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Craig Sims, Dana Weber and Chris Johnson (eds.) A Guide to Pediatric Anesthesiahttps://doi.org/10.1007/978-3-030-19246-4_3

3. Behavioral Management of Children

Craig Sims¹ and Lisa Khoo¹

(1)

Department of Anaesthesia and Pain Management, Perth Children’s Hospital, Nedlands, WA, Australia

Craig Sims (Corresponding author)

Email: craig.sims@health.wa.gov.au

Lisa Khoo

Email: Lisa.Khoo@health.wa.gov.au

Keywords

Perioperative anxietyAnesthetist behaviors and child anxietyDistraction techniques for anesthesia inductionParental presence at inductionPremedication for pediatric anesthesia

Children are anxious before anesthesia and surgery because of unfamiliar surroundings, a sense of loss of control, the presence of strangers, parental anxiety and many other perceived threats. Like adults, they respond to stress depending on their temperament and personality. At induction of anesthesia some children will say they are frightened, others will cry, withdraw, cling to their parent or become uncooperative. Unlike adults who will remain cooperative despite being nervous, young children will let you know one way or another they are frightened. Many anesthetists may be uncomfortable caring for children because of the potential for frightened children to become uncooperative. Behavioral management includes techniques to reduce children’s anxiety at induction and improve cooperation.

3.1 Anxiety at Induction of Anesthesia

Anxiety increases from admission to induction, with induction of anesthesia being the most stressful part of a child’s hospital admission (Fig. 3.1). Children can display their anxiety with verbal or physical resistance, crying, screaming, becoming quiet and withdrawn, or expressing fear or sadness. These signs of anxiety are more frequent in younger children and are unfortunately very common: 42% of 2–10 year olds show one of these signs and 17% show three or more. Up to 25% of children who have not had a premed or parent present require restraint at induction. The anxiety experienced by the child depends on many factors, including temperament, their coping strategies, past experiences, the anxiety of parent and the behaviors of staff.

../images/467929_2_En_3_Chapter/467929_2_En_3_Fig1_HTML.png — Fig. 3.1

A child’s anxiety increases during the different preoperative stages towards induction, although there is great variation between children depending on their temperament, past experiences and many other factors. Based on Chorney JM, Kain ZN. Anesth Analg 2009;109: 1434–40

3.2 Consequences of Anxiety at Induction

There are five consequences of anxiety at induction:

Reduced cooperation
Agitation during emergence from anesthesia
Possibly increased postoperative pain
Regression of behavior for up to several weeks afterwards.
Increased anxiety at subsequent hospital admissions and anesthetics.

The stress associated with hospitalization and surgery contributes to postoperative behavior changes (Table 3.1). Initial studies have found these changes in children admitted overnight to hospital, and more recent studies also found them in children having surgery as outpatients. These behavioral changes may persist long after discharge, and a small proportion of children may have them for a few weeks or months (Fig. 3.2). Their incidence depends on the temperament and personality of the child but they are more likely to occur in preschool-aged children and those who were anxious at induction. Children who have a ‘stormy’ induction are more likely to be agitated when awakening and more likely to have postoperative behavioral disturbances (Fig. 3.3). They may also become more anxious about future anesthetics (Fig. 3.4). These effects are probably reduced with premedication or other strategies to reduce pre-operative anxiety.

Table 3.1

A child’s behavior may regress to that of a younger child in response to the stress of hospitalization and surgery

Behavior change after anesthesia and surgery
Sleep disturbances and night terrors
Clingy and separation anxiety
Withdrawn and quiet
Fear of doctors or hospital
Food refusal; disobedience
Tantrums
Enuresis

../images/467929_2_En_3_Chapter/467929_2_En_3_Fig2_HTML.png — Fig. 3.2

Percentage of children aged 1–7 years with behavior changes at different times after anesthesia and surgery. Based on Kain ZN et al. Anesth Analg 1999;88: 1042–7

../images/467929_2_En_3_Chapter/467929_2_En_3_Fig3_HTML.png — Fig. 3.3

A difficult, ‘stormy’ induction is associated with an increased incidence of behavioral changes after anesthesia. Since children can’t be randomized to calm or stormy inductions, it isn’t known if the child’s temperament that predisposed them to anxiety also predisposed them to behavioral changes afterwards. Data from Kain ZN et al. Anesth Analg 1999;88: 1042–7

../images/467929_2_En_3_Chapter/467929_2_En_3_Fig4_HTML.png — Fig. 3.4

Preoperative anxiety may affect emergence from anesthesia and cause dysfunctional behavior in the postoperative period. This experience may then increase the child’s anxiety at the next anesthetic

3.3 Reduction of Anxiety at Induction

Most strategies to reduce anxiety are aimed at the child and parent, and include psychological preparation or education programs, parental presence at induction, and pharmacological premedication. The child’s anxiety however, is greatly affected by the behavior of the anesthetist.

