Effects of non-drug interventions to alleviate anxiety in children undergoing surgery: a systematic review and meta‑analysis

Introduction

Surgery is a challenge at any age. The disruption of daily life, temporary immobility, and unfamiliar environment can cause anxiety in the preoperative period. These factors especially affect the pediatric population and their family (1). Additionally, the invasive procedures, pain, and risk of complications increase anxiety during surgery. As a result, patients exhibit heightened anxiety, stress, and depression symptoms (2,3).

Five million children in the United States undergo surgery each year, with 75% reporting anxiety symptoms preoperatively (4). Children’s anxiety responses to the surgical period are influenced by age, previous experience with medical procedures, individual capacity for anxiety regulation, separation from parents, and parental anxiety levels (5,6). Enhanced anxiety symptom decrease children’s efficacy coping with medical treatment and reduce their cooperative behavior towards healthcare professionals during the surgery. Thus, high levels of anxiety during preoperative period could complicate the surgery and lead to postoperative complications (7,8).

Behavioral changes resulting from preoperative anxiety affect up to 60% of all children undergoing surgery, leading to issues such as enuresis, feeding difficulties, apathy, and sleep disturbances preoperative (6,9). Besides, anxiety symptoms can cause harmful change in neuroendocrine hormones levels, delaying wound healing, causing bleeding, and increasing pain after surgery (10,11). Hence, low levels of preoperative anxiety predict good postoperative outcomes, including lower pain intensity, reduced analgesic demands, shorter hospital stays, and higher patient satisfaction (5). Several studies suggest that preoperative preparation programs reduce anxiety symptom and enhance coping in children (12-14). Several variables influence the responses of pediatric population, so the preoperative programs should be designed age-appropriate and tailored to the individual child’s needs (5,15). The use of sedative drugs for children undergoing surgery can provide rapid, effective, and safe sedation, but mild adverse effects may occur (16). In order to reduce anxiety, many non-drug interventions have been effectively used with children who have adequate cognitive development (17,18). Non-drugs interventions are simple, effective, and cost-effective, leading to improved patient satisfaction (19). These approaches include reassuring the child that it’s normal not to be perfect, focusing on the positive, encouraging the child to express their anxiety, helping them solve problems, and staying calm (20). Most preoperative programs for children are based on education and the presence of a parent (21,22). Additionally, the information provided should be presented in a way that is engaging for children (6). Distraction techniques include both active and passive distraction (23,24), and both types of distraction are useful for reducing preoperative anxiety (25,26). No previous meta-analysis has included all types of non-drug interventions aimed at reducing anxiety in children during the preoperative period to assess the efficacy of multiple approaches. Thus, the aim of this meta-analysis was to evaluate the efficacy of various non-drug programs in decreasing anxiety symptoms in children during the preoperative period. We present this article in accordance with the PRISMA reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-99/rc) (27).

Methods

Study registration

The study was pre-registered in the International Prospective Register of Systematic Review and Meta-analysis (PROSPERO) under registration number CRD42019116237.

Search strategy

A comprehensive literature search was carried out on PubMed, Web of Science and Scopus for randomized controlled trials from inception to July 2024. The Population, Intervention, Comparison, and Outcome (PICO) framework (28) was applied to identify the inclusion criteria: (I) children aged 2–12 years without chronic diseases or cancer; (II) any preoperative intervention focused on reducing anxiety in children without drugs; (III) the preoperative program was compared with standard care or no intervention to reduce preoperative anxiety; (IV) anxiety outcomes were reported; and (V) only randomized control trial designs were included. Detailed information about the search strategy is provided in Table S1. Only publications written in English were included.

Quality assessment and data extraction

After the initial search results from the different databases, duplicates were removed. Studies were then excluded based on PICO search strategy. Two researchers independently reviewed the titles and abstracts of the studies. Any discrepancies were resolved by a third researcher. Results and reported outcomes were extracted from the articles and entered into a database for analysis. When data was not available in the study, reviewers contacted the authors to request additional information.

