Professional Documents
Culture Documents
Psychological Issues in
Paediatric Surgery
Akanidomo J. Ibanga
Hannah B. Ibanga
Introduction
Many parents who may be present during ward rounds or may have
overheard discussions or may have had consultations with their childs
physician come across terms that refer more to the type of surgery for
the child. They may thus hear the surgery being referred to as either
major, minor, emergency, elective, or required. It is outside the scope of
this chapter to discuss these in detail, but it suffices to briefly describe
these terms here.
Major Surgery
Emergency surgery is carried out with a focus on correcting a lifethreatening condition. Examples of these would be a result of an accident (motor vehicle or many forms of domestic accidents) or where
there is an intestinal obstruction or any other life-threatening condition.
Elective Surgery
Unlike the previous surgeries, elective surgery does not correct a lifethreatening condition and is not an absolute necessity for the health
of the child. It is, however, a surgery that is carried out with the hope
of improving the childs quality of life. Surgery to remove a hernia or
tonsils, as well as circumcision, would fall under this class.
Required Surgery
Any procedure that is required in order to improve the quality of life for
the child is termed required surgery. Required surgery does not need to
be done immediately, as is the case for emergency surgery. In this situation, more time is available to plan and prepare the child and parents
involved for the surgery
Minor Surgery
Childrens Anxiety
Numerous researchers79 have found an association between preoperative anxiety and negative postsurgical outcomes. When a child is about
to undergo surgery, for instance, and is to be anaesthetised, the child
who is anxious at this stage is very uncooperative, often making the
process more pronounced and prolonged. The greatest risk of nonco-
Parental Anxiety
Cost of Procedure
Over the last four decades, a number of efforts have focused on alleviating the potential trauma experienced by parents and their children
as they await or undergo an invasive surgical procedure. These efforts
also aim to maximise the effect of medical treatment.51 Thus, children
(and their parents) are prepared for surgery in an attempt to prevent
or decrease the severity of associated distress. These preparatory
interventions range from pharmacological (administration of premedication) to psychosocial approaches, the latter of which has been the
focus of this chapter.
In looking at the psychological preparation of children for surgery,
various authors have presented slightly different paths. For instance,
Vernon et al.22 reviewed existing preparatory programmes and
highlighted three main themes that were evident in these programmes:
(1) giving information to the child, (2) encouraging emotional
expression, and (3) establishing a relationship of trust and confidence
with the hospital staff. These three themes were later expanded by
Elkins and Roberts52 to include (4) preparing parents and (5) providing
or teaching coping strategies to parents and children.
In a more recent review, Maclaren, and Kain30 adopted a historical
approach, suggesting that preparation programmes moved through
three different phases: information orientation and design in the 1960s,
aimed at facilitating emotional expression and trust between the parties;
modelling and stress-point nursing procedures in the 1970s; and then
in the 1980s came the teaching of children skills and the involvement
of parents. They concluded that evidence supports the development of
coping skills as being the most effective preoperative preparation. This
is followed by modelling, play therapy, an operation room tour, with the
least effective being print media.
In discussing preoperative psychological preparation, we now look
briefly at the various programmes with a focus on what is involved and
how they attempted to accomplish this.
Conclusion
It is important to point out that hospitals differ in regard to recommended practices in preparing a child for an invasive procedure. Some
have formal policies on some of these procedures, whereas others rely
more on the clinical judgement of the attending health care professional and what is feasible within that setup. For instance, the United
States and United Kingdom vary vastly on the issue of parental presence (or absence) during anaesthetic induction. Kain et al.50 found that
85% of anaesthetists in the UK allowed parents to be present during
anaesthetic induction in 75% of the cases, but a much lower percentage
was obtained for the USA, where only 58% of the respondents allowed
parents to be present in less than 5% of the cases. This could be a
result of inconclusive evidence concerning the advantages (alleviating
childs anxiety and gaining cooperation)62 or disadvantages (making the
anaesthetist nervous or causing child to be stressed from the parents
own response).63 It could also be that the difference reflects the fear of
litigation or other possible legal proceedings that may exist.53
In their review of preoperative preparation programmes for children,
Watson and Visram64 concluded that these programmes are not
universally helpful in reducing anxiety or postoperative behaviour
problems. What we do know is that some programmes have better
outcomes than others and that they need to be tailored to the individual
child, taking into account the childs age, previous hospital experiences,
and temperament.
