About the Author(s)


Katherine R. Drennan Email symbol
Department of Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Grace Manjooran symbol
Department of Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Cara Redelinghuys symbol
Department of Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Citation


Drennan KR, Manjooran G, Redelinghuys C. Pre-operative anxiety and the effect of soft toys in children at an academic hospital in Johannesburg, South Africa. South Afr J Anaesth Analg. 2026;32(1), a1522. https://doi.org/10.4102/sajaa.v32i1.1522

Original Research

Pre-operative anxiety and the effect of soft toys in children at an academic hospital in Johannesburg, South Africa

Katherine R. Drennan, Grace Manjooran, Cara Redelinghuys

Received: 02 Dec. 2025; Accepted: 15 May 2026; Published: 22 July 2026

Copyright: © 2026. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Paediatric pre-operative anxiety is common. Pharmacological and non-pharmacological methods can reduce pre-operative anxiety. Low- and middle-income countries require safe, affordable, accessible methods such as soft toys to minimise anxiety.

Aim: This study aimed to describe pre-operative anxiety in children and the effect of soft toys in managing anxiety.

Setting: The study involved children ages 2–17 years receiving general anaesthesia for elective surgery at a South African academic hospital.

Methods: This prospective, cross-sectional observational study assessed 114 children using the modified Yale Pre-operative Anxiety Scale (mYPAS) at three points: Waiting area (T1); after being offered a soft toy (T2); and at mask introduction (T3). Scores of 30 or greater indicated high anxiety.

Results: At baseline, 54% of children displayed high anxiety (T1 median mYPAS = 30). Those who refused a toy were more anxious than those who accepted a toy (median mYPAS = 37 vs 30; p = 0.10). Anxiety decreased after toy introduction (T2 median mYPAS = 28) with significantly lower scores in children who chose a toy (p = 0.006). Anxiety spiked at mask introduction (T3 median mYPAS = 41) with 93% showing high anxiety regardless of toy presence (p = 0.63). Toys were associated with lower anxiety at T2 (p = 0.039) but not at T3 (p = 0.61). Older age correlated with lower anxiety at T3 only (p < 0.001). Caregiver presence approached statistical significance at T3 (p = 0.054).

Conclusion: Soft toys help reduce anxiety initially, but not during mask introduction. Combining low-cost, non-pharmacological strategies may improve outcomes in resource-limited settings.

Contribution: Soft toys are safe, affordable, and accessible for peri-operative anxiolysis in low- and middle-income countries.

Keywords: pre-operative period; anxiety; paediatrics; toys; non-pharmacological.

Introduction

Pre-operative anxiety occurs commonly in paediatric patients for many reasons, for example, fear of the unknown; previous negative healthcare exposures; separation from caregivers, pain anticipation, or limited understanding.1,2 Pre-operative anxiety is described as ‘an unpleasant state of tension or uneasiness, and accompanied by physiological (e.g. sweating, tachycardia, and nausea) and psychological (apprehension, nervousness, and aggression) effects’.3 The anaesthetist’s motivation for reducing pre-operative anxiety is two-fold: To minimise negative feelings in the immediate pre-operative period and to minimise negative post-operative sequelae such as delirium, increased analgesic requirements, aggression, sleep disturbances, and enuresis.1,4,5

The incidence of pre-operative anxiety ranges widely across the globe, with lower numbers reported in high-income countries compared with low- and middle-income countries. Studies in Brazil (42%),6 India (47% – 70%), Pakistan (62% – 97%) and Ethiopia (40% – 70%)7 show considerably higher prevalence rates than those of a high-income country such as the Netherlands (20% – 28%).7 Recent studies in South Africa demonstrated incidences ranging between 30% and 95%.8,9,10,11