Multiple preoperative anxiety interventions were identified in the included studies. Education includes activities that provide information about the surgery process, allowing children to ask question and resolve problems (29). Emotional support provides strategies to reduce anxiety symptoms during the surgery process, including active listening, relaxation techniques, and emotional validation (30,31). Distraction techniques include active distraction, which involves engaging children in activities such as playing video games, and passive distraction, which does not require active participation, such as watching cartoons or listening to music (23,24). Sometimes, these interventions can be combined with one another. In addition, Standard care usually includes pre-medication, anesthesia is induced intravenously, and take-home analgesics such as paracetamol and/or non-steroidal anti-inflammatory drugs (NSAIDs) are often provided after discharge (32).

Finally, a methodological quality assessment of each included clinical trial was performed using Jadad scale (33), which assigs a score ranging from 0 (poor quality) to 5 (high quality), with scores lower than 3 indicating poor methodological quality of the study. Additionally, an assessment of the risk of bias in the included studies was conducted using the Cochrane Risk of Bias 2 (RoB 2) tool (34).

Meta-analysis

Quantitative synthesis was performed using The Review Manager 5 (RevMan 5) software for all studies that reported anxiety symptoms, including post-intervention means and standard deviations. Data extracted from these studies included final mean values, standard deviations, and the number of patients assessed, which were used to estimate the overall mean differences (MDs) between intervention groups. Only anxiety data collected at the end of the preoperative intervention were included, with all interventions taking place before the induction of anesthesia. When P values or 95% confidence intervals were provided but standard deviations were missing, these were calculated using the Review Manager’s embedded calculator. Most studies used the modified Yale Preoperative Anxiety Scale (mYPAS) (35) to measure anxiety, though some used different scales. We assumed that these scales measured the same underlying symptom or condition and thus standardized MDs were used across all scales. Overall mean effect sizes were estimated using either random effect models or fixed effect models, depending on the results of statistical heterogeneity I² tests (fixed effect models were used for I² values less than 50%). Additionally, we conducted a visual inspection of the forest plots to identify outlier studies, explored sources of heterogeneity, and performed sensitivity analyses by excluding trials with a high risk of detection or attrition bias.

Results

Study selection

A total of 866 studies were selected from electronic databased. After removing duplicates, 781 records remained. Screening based on the title and abstract resulted in 179 articles being selected. From these records, 125 were excluded after reading the full text. Finally, we included a total of 30 articles in the systematic review, some of which did not report the country (36-43), while others were conducted in the USA (44,45), China (46-49), Iran (50-52), Italy (53,54), New Zealand (55,56), England (57), Korea (58,59), Turkey (60), Canada (61), Denmark (62), Singapore (63), Brazil (64), and France (65). Only 24 articles could be included in the meta-analysis (39,41-49,51-64). The flowchart of the search and screening process is detailed in Figure 1.

Figure 1 PRISMA flow chart of literature search and study selection. RCT, randomized controlled trial.

Study characteristics

Of the 30 studies included, 20 were of good quality (37-42,44,45,48,49,51,52,56-61,63,65), with the Jadad risk of bias scale showing that the bias was uncertain or low (66.6% of studies had Jadad scores of ≥3; good quality). Additionally, Figure 2 shows the RoB 2 summary; of the studies included, fourteen showed a low risk of bias (41,43,44,48,49,51,55-60,63,65), twelve showed some concerns (37-39,42,45-47,50,52-54,61), and four studies showed a high risk of bias (36,40,62,64).

Figure 2 Risk of bias summary.

A total of 3,096 children were included in this systematic review. The majority of sample were male (58.24%) with an age range from 2 to 12 years old. The type of surgery among these children was heterogeneous. There were elective outpatient surgeries (38,39,45,50,52,55,64), ambulatory surgeries (47), minor surgeries (48) and miscellaneous surgeries (40,44,63). In some cases, the type of surgery was specified, with the most common being otolaryngological (40-42,44,46,58,59,61,63,65), herniorrhaphy (37,43,46,53,54,58,60,62) and ophthalmological (40,44,46,58,59,61,65). Additionally, surgeries for appendicitis (51,53), tonsillectomy (36,37,41,49), adenoidectomy (36,37,41,49), orchiopexy (37,43,62), hydrocelectomy (37,43,53), circumcision (37,43,46,49,60,62), urology (43,44,61,63), plastic surgery (40,44), dental surgery (41,46,56,57,61), orthopedic surgery (46,54), phimosis (53,54), and cryptorchidism (53) were included (Table 1).