A gap still exists, however, in transferring the results obtained
in clinical research trials to routine clinical settings. Many of these
preparation programmes have been evaluated in the controlled
environments of clinical research trials, where factors are manipulated
to allow for clearer understanding; in routine clinical settings, these
factors may not necessarily be the same, thus leading to potentially
different results.15 Bridging this gap is a necessity.
Generally speaking, however, in the developed countries such as
the United States and in Europe, there is a continuous search for ways
of incorporating these evidence-based findings into routine clinical
settings to improve the lot of both children and parents awaiting
invasive surgical procedures. For paediatric surgeons in the subSaharan region, in contrast, the greater challenge and focus are on
providing basic health and counselling services for this group.
In the sub-Saharan region, the compounding factor is the acute
shortage of paediatric surgeons and other supporting health care
professionals. In the more developed settings, where the ratio of children
to paediatric surgeons is much lower, the inability to adequately prepare
a child and parents for invasive procedures is due largely to a lack of
time. The high volume of ambulatory patients seen in surgical units and
the policy at some institutions to forgo a separate preoperative visit, as
is typical for inpatient surgical procedures, is common. Clinicians who
work with families in the ambulatory setting have an increased burden
of identifying family needs and providing interventions to parents
and children in a very brief time period. As expected, the situation in
sub-Saharan Africa can be considered a lot worse because the child-tosurgeon ratio is so much larger.
In addition to these challenges are specific considerations when
implementing preparatory programmes in sub-Saharan Africa.
Notably, evidence on the effectiveness of these programmes is from
the industrialised world and may not necessarily be applicable in
sub-Saharan practice. Several questions arise that would be worth
considering: Do children in sub-Saharan Africa respond to information
in the same way as do children in the more developed societies, or are
they more dependent on their parents and guardians in determining
how they respond to new situations? Are the hospitals equipped to
offer the preoperative preparatory sessions that are required, and
do they have mental health workers or other professionals that can
facilitate these sessions, or will preoperative preparation be a part of
the paediatricians already overcrowded role? Are there plans in place
to confront fundamental societal beliefs and values that may, as in the
earlier described case, affect the acceptance of certain procedures that
have been found effective for managing or treating certain conditions?
A great need exists for research with a focus on finding brief costeffective preoperative programmes that are relevant for surgical
practice in the sub-Saharan region. Raising the bar to a point where
every child has access to a well-thought-out preoperative programme
will continue to be a challenge, but nevertheless one that African
nations should strive to overcome.
Evidence-Based Research
Authors
Institution
Reference
Problem
Intervention
Comparison/
control
(quality of
edvidence)
Outcome/
effect
Historical
significance/
comments
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10. Kain ZN, Wang SM, Mayes LC, Caramico LA, Hofstadter MB.
Distress during the induction of anesthesia and postoperative
behavioral outcomes. Anesth Analg 1999; 88:10421047.
11. Holm-Knudsen RJ, Carlin JB, McKenzie IM. Distress at induction of
anaesthesia in children. A survey of incidence, associated factors
and recovery characteristics. Paed Anaes 1998; 8:383392.
12. Kotiniemi LH, Ryhanen PT, Moilanen IK. Behavioural changes in
children following day-case surgery: a 4-week follow-up of 551
children. Anaesthesia 1997; 52:970976.
13. Eckenhoff JE. Relationship of anesthesia to postoperative
personality changes in children. Amer J Dis Childhood, 1958;
86:587591.
14. Meyers E, Muravchick S. Anesthesia induction techniques in
pediatric patients: a controlled study of behavioral consequences.
Anesth Analg 1977; 56:538542.
15. Kain ZN, Caldwell-Andrews AA, Maranets I, McClain B, Gaal
D, Mayes LC, Feng R, Zhang H. Preoperative anxiety and
emergence delirium and postoperative maladaptive behaviors.
Anesth Analg 2004; 99:16481654.
16. Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain
BC. Preoperative anxiety, postoperative pain, and behavioral
recovery in young children undergoing surgery. Pediatrics 2006;
118:651658.
19. Utens EM, Verhulst FC, Meijboom FJ, et al. Behavioural and
emotional problems in children and adolescents with congenital
heart disease. Psychol Med 1993; 23:415424.
20. Casey FA, Sykes DH, Craig BG, et al. Behavioral adjustment of
children with surgically palliated complex congenital heart disease.
