The Child’s Previous Experiences of Health Care Affects on the Child’s Anxiety in Connection to Anaesthetic Induction: A Systematic Review

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Örebro University

School of Medicine

Medicine, Advance course

Degree project, 15 ECTS

May 2018

The Child’s Previous Experiences of Health

Care Affects on the Child’s Anxiety in

Connection to Anaesthetic Induction: A

Systematic Review

Author: Janina Björklund

Supervisor: Elisabeth Ericsson

Associate Professor, PhD, RNA

Örebro University

Sweden

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Abstract

Background: Preoperative anxiety in children is a common phenomenon, 40-70% of all children shows signs of fear, distress or anxiety, which peaks during the time of anesthesia induction. These preoperative emotions have also been associated with a number of negative clinical postoperative outcomes including slower postoperative recovery, and higher doses of postoperative analgesia

Aim: To summarize published studies that explore the relationship between

children´s previous experience of health care and preoperative anxiety in connection with anesthetic induction.

Method: A review with systematic approach based on SBU directions was conducted. Articles were searched in PubMed. The methodological quality of the included studies was evaluated. The analysis included both prospective and retrospective observational studies.

Results: In all, 13 studies were included. The factor previous negative experience of health care (eg vaccination and previous dental and surgery procedures) increases the distress during the preoperative period. This finding was demonstrated in 70% of all articles that were included in the review.

Conclusions: The present review highlights how children’s previous negative experiences of healthcare affect their anxiety during the preoperative period.

Attention to pharmacological and psychological issues relieving children´s anxiety at anesthesia induction is important. The health care staff plays an important role, and are responsible in these situations.

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Introduction

Pre-operative anxiety is one of the most common emotional responses that children can experience prior to surgery. About 60% of all young children undergoing anesthesia and surgery reported significant fear, anxiety, or distress [1,2]. Preoperative anxiety is predictive of a number of negative clinical postoperative outcomes including slower postoperative recovery, and higher doses of postoperative analgesia [3–5].

The stress during the preoperative period has been noted to peak at the time of induction of anesthesia [6–9]. How previous experiences of medical procedures in health care impacts the child’s anxiety prior to and during anesthetic induction needs to be evaluated.

Bakground

Anxiety

Anxiety is often diffuse and unpleasant; it can be accompanied by autonomic

symptoms of varying degree such as headache, discomfort in the stomach, increase in heart rate, sweating and restlessness. Both fear and anxiety is used as an alerting signal of the body for impending threat. The difference between anxiety and fear is that fear alerts for a known external threat, whereas anxiety alerts for a unknown internal threat which may be vague and conflicting[10].

Distress is often expressed and measured in five types of distress behaviors: crying, screaming, nonverbal resistance, vocal resistance and negative verbal emotions [11]. Anxiety and distress is a common emotion during stressful life events and children <5 years of age are the most sensitive [2,12,13]. This might be due to the psychobiology and a less developed view of the world around them [2].

Anesthesia and anxiety

The induction of anesthesia is included in the preoperative period. The preoperative period also includes placement of the peripheral venous catheter usually in the pre-holding area, followed by movement to the Operation Theater and injection or inhalation of the anesthetic medication. This might in some cases or certain cultures include separation from the parents before moving into the induction area [6].

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Anxiety in children is a big issue during induction of anesthesia. There are

approximately 450,000 children under the age of 18 that undergo surgery annually in the United States [14]. About 40-70% of all children undergoing surgery with general anesthesia shows signs of fear, distress or anxiety [11,12], which peaks during the time of induction [6–9]. This anxiety has been shown to affect compliance of children and up to 21% of all children are non-compliant or show poor compliance during the induction of anesthesia [15]. Non-compliant behavior from the child may evolve to a point where physical restraint is used, up to 31% of 1-3 years olds have to be

physically restrained by their parents during induction of anesthesia [16].

Preoperative anxiety can affect the child in a number of different ways. Children with high preoperative anxiety have increased postoperative pain [3,17] as well as a

threefold higher risk of postoperative anxiety [18]. High preoperative anxiety has also been shown to correlate with a higher consumption of analgesics during their home recovery [3]. There is also a correlation with preoperative anxiety and postoperative maladaptive behavior changes or worsening of already existing negative behaviors. These behaviors include disturbance in eating and sleeping habits [3] as well as night cries or terrors, temper tantrums, fear of darkness, strangers and having their face covered and bed-wetting. Up to 80% of children undergoing general anesthesia show at least one maladaptive behavior two days after surgery [9] and 57% of all three year olds have continuous negative behavior changes two months after the surgery whereas 32% of all 6-year olds show the same changes [19].

Emergence from the anesthesia can also be affected by preoperative anxiety.

Emergence may be uneventful but in about 12-19% of all cases it can be complicated by agitation which is called emergence delirium [9,20,21]. Agitation can last 3-45 minutes and is associated with a longer postoperative recovery. Sixty percent of the children undergoing emergence delirium requires physical restraint [20]. There is a clear correlation between emergence delirium and preoperative anxiety where the higher anxiety significantly increases the risk for agitation [9].

Prevention and intervention strategies

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approaches. Examples of non-pharmacological approaches are behavior preparation programs with information brochures, preoperative guide tours, play rooms with anesthetics equipment, and also web-based age-specific information systems [5,22]. One example of a preoperative strategy to help children is a web-site

(http://www.narkoswebben.se/) in Sweden. The web site is translated to many languages and is provided for caregivers and children who will undergo anesthesia [23]. Play intervention has been shown to reduce state-anxiety before induction of anesthesia as well as lower negative emotional manifestations and decrease postoperative pain [24].

