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Preoperative preparation of children
Priya Reshma Aranha, Larissa Martha Sams1, Prakash Saldanha2

Abstract:
Surgery is a stressful and anxiety provoking experience for children. Millions of children undergo surgery every
year. The majority of children experience significant preoperative anxiety which intern can affect their recovery.
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Preoperative anxiety may bring about physical and physiological changes in children, which can be particularly
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evident in terms of increased heart rate and blood pressure. To identify various strategies used to minimize the
DOI: preoperative anxiety of children and update their clinical effectiveness among children undergoing surgery, the
10.4103/ijhas.IJHAS_76_16 authors searched PubMed, MEDLINE, CINAHL, ScienceDirect, Google Scholar, Scopus, and Cochrane Library
for identifying the relevant studies and retrieved available literature. It is concluded that utilization of the strategies
available to reduce the preoperative anxiety of children will be a promising intervention to reduce anxiety, to
promote relaxation, satisfaction, and speedy recovery. Many of these techniques are simple, cost‑effective and
can be easily carried out by nurses. It is essential to use the age appropriate and individualized methods in
preparing children for surgery. Further research is required to strengthen the evidence.
Key words:
Children, evidence‑based practice, preoperative preparation

H ospitalization and surgery are stressful

Department of Child
Health Nursing,
Yenepoya Nursing
College, Yenepoya
University, 1Department
of Medical Surgical
Nursing, Laxmi
Memorial College of
Nursing, 2Department
of Paediatrics,
Yenepoya Medical
College, Mangalore,
Karnataka, India
Address for
correspondence:
Mrs. Priya Reshma Aranha,
Yenepoya University,
Mangalore ‑ 575 018,
Karnataka, India.
E‑mail: priyaresh.
menezes@gmail.com
Submission: 31‑05‑2016
Accepted: 21‑01‑2017
events in the life of a child and parents.
When a child undergoes surgery, it often
becomes a very significant and memorable
event in the life of the entire family. Unlike other
significant events in the child’s life, it has an
element of threat, and the fear of the unknown
can be overwhelming.[1]
It has been seen that 75% of children undergoing
surgery experience anxiety.[2] In a study, it
was observed that 67% of children developed
postoperative negative behavioral changes.[3]
Physiological changes such as elevated pulse
rate and blood pressure are also anticipated
when there is a painful procedure as well as
preoperative anxiety.[4,5]
Preoperative anxiety is a distressing feeling
which results in adverse physiological and
psychological reactions in children. With a high
level of anxiety, they are more likely to exhibit
signs of the emergence of delirium and develop
maladaptive behavior postoperatively. They
may need additional postoperative pain control
medications.[6]
Parents also may be anxious regarding anesthesia
and associated risks, how the child would
respond to the surgical experience and their own
inadequacy in taking care of their child after the
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discharge from the hospital.[7] Well prepared
parents, in turn, will be able to support their
children and help them to prepare well for the
upcoming surgery.
Importance of this review
The child is different from an adult. Therefore, it
is essential to have a tailored approach to their
preoperative preparation. Adequate preoperative
psychological preparation of children is the
responsibility of the health‑care workers. The
aim of the preparation is to reduce the anxiety
of children and family, improve cooperation,
enhance recovery, and increase self‑control,
improve long‑term emotional, and behavioral
adjustments.
The factors to be considered while planning
preoperative preparation of children
are – developmental stage of child, previous
medical experiences, duration of the procedure,
temperament, current anxiety levels, coping
skills, and parental involvement.
Many strategies have been developed for
the alleviation of preoperative anxiety of
children and their parents and implemented
in pediatric surgical settings. These strategies
are based on rigorous research evidence and
can be implemented in the nursing care during
the preoperative preparation of children and
their parents. Nurses and other health‑care
providers should be able to identify an
How to cite this article: Aranha PR, Sams LM,
Saldanha P. Preoperative preparation of children. Int
J Health Allied Sci 2017;6:1-4.