Details about preoperative interventions and obtained results are reported in Table 2.

There were passive distractions (37,39,40,42-44,49,51,56,58,59), active distractions (45,51,52,55,60-62,65), emotional support (36) and mixed interventions (36,38,39,41,44,46-48,50,53-55,57,63,64) as preoperative interventions for children. Most of these interventions were provided at the hospital (36-47,49-56,58-65), except for one study conducted at home (48). In addition, parental presence was included in the preoperative interventions in 21 studies (38-41,43,45-49,52,56-65). The preoperative interventions were conducted on the same day before surgery (37-39,41-44,49-53,56,58-62,65), the evening of hospital admission (36), 1 day before surgery (47,63), 1 week before surgery (46,48,57), 5 to 10 days before surgery (40). The duration of the interventions ranged from 5 minutes (56) to 1 hour (40,43,46,51), with 30 minutes being reported in five studies (38,39,49,50,52).

The outcome measure most used to evaluate children’s anxiety was mYPAS (37-41,44,45,47,50,53-58,64), and modified Yale Preoperative Anxiety Scale Short Form (mYPAS-SF) (48,49,56,59,61,62,65). The mYPAS was assessed before and after the preoperative anxiety intervention. It consists of 5 items (activity, vocalizations, emotional expressivity, state of apparent arousal, and use of parent). Each item has Likert-type response options reflecting behaviors observed by the healthcare professional. Reported inter-rater reliability scores are generally above 0.9, indicating strong agreement (66). In addition, the Manifest Anxiety Test (MAT) (36), Callahan Anxiety Pictures Test (CAP) (36), Chinese version of the State Anxiety Scale for Children (CSAS-C) (46), Revised Children’s Manifest Anxiety Scale (RCMAS) (51), Facial Image Scale (FIS) (57), Face Anxiety Scale (FAS) (60), State-Trait Anxiety Inventory for Children (STAIC) (42,63), Children’s Anxiety Questionnaire (CAQ) (64), Visual Analog Anxiety Scale (VAS) (64), and Children’s Anxiety Meter-State (CAM-S) (43) were used. All the measures used were observation grids completed by healthcare professionals.

An improvement in anxiety symptoms in children before surgery was observed in multiple studies (36,37,39,42-56,58-65), with nine studies showing significant differences between groups in favor of the intervention group (P<0.001) (36,42,43,50-52,55,56,60); however, ten studies (38,40,41,48,57,58,62-65) did not report significant differences.

Results obtained in meta-analysis

The results for anxiety have been analyzed as shown in Figure 3. The preoperative interventions were categorized into three groups: active distraction interventions, passive distraction interventions, and mixed interventions which combined education, emotional support, active distraction or passive distraction.

Figure 3 Meta-analysis: forest plot illustrating changes in anxiety. Numbers (1) and (2) refer to the intervention groups indicated in Table 2. SD, standard deviation; IV, inverse variance; CI, confidence interval.

For active distraction interventions, the pooled MD showed significant overall effect, experimental group compared with control group [MD =−1.03, 95% confidence interval (CI): −1.55, −0.51; P<0.001]. The results show heterogeneity, detecting significant variability of I²=88%, not attributable to chance.

For passive distraction interventions, the pooled MD showed significant overall effect, experimental group compared with control group (MD =−0.88, 95% CI: −1.37, −0.40; P<0.001). The results show heterogeneity, detecting significant variability of I²=89%, not attributable to chance.

For mixed interventions, the pooled MD showed significant overall effect, experimental group compared with control group (MD =−0.26, 95% CI: −0.44, −0.08; P=0.005). The results show heterogeneity, detecting significant variability of I²=54%, not attributable to chance.

Finally, the pooled MD showed significant overall effect of all preoperative interventions, experimental group compared with control group (MD =−0.68, 95% CI: −0.90, −0.45; P<0.001). The results show heterogeneity, detecting significant variability of I²=86%, not attributable to chance.

