At What Age Are Patients Most Likely to Develop Separation Anxiety?

Between 7–10 months of age, infants will become anxious when being separated from their parents. This separation anxiety can persist throughout all ages of childhood.

What Is the Incidence of Preoperative Anxiety in Children?

Estimates reveal that at least 60% of children develop significant fear and anxiety before surgery. Many children and families list the separation from parents and induction of anesthesia as the most stressful time during the surgical experience.

What Are the Risk Factors for Preoperative Anxiety in Children?

There are child, parent, and environmentally related risk factors for children having preoperative anxiety.

The preoperative period is often a stressful and anxiety-provoking phase for children and their family. It is not unusual for the parents to be frightened and to project their fear and anxiety on the child, thereby unintentionally contributing to the child’s fear and anxiety. Increased parental anxiety is noted in parents of children less than one year of age, and in children with repeated hospital admissions.

What Are the Overall Benefits of Reducing Preoperative Anxiety?

The most important outcomes related to preoperative distress in children are postoperative behavioral disorders. These include nightmarish sleep disturbances, feeding difficulties, apathy, withdrawal, increased level of separation anxiety, aggression toward authority, fear of subsequent medical procedures and hospital visits, and regressive behaviors such as bed wetting. Although these disturbances are primarily present within the first two postoperative weeks, in some children they may last for several months. Much has been made of this issue in the recent literature, but the concept is not new.

Children who were anxious in the preoperative period were found to have more postoperative pain, require more pain medications while hospitalized and during their first 3 days at home, and have a greater incidence of emergence delirium, postoperative anxiety, behavioral changes (apathy, withdrawal, enuresis, temper tantrums, eating disturbances), and sleep disturbances. In adults, increased preoperative anxiety is associated with poor postoperative clinical and behavior recovery.

How Should You Prepare the Parents Prior to Induction?

One of the most important preoperative responsibilities of the pediatric anesthesiologist is to allay anxiety in the parents and other family members. During the preoperative visit the anesthesiologist, while talking to the parents, should initiate contact and communication with the child. It does not matter if the child is too young to understand or is too premedicated to remember any events. The parents will key in on the anesthesiologist’s manner and how he or she relates to the child. Asking children about their interests and performing a simple fist-bump will establish confidence and minimize parental anxiety.

A controversial issue in pediatric anesthesia is the extent to which the anesthesiologist should reveal the risks of anesthesia to the parents. Will this discussion increase or decrease parental (or child) anxiety? Should the anesthesiologist discuss the risk of death? What risks are appropriate to reveal? The answers to these questions are not easily found and may partly depend on the informed consent laws of the state in which one practices. Studies universally demonstrate that anxiety is decreased with more information, even though that information may allude to more harmful risks. For example, in a questionnaire study, most parents whose anesthesiologist mentioned the risk of death indicated they were satisfied to hear about this rare risk. Many parents whose anesthesiologist did not specifically mention the risk of death indicated that it should have been mentioned.

During the preoperative informed consent process, it is helpful to know the modern-day risks of general anesthesia in children. A study from the Mayo Clinic revealed an incidence of cardiac arrest in anesthetized children (for noncardiac surgery) of 2.9 per 10,000, although when attributed only to anesthetic causes, the incidence decreased to 0.65 per 10,000 anesthetics. Only a small percentage of these patients were initially healthy prior to the procedure.

What Are the Methods Used to Reduce Preoperative Anxiety?

Many different modalities have been used in an attempt to decrease fear and anxiety in patients and their families. There are two broad categories of interventions:

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  Behavioral interventions: preoperative preparation programs (child life therapy), distraction techniques, parental presence at induction, preoperative interview, and tour of hospital and/or operating complex.

  
  
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  Pharmacological/premedication: midazolam (IV, oral, nasal, or rectal routes of administration), dexmedetomidine (oral or nasal).

What Is the Efficacy of Behavioral Interventions?

In carefully performed and controlled studies, these aforementioned behavioral interventions do not fare much better than placebo in decreasing the incidence of postoperative behavioral disturbances. Although distraction techniques are often effective for allaying anxious behavior during induction of anesthesia, premedication with an anxiolytic drug is the only proven intervention to decrease these undesirable outcomes.