3.3.1 Psychological Preparation for Anesthesia and Surgery

The aim of psychological preparation is to reduce the child’s anxiety and improve their behavior at induction. A range of preparation techniques are required and must be appropriate to the child’s developmental age, temperament and personality.

The most intensive preparation is performed by Child Life Therapists (Play Therapists) and Occupational therapists. They are experts in child development and promote coping strategies through play, education, and self-expression activities. This preparation teaches children coping and relaxation skills, provides information about events and procedures, and supports the child and parents during the preoperative period. Another form of preparation is modelling, in which the child indirectly experiences the theatre environment through video, puppet shows and other media. These programs are labor-intensive and expensive, and are usually reserved for children who have behavioral issues from frequent medical procedures. Unfortunately, although these techniques reduce anxiety leading up to anesthesia, they do not reduce the intense anxiety at the time of induction in most children. The anesthetist can teach simple relaxation techniques such as deep breathing and muscle relaxation on the day of surgery. Younger children can be taught to hold their breath. These techniques then can be brought out if anxiety and distress occur: “remember your job is to take a big breath and hold it still like a statue, so go ahead now and take that breath”.

Hospital tours are another form of preparation, but time and economic factors mean that in practice this high-level preparation is given only to a small proportion of children, and often to well-motivated families whose children are least likely to need or benefit from the preparation.

The commonest, though least effective form of preparation is written or video information for the child and parent (Table 3.2). The information needs to be specific and contain a description of what will happen, as well as sensory information about what will be seen, heard, smelt, tasted or felt. Less information needs to be given to preschool children as they have a limited ability to conceive alternate physical states. In this age group, it is best to concentrate on giving information to prepare their parents. In the future, web-based programs will give information tailored to each child’s developmental age and personality, and may be more effective.

Table 3.2

Summary of recommendations for preoperative information to children

Recommendations for preoperative information
Methods of delivering information: – Video format – Written, especially with illustrations (book)
Information to be included: – Specific, age appropriate information – Include both what will happen and what will be felt or seen – Specifically mention pain if likely to happen, but care with word choices and suggestion – Choices or preferences for aspects of anesthesia can be discussed with adolescents to help them feel more in control and reduce anxiety, but younger children unlikely to comprehend – Provide all children opportunity for questions
Best time to give: – 6 years or younger, give closer to time of procedure – Older than 6 years, give more than 5 days beforehand

Recommendations for preoperative information

Methods of delivering information:

– Video format

– Written, especially with illustrations (book)

Information to be included:

– Specific, age appropriate information

– Include both what will happen and what will be felt or seen

– Specifically mention pain if likely to happen, but care with word choices and suggestion

– Choices or preferences for aspects of anesthesia can be discussed with adolescents to help them feel more in control and reduce anxiety, but younger children unlikely to comprehend

– Provide all children opportunity for questions

Best time to give:

– 6 years or younger, give closer to time of procedure

– Older than 6 years, give more than 5 days beforehand

Note

Both the parent and child need to have their anxieties and concerns managed. Always remember the parent-parental anxiety increases the child’s anxiety and worsens their behavior at induction.

When to give information depends on the age of the child. Young children don’t retain information very long whilst older children may become more distressed if information is given too close to the time of the procedure. Children older than 6 years benefit from receiving information at least 5 days before the procedure. Closer to surgery, the information is better kept less specific and intimidating. Children younger than 6 years can receive information 1 or 2 days beforehand. Some parents do not tell their child that a procedure is going to happen, believing this will cause the child less stress. However, these children are nearly always very distressed at wakeup and afterwards, demonstrating the need to at least mention the procedure to the child beforehand.

If the anesthetist is not used to talking to children, a pragmatic alternative is to provide information to the parents, and then rely on them to explain to the child in an appropriate manner or language. This approach avoids inappropriate words or concepts, but perhaps risks misinformation.

3.3.2 The Behavior of the Anesthetist at Induction and Its Effect on the Anxiety of the Child

The behavior of an adult affects the behavior of a child. Observational studies of anesthetic staff and children at the time of induction show the behaviors of anesthetic staff can either worsen or reduce a child’s anxiety. Aspects including the staff’s posture, facial expression and position relative to the child may affect the child’s anxiety. The anesthetist can make a big difference to the child’s anxiety and experience of anesthesia by getting the child’s attention and keeping it. This stops the child from becoming internally focused due to fear, and then becoming inaccessible. Distracting the child at induction avoids behaviors that increase anxiety. Reassurance and empathic statements focus the child on their feelings or distress and increase anxiety. Distraction steers attention away from the medical procedure and reduces anxiety (Table 3.3). The words chosen by the anesthetist also affect the child’s behavior. Framing discomfort using playful imaginative or abstract language is helpful—‘sparkles’ up the arm rather than ‘this may sting a little’, or ‘a beautiful perfume’ rather than ‘this gas might smell’.