Risk factors for pre-operative anxiety relate to the child, the parent or caregiver, and the environment. Children aged 1–5 years are most likely to experience high levels of anxiety, often because of separation from their caregiver.5 Older children may give reasons such as fear of pain, awareness, or death.12 The role of gender has not been conclusively delineated, but children with a shy or avoidant personality or who have had previous negative experiences with healthcare are more likely to be anxious.12 Anxiety levels spike at mask introduction for induction of anaesthesia, when siting an intravenous catheter in awake patients, and when being separated from caregivers.5 Risk factors associated with the parent or caregiver include female gender, divorce, and parental anxiety.5,12 Environmental factors include many people in the operating room, long waiting times, noise, and the anaesthetist’s temperament.5

The gold standard for quantifying paediatric pre-operative anxiety is the modified Yale Pre-operative Anxiety Scale (mYPAS), which was developed by Kain in 1997.10,13,14 This tool has been validated to assess anxiety prior to surgery in children 2 years and older with good inter- and intra-observer reliability.11,13 It does not require verbal interaction with the child and can be performed in approximately 1 min.15 Five domains (activity, vocalisations, emotional expressivity, state of apparent arousal, use of parents) are scored in real time and combined to give a final weighted score (Figure 1).2,14 Scores range from 23.3 to 100, and a score greater than or equal to 30 is high anxiety.13,14,15,16 While extreme anxiety is not clearly defined, Kain et al. identified the mYPAS descriptors ‘crying or whimpering’, ‘frightened and/or sad facial expressions’, and ‘vigilance or panic’ as indicating extremely high anxiety.17

FIGURE 1: Equation used to calculate the modified Yale Pre-operative Anxiety Scale score.

Management of pre-operative anxiety can be divided into four broad categories: pharmacological, parental presence, educational, and non-pharmacological.4 Pharmacological anxiolytics such as midazolam or dexmedetomidine are effective but risk unwanted side-effects such as respiratory depression, haemodynamic compromise and oversedation, which may be dangerous if not adequately monitored, as may be the case in under-resourced hospitals.4,18 Parental presence is a cost-free anxiolytic technique, but may worsen anxiety in the child if their parent is overtly anxious or even over-reassuring.15 Educational techniques, such as pamphlets or videos, are cheap and efficient but may require internet access and personalisation to the child’s and parents’ level of understanding.5

Many non-pharmacological techniques can be tailored to the child’s age and developmental stage.5 Distraction, such as play, reading, watching videos, or listening to music, is highly effective in young children.3,5,19 Older children may respond to deep breathing or pre-exposure to anaesthetic equipment.5 More costly techniques include art therapy, clowns, virtual reality headsets, or child life specialists.2,4,20 South Africa’s public healthcare system already faces debilitating financial restrictions, rendering many of these inaccessible. Offering a soft toy to the child is a safe, low-cost intervention shown to reduce pre-operative anxiety in other settings.21,22,23 This study aimed to assess the levels of pre-operative anxiety in children at a teaching hospital and to determine whether a soft toy is effective in reducing pre-operative anxiety scores using the mYPAS.

Research methods and design

Study design and setting

This prospective, cross-sectional observational study was conducted at Chris Hani Baragwanath Academic Hospital (CHBAH) in Johannesburg, South Africa. This teaching hospital conducts approximately 1500 elective paediatric surgeries each year. It serves a large population and is affiliated with a large public university in Gauteng.

Study population and sampling strategy

Children aged 2–17 years inclusive, irrespective of gender or race, undergoing elective surgery at CHBAH were included. Procedures requiring general anaesthesia from the orthopaedic, otorhinolaryngological, plastic, and paediatric surgery disciplines were included. Children with an American Society of Anesthesiologists’ (ASA) physical status of I to III were included. Children presenting for emergency surgery, those who had received sedative or anxiolytic premedication, those already intubated upon arrival to theatre, and those who refused to participate were excluded.

Using the conservative proportion for pre-operative anxiety in South African children of 69.2% from Jooma’s study,10 a 95% confidence interval (CI), alpha of 0.05, and a ± 12% change in the mean mYPAS score with the intervention, a sample size of 106 children was imputed. The Stata® 18 statistical programme (StataCorp, College Station, Texas, United States) was used for this calculation.