Discussion

The aim of this meta-analysis was to evaluate the efficacy of various non-drug programs in decreasing anxiety symptoms in children during the preoperative period. We found that non-drug preoperative anxiety interventions are more effective at reducing anxiety levels than standard care or no intervention, with active distraction interventions demonstrating the greatest reduction in anxiety symptoms.

The most common type of surgery was otolaryngological. Otitis media with effusion is the leading otolaryngological problem in children, and approximately 80% of children will have at least one episode of otitis media with effusion by the age of 10, requiring surgical tympanic membrane perforations to resolve in most cases (67).

There are various opinions regarding the advantages and disadvantages of using drugs (68,69). Midazolam has been shown to be effective in reducing anxiety in children undergoing procedures in various clinical settings (70,71). However, there were adverse effects associated with the administration in children (72). Our meta-analysis showed significant reductions in anxiety using preoperative programs without drugs. Thus, non-drugs preoperative programs are a good option to avoid the side effects of extra-medication, decreasing postoperative complications in the pediatric population (73).

According to Wright et al. 2010 (74) child anxiety was significantly lower in the parental presence group than in the parental absence group at the time-point. We observe Ryu et al. 2019 (58) and Park et al. 2020 (59), which included the use of wagon on the same day as surgery, with a significant reduction in anxiety in the study by Park et al. 2020 (59). The only difference between them is the presence of parents during the intervention.

We observed that the isolated active and passive distractions interventions showed a greater reduction in anxiety symptoms than mixed programs when compared to standard care or no interventions, with passive distraction interventions being the most used in the studies. A previous meta-analysis (75) showed that distraction has a significant effect on reducing operational pain in children’s surgery. However, active distraction interventions showed a significant reduction in the attention given to perceived threatening stimuli, thereby potentially minimizing the distress associated with perioperative procedures (25,26,76), consistent with our results. Therefore, it is necessary to implement personalized distraction methods according to children’s age, level of development, temperament, type of surgery, and interest (77,78). Additionally, previous meta-analysis (79,80) of different interventions in healthy children used a duration of interventions similar to our study.

Several limitations of this systematic review and meta-analysis are evident. Firstly, the quality of the included studies was not entirely optimal due to the lack of blinding among the professionals, which could influence the analysis and future randomized controlled trials (RCTs) should adopt more robust study designs to further minimize the risk of bias. Secondly, there was significant heterogeneity in the overall analysis. Additionally, we did not classify the children according to the type of surgery, which may have multiple etiologies. Moreover, we did not collect data to calculate Cohen’s kappa or inter-rater agreement statistics. Additionally, we are unable to analyze all types of interventions in subgroups in the meta-analyses. Furthermore, this meta-analysis only examined short-term effects due to a lack of follow-up data in the included studies. In addition, the high heterogeneity observed in the results raises concerns about the reliability of our findings, indicating that the variability among studies may limit the generalizability of our conclusions. Finally, several studies included in the systematic review were not part of the meta-analysis because they lacked the necessary data for comparison and analysis with other studies.

Conclusions

This meta-analysis showed that non-drug programs reduce anxiety symptoms in children during the preoperative period, with active distraction interventions showing the greatest reduction in anxiety symptoms. However, due to the high heterogeneity identified in our analysis, the conclusions should be interpreted with caution. Further research is needed to evaluate the effects of different types of preoperative anxiety interventions and to observe their long-term effects after the postoperative period.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-99/rc