The usefulness of parental presence during induction of anesthesia to reduce the anxiety of children has been published in many studies, despite that the conclusions are not straightforward [22]. During the time of the surgery and the induction of anesthesia parents who are calm overall lowers the anxiety levels in the children while anxious parents would enhance the anxiety in children who might have expressed calm behaviors earlier. This shows the influence of parent’s behavior and emotions on children’s behavior and emotions [25].

Prevention and intervention with preoperative sedative medications is most used to achieve general stress reduction. Sedative medications also have limitations with side effects such nausea and vomiting [5,22]. A limitation is also that one of the most commonly used drug for sedation, benzodiazepine (midazolam) block the explicit memory but not the implicit memory [22]. Explicit memory loss can reduce the possibility to treat traumatic experience. Midazolam has been seen to decreased the incidence of postoperative behavioral changes. Alternatives to midazolam are the alpha-2 adrenoceptor agonist clonidine, with significant sedative properties. Clonidine does not affect memory and also have analgesics properties [22].

There is lack of synthesis of reviews about children’s previous experience in healthcare, if this factor affects the child’s anxiety and or compliance in connection with anesthesia induction. Systematically reviewing the literature in this area can help to pinpoint problems and needs for strategies alleviate this and reduce the risk for future healthcare situations.

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Aim

To summarize published studies that explore the relationship between children´s previous experience of health care and preoperative anxiety in connection with anesthetic induction.

Method

Design

A review with a systematic approach was conducted, as it is the most non-bias approach for the research question.

Selection Criteria

The following criteria for inclusion were applied: children aged between birth and 18 years, outcomes of preoperative anxiety in relation to the induction of anesthesia, English language, and humans.

The exclusion criteria were reviews, case studies, studies presented only in abstract form, editorials and studies about hospitalized oncology patients.

Search

The method of the searches were performed according to the regulation of SBU (Statens Beredning för medicinsk och social Utvärdering) [26]. To locate eligible studies, several test searches were performed to acquire an understanding and an overview of the subject. PubMed database was chosen as the source for this review. Supplementary search approaches such checking reference lists were also used to identify articles.

Two main searches were carried out.

Selection process

The author, based on the inclusion criteria outlined above, completed the screening process. The titles and abstracts of each study were initially screened, and non-relevant and duplicate studies were eliminated. The full text of potential studies was further examined to determine whether inclusion criteria were met In case of

uncertainty, a second person was brought in to aid in resolution.

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paired with Anesthesia or the preoperative period, therefore the MeSH terms Anesthesia OR (Preoperative care OR Preoperative Period) were chosen. Adding previous experience, not as a MeSH term, to the search made it more specific and yielded 52 results. The extra filters added and inclusion criteria for this article were children, Child: birth-18 years, and the language English, which yielded 35 results (Figure 1). Of these, 11 articles were selected for further evaluation.

Figure 1: Flow Chart First Search

The second search was executed the 20th of April 2018. The second search was performed to be broader. The MeSH terms Preoperative Care AND

Anxiety/Psychology* AND Child was used. This yielded 93 results. After adding the filters Child: birth-18 years, and English the search yielded 85 results (Figure 2). Thirty-four articles were picked out for further evaluation and ordered in full text.

Figure 2: Flow Chart Second Search

All excluded articles from the second step in the selection process can be viewed in attachment A. The most common reason for exclusion was that the article did not contain the specifics of children’s previous experiences of medical procedures and its influence on anxiety.

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Additionally to the two searches in database PubMed the reference lists from the retrieved articles were searched manually. Through this search three additional articles [37,45,40] were found and included in the review.

Quality review

To assess the methodological quality of the included studies an evaluation form was used (Örebro universitet 2015) [27,28].

Two different templates were used for quantitative studies without control group or randomized controlled studies and observational studies with control group. The evaluations forms have three-point score “high”, “medium” and low”.

To maximize the inter-evaluator reliability a second person reviewed the quality of all included articles as well [26].

Ethical consideration

The present is a systematic review and does not include any original personal data. The review of the articles has assured that the research is conducted in accordance with the Declaration of Helsinki [29]. Key elements criteria of ethics in clinical research [29] are informed consent, confidentiality, privacy, privileged

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Results

Both data searches as well as the manual search of the references yielded together 13 articles that were included in this systematic review, six from the first search, four from the second and three from the reference search. A summary overview of the included studies is presented in Table 1.

Characteristics

All 13 studies included were published between 1992 and 2017, and contained 2425 children in total ranging in ages from 2-18 years of age. The number of participants varied from 50-1224. The majority of the included studies were from United States (n=4) and Sweden (n=4) (Table 2).