© 2017 International Journal of Health & Allied Sciences | Published by Wolters Kluwer ‑ Medknow 1

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Aranha, et al.: Preoperative preparation of children undergoing surgery
appropriate strategy based on individualized child and
parent’s needs.
Methods
We searched PubMed, MEDLINE, CINAHL, ScienceDirect,
Google Scholar, Scopus, and Cochrane Library for identifying
the relevant studies and available literature. Different
combinations of search terms were used to collect available
literature and retrieved relevant research studies. Search terms
included were preoperative anxiety of children, preoperative
fear of children, pharmacological and nonpharmacological
interventions to manage the preoperative anxiety of children,
preoperative preparation of children, and postoperative
outcomes. The descriptive synthesis was adapted to report
the findings.
Outcomes of systematic reviews
Systematic reviews and meta‑analyses of studies have
established the beneficial effects of various preoperative
preparation strategies on the children undergoing surgery.
A systematic review [8] analyzed the use of sedative
premedications, parental presence during induction of
anesthesia and various behavioral preparation techniques.
Evidence indicates that the role of sedative premedication is
firmly established while behavioral techniques are gaining
wider acceptance. Routine parental presence does not confer
a benefit to the child although parental satisfaction is enabled.
There is little evidence comparing preinduction techniques for
children with chronic illness requiring repeated visits to the
operation theater. Review by National Clinical Guidelines[9]
showed that preoperative psychological preparation is effective
in reducing anxiety of children undergoing surgery and their
parents. Evidence shows that psychological preparation
for anesthesia induction, perioperative anxiety reduction
programs, psychological preparations/interventions for other
medical procedures, dental procedures is effective. To know
the desire of children and parents regarding the need for
preoperative information is essential. Parental presence during
anesthesia induction can also help children. Another review[10]
has identified that the preparation programs, although relevant,
are not the only form to soothe preoperative anxiety in children.
The methods should be tailored for each child and can be
supplemented by preoperative sedative medications. The
literature shows various well‑tried methods of preoperative
management can be applied before hospitalization. The crucial
elements of such a strategy are to dissipate the emerging
doubts by providing children and parents with relevant
and understanding information. It was also reviewed that
audiovisual interventions[11] appear potentially useful in
reducing preoperative anxiety and its associated outcomes in
children undergoing elective surgery. The systematic review
suggested that videos, multifaceted programs, and interactive
games appear to be most effective, whereas music therapy
and internet programs are less effective. A literature survey[12]
was done to review and analyze the studies on the effect of
perioperative music in pediatric surgery for children from
day 1 to 18 years of age. The evidence indicates that music
interventions may have a statistically significant effect in
reducing postoperative pain, anxiety, and distress in children
undergoing surgical procedure and music therapy may be
considered for clinical use. An integrative review[13] showed
2 International Journal of Health & Allied Sciences - Volume 6, Issue 1, January‑March 2017
that nursing interventions can be used as effective techniques to
reduce the preoperative anxiety in school‑age children. Both the
quality of the preoperative program and the preparation and
support for the hospitalization/surgery provided by parents
to their children are essential to help both child and parents
find strategies to overcome their anxiety, stress, and anguish
caused by the situations. Cost effectiveness and feasibility
of the interventions to be considered. Another systematic
review[14] revealed that nonpharmacological interventions for
assisting the induction of anesthesia in children were studied.
Evidence showed that the presence of parents during induction
of general anesthesia does not reduce the child’s anxiety.
Promising nonpharmacological interventions such as parental
acupuncture, clown doctor, hypnotherapy, low sensory
stimulation, and hand‑held video games proved to be effective.
Pharmacological and nonpharmacological interventions for
preparing children for surgery
While pharmacological measures used to reduce the
preoperative anxiety, a wide range of nonpharmacological
techniques being successfully used for the children. These
techniques can be used as a single measure or in combination
or complementing with the pharmacological measure. The
literature reveals that preparation programs such as role
rehearsals with dolls,[15‑18] puppet shows[19,20] the teaching
of coping and relaxation skills[21,22] orientation tours of the
operating room[16,17] as well as educational videos.[23‑25] Some
programs focus exclusively on preparing the child.[26‑28] The
evidence[29] shows that when the oral midazolam and clowns