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-99/prf

Funding: The author A.N.O. has received funding support from Spanish Ministry of Education (No. FPU:22/01543).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-99/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Liu W, Xu R, Jia J, et al. Research Progress on Risk Factors of Preoperative Anxiety in Children: A Scoping Review. Int J Environ Res Public Health 2022;19:9828. [Crossref] [PubMed]
2. Kerper LF, Spies CD, Lößner M, et al. Persistence of psychological distress in surgical patients with interest in psychotherapy: results of a 6-month follow-up. PLoS One 2012;7:e51167. [Crossref] [PubMed]
3. Sandoval V, Hernández J. Hospital culture and the narrative process in children. Estudios sobre las Culturas Contemporáneas 2011;17:23-44.
4. Talbot S. The Pediatric Patient. 2nd ed. St. Louis, MO: Saunders Elsevier; 2010.
5. Gulur P, Fortier MA, Mayes LC, et al. Perioperative behavioral stress in children. In A Practice of Anesthesia for Infants and Children 2019:25-34.
6. Getahun AB, Endalew NS, Mersha AT, et al. Magnitude and Factors Associated with Preoperative Anxiety Among Pediatric Patients: Cross-Sectional Study. Pediatric Health Med Ther 2020;11:485-94. [Crossref] [PubMed]
7. William Li HC, Lopez V, Lee TL. Effects of preoperative therapeutic play on outcomes of school-age children undergoing day surgery. Res Nurs Health 2007;30:320-32. [Crossref] [PubMed]
8. Chieng YJ, Chan WC, Klainin-Yobas P, et al. Perioperative anxiety and postoperative pain in children and adolescents undergoing elective surgical procedures: a quantitative systematic review. J Adv Nurs 2014;70:243-55. [Crossref] [PubMed]
9. Reddy SK, Deutsch N. Behavioral and Emotional Disorders in Children and Their Anesthetic Implications. Children (Basel) 2020;7:253. [Crossref] [PubMed]
10. Pritchard MJ. Managing anxiety in the elective surgical patient. Br J Nurs 2009;18:416-9. [Crossref] [PubMed]
11. Caumo W, Ferreira MBC. Perioperative anxiety: psychobiology and effects in postoperative recovery. The Pain Clinic 2003;15:87-101. [Crossref]
12. Wu J, Yan J, Zhang L, et al. The effectiveness of distraction as preoperative anxiety management technique in pediatric patients: A systematic review and meta-analysis of randomized controlled trials. Int J Nurs Stud 2022;130:104232. [Crossref] [PubMed]
13. Álvarez-García C, Yaban ZŞ. The effects of preoperative guided imagery interventions on preoperative anxiety and postoperative pain: A meta-analysis. Complement Ther Clin Pract 2020;38:101077. [Crossref] [PubMed]
14. Chen YJ, Wang CJ, Chen CW. Effects of virtual reality on preoperative anxiety in children: A systematic review and meta-analysis of randomised controlled trials. J Clin Nurs 2023;32:2494-504. [Crossref] [PubMed]
15. Gunter RW, Whittal ML. Dissemination of cognitive-behavioral treatments for anxiety disorders: Overcoming barriers and improving patient access. Clin Psychol Rev 2010;30:194-202. [Crossref] [PubMed]
16. Cheuk DK, Wong WH, Ma E, et al. Use of midazolam and ketamine as sedation for children undergoing minor operative procedures. Support Care Cancer 2005;13:1001-9. [Crossref] [PubMed]
17. Saxena S, Janakiram C. Non-pharmacological interventions for anxiety in children: a review. Indian Journal of Pediatrics 2011;78:853-9.
18. Harrison RL, O’Rourke M. The effectiveness of non-pharmacological interventions in reducing anxiety in children: a systematic review. International Journal of Nursing Studies 2015;52:965-73.
19. Moll-Bertó A, López-Rodrigo N, Montoro-Pérez N, et al. A Systematic Review of the Effectiveness of Non-Pharmacological Therapies Used by Nurses in Children Undergoing Surgery. Pain Manag Nurs 2024;25:195-203. [Crossref] [PubMed]
20. Mahmoud Farrag J, Mohamed Ahmed S, Abdallah Mohammed H, et al. Non-pharmacological strategies to mitigate pain and anxiety among children on dialysis. Egypt J Health Care 2022;13:1609-25. [Crossref]