Eight of the studies were observational studies [30–37] and five were controlled studies [38–42]. All studies used quantitative method, two of the studies were retrospective [38,42] while the rest were prospective studies. The overall

methodological quality of the studies ranged from high to low quality based on the evaluation form used (see table 1). Three articles were evaluated to be high quality articles [30,35,39], eight were evaluated to be medium quality articles [32–

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Table 1. Summary of studies

Authors, year, country of origin

Type of study and Aim Population Previous experience

Measurement of anxiety and study time

Key findings for Review Quality score

Al-Jundi SH et al. 2010 Jordan [33] Quantitative prospective observational study To examine anxiety levels, and to identify factors affecting preoperative anxiety among children undergoing general anesthesia for dental rehabilitation. To assess parental distress and attitude to accompanying their children during procedure 118 children Aged 2-12 Previous experience of GA Global Mood Score (GMS) Waiting room GA induction room and Time of induction A significant correlation between anxiety and previous experience of general anesthesia (p=0.012)

Medium

+Large population size - Loss is not presented - No analysis of population size - No ethical reasoning Beringer RM et al. 2014 Australia [30] Quantitative Prospective observational study To determine the incidence of behavioral changes within out institution and identify which children are at increased risk. 102 children Aged 2-12 Quality of previous events with doctors and dentists Modified Yale Preoperative Anxiety Scale, Pediatric anesthesia Behavior During induction of anesthesia A significant correlation between distress behavior at induction of anesthesia and a previous history of traumatic events with doctors or dentists (P<0.001)

High –

+ Analysis of population size + Inclusion and exclusion criterions

+ Large population size - No presentation of losses - No suggestions for future research

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Cropper J et al. 2011 UK [31] Quantitative, prospective, observational study To measure the amount of behavioral distress at induction of GA. 84 children Aged 4-7 Previous procedures under GA Induction compliance checklist Induction of anesthesia There is a Relationship between distress at induction and number of previous procedures (P=0.001) Low - No inclusion or exclusion criteria - No presentation of population - No presentation of losses - No discussion about weaknesses

- No suggestion for further research - No ethical reasoning Davidson A J et al. 2006 Australia [35] Quantitative prospective observational study To identify possible risk factors of high anxiety at induction in a large representative sample of children presenting for anesthesia. 1224 children Aged 3-12 Number of previous hospital admissions and GA. Behavior at previous GA and healthcare attendances. Modified Yale Preoperative Anxiety Sclae (mYPAS) Immediately prior to induction of anesthesia. No correlation between anxiety and less than five previous hospital

admissions (p=0.4) or previous GA (p=0.5) High correlation between anxiety and more than five previous hospital

admissions (p<0.001) and previous GA (0.002). High correlation between anxiety and behavioural problems with any previous

anesthesia (p<0.001) or previous health care attendance (p<0.001)

High

+ Inclusion and exclusion criteria

+ Presentation of loss

+ Analysis of population size + Large study population - No ethical reasoning

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Ellerton M L et al. 1994 Canada [38] Quantitative, non-randomized retrospective study To evaluate a preadmission program to prepare children and families psychologically for day surgery

75 children Aged 3-15 Previous day surgery experience FACES Scale Retrospective about induction of anesthesia

Double the amount of children who had previous day surgery experience reported high levels of anxiety just prior to surgery (P<0.08)

Low

+ Ethical reasoning present - Not randomized

- Less not presented - Retrospective - No inclusion or exclusion criteria Ericsson E et al. 2006 Sweden [39] Quantitative randomized prospective control study To compare child behavior before surgery with experience of pain and anxiety in relation to two techniques of tonsil surgery

92 children Aged 5-15 Previous experience of surgery State.Trait Anxiety Inventory for Children During preholdning area 1 hour before surgery.

Children with previous experience of surgery did not differ significantly in anxiety pre operatively. High + Consort + Procedure flowchart - No ethical reasoning - No analyses of population size

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Fortier A M et al. 2011 U.S.A [37] Quantitative prospective observational study To conduct a prospective assessment of preoperative anxiety in adolescents undergoing surgery 59 Adolescent Aged 11-18 Previous surgery and behavior at previous medical visits. Visual analog scale:during preoperative holding area, separation from parents and introduction of anesthetic mask. Heart rate and Skin conductance level throughout preoperative care. Blood pressure at holding area and enter to operating room.

History of previous surgery and behavior at previous medical visits did not correlate with higher anxiety.

Medium -

+ Inclusion and exclusion criteria

- No report of limitations - No analyses of losses - Small population size - No ethical reasoning Hatava P et al. 2000 Sweden [42] Quantitative randomized retrospective control study To evaluate a new

preoperative information programme, with regard not only to retrieval of

information but also to possible alleviation of pre- and postoperative distress.

160 children aged 2-10 Previous experience of GA. Selfrating questionnaire for childrens and parents emotional experience of premedication, operation theatre, preanesthetic preparation and induction of anesthesia Retrospective

Older children without previous experience had an incidence of negative attitudes towards premedication of 18%.

Corresponding group with such experience had 56%. (P<0.001)

Among younger children (<5years) with previous experience in control group 67% were negative.

Medium -

+ Large population size - No ethical reasoning - Presentation of population is not correct - No analysis of population size - No presentation of losses - Retrospective

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Kain, N Z et al. 1996 U.S.A [36] Quantitative prospective observational study

To determine predictors and behavioral outcomes of preoperative anxiety in children undergoing 163 children aged 2-10 Quality of past medical encounters and previous surgeries. Clinical Anxiety rating scale: at separation from parents Anxiety Visual Analog Scale: in preoperative holding area and at separation Venham Picture test: in

preoperative holding area.

