Allaying pediatric preoperative anxiety, where are we now? – A nationwide survey

Shreya Bharat Shah; Renu Sinha; Sana Yasmin Hussain; Amit Kumar; Anju Gupta

doi:10.4103/jiaps.jiaps_114_23



ORIGINAL ARTICLE

Year : 2023 \| Volume : 28 \| Issue : 6 \| Page : 479-485

Allaying pediatric preoperative anxiety, where are we now? – A nationwide survey

Shreya Bharat Shah, Renu Sinha, Sana Yasmin Hussain, Amit Kumar, Anju Gupta
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Submission	20-May-2023
Date of Decision	08-Jul-2023
Date of Acceptance	23-Jul-2023
Date of Web Publication	02-Nov-2023

Correspondence Address:
Sana Yasmin Hussain
Room No. 5011, Anaesthesia Office, Fifth Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jiaps.jiaps_114_23

Abstract

Background: Preoperative anxiety (PA) in children is a common phenomenon associated with various negative patient outcomes. Allaying PA is accepted as a standard of care, but its use is not universal and often overlooked. This survey is designed to evaluate the nationwide current practice patterns and attitudes of anesthesiologists toward the practice of allaying PA in children.
Materials and Methods: A questionnaire of 25 questions, including information on methods of relieving PA in children, reasons for noncompliance, and associated complications, was framed. It was circulated among members of the Indian Society of Anaesthesiologists through an online survey of Google Forms and manually.
Results: Four hundred and fifty anesthesiologists were surveyed. Responses were predominantly from anesthesiologists practicing in medical colleges across the country. Although 97% of the surveyed respondents practiced anxiety-relieving strategies, only 37% used it consistently. Seventy-three percent of anesthesiologists practiced both pharmacological and nonpharmacological techniques. The most common reason for avoiding premedication was an anticipated difficult airway (88%). Inadequate sedation was a commonly reported problem. Ninety-five percent of participants felt that PA-relieving strategies should be integral to pediatric anesthesia practice. The most common reason for not following these practices was an inadequate hospital infrastructure (67%). Ninety-seven percent of the participants believed that more awareness is required on this crucial perioperative issue.
Conclusion: Only 37% of the surveyed anesthesiologists consistently used some form of PA-relieving strategy and the practice varied widely. Further improvement and team approach involving anesthesiologists, surgeons, and nurses is required to ensure the quality of pediatric PA-relieving services and establish it as a standard of care.

Keywords: Behavioral interventions, pediatric, practice patterns, premedication, preoperative anxiety

How to cite this article:
Shah SB, Sinha R, Hussain SY, Kumar A, Gupta A. Allaying pediatric preoperative anxiety, where are we now? – A nationwide survey. J Indian Assoc Pediatr Surg 2023;28:479-85

How to cite this URL:
Shah SB, Sinha R, Hussain SY, Kumar A, Gupta A. Allaying pediatric preoperative anxiety, where are we now? – A nationwide survey. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Nov 28];28:479-85. Available from: https://www.jiaps.com/text.asp?2023/28/6/479/389310

Introduction

Preoperative anxiety (PA) in children is a common phenomenon associated with the hospital environment. The reported incidence of PA in children is 60%–65%.^[1]

A child's anxiety can pose a significant challenge for the perioperative health-care team and can be distressing for parents. Unfamiliar hospital environment and procedures, previous unpleasant hospital experience, prolonged fasting, parental detachment, and stranger anxiety contribute to PA in children. It is associated with immediate behavioral outcomes such as trembling and enuresis and clinical outcomes such as longer induction time, increased analgesic requirement, emergence delirium, and delayed recovery.^{[2],[3],[4],[5]} It can also lead to maladaptive behavior postsurgery like feeding disturbances, temper tantrums, neuroendocrine changes, and a potential interference with the normal development.^[4],[6]

Due to the immediate and long-term negative effects of PA, several preventive and intervention strategies have been examined to alleviate anxiety. Both pharmacological and nonpharmacological approaches such as parental presence, video distraction, and behavioral preparation programs have been employed.^{[3],[4],[5],[6]}

There is heterogeneity among health-care professionals in advocating various methods of allaying PA in children. Considering the high incidence of PA and associated adverse outcomes, it would be worthwhile to know if these anxiety-relieving practices are being followed in our country. A nationwide survey will highlight the different practice patterns, help identify the unrecognized hurdles to its implementation, and bridge the lacunae in the existing literature.

