Intervention Review

Non-pharmacological interventions for assisting the induction of anaesthesia in children

  1. Anne Manyande1,
  2. Allan M Cyna2,*,
  3. Peggy Yip3,
  4. Cheryl Chooi2,4,
  5. Philippa Middleton5

Editorial Group: Cochrane Anaesthesia, Critical and Emergency Care Group

Published Online: 14 JUL 2015

Assessed as up-to-date: 28 AUG 2014

DOI: 10.1002/14651858.CD006447.pub3

How to Cite

Manyande A, Cyna AM, Yip P, Chooi C, Middleton P. Non-pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD006447. DOI: 10.1002/14651858.CD006447.pub3.

Author Information

  1. 1

    University of West London, School of Psychology, Social Work and Human Sciences, London, UK

  2. 2

    Women's and Children's Hospital, Department of Women's Anaesthesia, Adelaide, South Australia, Australia

  3. 3

    Starship Children's Hospital, Department of Paediatric Anaesthesia, Auckland, New Zealand

  4. 4

    The University of Adelaide, Department of Acute Care Medicine, Adelaide, Australia

  5. 5

    The University of Adelaide, Women's and Children's Research Institute, Adelaide, South Australia, Australia

*Allan M Cyna, Department of Women's Anaesthesia, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, 5006, Australia.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 14 JUL 2015




  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung
  5. Laički sažetak


Induction of general anaesthesia can be distressing for children. Non-pharmacological methods for reducing anxiety and improving co-operation may avoid the adverse effects of preoperative sedation.


To assess the effects of non-pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their co-operation.

Search methods

In this updated review we searched CENTRAL (the Cochrane Library 2012, Issue 12) and searched the following databases from inception to 15 January 2013: MEDLINE, EMBASE, PsycINFO and Web of Science. We reran the search in August 2014. We will deal with the single study found to be of interest when we next update the review.

Selection criteria

We included randomized controlled trials of a non-pharmacological intervention implemented on the day of surgery or anaesthesia.

Data collection and analysis

At least two review authors independently extracted data and assessed risk of bias in trials.

Main results

We included 28 trials (2681 children) investigating 17 interventions of interest; all trials were conducted in high-income countries. Overall we judged the trials to be at high risk of bias. Except for parental acupuncture (graded low), all other GRADE assessments of the primary outcomes of comparisons were very low, indicating a high degree of uncertainty about the overall findings.

Parental presence: In five trials (557 children), parental presence at induction of anaesthesia did not reduce child anxiety compared with not having a parent present (standardized mean difference (SMD) 0.03, 95% confidence interval (CI) -0.14 to 0.20). In a further three trials (267 children) where we were unable to pool results, we found no clear differences in child anxiety, whether a parent was present or not. In a single trial, child anxiety showed no significant difference whether one or two parents were present, although parental anxiety was significantly reduced when both parents were present at the induction. Parental presence was significantly less effective than sedative premedication in reducing children's anxiety at induction in three trials with 254 children (we could not pool results).

Child interventions (passive): When a video of the child's choice was played during induction, children were significantly less anxious than controls (median difference modified Yale Preoperative Anxiety Scale (mYPAS) 31.2, 95% CI 27.1 to 33.3) in a trial of 91 children. In another trial of 120 children, co-operation at induction did not differ significantly when a video fairytale was played before induction. Children exposed to low sensory stimulation were significantly less anxious than control children on introduction of the anaesthesia mask and more likely to be co-operative during induction in one trial of 70 children. Music therapy did not show a significant effect on children's anxiety in another trial of 51 children.

Child interventions (mask introduction): We found no significant differences between a mask exposure intervention and control in a single trial of 103 children for child anxiety (risk ratio (RR) 0.59, 95% CI 0.31 to 1.11) although children did demonstrate significantly better co-operation in the mask exposure group (RR 1.27, 95% CI 1.06 to 1.51).

Child interventions (interactive): In a three-arm trial of 168 children, preparation with interactive computer packages (in addition to parental presence) was more effective than verbal preparation, although differences between computer and cartoon preparation were not significant, and neither was cartoon preparation when compared with verbal preparation. Children given video games before induction were significantly less anxious at induction than those in the control group (mYPAS mean difference (MD) -9.80, 95% CI -19.42 to -0.18) and also when compared with children who were sedated with midazolam (mYPAS MD -12.20, 95% CI -21.82 to -2.58) in a trial of 112 children. When compared with parental presence only, clowns or clown doctors significantly lessened children's anxiety in the operating/induction room (mYPAS MD -24.41, 95% CI -38.43 to -10.48; random-effects, I² 75%) in three trials with a total of 133 children. However, we saw no significant differences in child anxiety in the operating room between clowns/clown doctors and sedative premedication (mYPAS MD -9.67, 95% CI -21.14 to 1.80, random-effects, I² 66%; 2 trials of 93 children). In a trial of hypnotherapy versus sedative premedication in 50 children, there were no significant differences in children's anxiety at induction (RR 0.59, 95% CI 0.33 to 1.04).