Previous poor medical encounters gave higher anxiety than previous good medical encounters p=0.01. Children with previous bad medical experience showed higher anxiety in pre-holding area. Children with previous hospitalization showed more anxiety at separation. Children with Previous surgery were significantly more anxious (p=0.01)

Medium

+ Large population size - No inclusion and exclusion criteria - Loss is not represented - Population size not explained - No ethical reasoning Lumley M A et al. 1993 U.S.A [32] Prospective quantitative observational study. To examine preexisting behavior problems as predictors of anxiety to induction. And to examine 50 children ages 4-10 Quality of past medical encounters and previous surgeries. Operating room behavioral rating scale: during walk from waiting area to operating room, placement on the table and induction HR in the operating room during induction. Significant correlation between poor past medical experience and behavioral distress p=0.03. Having one prior surgery predicted increase in HR p=0.04. Medium - No ethical reasoning - No analysis of population size - No presentation of losses

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Proczkowska -Björklund M et al. 2004 Sweden [34] Quantitative prospective observational study

To identify factors that could easily be assessed by

anesthetic personnel

preoperatively and that could thus predict the level of cooperation that might be expected of the child during the anesthetic induction

102 children aged 2-7 Quality of previous hospitalizatio ns and vaccinations Compliant Situation check list and Preoperative Behavior Check list At premedication, needle insertion and induction of anesthesia.

Negative reaction when vaccinated correlated with noncompliance during induction of anesthesia and i.v. insertion.

History of traumatic hospital events correlated with noncompliance

premedication, sedation, i.v. insertion and anesthetic induction. Medium - No ethical reasoning - No analysis for population size - No inclusion and exclusion criteria - No presentation of weaknesses. Sola C et al. 2017 France [41] Quantitative Randomized Prospective Control Study To assess three different strategies for child-hood preoperative anxiolytics: midazolam premedication, midazolam in combination with portable Digital Video-Disk player, or video distraction strategy alone.

135 children aged 2-12 Previous experience of surgery Modified Yale Preoperative Anxiety Scale, Visual Analog Anxiety Scale During presurgical holding area and at separation from parents,

Children with previous experience of surgery was significantly less anxious than children without previous experience (p=0.002) Medium + + Procedure flowchart + Analyses of population size

+ Inter and intra-evaluator reliability

+ Large population size - No presentation of excluded patients - No consort - No ethical reasoning Wright K. D et al. 2010 Canada [40] Quantitative randomized prospective control study To provide further

examination of the utility of parental presence as a method of alleviating anxiety in children undergoing day surgery 61 children Aged 3-6 Previous surgeries Modiefied Yale Preoperative Anxiety Scale Throughout day surgery procedures. No significant difference in anxiety depending of previous surgeries at separation (p=0.91) or at induction (p=0.56). Medium - No ethical reasoning - Consort diagram missing - No procedure flowchart - No ethical reasoning - No population size explanation

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Both boys and girls were included in the studies. Patients in all studies underwent procedures under general anesthesia. Two of the studies focused on dental surgery [30,33], four of the studies focused on ear, nose, and throat surgery [32,34,39,42], five studies focused on day surgeries not specified [31,36–38,40], and the remaining two studies included all types of surgery under general anesthesia in both in- and

outpatients during a certain period of time. Nine of the studies included children from the age of 2 or 3 years, one of these had a narrow age range 3-6 years [40] the others had a range of at least 5 years. Four studies had older age ranges from 4-7 years [31], 4-10 years [39], 5-15 years [39] and the oldest age group from 11-18 years [37].

Measurements and assessment times

The method for measuring anxiety varied among the different studies. The most common measurement tool was the modified Yale Preoperative Anxiety Scale, see table 2 [30,35,40,41]. The studies also varied in when during the preoperative period the anxiety was assessed. Where one study included anxiety measurements only from the pre-holding area [39], two studies included measurements from pre-holding area and at separation from parents [36,41], four included only anxiety at induction [30,31,35,38], and six studies measured at several point before and during induction of anesthesia.

In seven of the studies the researcher rated the child’s anxiety [30–35,40], in four studies the child rated his or her own anxiety [37–39,42], and in two studies both the researcher and the child rated the child’s anxiety [36,41].

Prevention and intervention strategies

In three of the studies included in this review sedative or hypnotic premedication was given to children that expressed high anxiety during the preoperative period

[30,36,39]. In two of the studies premedication was given routinely to all children [34,42]. One study was a controlled study where two of the groups were given premedication [41]. In one of the studies premedication was given to children with a history of previous difficulty with induction of anesthesia [30].

Four of the studies routinely offered some kind of information designed to help the children and parents understand the procedures during the day of the surgery. In one study two nurses explained the procedures during the day and helped the parents and children with coping techniques [38], in the second study the child was offered a

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study offered a program with demonstrations of the procedures on teddy bears before the preoperative care [36] and in the fourth study video distraction was used as an intervention in two groups compared to midazolam as premedication [41].