We, therefore, designed this survey among the practicing anesthesiologists to get an overview of preoperative anxiety-relieving strategies (ARS) in children. The objectives of our survey were (1) to determine adherence to these ARS or the reasons for not using them, (2) to evaluate the choice and reason of using various pharmacological and behavioral techniques, and (3) to analyze the problems encountered and the risks-benefits of various techniques.

As this is an area of clinical practice that deserves greater emphasis, this survey may contribute to establish a standardized nationwide practice to allay pediatric PA.

Materials and Methods

A questionnaire was prepared by doing a thorough literature search on web-based electronic databases. Previous surveys on interventions to alleviate PA in pediatric patients were explored for questionnaire development. The investigators prepared questions based on their experience and problems encountered in clinical practice. All the questions were thoroughly analyzed, and 30 questions were shortlisted. Its comprehensiveness and validity were first determined by circulating the survey among ten senior departmental faculty members. Suggestions and changes were then incorporated into the questionnaire. It was subsequently validated by six senior anesthesiologists from other institutes practicing pediatric anesthesia for nearly 20 years but not a part of the study. The relevant questions were retained and subsequently revised based on their opinion. In the final version of the survey, 25 questions were included. The questionnaire [Annexure 1] was brief, in English, and had three sections:

Section 1: General data of the respondent
Section 2: ARS

2a. Sedative premedication, including special situations
2b. Behavioral interventions/nonpharmacological methods.

Section 3: Attitude toward the practice of pediatric ARS.

Ethics committee approval was obtained (IEC-585/15.07.2022). The survey was registered with the Clinical Trials Registry of India (CTRI/2022/07/044441). The procedures followed were in accordance with the ethical standards and the Helsinki Declaration.

Respondents

Four hundred and fifty anesthesiologists who are life members of the Indian Society of Anaesthesiologists (ISA) were included in the survey. Anesthesiologists practicing outside India were excluded from the study.

Distribution of questionnaire

It was distributed via E-mail, electronic media, or manually. Two reminders 10 days apart were sent to those who did not respond. Completion and submission of the questionnaire by the respondents implied their consent. To maintain respondent anonymity, no personal identifying information was enquired in the survey.

The statistics of the World Federation of Societies of Anaesthesiologists reveal 12,000 qualified practicing anesthesiologists in India. To adequately represent the population, with a margin of error of 5%–95% confidence interval, we required 373 responses. Considering incomplete forms to be 10%, 450 responses were targeted. All responses were recorded and transferred to a Microsoft Excel spreadsheet. Data were analyzed with Stata version 12 ( Statacorp, USA). Chi-square test was used to analyze categorical data, and Fisher's exact test was applied where Chi-square test was not feasible. Descriptive results were expressed as numbers and proportions (%). P < 0.05 was considered statistically significant.

Results

The response rate of the survey was 22.5% which was obtained from the members of ISA comprising all zones. Four hundred and fifty valid and complete responses were analyzed. The general details of the study participants are illustrated in [Table 1].

Table 1: General details of survey respondents

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Thirty-seven percent of the anesthesiologists always implemented some ARS, while these techniques were frequently followed by 38% of anesthesiologists. Maximum participants (73%) utilized both pharmacological and nonpharmacological techniques. Behavioral interventions or pharmacological methods were utilized by 9% and 17% of the anesthetists, respectively. The practice of ARS stratified according to the experience of anesthesiologists and the setup of practice is shown in [Table 2] and [Table 3], respectively.