Convenience sampling was used to obtain the study sample. Theatre booking lists were reviewed during the data collection period, and patients who met the inclusion criteria were approached in the ward or at the theatre reception area. Informed consent was obtained from the parent or legal guardian of each child, and, where possible, assent was obtained from children aged 6 years and older.

Data collection

The mYPAS was used with permission from the office of Dr Zeev Kain. A single investigator, dressed in unobtrusive hospital attire, conducted every assessment to reduce inter-rater variability. Each child was scored while in the pre-operative waiting area (T1). They were then offered a soft toy and assessed again (T2). The child (accompanied by the soft toy and, if present, their caregiver) was taken into the operating theatre by the theatre team. The child could sit or lie on the operating table or be held by their caregiver, according to preference and the anaesthetist’s discretion. Anxiety was assessed for the final time as the face mask was introduced for the induction of anaesthesia (T3). Additional data relating to other non-pharmacological methods employed by the anaesthetist were recorded. All raw data were digitally captured on a REDCap® database (Nashville, Tennessee, United States) hosted at the University of the Witwatersrand, Johannesburg.

Any child who displayed the descriptors indicating extreme anxiety17 at all three time points would be referred to the responsible anaesthetist for further management in the peri-operative period, as well as being referred by the principal investigator to the CHBAH child psychology department.

Data analysis

Raw data were analysed in consultation with a biostatistician using the Stata® 18 statistical programme. The mean and standard deviation describe the central tendency of symmetric variables, and the median and interquartile range (IQR) describe the central tendency for asymmetric variables. The Kruskal–Wallis rank sum test, Wilcoxon rank sum test, Pearson’s Chi-squared test, and Fisher’s exact test were used to estimate associations. A p-value of less than or equal to 0.05 is considered statistically significant. Logistic regression and multinomial logistic regression were used to estimate risk factors, odds ratios, and 95% CIs.

Ethical considerations

Prior to commencement of the study, ethical approval was obtained from the University of the Witwatersrand’s Human Research Ethics Committee (Medical) (reference number M240118). Additional approval was obtained from the university’s Faculty of Health Sciences Postgraduate Committee and the Chris Hani Baragwanath Academic Hospital’s Medical Advisory Committee. This study was registered with the National Health Research database (reference number: GP_202402_079). All procedures were in accordance with the ethical standards of the institutional committee on human experimentation and with the 1964 Declaration of Helsinki and its later amendments.

The same investigator who would offer the soft toy and score the participants’ anxiety obtained informed written consent from all parents or legal guardians of participants being included in the study. Additionally, each participant aged 6 years and older who was capable provided assent to their involvement in this study. This was done the day prior to surgery or on the day of surgery.

Raw data were collected and stored on REDCap®, a controlled-access repository. The data are not linked to any identifying features of the participants.

Results

A total of 114 children were included in this study (Table 1). The median age was 7 years (IQR 4–10 years). Male participants comprised 62% of the sample. A caregiver was present and accompanied 68% of participants into the theatre. The surgical disciplines represented were paediatric surgery (43%), orthopaedic surgery (34%), otorhinolaryngological surgery (16%), and plastic surgery (7%). A wide range of elective procedures was performed. Most children were classified as ASA I (56%), with the remainder classified as ASA II (31%) or ASA III (13%).

TABLE 1: Demographic characteristics of children presenting for surgery.

Every child, as is the standard of care at CHBAH, was offered a soft toy in the waiting area. Each soft toy was actively offered to the child by the investigator, and the child and caregiver were told that the toy was theirs to keep. After being offered a toy, 14 children in the sample refused to take one. These children were more likely to be older (median age: 11 years; IQR: 8.0–14.0). Of the 100 who chose a toy, 79 (69%) brought it into the theatre. The median mYPAS score for all children at T1 (prior to being offered a toy) was 30 (IQR: 23 – 45), which indicates high anxiety at baseline. Most children (n = 61, 54%) had a score of 30 or higher at T1. The lowest score recorded at T1 was 23 (the lowest possible score on mYPAS), and the highest was 70. The group of children who did not choose a toy had higher anxiety at T1 than those who did (median mYPAS 37 vs 30; p = 0.10).

