Parental presence during induction of anaesthesia

Preoperative anxiety in children is a common problem, and anaesthesiologists often encounter extreme emotional distress in children undergoing surgery (Corman ef al. 1958). Appropriate identification and treatment of this clinical phenomenon is critical since it may lead to psychological and physiological damage to both the child and parent (Schulman et al. 1967; Boeke et al. 1991; Kain ef al. 1994). Premedication prior to surgery is widely used to reduce preoperative anxiety in young children. Routine preoperative use of sedatives, however, may result in increased pharmacy costs, additional nursing staff and the need for appropriately equipped bed space in the holding area. Delayed recovery room and home discharge in patients undergoing short outpatient procedues may also occur. As an alternative, behavioural interventions such as parental presence during the induction of anaesthesia have been suggested (Schulman et al. 1967; Hannallah & Rosales 1983; Hickmott ef al. 1989; Bevan et al. 1990; Yemen & Nelson 1992). Although there is general agreement about the desirability of parents visiting during their child’s hospitalization (Vernon et al. 1965), their presence during invasive medical procedures is controversial. While some investigators believe that such presence will benefit the child, others have suggested that parental presence may make the situation more stressful (Shaw & Routh 1982; Bauchner, Vinci & Waring 1989). Shaw & Routh examined the effect of parental presence on behaviour of children age 1’/2 to 5 years receiving routine immunization in a paediatrician’s office (Shaw & Routh 1982). The investigators concluded that when the mother was present children cried longer after receiving an injection and continued to fuss more while being dressed and taken from the examination room. Most parents however, feel that they are helping their child and prefer to be present during procedures such as bIood drawing (Bauchner, Vinci & Waring 1989). In 1985, a consultant ophthalmologist reported in the British Medical Journal the profound dismay that he and his wife felt when their request to be present at the induction of general anaesthesia in their threeyear-old daughter was firmly denied (While 1985). The physician stated that his daughter awoke from the anaesthetic screaming and that later that day she recalled the experience of being forcefully held down and a mask being placed over her face. The publication of Dr While’s article provoked a widespread debate in the anaesthesia community and began a movement to allow parents to be present at induction of anaesthesia (Holt 1985; Roberts 1985; Anonymous 1986). Potential benefits from parental presence include minimizing the need for premedication, and avoiding screaming and struggling that may result upon separation from the parents. Other benefits such as decreasing the child’s anxiety during induction, and potentially decreasing the long term behavioural effects of surgery remain controversial. Although early studies suggested reduced anxiety and increased cooperation if parents were present during induction (Schulman et al. 1967; Hannallah & Rosales 1983), more recent reports indicate that parental presence may not be beneficial (Bevan et al. 1990; Yemen & Nelson 1992). Bevan ef a/. in a randomized trial found that parental presence had no effect on the behaviour of the child during induction. However, when parental behaviour was introduced as a covariable, the most upset group of children at induction were those who were accompanied by extremely ‘anxious’ parents. Children of ’calm’ parents did not differ in their mood as a result of having a parent accompany them during induction. Furthermore, a recent preliminary report found less anxiety in preschool and school aged children who were not accompanied by a parent during induction (Yemen and Nelson 1992). Some of the contradictory results can be explained by the design of previous studies. Some of the studies enrolled children who had a previous hospitalization while others enrolled children who were never hospitalized. Futhermore, Hannallah ef al.