were used to reduce the preoperative anxiety of children, the
children in the clown group exhibited statistically significant
lower anxiety score in comparison with the children in the
midazolam group. Thus, it is evident that psychological
preparation techniques can be used to manage the preoperative
anxiety of children.
Discussion
The review of literature suggests that the use of toys and
preoperative visit[30] can reduce the preoperative anxiety in
children. Along with the children, the parents too were involved
in a study, and there was a high level of satisfaction among
the parents who underwent this intervention. Performing
preoperative preparation program for children is essential. It
was seen that when the children received therapeutic play[31]
consisting of operation room tour, demonstration and return
demonstration of procedures on the mannequins had a better
impact. Having encountered with clown and developmentally
appropriate techniques such as magic tricks, gags, music,
games, puppets, word games, and bubbles can also reduce
the preoperative anxiety in children.[32] It is well studied that
children who are viewing animated cartoon and playing with
a favorite toy,[33] working on cartoon coloring book,[34] picture
book[35] are effective methods, whereas video distraction and
parental presence and combination of both is also effective in
minimizing preoperative anxiety of children.[36]
It was a promising result of a study which concluded that
video glasses are not inferior to midazolam for preoperative
anxiolysis and provide a safe, noninvasive nonpharmacological
and pleasant alternative.[37]
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Aranha, et al.: Preoperative preparation of children undergoing surgery
While various activities such as video and toys being effective
in reducing preoperative anxiety of children, evidences also
suggest that surgery virtual tour offered on a website,[38]
orientation tours,[39] providing conventional verbal information
including role play,[17] operation room tours, information,
modeling, coping‑based programs could also effectively reduce
the preoperative anxiety of children.[18]
Researchers have also compared many such interventions
to rule out the best for children. One such study where the
family‑centered behavioral preparation including – anxiety
reduction, distraction, video modeling and education, adding
parents, no excessive reassurance, coaching, and exposure
is more effective over providing standard care, parental
presence, and oral midazolam was used in preparing children
for surgery[40] and it showed a significant result in reduction of
preoperative anxiety of parents and their children.
On the other hand, when the effectiveness of interactive music
intervention and midazolam was investigated, it was seen that
music therapy did not appear to alleviate children’s anxiety at
anesthesia induction.[41]
Structured preoperative preparation has a significant effect on
the anxiety of the child and parent, child’s behavioral changes
and parent satisfaction.[42] Internet preparation program can
also help adolescents to get well prepared for their surgery.[43]
Preadmission visits can help to increase the parents and their
child’s knowledge on hospital experience and help them to
reduce their anxiety[44] On the other hand, it was proved that
home based preparation of children for cardiac surgery is
effective when compared to the hospital based preparation.[45]
Implications for clinical practice
Preoperative preparation of children and their parents is
an important aspect of nursing care where psychological
preparation should be more emphasized. Studies have shown
that many nonpharmacological methods are effective in
reducing preoperative anxiety of children and their parents.
Therefore, it is the need of the hour to utilize these study
findings in clinical practice, thereby prepare the children and
their parents well for surgery. However, the techniques to be
used should be age appropriate, according to the developmental
stage of the child. It is also important to have further research
on preoperative preparation of children to focus on target
interventions to promote physical, psychological wellbeing as
well as to enhance speedy recovery among children undergoing
surgery.
Conclusion
There is emerging evidence that preoperative preparation of
children and their parents can reduce preoperative anxiety
and help to prepare well for the upcoming surgery. Many
psychological preparations have been developed and tested
for its effectiveness and evidence given that these strategies
are effective in reducing preoperative anxiety in children and
their parents. Therefore, health‑care professionals should
incorporate such evidence‑based practice on utilizing the
most advantageous and safe strategies in preparing children
for surgery.
International Journal of Health & Allied Sciences - Volume 6, Issue 1, January‑March 2017 3
Acknowledgments
We greatly acknowledge all the authors of the original research
articles that have been found useful to write this review
article and extend our thanks to the central library, Yenepoya
University for providing facilities to retrieve relevant studies
from various online databases.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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