, and the patients received pyridostigmine and glycopyrrolate for reversal of neuromuscular blockade. At skin closure, patients received 1 mg/kg ketorolac or 1 µg/kg fentanyl for postoperative pain control.
Sample Size Determination and Statistical Analysis
A pilot study of 18 children in the OR had mean (SD) mYPAS scores of 62 (18), 49 (23), and 30 (12) in group 1, 2, and 3, respectively. We considered a clinically significant decrease in mYPAS score to be ≥15 points. It was ascertained that 35 patients were required in each group to show a difference in mean mYPAS scores of 15 for an expected standard deviation of 20 with a significance level of 0.05 (α = 0.05) and a power of 80% (β = 0.20). Sample size was calculated by 1-way analysis of variance (ANOVA) using SigmaStat 3.5 (Systat Software Inc., San Jose, CA). To allow for attrition, sample size was enlarged to 130.
Data are presented as mean ± SD or median and interquartile range. Patient characteristics and anxiety scores among groups were analyzed using 1-way ANOVA followed by the Tukey test for multiple comparisons for variables that were normally distributed or the Kruskal-Wallis test followed by Dunn’s method for variables that had nonparametric data or were not normally distributed. Anxiety scores within groups were analyzed using repeat-measures ANOVA followed by the Holm-Sidak test for multiple comparisons. A P value <0.05 was regarded as significant.
Of the 130 enrolled children, 4 children in group 2 were excluded for data analysis because they did not bring a toy. The number of patients with analyzed anxiety scores was 44 in group 1, 40 in group 2, and 42 in group 3. The 3 study groups were comparable with respect to demographic data, ASA physical status, fasting time, times from peripheral IV catheter placement to anesthesia induction, a guardian who accompanied the child to the OR, and type of surgery (Table 1). The most common surgical procedure in all groups was tonsillectomy. Other common procedures were herniorrhaphy and eye surgery. The mother was the most likely parent to accompany the child into the OR. The toys brought by children in group 2 were dolls, robots, mobile phones, and portable video games (VGs), in order of decreasing frequency. In group 3, the selected animated cartoons by children and the number of patients who selected the cartoon were Power Ranger (15 children), Pororo (10 children), Doraemon (5 children), and Keroro (5 children), Chiro (3 children), Cinderella (2 children), Power Ranger Jungle Force (1 child), and Robocar Poli (1 child).
There were no significant differences among the 3 groups in the initial mYPAS and parent-recorded VAS scores on the pediatric ward. In the preanesthetic holding room, in group 2, the mYPAS and parent-recorded VAS scores were significantly lower than in groups 1 and 3. In the OR, the children in group 3 had the lowest mYPAS and parent-recorded VAS scores among the 3 groups, and group 2 had the next lowest scores (Table 2). In the OR, the mYPAS scores of only 3 children in group 3 were increased compared with the preanesthetic holding room, whereas 32 children in group 1 and 25 children in group 2 had increased anxiety scores (P < 0.001). Similarly, for the parent-recorded anxiety VAS, 34 children in group 1 and 32 children in group 2 had increased anxiety scores in the OR compared with the preanesthetic holding room, whereas only 5 children in group 3 demonstrated an increase (P < 0.001) (Fig. 1). The number of children whose scores indicated no anxiety (mYPAS score <30) in the OR was 3 (7%), 9 (23%), and 18 (43%) in groups 1, 2, and 3, respectively. Within groups in the OR, there was no significant difference in mYPAS scores of children who were accompanied by their mothers compared with their fathers. The mYPAS and parent-recorded VAS scores within-patient changes from the preanesthetic holding room to the OR were also significantly lower in group 3 than in groups 1 and 2 (Fig. 2). There were significant correlations between mYPAS and parent-recorded VAS scores in all groups in the OR (group 1: r = 0.670, P < 0.001; group 2: r = 0.760, P < 0.001; group 3: r = 0.634, P < 0.001; overall: r = 0.789, P < 0.001).
The principal finding of this investigation is that the children who watched animated cartoons in the OR had significantly lower anxiety scores (mYPAS and parent-recorded VAS) than the children in the control and toy groups. Furthermore, mYPAS and parent-recorded VAS scores of the majority of group 3 (animated cartoon) children were decreased or unchanged in the OR compared with the preanesthetic holding room, whereas the scores of most children in group 1 (control) and group 2 (toy) were significantly increased. This is the first study to show that viewing animated cartoons can prevent or alleviate preoperative anxiety in 3- to 7-year-old children.
