Allaying Anxiety in Children

I T was a dark and stormy oncall night when I first read the manuscript by Martin et al. that appears in this month’s ANESTHESIOLOGY. The groups from the Universities of California at Irvine and Los Angeles report on their validation of a “new intervention” that can be used by anesthesia practitioners to more effectively allay preoperative anxiety immediately before induction of general anesthesia in unpremedicated children. What is this “new intervention”? Is it a new sedative or hypnotic? An appearance by Kanye West or Beyoncé? An immobulus or impedimenta charm? No, it’s ... a story! For the past two decades, Zeev Kain’s group has been extensively studying patient risk factors and possible treatments for preoperative anxiety. Preoperative anxiety is important to prevent because it is correlated with adverse postoperative behavioral abnormalities. In this latest of their work, they have developed a method to teach healthcare providers and parents (or any adult that needs to allay anxiety in a child) the difference between “distress-promoting behaviors” and “coping-promoting behaviors.” Distress-promoting behaviors include seemingly reassuring and well-meaning comments that are actually contrary to the child’s perceptive reality. Coping-promoting behaviors include distraction techniques, such as humorous stories and “medical reinterpretation” (e.g., pretending the anesthesia machine is a rocket ship). They call this educational intervention the Provider-Tailored Intervention for Perioperative Stress. This initial pilot study was not meant to test the intervention on the child but rather to see if anesthesiologists could be trained to use these coping-promoting behaviors. Who would have ever thought that an anesthesiologist could exert a positive influence on a child without drugs? Once upon a time, in a land not so far away, it was common to anesthetize children without premedication, relying on one’s charm and charisma to soothe the child before smothering their face with an anesthesia mask. Then, in 1959, Freeman and Bachman, from The Children’s Hospital of Philadelphia, reported the use of premedication in children, using different combinations of intramuscularly administered sedatives. But it was both the best of times and the worst of times: intramuscular administration ran contrary to the popular trend of children’s hospitals becoming “ouchless” places. Premedication administered orally wasn’t described until 1984. In the 1990s, we began using the oral formulation of midazolam and soon discovered that remarkable euphoric state of inebriation and reliable amnesia that delights parents and perioperative personnel. Like propofol and the laryngeal mask, orally administered midazolam radically altered pediatric anesthesia practice. Notwithstanding its objectionable aftertaste, oral midazolam premedication closely approaches the ideal premedication. It is easy to administer, has a predictably rapid onset and offset, does not increase oropharyngeal secretions, provides reliable anxiolysis and amnesia, and does not cause significant cardiovascular or respiratory depression in otherwise healthy children. Its possible prolongation of postoperative recovery in certain short-duration anesthetics is clinically inconsequential. So why look for something else? For starters, oral midazolam isn’t useful in all children. Anyone who has been in this business long enough knows that the bitter-tasting midazolam solution is spit out by a significant number of children. Other children are variously described as allergic to midazolam (“It makes my child dizzy”) or hypersensitive if it caused a paradoxical reaction in the past. And some children just refuse to take it again if it once caused them to have a memorably un-