21. Lööf G, Lönnqvist PA. Role of information and preparation for improvement of pediatric perioperative care. Paediatr Anaesth 2022;32:600-8. [Crossref] [PubMed]
22. Piira T, Sugiura T, Champion GD, et al. The role of parental presence in the context of children's medical procedures: a systematic review. Child Care Health Dev 2005;31:233-43. [Crossref] [PubMed]
23. Dahlquist LM, McKenna KD, Jones KK, et al. Active and passive distraction using a head-mounted display helmet: effects on cold pressor pain in children. Health Psychol 2007;26:794-801. [Crossref] [PubMed]
24. Nilsson S, Enskär K, Hallqvist C, et al. Active and passive distraction in children undergoing wound dressings. J Pediatr Nurs 2013;28:158-66. [Crossref] [PubMed]
25. Chow CH, Van Lieshout RJ, Schmidt LA, et al. Systematic Review: Audiovisual Interventions for Reducing Preoperative Anxiety in Children Undergoing Elective Surgery. J Pediatr Psychol 2016;41:182-203. [Crossref] [PubMed]
26. Tordet C, Erhel S, Dodeler V, et al. The benefits of experiencing flow through distracting activities: flow reduces preoperative anxiety in children before surgery, but not postoperative difficulties. Psychol Health 2025;40:321-40. [Crossref] [PubMed]
27. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. J Clin Epidemiol 2021;134:178-89. [Crossref] [PubMed]
28. Schardt C, Adams MB, Owens T, et al. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak 2007;7:16. [Crossref] [PubMed]
29. Horne M. Improving children's preoperative experience: A literature review. Journal of Child Health Care 2012;16:357-69.
30. Kain ZN, Caldwell-Andrews AA, Krane EJ, et al. Preoperative anxiety, postoperative pain, and satisfaction in children undergoing surgery. Pediatric Anesthesia 2007;17:271-7.
31. Lepage JF, Huynh T. Child and parent perceptions of anxiety and pain during the perioperative period. Journal of Pediatric Surgery 2015;50:1343-8.
32. Segerdahl M, Warrén-Stomberg M, Rawal N, et al. Children in day surgery: clinical practice and routines. The results from a nation-wide survey. Acta Anaesthesiol Scand 2008;52:821-8. [Crossref] [PubMed]
33. Clark HD, Wells GA, Huët C, et al. Assessing the quality of randomized trials: reliability of the Jadad scale. Controlled Clinical Trials 1999;20:448-52. [Crossref] [PubMed]
34. Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898. [Crossref] [PubMed]
35. Jenkins BN, Fortier MA, Kaplan SH, et al. Development of a short version of the modified Yale Preoperative Anxiety Scale. Anesth Analg 2014;119:643-50. [Crossref] [PubMed]
36. Fassler D. Reducing preoperative anxiety in children: information versus emotional support. Patient Couns Health Educ 1980;2:130-4. [Crossref] [PubMed]
37. Kain ZN, Wang SM, Mayes LC, et al. Sensory stimuli and anxiety in children undergoing surgery: a randomized, controlled trial. Anesth Analg 2001;92:897-903. [Crossref] [PubMed]
38. Kain ZN, Caldwell-Andrews AA, Krivutza DM, et al. Interactive music therapy as a treatment for preoperative anxiety in children: a randomized controlled trial. Anesth Analg 2004;98:1260-6. table of contents. [Crossref] [PubMed]
39. Golan G, Tighe P, Dobija N, et al. Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial. Paediatr Anaesth 2009;19:262-6. [Crossref] [PubMed]
40. Fincher W, Shaw J, Ramelet AS. The effectiveness of a standardised preoperative preparation in reducing child and parent anxiety: a single-blind randomised controlled trial. J Clin Nurs 2012;21:946-55. [Crossref] [PubMed]
41. Eijlers R, Dierckx B, Staals LM, et al. Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial. Eur J Anaesthesiol 2019;36:728-37. [Crossref] [PubMed]
42. Meteİzci S. Çetinkaya B. The impact of digital storytelling for children during paediatric day surgery on anxiety and negative emotional behaviors: Randomized controlled trial. J Pediatr Nurs 2024;77:e231-41. [Crossref] [PubMed]