J Pediatric Psych 1996; 21:335352.
21. Lavigne JV, Faier-Routman J. Psychological adjustment to
pediatric physical disorders: a meta-analytic review. J Pediatric
Psych 1992; 17:133157.
22. Vernon, DTA, Schulman JL, Fooley JM. Changes in childrens
behavior after hospitalization. Amer J Dis Children 1966; 111:481497.
23. Bondy L, Sims N, Schroeder DR, Offord KP, Narr BJ. The effect of
anaesthetic patient education on preoperative patient anxiety. Reg
Anesth Pain Mgmt 1999; l24:158164.
24. Devine EC. Effects of psychoeducational care for adult surgical
patients: a meta-analysis of 191 studies. Patient Educ Couns
1992; 19:129142.
25. Kain Z, Caramico L, Mayes L, Genevro J, Bornstein M, Hofstadter
M. Preoperative preparation programs in children: a comparative
study. Anesth Analg 1998; 87:12491255.
26. Maligalig RM, Parents perceptions of the stressors of pediatric
ambulatory surgery. J Post Anesth Nurs 1994; 9:278282.
27. Ben-Amitay Kosov I, Reiss A, Toren P, Yoran-Hegesh R, Kotler
M, Mozes T. Is elective surgery traumatic for children and their
parents? J Paed Child Health 2006; 42:618624.
41. Campbell EK, Campbell PG. Family size and sex preferences and
eventual fertility in Botswana. J Biosoc Sci 1997; 29:191204.
42. Mwageni EA, Ankomah A, Powell RA. Sex preference and
contraceptive behaviour among men in Mbeya region, Tanzania. J
Fam Plan Reprod Health Care 2001; 27:8589.
43. Olusoye S. The girl child: a blessing or an abomination. Nigerias
Pop 1993; (OctDec):4142.
44. Hake JM. Child-Rearing Practices in Northern Nigeria. Ibadan
University Press, 1972.
45. Gupta B. Incidence of congenital malformations in Nigerian
children. W Afr Med J 1969; 8:2227.
46. Archibong AE, Idika IM. Results of treatment in children with
anorectal malformations in Calabar, Nigeria. S Afr J Surg 2004;
42(3):8890.
47. Bender RE. The Conquest of Deafness. The Press of Case
Western Reserve University, 1970.
48. Goffman E. Stigma, Notes on Management of Spoilt Identity.
Prentice-Hall, 1963.
49. Ojofeitimi, Oyefeso. Beliefs, attitudes and expectations of mothers
concerning their handicapped children in Ile-Ife, Nigeria. J Royal
Soc Promotion Health 1980; 100:101103.
50. Onwuegbu OL. The Nigerian Culture: Its Perception and
Treatment of the Handicapped. Unpublished essays, Federal
Advanced Teachers College for Special Education, Oyo, Oyo
State, Nigeria, 1977.
51. Kenny TJ. The hospitalized child. Pediatr Clin N A 1975; 22:583593.
52. Elkins PO, Roberts MC. Psychological preparation for pediatric
hospitalization. Clin Psychol Rev 1983; 3:275295.
53. Kain ZN, Mayes LC, OConnor TZ, Cicchetti DV. Preoperative
anxiety in children. Predictors and outcomes. Arch Pediatr Adoles
Med 1996; 150:12381245.
54. Faust J, Melamed BG. Influence of arousal, previous experience,
and age on surgery preparation of same day of surgery and inhospital pediatric patients. J Consult Clin Psych 1984; 52:359
365.
55. Skipper JK, Leonard RC. Children, stress, and hospitalization: a
field experiment. J Health Soc Behav 1968; 9:275287.
56. Cassady JF Jr, Wysocki TT, Miller KM, Cancel DD, Izenberg N.
Use of a preanesthetic video for facilitation of parental education
and anxiolysis before pediatric ambulatory surgery. Anesth Analg
1999; 88:246250.
57. Scrimin S, Haynes M, Alto G, Bornstein, MH, Axia G. Anxiety and
stress in mothers and fathers in the 24h after their childs surgery.
Child: Care, Health Dev 2009; 35:227233.
58. McEwen A, Moorthy C, Quantock C, Rose H. Kavanagh R. The
effect of videotaped preoperative information on parental anxiety
during anesthesia induction for elective pediatric procedures.
Pediatric Anesth 2007; 17:534539.