Table 2. Methods of Measuring Anxiety

Measurements Number _{of studies Scored by} References Modified Yale

Preoperative Anxiety

Scale 4 Researcher

[30,35,40,4 1] Visual Analog Anxiety

Scale (VAS) 3 Child or Researcher [36,37,41] Induction compliance

check list 1 Researcher [31]

FACES Scale 1 Child [38]

Pediatric Anesthetic

Behavior 1 Researcher [30]

Global Mood Score 1 Researcher [33]

State and trait anxiety

inventory for children 1 Child [39]

Operating room behavior rating scales

(ORBRS) 1 Researcher [32]

Clinical anxiety rating

scale 1 Researcher [36]

Venham Picture Test 1 Child [36]

Selfrating

questionnaire 1 Child [42]

Compliance situation

check list 1 Researcher [34]

Preoperative

behavioral checklist 1 Researcher [34]

Heart rate 2 Staff [32,37]

Blood pressure 1 Staff [37]

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Anxiety and previous experience

The studies also differed in which previous experience were analyzed (see table 1). In ten of the studies they asked if the child had experience with surgery but not if the experience was positive or negative. [31,33,37–42], five articles also asked about the quality of the previous experiences the child had [30,32,34–36], four studies asked about quality of other health care experiences [32,34–36], one study asked

specifically about doctors and dentists [30], one study asked specifically about behavior at vaccinations [34] and one study asked specifically about behavior at past medical visits [37].

Table 3. Summery of results: anxiety and previous experiences

Outcome _StudiesNr of

Previous experience of surgery has a correlation to increased

anxiety 5

Previous experience of surgery has no correlation to anxiety 4 Previous experience of surgery has a correlation to decreased

anxiety 1

Increasing number of previous surgeries has a correlation with

increased anxiety 2

Previous negative experiences has a correlation to increased

anxiety 5

Previous negative experiences has no correlation to anxiety 0 Previous negative experiences with vaccinations has a

correlation to increased anxiety 1

Previous experience of dentists has a correlation to increased

anxiety 1

Previous negative experiences with dentists has a correlation to

increased anxiety 1

Of the ten studies that asked about previous experience with surgery but did not specify if the experience was positive or negative, five studies showed that previous experience was correlated with a greater anxiety during the preoperative care [31,33,36,38,42], and four studies did not find a relationship between previous experience of surgery and increased anxiety [35,37,39,40] (see table 3). One study by Sola et al. (2017) [41] reported that children with previous experience of surgery were significantly less anxious than children without any experience.

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When considering if the past experiences where negative or positive all five articles agreed on that traumatic or poor quality past experiences of hospitalization increases anxiety (table 3). Kain et al. (1996) [36], showed that previous poor quality medical encounters gave significantly higher anxiety than previous medical encounters of good quality.

Two studies showed that there is a correlation between higher levels of anxiety and the number of previous surgeries the child has been through, where an increasing number of surgeries gave increased anxiety [31,35] (table 3). Three studies showed a significant correlation between previous traumatic events with doctors or

hospitalization and distressed behavior [30,32,34]. The two studies that included only dental procedures both show that there is a significant correlation between anxiety and previous experiences. Beringer et al. (2014) [30] also shows that there is a correlation between anxiety and previous traumatic experiences with dentists. Björklund-Proczkowska et al. (2004) [34] showed that there is a correlation between negative reactions during vaccination and noncompliant behavior. One study showed a correlation between the children having one prior surgery and an increase in heart rate during the induction of anesthesia in the operating room [32].

Anxiety and timing of assessment

The study which only measured anxiety at the pre-holding area did not show a

correlation between anxiety and previous experiences of surgery [39]. The studies that measured during pre-holding area and separation from parents came to opposites results [36,41]. Sola et al. 2017 illustrated that children with previous experience were less anxious than children with no experience of surgery, and Kain et al. 1996 showed that children with previous experience of surgery were significantly more anxious at separation than children without.

The studies that looked at anxiety during induction all came to the conclusion that there is a correlation between anxiety and previous poor quality experiences [30,31,35,38].

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Anxiety and age

When considering the different age groups only one study took into consideration of how the impact of previous experiences may be different depending on the age, and came to the conclusion that older children with previous experience were significantly more negative towards premedication than older children without previous

experiences of general anesthesia [42]. When looking at the different studies and their age groups there were three studies that included children above the age of 12 [37– 39], two of these came to the conclusion that there was no correlation between previous experiences and anxiety[37,39] and one showed that there was a correlation [38]

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Discussion

The objective of this study was to examine the effect of previous experience of health care on children’s anxiety before and during induction of anesthesia. The analysis included both prospective and retrospective observational studies. This systematic review shows that there is a significant correlation between previous poor quality experiences within healthcare and anxiety prior to surgery in children. This finding was demonstrated in 70% of all articles that were included in the review.

The analysis of these articles clearly shows that the quality of previous experiences within the healthcare is very important. When the quality is not taken into account there is no clear evidence that previous experience correlates with an increased anxiety. However when looking at the articles that include the quality of the previous experience it is clear that a poor quality of previous medical experiences correlates with an increased anxiety during the induction of general anesthesia. There is a need in future research to examine the influence of both poor and good quality past experiences’ effect of preoperative anxiety in children. A greater understanding of this could reveal interventions for those children with a greater risk for anxiety.

It is also important to look at all different kinds of medical experiences and not only major ones such as surgery and previous anesthesia. This article shows that even previous problematic vaccination might have a negative effect on the anxiety during future health care and thought should therefore be given to other small procedures such as blood draw and other examinations. More research is needed where the kind of previous experience is taken into account and also research where anxiety during other medical events is studied.

The decision to refer a child to general anesthesia for dental procedures such as extraction or reconstruction is mostly based on high dental fear, non-compliance or that the child has extensive dental needs [43]. This is not the same situation for children undergoing anesthesia for other types of surgeries. The children included in the studies where only dental procedures where performed [30,33], might have been referred to general anesthesia because of a high fear of dentists created from previous

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experiences of dentists. There might therefore be a larger outcome between previous experience and anxiety and a lack of children with previous good experiences, as these would not be referred to general anesthesia.