Table 2: Practice of anxiety-relieving strategies stratified according to the experience of anesthesiologists

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Table 3: Anxiety-relieving strategies stratified according to the area of practice

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Amongst the nonpharmacological methods, parental education and counseling were utilized by 74%, while 51% of respondents acquainted their child with a mask. Reported advantages of parental presence during induction were decreasing child anxiety (84%) and increasing child cooperation (72%). Disadvantages pointed out were parental anxiety (75%), disruption of OT routine (48%), stress on anesthesia providers (45%), and the need for additional staff to escort relatives (42%). Nonpharmacological methods were used more by anesthetists practicing in nursing homes in comparison to those practicing in medical colleges (P = 0.002), private hospitals (P = 0.005), or nonteaching government hospitals (P = 0.036).

The drugs used for premedication are graphically represented in [Figure 1]. Midazolam was the most common drug administered for sedation (80%). The choice of agent did not differ significantly according to the experience of the anesthesiologist [Table 2]. Common clinical circumstances where respondents avoided premedication were difficult airway (88%), full stomach (85%), sleep apnea (75%), and syndromic child (72%).

Figure 1: Drugs used for premedication

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For carrying the child into the operating room (OR), distraction technique via video games was utilized by 89%, while 37% of respondents used play therapy. During induction, “blowing up the balloon” technique was most commonly used (78%). Other methods included engagement with the anesthesiologist, parental presence, and personalizing masks.

Ninety-five percent of participants opined that preoperative ARS should be integral to pediatric surgery practice. The common reasons for not following them were inadequate hospital setup (67%), lack of time (55%), OT list not running in sequence (45%), lack of knowledge or training (39%), and apprehension regarding the safety of drugs (30%). In addition, various shortcomings were faced by the respondents [Figure 2]. Of the several problems faced, inadequate sedation was the most common [Figure 3]. Ninety-seven percent of the participants believed that more awareness about ARS and protocol-based practices should be encouraged regarding this common perioperative problem.

Figure 2: Infrastructural shortcomings during premedication

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Figure 3: Complications following premedication

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Discussion

This survey provides an insight into the practice patterns on preoperative ARS in pediatric patients. PA-relieving practices have been surveyed to some extent in the United States, China, Great Britain, Europe, and Australia.^{[7],[8],[9],[10]} However, there is a dearth of comprehensive pan-Indian data in children. Therefore, we aimed to study the current practices so that a standardized practice of pediatric anxiety-relieving methods can be followed.

The survey clearly points out that more awareness should be spread regarding the importance of allaying PA since only 37% of anesthesiologists consistently utilized some type of ARS.

This survey emphasizes that despite the study results showing more usage of pharmacological techniques over nonpharmacological, these nonpharmacological techniques must be considered for all anxious children and may be used in conjunction with premedication or independently. This especially holds importance in peripheral setups where access to sedative drugs and availability of staff and equipment is difficult. In our study, parental education and counseling were the most common nonpharmacological methods utilized. According to a study by Musa et al., 78.3% of surgeons preferred preoperative education about the procedure as a mode to reduce patient anxiety.^[11] Surgeons play a pivotal role in allaying anxiety of patients and their parents by addressing their concerns related to the surgical procedure, perioperative experiences, and postoperative pain relief. Their direct contact with children from admission to discharge and care imparted by them provides a close relationship and promotes trust, thereby addressing both the physical and emotional aspects of PA. In our survey, 37% of anesthesiologists used parental presence to relieve a child's anxiety. Numerous studies highlight the benefits of parental presence, including the reduced requirement for premedication and increased child cooperation, whereas other studies point to the possibility of an increased parental anxiety.^{[12],[13],[14],[15],[16]} In a study, the overall prevalence of preoperative parental anxiety was found to be 74.2%.^[17] As per the Cochrane review, the presence of parents during induction did not diminish anxiety.^[18] Other nonpharmacological techniques like child preparation programs with play therapists, child psychologists, and clown doctors have proven to be of particular value in the Western world but have not been much popular in India.^[19]

