Pediatric anxiety

Learning objectives

Understand the impact of preoperative anxiety in pediatric patients
Management of preoperative anxiety in children with nonpharmacologic methods
Describe the role of sedative premedication in managing preoperative anxiety in children
Discuss the considerations for the selection of which premedication to use

Hospitalization and surgery provoke stress and anxiety in pediatric patients
Children experience the induction of anesthesia as the most stressful procedure during the entire perioperative period
Intense levels of anxiety during anesthetic induction are associated with a higher risk of pain (i.e., increased opioid requirements), poor recovery, and emergence delirium
Preoperative anxiety is also associated with psychological problems and negative behavioral changes in the 2 weeks after surgery, including apathy, separation anxiety, sleeping disturbances, enuresis, and aggression toward authority
Predictors of anxiety are the age and temperament of the child → anesthetic plan must take these factors into account

Use nonpharmacologic methods for all pediatric patients
Use pharmacologic methods only in carefully selected pediatric patients
Avoid pharmacologic methods in children with
- Potential difficult airway
- OSA or central sleep apnea
- Renal or hepatic impairment
- Altered loss of consciousness (LOC)
- Increased intracranial pressure
- Acute systemic illness
- Upper respiratory tract infection
- New or unexplained oxygen desaturations
- Allergies or adverse reactions to proposed medications
When considering pharmacologic methods
- Ensure patient monitoring
- Have resuscitation equipment available
- Transfer to OR or stretcher bed with portable suction and Ambu bag available, accompanied by a nurse or physician
- Reduced LOC or respiratory depression → protect the airway, support ventilation, and consider naloxone (if opioid given) and flumazenil (if midazolam given)

Nonpharmacologic methods

Prehospital information and preparation (e.g., information leaflets, books, videos, OR tours)
Play therapy (e.g., interaction with trained play therapists using visual aids and toys, and accompanying the patient to OR)
Distraction techniques (e.g., blowing bubbles, toys, videos, and games)
Engagement with anesthetic equipment (e.g., holding the mask, “blowing up the balloon”)
Environment adjustments (e.g., lighting, music, minimal extraneous noise, limiting healthcare staff)
Actively involving parents/caregivers (e.g., parental presence for induction)
Communication aids (e.g., info about the child’s needs/routines)
Relaxation techniques (e.g., breathing exercises, hypnosis)

Pharmacologic methods – Sedative premedication

Drug	Route of administration	Dose	Remarks
Benzodiazepines
Midazolam	PO	0.5-0.75 mg/kg, max. 20 mg	Paradoxical agitation in some patients
	IN	0.3 mg/kg	Causes stinging
Lorazepam	IV	0.05-0.1 mg/kg
Temazepam	PR	0.05-0.1 mg/kg	Preferred in older children
	PO	0.025-0.05 mg/kg, max. 4 mg
	PO	0.3-0.5 mg/kg, max. 20 mg
Alpha-2 agonists
Clonidine	PO	3-4 mcg/kg	Added benefits of reduced need for rescue analgesia, reduced emergence agitation, PONV, and shivering Caution in patients with grade 2 or 3 heart block, hypertension, cardiovascular disease, instability, on digoxin
	IN	2-4 mcg/kg
Dexmedetomidine	PR	2.5-5 mcg/kg
	IN	1-2 mcg/kg
NMDA antagonist
Ketamine	PO	5-8 mg/kg	Hallucinations and increased secretions can occur, emergence delirium, and PONV; IM ketamine is reserved for older uncooperative children with developmental problems
	IM	4-6 mg/kg
	IV	0.5-1 mg/kg
Opioids		0.2 mg/kg, max. 10 mg	Risk of respiratory depression

PONV, postoperative nausea and vomiting; PO, per oral; PR, per rectal; IN, intranasal; IM, intramuscular; IV, intravenous.

Preoperative anxiety in pediatric patients is associated with adverse clinical and behavioral outcomes
Multiple techniques may be valuable in managing preoperative anxiety
Consider the need for sedative premedication during the preoperative assessment of every child
Many factors influence the choice of premedication, including the pharmacological profile, possible adverse effects, and presence of comorbidities