It is well known that age influences the degree and source of anxiety. In 1958 Corman et al. [44] discussed the different fears at different ages and he concluded that

separation is a bigger concern for younger children while the implications of anesthesia and surgery is a bigger concern for older children. Younger children are also known to fear more imaginary things such as ghosts and monsters while older children fear more physical things such as injury or bodily harm[45]. Six of the included studies took into account the effect of age on anxiety and five of the studies found that the younger children were the most anxious [32,34–36,42]. Lumley et al. 1993 [32] found that children aged 4-5 years were the most anxious while children aged 8-10 years were more anxious than children aged 6-7 years. This might be due to the child’s development. The effect of age on the perception of previous experiences is not fully explored and needs more research. Whether fear generated from previous experiences is more of a conditioned response to traumatic events or the recognition that something painful might be ahead is an open question.

Five of the included studies all separated the children from their parents before entering the operating theatre [32,36,37,40,41]. Wright et al. 2010 [40] found that children who were separated from their parents had an increase in anxiety at separation compared with children who were not separated at the same time point. However, they did not find a difference in anxiety between the two groups during the point of induction. Other studies have shown that emotion focused behavior from the parents, such as empathy and reassurance correlate significantly with the child’s stress and is negatively related to coping behaviors [46–48]. However more

coping-promoting behaviors from the parents consequently led to less stress in the children and better stress coping behaviors. [49]. The discussion of having the parents present or not have been going on for a long time and many studies have shown that parental stress might affect child stress negatively while parental coping behaviors might do the opposite [6,46,47,49]. It is therefore important to find different risk factors for

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Premedication and non-pharmacological interventions has shown to effect the anxiety in children before surgery [38,41,42,50]. Premedication diminishes anxiety and increase sedation. Non-pharmacological preoperative interventions potentially decrease the overall anxiety and decrease the fear from previous surgeries. Future research on how such interventions affect the fear from previous experiences could potentially help these children.

In most of the studies the researcher as an observer rated the anxiety, only in a few, the child had the possibility to rate his or her own anxiety. Having an observer rate the anxiety gives a higher risk of bias than having the child answer for him- or her-self. Self-report is always the gold standard. Since this was not the case in the majority of the studies involved it must be viewed as a limitation.

The Modified Yale Preoperative Anxiety Scale (mYPAS) was the most common tool for measuring anxiety in the present review. The instrument Yale Preoperative

Anxiety Scale was published in 1995 and modified 1997 [51] mYPAS was developed as a tool to be able to measure the anxiety in children that is supposed to go through surgery under general anesthesia. The modified version of Yale Preoperative Anxiety Scale is used world wide and has been shown to have good reliability and validity when used in connection to preoperative care and anesthetic induction [51].

In future systematic reviews, as mYPAS becomes more used, and more

heterogeneous articles are published a meta-analysis might be possible. For this systematic review, however, the articles included are not homogeneous enough to perform a meta-analysis as the method of measurement differed between the studies.

Research including children is a sensitive subject. It is not ethical to induce anxiety for research purposes. Therefore studying anxiety in children always has to be in a clinical situation, which includes other confounding variables. In Sweden it is not considered ethical to separate the children from the parents before surgery. In other countries, separating the children from the parent is a routine and a common subject for research. The separation from the parent is an event that causes anxiety in the child undergoing surgery and it should be considered wheather it is ethical to add an additional moment of stress for the child.

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One should also consider the ethical implications of medicating children for research purposes to see the effect on anxiety. Some of the articles included in this review medicated children as a standard procedure or as part of a randomized controlled study [34,41,42]. The ethical implications of this should be discussed, thinking of possible side effects. However, the ethical implication of not giving sedative premedication to any children even though some children express extremely high levels of anxiety is also a point for discussion.

In the year 1989 the United Nations recognized and underlined the children´s rights that the child must be consulted and that their opinions should be respected in all matters. In this review, six of the included articles asked the child to self evaluate/rate their anxiety while seven articles had an observer rate the anxiety of the child. It is important to receive the child’s perspective according to the European Association for Children in Hospital (EACH). One of the ten goals formulated by EACH concerning children’s care in hospital is “children and parents have the right to informed

participation in all decisions involving their healthcare” [52].

The current study underwent a review process by limited searching in one database and more studies may have been found if the literature searched had been broadened include additional databases, like CINAHL, PsycINFO, etc. The search might also have broadened if more than two searches were performed in the PubMed database. The studies included did not have the main objective to study how previous

experiences of health care influenced the preoperative anxiety. This was a second outcome, which may have affected the result and is a limitation to this review.

Another limitation is that two of the studies included have low methodological quality. These were included in the study due to the small number of studies found and also because the primary outcome was not the correlation between previous experience and anxiety. Only three of the studies included have a high methodological quality, however none of these had the primary outcome of the correlation between previous experience and anxiety either. The rest of the studies had a medium

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Conclusion

There is evidence that distress is highest during general anesthetic induction

procedures. The present review highlights that children’s previous poor experiences of healthcare affects preoperative anxiety negatively.

Attention to pharmacological and psychological issues to relieving children´s anxiety at anesthesia induction is important. The health care staff plays an important role, and are responsible in this process.