In our survey, midazolam was the most preferred drug (80%), followed by ketamine (56%) [Figure 1]. Midazolam has a rapid onset of action with a short half-life and is readily available in most health setups.^[20] Our results are in accordance with the study by Kain et al., where midazolam was used by more than 80% of the respondents.^[7] Various randomized controlled trials have shown that premedication with midazolam provides superior anxiolysis compared to preparation program or parental presence.^[18],[21] Recently, α2-agonists such as clonidine and dexmedetomidine (mucosal or iv route) have gained popularity. A few meta-analysis have provided evidence that dexmedetomidine provides less respiratory depression, easy parental separation, more satisfactory sedation, and mask acceptance than midazolam.^{[22],[23],[24]} In our study, 13% of respondents used dexmedetomidine. There is a growing interest in the perioperative use of melatonin predominantly as anxiolytic in children. Available clinical data show that it is a safe and effective alternative to benzodiazepines with minimal action on psychomotor performance with an opioid-sparing effect.^[25],[26] In the survey, mainly the intravenous route was preferred, probably because most of the patients already had an intravenous cannula in situ. Transmucosal (intranasal, sublingual, buccal) route is an effective alternative to the oral route due to relatively better bioavailability accounted by bypass of first-pass metabolism.^[4] This route was utilized by 14% of the respondents.

When adjusted for area of practice [Table 3], respondents in the corporate sector used premedication more frequently than in medical colleges (P = 0.023). In contrast, practitioners in medical colleges were more likely to administer premedication than those in nursing homes (P = 0.017). It might be due to the better availability of personnel, drugs, and monitoring equipment in the corporate setup. The practice of premedication, however, did not differ when adjusted for the experience of the anesthesiologist [Table 2]. However, respondents with >10 years of experience felt that pharmacological techniques are safer compared to those with <5 years of experience (P = 0.007). This might be attributed to better knowledge of drug dose, route of administration, and competence of an experienced anesthesiologist in preventing and managing drug side effects. Sedative premedication is particularly important for children requiring multiple surgeries, children with a previous traumatic perioperative experience, and children with special needs that limit the child's ability to cooperate.^[3]

The survey suggests that premedication practices in a particular setup depended on the available health-care infrastructure including staff and monitors. Practitioners from nursing homes more commonly premedicated the children in the ward, inside OR, or in preoperative areas without monitors. A significant difference was found between medical colleges and nursing homes (P = 0.002), corporate versus nonteaching (P = 0.048), and corporate versus nursing homes (P = 0.041), as depicted in [Table 3]. In our survey, 50% of respondents premedicated children in unmonitored preoperative holding areas which could compromise the safety. Approximately 15% of respondents premedicated inside the OR, which may not fulfill the purpose of premedication. The most common (67%) problem encountered was inadequate sedation [Figure 3]. Despite the use of various ARS, only 27% of the respondents always carried a calm child into the OR, while the rest had difficulty in achieving adequate anxiolysis. This may be attributed to insufficient time for the onset of drug action, inadequate drug dose, or an improper administration technique.

We highlight a few points that can help improvise the practices of allaying pediatric PA. A family-centered preoperative behavioral preparation program with a multimodal approach should be stressed as it creates a child-friendly atmosphere and reduces the need for pharmacological intervention.^[27],[28] An appropriate drug dose, timed properly despite a change in the order of the OR list schedule, is the key to mitigate the problem of inadequate sedation. All sedative premedication drugs have varying cardiorespiratory side effects, and they should be administered preferably in a supervised area with the availability of monitoring and resuscitation equipment. The preoperative prevalence of parental anxiety is high and least recognized. It is worthwhile to address parental anxiety as ameliorating it may have a positive impact on children's perioperative anxiety. Special care with a more compassionate attitude has to be exercised in dealing with children with special needs and those with previous unpleasant hospital experiences. Management of PA should be an integral part of the perioperative period involving teamwork by anesthesiologists, surgeons, nurses, and family members. This survey may stimulate debate and discussion, leading to the development of national practice guidelines on this important topic. Further, age group-specific methods can be analyzed and the impact of decreased PA on the overall perioperative outcomes can be investigated.