At T2 (after being offered a toy), the median mYPAS score across all children was 28 (IQR: 23–35). Fewer than half (n = 45, 39%) had a score of 30 or higher at T2. The lowest score recorded at T2 was 23 and the highest was 78. The group of children who did not choose a toy had significantly higher anxiety at T2 than those who did (median mYPAS 32 vs. 28; p = 0.006).

The median mYPAS score for all children at T3 (induction of anaesthesia) increased to 41 (IQR: 35 – 55). Almost every child (n = 106, 93%) had a score of 30 or higher at T3. The lowest score recorded at T3 was 23 and the highest was 90. The median mYPAS scores of those who did or did not choose a toy were equal at T3 (41 vs 41; p = 0.63). No child fulfilled the criteria for extreme anxiety requiring referral to the child psychology department.

Various other non-pharmacological anxiolytic strategies were employed in the pre-operative period, either by the children independently or led by the anaesthetist. These ranged from the use of a pacifier, rocking, simple explanations about what to expect, general play, reading a book, watching a video, playing a mobile game, exposure to anaesthetic equipment, deep breathing, and drawing. The most common technique used prior to entering the theatre was play (n = 48, 42%). The most common techniques used in theatre were simple explanations about what to expect (n = 22, 19%) and exposure to anaesthetic equipment (n = 19, 17%). One anaesthetist gave a coloured sticker to each child (n = 5, 4%). Some children (n = 25, 22%) were not offered any other form of non-pharmacological anxiolysis other than the soft toy.

Using a univariate linear model (Table 2) and comparing scores between the groups, the following results were obtained. The effect of older age resulted in a significant decrease in anxiety scores at T3 (induction of anaesthesia) only (Beta: –1.3; CI: −1.9 to –0.70; p < 0.001). Gender was not significantly associated with a change in anxiety at any time point, although the presence of a caregiver approached statistical significance at T3 (p = 0.054). Children who chose a toy and brought it into the theatre showed a statistically significant decrease in their mYPAS scores at T2 (Beta: –6.4; CI: −13 to –0.33; p = 0.039). This effect was not carried through to T3 (Beta: 2.2; CI: −6.3 to 11; p = 0.61). Changes in individual participant scores were not analysed for this study.

TABLE 2: Univariate analysis of the effect on the modified Yale Pre-operative Anxiety Scale score at each time point.

When controlling for confounders, the effects identified in univariate analysis were confirmed. Older age resulted in a statistically significant lowering in mYPAS at T3 (Beta: –1.6; CI: −2.5 to –0.79; p < 0.001). Children who chose a toy and brought it into the theatre had lower anxiety at T2 (Beta: −7.2; CI: −14 to –0.61; p = 0.032), but this did not carry through to T3 (Beta: −3.2; CI: −12 to 5.2; p = 0.45).

Discussion

Research relating to pre-operative anxiety in the South African paediatric population is scarce. This study elucidates the burden of pre-operative anxiety in children undergoing surgery at a large teaching hospital. It also describes the various non-pharmacological anxiolytic techniques used by anaesthetists in a resource-constrained environment. While this study specifically examines soft toys as a means of reducing anxiety, it also considers the complex, real-world journey of a child from the pre-operative visit through the waiting area, into the theatre, and up to the point of mask introduction.

Most of the participants accepted toys and brought them into the theatre. Only 21% of children who chose toys did not bring them into the theatre. They either forgot it in the waiting room or had it packed away by their caregiver prior to entering the theatre. While investigating the reasons behind this is beyond the scope of this study, a tentative suggestion related to poverty in South Africa is that some caregivers may have wanted to ensure the toy was brought home with the child, as it may have been one of the very few toys the child possessed.

Each child is allowed to keep their soft toy in accordance with the standard of care at CHBAH. Generous donations of soft toys from employees of the hospital, members of the public, and private companies ensure that this intervention has been sustainable and cost-free to the anaesthetic department since its introduction in 2022.