More research needs to be done regarding the different qualities and kind of previous experiences and how this might affect children in the future as well as the best method of treating anxiety caused especially by previous traumatic experiences. Care must also be taken to not let children go through traumatic experiences within the health care system as to prevent future anxiety.

Additional Points

References [30–42]are the studies included in the review while all the other references are additional references.

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References

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30. Beringer RM, Segar P, Pearson A, Greamspet M, Kilpatrick N. Observational study of perioperative behavior changes in children having teeth extracted under general anesthesia. Paediatr Anaesth. 2014 May;24(5):499–504. 31. Cropper J, Edwards L, Hearst D, Durling E, Ward C, Albon H, et al. Factors

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34. Proczkowska-Björklund M, Svedin CG. Child related background factors affecting compliance with induction of anaesthesia. Paediatr Anaesth. 2004 Mar;14(3):225–34.

35. Davidson AJ, Shrivastava PP, Jamsen K, Huang GH, Czarnecki C, Gibson MA, et al. Risk factors for anxiety at induction of anesthesia in children: a

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36. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med. 1996 Dec;150(12):1238–45.

37. Fortier MA, Martin SR, Chorney JM, Mayes LC, Kain ZN. Preoperative anxiety in adolescents undergoing surgery: a pilot study. Paediatr Anaesth. 2011 Sep;21(9):969–73.

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40. Wright KD, Stewart SH, Finley GA. When are parents helpful? A randomized clinical trial of the efficacy of parental presence for pediatric anesthesia. Can J Anaesth J Can Anesth. 2010 Aug;57(8):751–8.

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for children undergoing ENT operations: a comparison of two methods. Pediatr Anesth. 2000 Sep 1;10(5):477–86.

43. MacCormac C, Kinirons M. Reasons for referral of children to a general anaesthetic service in Northern Ireland. Int J Paediatr Dent. 1998 Sep;8(3):191–6.

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46. Chorney JM, Torrey C, Blount R, McLaren C, Chen W-P, Kain Z. Healthcare Provider and Parent Behavior and Children’s Coping and Distress at Anesthesia Induction. Anesthesiology. 2009 Dec;111(6):1290–6. 47. Wright KD, Stewart SH, Finley GA, Raazi M. A sequential examination of

parent-child interactions at anesthetic induction. J Clin Psychol Med Settings. 2014 Dec;21(4):374–85.

48. Platt R, Williams SR, Ginsburg GS. Stressful Life Events and Child Anxiety: Examining Parent and Child Mediators. Child Psychiatry Hum Dev. 2016 Feb;47(1):23–34.

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49. Noel M, McMurtry CM, Chambers CT, McGrath PJ. Children’s memory for painful procedures: the relationship of pain intensity, anxiety, and adult behaviors to subsequent recall. J Pediatr Psychol. 2010 Jul;35(6):626–36. 50. McMillan CO, Spahr-Schopfer IA, Sikich N, Hartley E, Lerman J. Premedication

of children with oral midazolam. Can J Anaesth J Can Anesth. 1992 Jul;39(6):545–50.

51. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale Preoperative Anxiety Scale: how does it compare with a “gold

standard”? Anesth Analg. 1997 Oct;85(4):783–8.

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APPENDIX

All excluded articles from the first and second search in the selection process.

Reference Reason for dismissal

First search

MacCormac C, Kinirons M. Reasons for referral of children to a general anaesthetic service in Northern Ireland. Int J Paediatr Dent. 1998 Sep;8(3):191–6.

The study does not include the details needed for the systematic review

Rosén S, Svensson M, Nilsson U. Calm or not calm: the question of anxiety in the perianesthesia patient. J Perianesthesia Nurs Off J Am Soc PeriAnesthesia Nurses. 2008 Aug;23(4):237–46.

The article population is >16 years

Jafar MF, Khan FA. Frequency of preoperative anxiety in Pakistani surgical patients. JPMA J Pak Med Assoc. 2009 Jun;59(6):359–63.

Population aged 16-80 Versloot J, Veerkamp J, Hoogstraten J. Dental

anxiety and psychological functioning in children: its relationship with behaviour during treatment. Eur Arch Paediatr Dent Off J Eur Acad Paediatr Dent. 2008 Feb;9 Suppl 1:36–40.

Does not involve general anesthesia

Boka V, Arapostathis K, Kotsanos N, Karagiannis V, van Loveren C, Veerkamp J. Relationship between Child and Parental Dental Anxiety with Child’s Psychological Functioning and Behavior during the Administration of Local Anesthesia. J Clin Pediatr Dent. 2016;40(6):431–7.

Does not contain the specifics of children’s previous experiences of medical procedures and its influence on anxiety.

Second search

Ko JS, Whiting Z, Nguyen C, Liu RW, Gilmore A. A Randomized Prospective Study Of The Use Of Ipads In Reducing Anxiety During Cast Room Procedures. Iowa Orthop J. 2016;36:128–32.

Not about anesthesia

Li HCW, Lopez V. Assessing children’s emotional responses to surgery: a multidimensional approach. J Adv Nurs. 2006 Mar;53(5):543–50.

Puura A, Puura K, Rorarius M, Annila P, Viitanen H, Baer G. Children’s drawings as a measure of anxiety level: a clinical pilot study. Paediatr Anaesth. 2005 Mar;15(3):190–3.

Watson AT, Visram A. Children’s preoperative anxiety and postoperative behaviour. Paediatr Anaesth. 2003 Mar;13(3):188–204.

