Elsevier

Journal of Clinical Anesthesia

Volume 36, February 2017, Pages 27-31
Journal of Clinical Anesthesia

Original Contribution
The effect of play distraction on anxiety before premedication administration: a randomized trial

https://doi.org/10.1016/j.jclinane.2016.04.044Get rights and content

Highlights

  • Pharmacological interventions aimed at reducing perioperative anxiety are paradoxically a source of stress for children themselves.

  • We aimed to assess the role of distraction in the form of playing with play dough (Play-Doh) on reducing premedication anxiety in children.

  • Children were randomized into 2 groups to receive either play dough or not.

  • Children's premedication anxiety was determined by the modified Yale Preoperative Anxiety Scale.

Abstract

Study objective

The majority of children scheduled to undergo surgery experience substantial anxiety in the preoperative holding area before induction of anesthesia. Pharmacological interventions aimed at reducing perioperative anxiety are paradoxically a source of stress for children themselves. Midazolam is frequently used as premedication, and the formula of this drug in Turkey is bitter. We aimed to assess the role of distraction in the form of playing with play dough (Play-Doh) on reducing premedication anxiety in children.

Design

Prospective randomized clinical trial.

Setting

Preoperative holding area.

Patients

One hundred four healthy children aged 3 to 7 years scheduled to undergo elective surgery were enrolled into the study.

Interventions

All children routinely receive sedative premedication (oral midazolam) before anesthesia. Children were randomized to 2 groups to receive either play dough (group PD) (n = 52) or not (group C) (n = 52) before administration of oral premedication.

Measurements

Children's premedication anxiety was determined by the modified Yale Preoperative Anxiety Scale (mYPAS).

Main results

The difference in mYPAS scores between groups at T0 (immediately after entering the preoperative holding area) was not significant (P = .876). Compared with group C, group PD was associated with lower mYPAS scores at T1 and T2 (P < .001). In group PD, mYPAS scores were significantly lower at both T1 and T2 as compared with the scores at T0 (P < .001); they were similar between T1 and T2 (P > .001).

Conclusion

This study showed that distraction in the form of playing with play dough facilitated administration of oral midazolam in young children.

Introduction

The majority of children scheduled to undergo surgery experience substantial anxiety in the preoperative holding area before induction of anesthesia [1], [2]. Potential causes of preoperative anxiety are separation from parents, unfamiliar environments and people, and negative anticipation of surgical procedures [1]. Anxiety in the preoperative holding area may manifest itself by facial expressions of fear, trembling, panic, crying, or even combativeness. Preoperative anxiety also has been associated with difficulty in anesthetic induction [2].

Pharmacological interventions aimed at reducing perioperative anxiety are paradoxically a source of stress in children themselves. Oral administration of such drugs may cause refusal, and insistence may aggravate anxiety [3]. Anxiety, in turn, may impair cooperation and induce refusal [4]. Taste is another factor associated with drug compliance [5]. Midazolam is frequently used in premedication [6], [7], [8] and routinely used in our department. However, the oral preparation of this drug in Turkey is bitter [9]. Premedication with midazolam, therefore, may not significantly reduce preoperative anxiety but, instead, may aggravate it in some cases if refused. The use of distraction in the form of clowns, video games, and cartoons has been shown to alleviate preoperative anxiety in children [10], [11], [12]. Although some of these interventions are more frequently used, others are not due to time constraints, adverse effects, or rising health care costs. Play dough (PD) is a simple, inexpensive toy enjoyed by the majority of preschool- and elementary school–aged children.

We performed this randomized, placebo-controlled study to test the hypothesis that playing with play dough would reduce premedication anxiety in preschool children undergoing elective surgery.

Section snippets

Methods

The study took place in August and September 2013 in Ministry of Health Yildirim Beyazit Diskapi Education and Research Hospital. Children were prospectively and consecutively enrolled in the study after their parents provided written informed consent [13]. The study protocol was approved by the Institutional Ethics Committee (reference no. 4/65, 24/09/2012) and was registered in the Australian New Zealand Clinical Trial Registry prospectively (ACTRN12613000928718).

One-hundred four healthy

Results

In August and September 2013, we enrolled 109 patients to the study (54 to group PD, 55 to group C) but dismissed 4 patients because of upper airway infection and 1 family refused the operation in the preoperative holding area so the study ended with 52 patients in each group (Fig. 1).

Group PD and group C were well matched in relation to age (P = .876), sex (P = .556), and body weight (P = .926) (Table 1).

The difference in mYPAS scores between groups at T0 was not significant (P = .876), but group PD

Discussion

In the current study, we let children play with PD before premedication with midazolam and examined whether this intervention would reduce their anxiety. We assessed anxiety using the mYPAS, which has previously been shown to be a reliable tool to measure anxiety in children [14]. We demonstrated that playing with PD significantly reduced preoperative anxiety and eased midazolam administration in children. Significant increase in mYPAS scores observed in children in the group C during midazolam

Author's contribution

GBA and RP designed the study and collected the data, GBA and SY generated the first draft of manuscript, and JE generated the last draft of the manuscript. FKA, MS, and ME performed the literature search. FKA and ÖO did the statistics.

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    Children in the play dough group reported lower mYPAS scores at 3 min after entering the preoperative holding area, and during the administration of premedication compared to the control (P ≤ 0.001). The study demonstrated that distraction in the form of playing with play dough facilitated administration of oral premedication in children [115]. This finding is similar to a previous review that revealed that parental presence during induction of anesthesia (PPIA) did not diminish the child's anxiety and that future focus should be on non-pharmacologic interventions such as video games or clips [116].

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Conflict of interest/support: There is no conflict of interest or any financial support.

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