43. Turgut A, Özcan İlçe A, Öztürk H. The Effect of Immersive Virtual Reality Application on Anxiety, Pain, and Parental Satisfaction in the Perioperative Process of Children: A Randomized Controlled Trial. Pain Manag Nurs 2024;25:584-90. [Crossref] [PubMed]
44. Kain ZN, Caldwell-Andrews AA, Mayes LC, et al. Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology 2007;106:65-74. [Crossref] [PubMed]
45. Jung MJ, Libaw JS, Ma K, et al. Pediatric Distraction on Induction of Anesthesia With Virtual Reality and Perioperative Anxiolysis: A Randomized Controlled Trial. Anesth Analg 2021;132:798-806. [Crossref] [PubMed]
46. Li HC, Lopez V. Effectiveness and appropriateness of therapeutic play intervention in preparing children for surgery: a randomized controlled trial study. J Spec Pediatr Nurs 2008;13:63-73. [Crossref] [PubMed]
47. Jin Y, Jiang A, Jiang W, et al. Self-produced audio-visual animation introduction alleviates preoperative anxiety in pediatric strabismus surgery: a randomized controlled study. BMC Ophthalmol 2021;21:163. [Crossref] [PubMed]
48. Yang Y, Zhang M, Sun Y, et al. Effects of advance exposure to an animated surgery-related picture book on preoperative anxiety and anesthesia induction in preschool children: a randomized controlled trial. BMC Pediatr 2022;22:92. [Crossref] [PubMed]
49. Wang X, Zhang J, Xin H, et al. Effectiveness of two distraction strategies in reducing preoperative anxiety in children in China: A randomized controlled trial. J Pediatr Nurs 2023;68:e8-e15. [Crossref] [PubMed]
50. Hosseinpour M, Memarzadeh M. Use of a preoperative playroom to prepare children for surgery. Eur J Pediatr Surg 2010;20:408-11. [Crossref] [PubMed]
51. Dehghan Z, Reyhani T, Mohammadpour V, et al. The effectiveness of dramatic puppet and therapeutic play in anxiety reduction in children undergoing surgery: A randomized clinical trial. Iran Red Crescent Med J 2017;19:1-8.
52. Forouzandeh N, Drees F, Forouzandeh M, et al. The effect of interactive games compared to painting on preoperative anxiety in Iranian children: A randomized clinical trial. Complement Ther Clin Pract 2020;40:101211. [Crossref] [PubMed]
53. Cuzzocrea F, Gugliandolo MC, Larcan R, et al. A psychological preoperative program: effects on anxiety and cooperative behaviors. Paediatr Anaesth 2013;23:139-43. [Crossref] [PubMed]
54. Liguori S, Stacchini M, Ciofi D, et al. Effectiveness of an App for Reducing Preoperative Anxiety in Children: A Randomized Clinical Trial. JAMA Pediatr 2016;170:e160533. [Crossref] [PubMed]
55. Bumin Aydın G, Yüksel S, Ergil J, et al. The effect of play distraction on anxiety before premedication administration: a randomized trial. J Clin Anesth 2017;36:27-31. [Crossref] [PubMed]
56. Al-Nerabieah Z, Alhalabi MN, Owayda A, et al. Effectiveness of using virtual reality eyeglasses in the waiting room on preoperative anxiety: a randomized controlled trial. Perioper Care Oper Room Manag 2020;21. [Crossref]
57. Huntington C, Liossi C, Donaldson AN, et al. On-line preparatory information for children and their families undergoing dental extractions under general anesthesia: A phase III randomized controlled trial. Paediatr Anaesth 2018;28:157-66. [Crossref] [PubMed]
58. Ryu JH, Oh AY, Yoo HJ, et al. The effect of an immersive virtual reality tour of the operating theater on emergence delirium in children undergoing general anesthesia: A randomized controlled trial. Paediatr Anaesth 2019;29:98-105. [Crossref] [PubMed]
59. Park SH, Park S, Lee S, et al. Effect of transportation method on preoperative anxiety in children: a randomized controlled trial. Korean J Anesthesiol 2020;73:51-7. [Crossref] [PubMed]
60. Ünver S, Güray Ö, Aral S. Effectiveness of a Group Game Intervention in Reducing Preoperative Anxiety Levels of Children and Parents: A Randomized Controlled Trial. AORN J 2020;111:403-12. [Crossref] [PubMed]