This is a review article Cuzzocrea F, Gugliandolo MC, Larcan R, Romeo

C, Turiaco N, Dominici T. A psychological preoperative program: effects on anxiety and cooperative behaviors. Paediatr Anaesth. 2013 Feb;23(2):139–43.

Li HCW, Lopez V. Do trait anxiety and age predict state anxiety of school-age children? J Clin Nurs. 2005 Oct;14(9):1083–9.

Not about general anesthesia and surgery Holm-Knudsen RJ, Carlin JB, McKenzie IM.

Distress at induction of anaesthesia in children. A survey of incidence, associated factors and recovery characteristics. Paediatr Anaesth. 1998;8(5):383– 92.

Vagnoli L, Caprilli S, Messeri A. Parental presence, clowns or sedative premedication to treat

preoperative anxiety in children: what could be the most promising option? Paediatr Anaesth. 2010 Oct;20(10):937–43.

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Hofstadter MB. Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective? Anesthesiology. 1998 Nov;89(5):1147–56; discussion 9A-10A.

previous experiences of medical procedures and its influence on anxiety.

Kain ZN, Mayes LC, Wang SM, Caramico LA, Krivutza DM, Hofstadter MB. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study. Anesthesiology. 2000 Apr;92(4):939–46.

Patel A, Schieble T, Davidson M, Tran MCJ, Schoenberg C, Delphin E, et al. Distraction with a hand-held video game reduces pediatric

preoperative anxiety. Paediatr Anaesth. 2006 Oct;16(10):1019–27.

Brewer S, Gleditsch SL, Syblik D, Tietjens ME, Vacik HW. Pediatric anxiety: child life intervention in day surgery. J Pediatr Nurs. 2006 Feb;21(1):13– 22.

MacLaren JE, Thompson C, Weinberg M, Fortier MA, Morrison DE, Perret D, et al. Prediction of preoperative anxiety in children: who is most accurate? Anesth Analg. 2009 Jun;108(6):1777–82.

Banchs RJ, Lerman J. Preoperative anxiety management, emergence delirium, and postoperative behavior. Anesthesiol Clin. 2014 Mar;32(1):1–23.

This is a review paper

Hilly J, Hörlin A-L, Kinderf J, Ghez C, Menrath S, Delivet H, et al. Preoperative preparation workshop reduces postoperative maladaptive behavior in children. Paediatr Anaesth. 2015 Oct;25(10):990–8.

Quinonez R, Santos RG, Boyar R, Cross H. Temperament and trait anxiety as predictors of child behavior prior to general anesthesia for dental surgery. Pediatr Dent. 1997 Oct;19(6):427–31.

Weber FS. The influence of playful activities on children’s anxiety during the preoperative period at the outpatient surgical center. J Pediatr (Rio J). 2010 Jun;86(3):209–14.

Kain ZN, Wang SM, Mayes LC, Krivutza DM, Teague BA. Sensory stimuli and anxiety in children undergoing surgery: a randomized, controlled trial. Anesth Analg. 2001 Apr;92(4):897–903.

Zuckerberg AL. Perioperative approach to children.

Pediatr Clin North Am. 1994 Feb;41(1):15–29. Not a research

Zahr LK. Therapeutic play for hospitalized preschoolers in Lebanon. Pediatr Nurs. 1998 Oct;24(5):449–54.

Lamontagne LL, Hepworth JT, Salisbury MH. Anxiety and postoperative pain in children who undergo major orthopedic surgery. Appl Nurs Res ANR. 2001 Aug;14(3):119–24.

Aguilera IM, Patel D, Meakin GH, Masterson J. Perioperative anxiety and postoperative behavioural disturbances in children undergoing intravenous or inhalation induction of anaesthesia. Paediatr Anaesth. 2003 Jul;13(6):501–7.

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Kain ZN, Caldwell-Andrews AA. Preoperative psychological preparation of the child for surgery: an update. Anesthesiol Clin N Am. 2005

Dec;23(4):597–614, vii.

Not a research

Li HCW, Lopez V, Lee TLI. Psychoeducational preparation of children for surgery: the importance of parental involvement. Patient Educ Couns. 2007 Jan;65(1):34–41.

Bailey KM, Bird SJ, McGrath PJ, Chorney JE. Preparing Parents to Be Present for Their Child’s Anesthesia Induction: A Randomized Controlled Trial. Anesth Analg. 2015 Oct;121(4):1001–10.

Not about the child’s anxiety

Kim H, Jung SM, Yu H, Park S-J. Video Distraction and Parental Presence for the Management of Preoperative Anxiety and

Postoperative Behavioral Disturbance in Children: A Randomized Controlled Trial. Anesth Analg. 2015 Sep;121(3):778–84.

The Child’s Previous Experiences of Health Care Affects on the Child’s Anxiety in Connection to Anaesthetic Induction: A Systematic Review

Örebro University

School of Medicine

Medicine, Advance course

Degree project, 15 ECTS

May 2018

The Child’s Previous Experiences of Health

Care Affects on the Child’s Anxiety in

Connection to Anaesthetic Induction: A

Systematic Review

Author: Janina Björklund

Supervisor: Elisabeth Ericsson

Associate Professor, PhD, RNA

Örebro University

Sweden

Abstract

Table of Contents

Introduction

Bakground

Aim

Method

Results

Discussion

Conclusion

References