Table 3.3

Reassuring, empathic statements focus the child on their feelings of distress and increase anxiety

Anesthetist behaviors that increase a child’s anxiety		Anesthetist behaviors that reduce a child’s anxiety
Reassurance, empathy and apologizing	“You’ll be OK” “Don’t worry” “I know it’s hard” “I’m sorry”	Non-procedural talk	Talking about toys, pets, favorite movies Story telling
Excessive technical or medical talk	Too much information about procedure or equipment	Humor	Jokes
Suggesting control when none exists	“Are you ready to come to theatre now?” “Can I put the mask on now?”	Choices with clear limitations and does not allow avoidance of procedure	“Walk or ride on trolley?”; “Strawberry or chocolate mask?” “You can breathe on the mask or just blow it away”
Multiple adults talking		Medical play	‘Astronaut space mask’
Allowing child to delay		Firm warm confidence
Poor word choice	Needle, sting, hurt Focusing on what child can’t do	Good word choice	Metal tube, plastic straw Focusing on what child can do

Distraction steers attention away from the induction and reduces anxiety

Based on Martin et al. Anesthesiol 2011;115: 18–27

3.3.2.1 Effective Distraction

Although some children will be relaxed with simple non-procedural talk about school or toys, other children are more anxious and benefit from stronger distraction. The choice of a distraction depends on a complex interaction between the anesthetist’s personality, the child’s age and temperament, equipment available and the theatre environment. Some anesthetists are great story tellers and are able to guide the child into an imaginary world; others can use pretty stickers or a toy, tell jokes, or do a few magic tricks. A popular technique uses video games or movies on a hand-held device. Effective distraction needs to start early, be continuous and increase as induction progresses (Table 3.4).

Table 3.4

No matter the distraction used, there are several characteristics to maximize its effect

Effective distraction
Is interesting and new to the child
Begins with a sense of anticipation to build excitement
Gets child’s attention as soon as entering theatre
Increases as induction approaches and anxiety increases
Is continuous with no pauses or gaps that might lose child’s attention
Has the strongest distraction saved for the time of mask acceptance or IV insertion when anxiety is maximal

3.3.3 Pharmacological Premedication

Premedication (premed) is the most reliable way to reduce a child’s anxiety and improve cooperation at induction. It also reduces parental anxiety and improves parental satisfaction. However, not every child requires a premed, and the skill is in choosing which child will benefit. A premed may slow wake up, cause dysphoria in recovery and carries a cost in nursing time. The premed is nearly always given orally, though this requires some cooperation from the child. The nasal or buccal route may be an alternative. The advantages and disadvantages of oral premeds are listed in Table 3.5. There are a few situations in which a premed should be avoided or used in a reduced dose. These are when a difficult airway is anticipated, there is severe sleep apnea, an increased risk of apnea, and when there is raised intracranial pressure.

Table 3.5

Comparison of oral premeds and their advantages and disadvantages

Oral premed agent (time to give before induction)	Advantages	Disadvantages
Midazolam 0.3–0.5 mg/kg, max 15 mg (30 min)	Rapid onset Short duration Anxiolytic Doesn’t delay discharge	Bad taste Dysphoria Amnesia
Clonidine 4 𝛍g/kg (60 min)	No amnesia Reduces emergence dysphoria Timing of administration less critical Tastes better than midazolam	Slow onset Long duration- may delay discharge Bradycardia Child easily awakens with noise or stimulation at induction
Dexmedetomidine 3 𝛍g/kg (45 min)	Well tolerated Analgesic, sleep-like sedation Possibly anxiolytic	Intranasal route may be better. Use 2 μg/kg Expensive
Ketamine 2–5 mg/kg (30 min)	A ‘heavy’ premed for autism, developmental delay, uncooperative older child	PONV Dysphoria Potential for airway obstruction Not suitable for routine use

Oral premed agent (time to give before induction)

Advantages

Disadvantages

Midazolam 0.3–0.5 mg/kg, max 15 mg (30 min)

Rapid onset

Short duration

Anxiolytic

Doesn’t delay discharge

Bad taste

Dysphoria

Amnesia

Clonidine 4 𝛍g/kg (60 min)

No amnesia

Reduces emergence dysphoria

Timing of administration less critical

Tastes better than midazolam

Slow onset

Long duration- may delay discharge

Bradycardia

Child easily awakens with noise or stimulation at induction

Dexmedetomidine 3 𝛍g/kg

(45 min)

Well tolerated

Analgesic, sleep-like sedation

Possibly anxiolytic

Intranasal route may be better. Use 2 μg/kg

Expensive

Ketamine 2–5 mg/kg (30 min)

A ‘heavy’ premed for autism, developmental delay, uncooperative older child

PONV

Dysphoria

Potential for airway obstruction

Not suitable for routine use

Midazolam is the most commonly used agent, though there is also strong support for clonidine

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