Parental interventions: Children of parents having acupuncture compared with parental sham acupuncture were less anxious during induction (mYPAS MD -17, 95% CI -30.51 to -3.49) and were more co-operative (RR 1.59, 95% CI 1.01 to 2.53) in a single trial of 67 children. Two trials with 191 parents assessed the effects of parental video viewing but did not report any of the review's prespecified primary outcomes.

Authors' conclusions

This review shows that the presence of parents during induction of general anaesthesia does not diminish their child's anxiety. Potentially promising non-pharmacological interventions such as parental acupuncture; clowns/clown doctors; playing videos of the child's choice during induction; low sensory stimulation; and hand-held video games need further investigation in larger studies.


Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung
  5. Laički sažetak

Non-pharmacological interventions for assisting the induction of anaesthesia in children


The initial process of giving general anaesthesia (i.e. induction of anaesthesia) to children can be distressing for them and their parents. Children can be given a sedative medicine (premedication) to drink such as midazolam before anaesthesia is induced in order to help the child relax. However these drugs can have undesirable effects, such as possible airway obstruction before anaesthesia begins and during recovery. In addition behaviour changes may occur after the operation. Some non-drug alternatives have been tested to see if they could help children relax and co-operate at the beginning of their anaesthesia. This review aims to assess the effects of non-drug interventions such as hypnosis, acupuncture and video games in helping with the beginning of general anaesthesia in children

Key findings

We included 28 trials (2681 children under the age of 18 years and or their parents) with a large number of interventions (17) assessed.

The presence of parents at induction of the child's anaesthesia has been the most commonly investigated intervention (eight trials), but has not been shown to reduce anxiety or distress in children, or increase their co-operation during induction of anaesthesia.

Although parents should not be actively discouraged from being present if they prefer to do so, equally parents should not be encouraged to be present at their child's induction if they prefer not to do so.

Most commonly other interventions are given to the child (e.g. video games or hypnosis) but sometimes the intervention is given to the parent. One study of acupuncture for parents found that the parent was less anxious, and the child was more co-operative, at induction of anaesthesia. Another study of giving parents information, in the form of pamphlets or videos, failed to show an effect. In other studies looking at interventions for children, clowns or clown doctors, a quiet environment, video games and computer packages (but not music therapy) each showed benefits such as improved co-operation in the children.

Quality of the evidence

Many of the studies were of poor quality and too small to provide clear answers to the study question. However potentially promising non-pharmacological interventions such as parental acupuncture; clowns/clown doctors; playing videos of the child's choice during induction, pre-operative hypnosis and hand-held video games require further testing in future studies. Non-drug interventions that might help parents relax need further study, as there is some evidence that more relaxed parents may improve their child's anaesthesia induction experience.


Laienverständliche Zusammenfassung

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung
  5. Laički sažetak

Nichtmedikamentöse Maßnahmen zur Unterstützung der Anästhesieeinleitung bei Kindern


Zu Beginn kann die Verabreichung einer Vollnarkose ( Einleitung einer Anästhesie) bei Kindern für das Kind selbst und für die Eltern belastend sein. Um Kindern dabei zu helfen, zu entspannen, kann ihnen ein Beruhigungsmittel in Form eines Getränks, beispielsweise Midazolam, verabreicht werden (Prämedikation), bevor die Anästhesie eingeleitet wird. Diese Medikamente können jedoch unerwünschte Wirkungen hervorrufen, beispielsweise eine Blockierung der Atemwege vor Narkosebeginn und während der Aufwachphase. Außerdem könnten nach der Operation Verhaltensänderungen auftreten. Es wurden verschiedene nichtmedikamentöse Alternativen getestet um herauszufinden, ob diese Kindern dabei helfen können, zu entspannen und sich zu Beginn der Narkose kooperativ zu verhalten. Ziel dieses Reviews ist die Bewertung der Wirkung nichtmedikamentöser Maßnahmen wie Hypnose, Akkupunktur und Einsatz von Videospielen zu Beginn der Verabreichung einer Vollnarkose bei Kindern.


In dem Review wurden 28 Studien berücksichtigt (mit 2681 Kindern unter 18 Jahren und deren Eltern). In den Studien wurde eine Vielzahl von Maßnahmen (17) untersucht.

Die am häufigsten untersuchte Maßnahme war die Anwesenheit der Eltern bei der Anästhesieeinleitung des Kindes (acht Studien). Doch aus den Studien ging nicht hervor, dass diese Maßnahme zur Reduzierung von Angst oder Stress bei den Kindern führte oder ihre Kooperation bei der Anästhesieeinleitung förderte.

Obwohl Eltern nicht aktiv davon abgehalten werden sollten, bei der Anästhesieeinleitung ihres Kindes anwesend zu sein, falls sie dies wünschen, sollten sie ebenso wenig dazu aufgefordert werden, anwesend zu sein, wenn sie lieber nicht dabei wären.