Most preschool- and elementary school-aged children very much enjoy watching animated cartoons. Many animated cartoons are in the public domain, so popular cartoons can be downloaded without cost in many countries. In this study, we downloaded 10 popular animated cartoons in South Korea for free or with low cost and played them for the children on PCs. Therefore, the intervention of viewing animated cartoons to reduce preoperative anxiety can be used without increasing health care costs. Most mobile devices can be used to play animated cartoons, including notebook and tablet PCs, portable multimedia players (PMPs), digital camcorders, and mobile phones. PMPs are less expensive and more convenient for this purpose than notebook or tablet PCs. Although display screens of smart phones are small, they are very convenient for viewing cartoons. Many anesthesiologists in our hospital use their smart phone or a PMP to show an animated cartoon for alleviating anxiety of pediatric patients. When the children watched an animated cartoon in the OR, they usually became engrossed in the cartoon, oblivious to the unfamiliar people and OR environment. Therefore, we suggest that viewing animated cartoons is a very simple and effective intervention to reduce preoperative anxiety in children.
A number of other preoperative preparation programs have been examined for their ability to prevent or alleviate anxiety, including sedative premedication, hypnosis, parental presence, behavioral preparation programs, music therapy, and acupuncture. Some of these programs are used frequently for pediatric surgical patients (i.e., midazolam, parental presence, and behavioral preparation programs), and others are used less frequently (i.e., acupuncture, hypnosis, and interactive music therapy).7 Although pharmacologic intervention with a sedative (i.e., midazolam) is an effective method to alleviate children’s anxiety, it has been associated with delays in hospital discharge8,12 and maladaptive behavioral changes.9,10,13 Additionally, the administration of oral premedication to children is not easy because of their reluctance or refusal. However, viewing animated cartoons has no side effects, and it is easy to administer. One of the frequently used interventions to treat preoperative anxiety is parental presence. Although the effects of parental presence on preoperative anxiety are controversial, many pediatric anesthesiologists believe that parental presence alleviates children’s preoperative anxiety in the OR. Kain et al.14 reported that there was an increasing trend toward allowing parental presence from 1995 to 2002. Because this practice is routine in our hospital, all children in this study were accompanied by their parent during anesthesia induction.
Patel et al.15 found that children aged 4 to 12 years who played with a handheld VG had less anxiety at induction of anesthesia than children who had only their parents present. Children can play with VG consoles anywhere, and children may be as engrossed in playing VGs as when watching an animated movie. Therefore, VGs can be applied in health care for distraction and behavior modification therapy.16–18 However, older children may benefit more than younger children because VG playing requires hand skill. Furthermore, most children are familiar with only a few VGs and cannot play others. It is also difficult to prepare many VG consoles in the OR. In contrast, viewing animated cartoons is an inexpensive, easy to administer, and comprehensive method for anxiety reduction in the younger pediatric surgical population.
There are several limitations to this study. First, observer bias is a limitation of studies that use an observer tool for anxiety measurement with interventions such as parental presence and distraction techniques.19–21 The observer could not be blinded to treatment group for obvious reasons. In this study, also, parent-recorded VAS for anxiety could have been biased by the parent’s perception of their child’s behavior, although there is good correlation between mYPAS and parent-recorded VAS. Second, all children had peripheral venous catheters placed before the start of anesthesia. There were no differences in mean times from IV catheterization to the start of the operation among the 3 groups. Third, all children in this study had their anesthesia induced with IV drugs because IV induction has been the usual pediatric practice in our hospital. Thus, these results may not be applicable to children undergoing inhaled inductions of anesthesia. Fourth, the children were admitted the evening before the operation because outpatient surgery is not popular in Korea. Although anxiety levels could be markedly influenced by the child’s preoperative hospitalization, baseline levels were similar for all 3 groups.
In conclusion, allowing the viewing of animated cartoons by pediatric surgical patients is a very effective method to alleviate preoperative anxiety. The study suggests that this intervention is an inexpensive, easy to administer, and comprehensive method for anxiety reduction in the pediatric surgical population.
Name: Jeongwoo Lee, MD.
Contribution: This author helped conduct the study and write the manuscript.
Attestation: Jeongwoo Lee has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
Name: Jihye Lee, MD.
Contribution: This author helped conduct the study.
Attestation: Jihye Lee has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
Name: Hyungsun Lim, MD.
Contribution: This author helped conduct the study and analyze the data.
Attestation: Hyungsun Lim has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
Name: Ji-Seon Son, MD, PhD.
Contribution: This author helped conduct the study and analyze the data.
Attestation: Ji-Seon Son has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
Name: Jun-Rae Lee, MD, PhD.
Contribution: This author helped conduct the study.
Attestation: Jun-Rae Lee has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
Name: Dong-Chan Kim, MD, PhD.