The survey has some methodological limitations. Although nationwide anesthesiologists were invited to participate in our survey, the responses of predominantly urban anesthesiologists may not necessarily reflect practice patterns across the country due to variability in workforce, facilities, and knowledge. A child with prolonged fasting will resist any type of nonpharmacological ARS. We did not assess whether the respondents adhered to the liberal fasting guidelines which could be one of the causes of failure of nonpharmacological methods.

Conclusion

A variety of ARS are being used for interventions in pediatric population across the country. Although there is a general consensus about the need and importance of allaying PA, the “actual practice pattern” in the Indian scenario has been portrayed in our survey. Of the surveyed anesthesiologists, only 37% consistently used these techniques. Our survey has highlighted the gaps in knowledge and practice of allaying pediatric PA. It has brought to light the commonly associated problems and deterrents to this essential practice. This survey can provide an insight to the practicing anesthesiologists on working toward alleviating pediatric PA. Second, this can provide future directions to address the challenges faced and can indirectly improve this work area. In comparison with the Western world, India is lacking behind in implementing ARS. Age and behaviour appropriate non-pharmacological techniques should be encouraged. Increasing awareness regarding the importance of allaying PA and improvement in health-care infrastructure with a coordinated team approach can help us in mitigating this common perioperative phenomenon.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Annexure 1

Preoperative Anxiety-Relieving Strategies in Pediatric Anesthesia Practice

(This is a survey on practice of premedication and anxiety-relieving strategies in children aged 1–12 years. Filling up this form implies your consent to participate in the survey. Personal details will be kept anonymous)

SECTION A

In which setup do you practice? (Check all that apply)

What is your place of practice? (Check all that apply)

Years have you been practicing anesthesia?

Do you exclusively practice pediatric anesthesia?

What is the average number of pediatric cases you perform per month?

SECTION B: Anxiety-relieving strategies

Do you consider premedicating children before wheeling them in operating/procedural room? (Mark only one)

What preoperative anxiety-relieving strategies do you follow? (Mark only one oval)

Which technique do you think is safer to practice? (Mark only one)

How do you wheel the child into the OT? (Check all that apply)

SECTION C: Pharmacological methods

What premedication do you generally use? (can select multiple options)

Where do you generally premedicate the child? (Check all that apply)

In cases of premedication in a monitored area, the monitoring employed

Do you generally give the drug well before time and have a calm child before wheeling in? (mark only one oval)

In which of the following scenarios would you not consider premedicating the child? (can select more than one option)

SECTION D: Behavioral intervention/nonpharmacological methods

Which of the following preoperative preparation techniques do you use? (Check all that apply)

What methods do you generally use in preoperative area while wheeling in the child? (Check all that apply)

Which of the following do you use while induction? (Check all that apply)

What do you think are the advantages of parental presence during induction? Check all that apply.

What do you think are the disadvantages of parental presence? (Check all that apply)

SECTION E: Attitude

Do you think preoperative Anxiety-relieving strategies should be an integral part of pediatric anesthesia practice? (Mark only one oval)

What do you think are the reasons for not following these practices commonly? (Check all that apply)

Infrastructural shortcomings that you face routinely in administration of sedative premedication: (Check all that apply)

Have you ever experienced any of the following problems in your practice with premedication? (can select more than one option)

Check all that apply.

Do you think premedication and other anxiety-relieving methods are often an overlooked part in pediatric anesthesia practice? (Mark only one oval)

Do you think more awareness and protocol-based practices regarding these methods should be encouraged for pediatric anesthesia practice? (Mark only one oval)

Yes

Maybe

**Thank you for taking part in the survey**

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