Meistens kommen andere Maßnahmen zum Einsatz (z.B. Videospiele oder Hypnose), und manchmal wird die Maßnahme auch bei den Eltern angewendet. Eine Studie zur Akkupunktur bei Eltern zeigte, dass der so behandelte Elternteil bei der Anästhesieeinleitung weniger Angst verspürte und das Kind sich kooperativer verhielt. In einer weiteren Studie, bei der Eltern Informationen in Form von Broschüren oder Videos erhielten, konnte keine Wirkung gezeigt werden. Weitere Studien ergaben einen positiven Effekt, beispielsweise ein kooperativeres Verhalten, durch die folgenden Maßnahmen für Kinder: Clowns oder Clown-Ärzte, ruhige Umgebung, Video- und Computerspiele (Musiktherapie erzielte hingegen keine Wirkung).

Qualität der Evidenz

Viele der Studien waren von niedriger Qualität und zu klein, um die Fragestellung eindeutig zu beantworten. Es besteht jedoch Bedarf an künftigen Studien zu vielversprechend erscheinenden, nichtmedikamentösen Maßnahmen wie Akkupunktur der Eltern, Clowns/Clown-Ärzte, Zeigen eines von dem Kind gewählten Films während der Anästhesieeinleitung, präoperative Hypnose und portable Videospiele. Da es Evidenz dazu gibt, dass entspanntere Eltern sich positiv auf die Erfahrungen des Kindes bei der Anästhesieeinleitung auswirken können, müssen auch nichtmedikamentöse Maßnahmen, die den Eltern bei der Entspannung helfen können, weiter erforscht werden.

Anmerkungen zur Übersetzung

I. Noack, freigegeben durch Cochrane Schweiz.


Laički sažetak

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung
  5. Laički sažetak

Postupci bez lijekova za lakši uvod u anesteziju kod djece

Dosadašnje spoznaje

Kad je riječ o djeci, uvod u opću anesteziju (dalje uvod u anesteziju) može biti stresan za njih i njihove roditelje. Djeci se može dati da popiju sedativ (lijek za uvod u anesteziju), primjerice midazolam prije početka anesteziranja da ih se opusti i smiri. Ali ti lijekovi mogu izazvati nepoželjne učinke, primjerice mogu suziti dišni put prije početka anestezije i tijekom oporavka od nje. Mogu se pojaviti i promjene u ponašanju nakon operacije. Stoga su istraženi drugi postupci kao pomoć djeci da se opuste i surađuju na početku anesteziranja. Ovaj Cochrane sustavni pregled procijenio je učinke alternativnih postupaka poput hipnoze, akupunkture i video igrica kao pomoć djeci na početku primjene opće anestezije

Ključni rezultati

Uključena su 28 istraživanja (2681 dijete mlađe od 18 godina ili njihovi roditelje) s velikim brojem (17) ispitanih postupaka.

Prisustvo roditelja kod uvoda u anesteziju djece bilo je najčešće istraživani postupak (8 istraživanja), ali nije značajno utjecalo na smanjivanje panike i straha kod djece, kao ni na povećanje suradljivosti tijekom uvoda u anesteziju.

Premda roditelje ne bi trebalo odgovarati ili obeshrabrivati da budu prisutni pri uvodu u anesteziju, ako to žele, jednako ih tako ne bi trebalo poticati da budu prisutni ako to nisu voljni.

U ostalim studijama najčešće su ispitani ostali postupci provedeni kod djece (npr. video igrice ili hipnoza), ali ponekad je intervencija bila usmjerena na roditelje. Studija o akupunkturi roditelja pokazala je manju razinu napetosti i straha kod roditelja, kao i veću suradljivost djece pri uvodu u anesteziju. Druga pak studija koja je ispitala davanje informacija roditeljima, u formi letaka ili videa, nije pokazala značajan učinak. Studije koje su ispitale postupke za djecu kao što su klaunovi ili klaunovi liječnici, mirno okruženje, video igrice i računalne aplikacije (ne i glazbenu terapiju) pokazale su korisne učinke poput bolje suradljivosti djece.

kvaliteta dokaza

Mnoga istraživanja bila su loše kvalitete ili premala da bi dala jasne odgovore na pitanja ove studije. Unatoč tome, potencijalno obećavajući alternativni postupci poput akupunkture kod roditelja; klaunovi/klaunovi liječnici; gledanje omiljenih filmova tijekom početka anestezije, predoperativna hipnoza i igranje video igrica zahtijevaju daljnja i bolja ispitivanja u budućim studijama. Alternativani postupci koji bi mogli pomoći roditeljima da se opuste i smire trebaju se još istražiti jer postoje dokazi da opušteniji roditelji mogu poboljšati iskustvo uvođenja u anesteziju kod njihove djece.

Bilješke prijevoda

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