61. West N, Christopher N, Stratton K, et al. Reducing preoperative anxiety with Child Life preparation prior to intravenous induction of anesthesia: A randomized controlled trial. Paediatr Anaesth 2020;30:168-80. [Crossref] [PubMed]
62. Clausen NG, Madsen D, Rosenkilde C, et al. The Use of Tablet Computers to Reduce Preoperative Anxiety in Children Before Anesthesia: A Randomized Controlled Study. J Perianesth Nurs 2021;36:275-8. [Crossref] [PubMed]
63. Nair T, Choo CSC, Abdullah NS, et al. Home-Initiated-Programme-to-Prepare-for-Operation: evaluating the effect of an animation video on peri-operative anxiety in children: A randomised controlled trial. Eur J Anaesthesiol 2021;38:880-7. [Crossref] [PubMed]
64. Garcia De Avila MA, Prata RA, Jacob FLDS, et al. Educational intervention through a comic book for preoperative anxiety in children, adolescents, and their parents: A randomized clinical trial. J Pediatr Nurs 2022;67:e208-14. [Crossref] [PubMed]
65. Pastene B, Piclet J, Praud C, et al. Pre-operative distraction using electric ride-on cars for children undergoing elective ambulatory surgery: A randomised controlled trial. Eur J Anaesthesiol 2023;40:190-7. [Crossref] [PubMed]
66. Kain ZN, Mayes LC, Cicchetti DV, et al. Measurement tool for preoperative anxiety in young children: the Yale Preoperative Anxiety Scale. Child Neuropsychol 1995;1:203-10. [Crossref]
67. Bloom J, Brodsky JR. Management of conductive hearing loss from otitis media in children operative techniques in otolaryngology. Operative Techniques in Otolaryngology-Head and Neck Surgery 2024;35:37-46. [Crossref]
68. Lundgren M, Steed LJ, Tamura R, et al. Analgesic antipyretic use among young children in the TEDDY study: no association with islet autoimmunity. BMC Pediatr 2017;17:127. [Crossref] [PubMed]
69. Moriarty C, Carroll W. Paracetamol: pharmacology, prescribing and controversies. Arch Dis Child Educ Pract Ed 2016;101:331-4. [Crossref] [PubMed]
70. Sunbul N, Delvi MB, Zahrani TA, et al. Buccal versus intranasal midazolam sedation for pediatric dental patients. Pediatr Dent 2014;36:483-8. [PubMed]
71. Baldwa NM, Padvi AV, Dave NM, et al. Atomised intranasal midazolam spray as premedication in pediatric patients: comparison between two doses of 0.2 and 0.3 mg/kg. J Anesth 2012;26:346-50. [Crossref] [PubMed]
72. Ljungman G, Kreuger A, Andréasson S, et al. Midazolam nasal spray reduces procedural anxiety in children. Pediatrics 2000;105:73-8. [Crossref] [PubMed]
73. Pietropaoli JA Jr, Keller MS, Smail DF, et al. Regional anesthesia in pediatric surgery: complications and postoperative comfort level in 174 children. J Pediatr Surg 1993;28:560-4. [Crossref] [PubMed]
74. 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 2010;57:751-8. [Crossref] [PubMed]
75. Jiang Y, Lu Q, Shao Z. Meta-analysis of the effectiveness of active and passive distraction in reducing operational pain in children. Nurs Res 2021;35:7-9.
76. Yahya Al-Sagarat A, Al-Oran HM, Obeidat H, et al. Preparing the Family and Children for Surgery. Crit Care Nurs Q 2017;40:99-107. [Crossref] [PubMed]
77. Alsibai E, Bshara N, Alzoubi H, et al. Assessing an active distracting technique during primary mandibular molar pulpotomy (randomized controlled trial). Clin Exp Dent Res 2023;9:283-9. [Crossref] [PubMed]
78. Ugucu G, Akdeniz Uysal D, Guzel Polat O, et al. Effects of cartoon watching and bubble-blowing during venipuncture on pain, fear, and anxiety in children aged 6-8 years: A randomized experimental study. J Pediatr Nurs 2022;65:e107-14. [Crossref] [PubMed]
79. Metcalf B, Henley W, Wilkin T. Effectiveness of intervention on physical activity of children: systematic review and meta-analysis of controlled trials with objectively measured outcomes (EarlyBird 54). BMJ 2012;345:e5888. [Crossref] [PubMed]
80. Magee L, Goldsmith LP, Chaudhry UAR, et al. Nonpharmacological Interventions to Lengthen Sleep Duration in Healthy Children: A Systematic Review and Meta-analysis. JAMA Pediatr 2022;176:1084-97. [Crossref] [PubMed]