Prevention and intervention strategies to alleviate preoperative anxiety in children: a critical review.

Preoperative anxiety (anxiety regarding impending surgical experience) in children is a common phenomenon that has been associated with a number of negative behaviors during the surgery experience (e.g., agitation, crying, spontaneous urination, and the need for physical restraint during anesthetic induction). Preoperative anxiety has also been associated with the display of a number of maladaptive behaviors postsurgery, including postoperative pain, sleeping disturbances, parent-child conflict, and separation anxiety. For these reasons, researchers have sought out interventions to treat or prevent childhood preoperative anxiety and possibly decrease the development of negative behaviors postsurgery. Such interventions include sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, and acupuncture. The present article reviews the existing research on the various modes of intervention for preoperative anxiety in children. Clinical implications and future directions are discussed.

Effects of midazolam on explicit vs implicit memory in a pediatric surgery setting.

RATIONALE: Placebo-controlled studies show that midazolam impairs explicit memory in children undergoing surgery (Buffett-Jerrott et al., Psychopharmacology 168:377-386, 2003; Kain et al., Anesthesiology 93:676-684, 2000). A recent within-subjects study showed that midazolam impaired explicit memory while leaving implicit memory intact in a sample of older children undergoing painful medical procedures (Pringle et al., Health Psychol 22:263-269, 2003). OBJECTIVES: We attempted to replicate and extend these findings in a randomized, placebo-controlled design with younger children undergoing surgery. MATERIALS AND METHODS: Children aged 3-6 years who were undergoing ear tube (myringotomy) surgery were randomly assigned to receive midazolam (n = 12) or placebo (n = 11). After surgery, they were tested on explicit (recognition) and implicit (priming) memory for pictures encoded before surgery. RESULTS: Relative to placebo, the midazolam-treated children showed poorer recognition memory on the explicit task but equivalent priming on the implicit task. CONCLUSIONS: Overall, it appears that midazolam induces a dissociation between explicit and implicit memory in young children in the pediatric surgery setting. Theoretical and clinical implications of the findings are discussed along with directions for future research.

High levels of impulsivity may contraindicate midazolam premedication in children.

PURPOSE: To investigate the effects of midazolam on emotional reactivity during induction of anesthesia in a pediatric day surgery setting. A secondary purpose was to determine if these effects were influenced by child temperament factors. METHODS: Forty children (age four to six years) scheduled for myringotomy were randomly assigned, in a double blind fashion, to receive either oral midazolam 0.5 mg.kg-1 mixed with acetaminophen suspension or acetaminophen alone. The Emotionality, Activity, Sociability, and Impulsivity (EASI) scale was used as a measure of child temperament. The modified Yale Preoperative Anxiety Scale (m-YPAS), an observer-rated measure of state anxiety, was employed to assess anxiety pre- and post-drug, and also at induction of anesthesia. RESULTS: Children who received midazolam reacted significantly less to induction of anesthesia than did children in the placebo control group, F (1, 38) = 7.46, P = 0.01. A significant positive association was observed between baseline levels of anxiety and observer-rated anxiety at anesthetic induction, but only in the placebo group, r = 0.58, P < 0.01. A significant positive association was observed between levels of impulsivity at baseline and observer-rated anxiety at anesthetic induction, but only in the midazolam group, r = 0.42, P < 0.05. CONCLUSIONS: Midazolam dampened adverse reactivity during anesthetic induction, particularly among children with high baseline levels of anxiety. Baseline level of impulsivity was positively associated with adverse reactions to anesthesia induction in the drug group, but not in the placebo group, suggesting that high levels of trait impulsivity may contraindicate the use of midazolam as a preoperative medication.

Effects of benzodiazepines on explicit memory in a paediatric surgery setting.

RATIONALE: Many laboratory-based studies indicate that benzodiazepines impair explicit memory performance, increase sedation, and impair attention. OBJECTIVES: The present study was designed to extend prior lab-based findings to an applied setting in which the amnestic effects of benzodiazepines may be beneficial for users. In addition, the study extended the previous adult-focused research by examining the cognitive effects of benzodiazepines in children. METHODS: The present study examined the use of a specific benzodiazepine (midazolam) as a premedicant among 40 children aged 4-6 years old having ear tube (myringotomy) surgery, who were randomly assigned to receive midazolam or placebo. RESULTS: Consistent with previous studies, the results indicated that midazolam causes significant amnesia on a cued recall task. In addition, free recall for post-drug events were also impaired by midazolam relative to placebo, indicating that benzodiazepine-induced amnesia occurs even for highly salient information. CONCLUSIONS: Overall, it appears that benzodiazepines do impair memory in a pediatric population. This amnesia was not secondary to the inattention and sedation also caused by midazolam administration. The theoretical and clinical implications of these findings are discussed, as are potential future studies.