Contribution: This author helped design the study.
Attestation: Dong-Chan Kim has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
Name: Seonghoon Ko, MD, PhD.
Contribution: This author designed the study, analyzed the data, and wrote the manuscript.
Attestation: Seonghoon Ko has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
This manuscript was handled by: Peter J. Davis, MD.
1. Davidson AJ, Shrivastava PP, Jamsen K, Huang GH, Czarnecki C, Gibson MA, Stewart SA, Stargatt R. Risk factors for anxiety at induction of anesthesia in children: a prospective cohort study. Paediatr Anaesth. 2006;16:919–27
2. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children: predictors and outcomes. Arch Pediatr Adolesc Med. 1996;150:1238–45
3. Aydin T, Sahin L, Algin C, Kabay S, Yucel M, Hacioglu A, Yaylak F, Kilicoglu A. Do not mask the mask: use it as a premedicant. Paediatr Anaesth. 2008;18:107–12
4. Kain ZN, Wang SM, Mayes LC, Caramico LA, Hofstadter MB. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg. 1999;88:1042–7
5. McCann ME, Kain ZN. The management of preoperative anxiety in children: an update. Anesth Analg. 2001;93:98–105
6. Lumley MA, Melamed BG, Abeles LA. Predicting children’s presurgical anxiety and subsequent behavior changes. J Pediatr Psychol. 1993;18:481–97
7. Wright KD, Stewart SH, Finley GA, Buffett-Jerrott SE. . Prevention and intervention strategies to alleviate preoperative anxiety in children: a critical review. Behav Modif. 2007;31:52–79
8. Viitanen H, Annila P, Viitanen M, Tarkkila P. Premedication with midazolam delays recovery after ambulatory sevoflurane anesthesia in children. Anesth Analg. 1999;89:75–9
9. McGraw T, Kendrick A. Oral midazolam premedication and postoperative behaviour in children. Paediatr Anaesth. 1998;8:117–21
10. Stewart SH, Buffett-Jerrott SE, Finley GA, Wright KD, Valois Gomez T. Effects of midazolam on explicit vs implicit memory in a pediatric surgery setting. Psychopharmacology (Berl). 2006;188:489–97
11. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale Preoperative Anxiety Scale: how does it compare with a “gold standard”? Anesth Analg. 1997;85:783–8
12. Viitanen H, Annila P, Viitanen M, Yli-Hankala A. Midazolam premedication delays recovery from propofol-induced sevoflurane anesthesia in children 1–3 yr. Can J Anaesth. 1999;46:766–71
13. Watson AT, Visram A. Children’s preoperative anxiety and postoperative behaviour. Paediatr Anaesth. 2003;13:188–204
14. Kain ZN, Caldwell-Andrews AA, Krivutza DM, Weinberg ME, Wang SM, Gaal D. Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative premedication in the United States, 1995-2002: results of a follow-up national survey. Anesth Analg. 2004;98:1252–9
15. Patel A, Schieble T, Davidson M, Tran MC, Schoenberg C, Delphin E, Bennett H. Distraction with a hand-held video game reduces pediatric preoperative anxiety. Paediatr Anaesth. 2006;16:1019–27
16. Redd WH, Jacobsen PB, Die-Trill M, Dermatis H, McEvoy M, Holland JC. Cognitive/attentional distraction in the control of conditioned nausea in pediatric cancer patients receiving chemotherapy. J Consult Clin Psychol. 1987;55:391–5
17. Fung V, So K, Park E, Ho A, Shaffer J, Chan E, Gomez M. The utility of a video game system in rehabilitation of burn and nonburn patients: a survey among occupational therapy and physiotherapy practitioners. J Burn Care Res. 2010;31:768–75
18. Denman WT, Tuason PM, Ahmed MI, Brennen LM, Cepeda MS, Carr DB. The PediSedate device, a novel approach to pediatric sedation that provides distraction and inhaled nitrous oxide: clinical evaluation in a large case series. Paediatr Anaesth. 2007;17:162–6
19. Kain ZN, Mayes LC, Caramico LA, Silver D, Spieker M, Nygren MM, Anderson G, Rimar S. Parental presence during induction of anesthesia: a randomized controlled trial. Anesthesiology. 1996;84:1060–7
20. Kain ZN, Mayes LC, Wang SM, Caramico LA, Krivutza DM, Hofstadter MB. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study. Anesthesiology. 2000;92:939–46
21. Calipel S, Lucas-Polomeni MM, Wodey E, Ecoffey C. Premedication in children: hypnosis versus midazolam. Paediatr Anaesth. 2005;15:275–81