The authors acknowledge that this study used a wider age range than Jooma’s, which examined 2- to 6-year-olds. The South African Children’s Act (No. 38 of 2005) defines a child as any person younger than 18 years, which is the upper limit of the target age group.24 Research in this field seldom includes children older than 12–14 years. They are considered too old to include in anxiety studies in children or too young to include in adult studies, and thus, inadvertently, adolescents become the ‘forgotten age group’. Their inclusion in this study is an attempt to better understand their pre-operative experience. A 2015 Belgian study examined, among other things, pre-operative anxiety in children up to 16 years of age using the mYPAS.25 Their findings were in line with other studies, namely that age is an important risk factor for anxiety at induction of anaesthesia and that anxiety in the holding area is associated with anxiety on induction. These authors make the important point that older children may downplay or internalise their anxiety. Whether this is similar in the South African population has not yet been investigated, and it is hoped that this study serves as a starting point for investigating adolescent pre-operative anxiety.

A few children declined the soft toy when it was offered. Approximately half of these children (57%) were 11 years or older. While this study aims to include adolescents’ experiences, this finding highlights the age-appropriateness of a soft toy for younger age groups compared with pre-teenagers and teenagers.5

The wide range in mYPAS scores recorded at T1 shows the variety of emotional states that children may present as when coming to the theatre. The median mYPAS score at T1 indicated that more than half the children arriving at the theatre complex had high anxiety. This is similar to findings from studies in other low- and middle-income countries, namely South Africa (66% – 80%),9 India (48%),16 and Pakistan (63% – 71%).15 Along with the other challenges associated with paediatric anaesthesia, it is incumbent on anaesthetists to focus their attention on reducing pre-operative anxiety from the moment the child arrives in theatre.

The drop in median mYPAS score at T2 after being offered a toy can potentially be attributed to a variety of factors, such as receiving the soft toy itself, the comfortable surroundings of a child-focused waiting area, or the presence of other children playing. Interestingly, the statistically significant difference in mYPAS scores between the children who chose a soft toy and those who did not suggests that this intervention may be associated with lessened pre-operative anxiety.

However, this difference did not carry through to mask introduction and induction of anaesthesia in theatre. Most children were highly anxious when face masks were introduced, regardless of whether they had a soft toy. This is well-recognised to be the most anxiety-provoking period for children26 and was confirmed by this study. In contrast, another South African study9 using cartoons showed preservation of effect through to mask introduction. Older age was determined to be the only statistically significant variable in lowering anxiety at T3. A scoping review by Liu et al.12 and studies in Brazil6 and the Netherlands27 corroborate this finding.

While receiving a soft toy prior to theatre is the current standard of care at CHBAH, anaesthetists are free to use any other form of non-pharmacological anxiolysis. Many of the children in the waiting area chose to play with each other or use the toys already there. Some caregivers offered their mobile phones for watching videos or playing games, which seemed to provide a powerful distraction. One child verbalised, unprompted, that he was practicing deep breathing to help quell his anxiety. Of the techniques initiated by the anaesthetic provider, mobile games or videos, simple explanations about what will happen, and exposure to anaesthetic equipment were most common. One anaesthetist gave a coloured sticker to each child while placing their electrocardiogram electrodes; this novel technique was not identified in the preliminary literature search. One-fifth of children did not receive any other form of non-pharmacological anxiolysis other than the soft toy. These other methods are not the main focus of this study, but bring to light other techniques that may be used in future research. We postulate that the combination of a soft toy and one or more other non-pharmacological techniques may greatly reduce anxiety prior to theatre and at mask introduction.

A potential limitation of the study is sampling bias from convenience sampling, as the sample may not be representative of the population. The contextual and purposive nature of the study, as well as its small sample size, may also be limiting factors. The use of a single hospital is another limitation, somewhat overcome by the considerable number of theatres available and the large volume of cases performed.

The unethical nature of randomising children to receive or not receive a toy (against standard practice at CHBAH) limits this study’s ability to determine the effectiveness of the soft toy intervention. The limitation of selection bias must be considered, as children were free to choose or refuse a soft toy. Consequently, those children who did not want a toy or who did not bring one into the theatre were used as the comparison group to the children who took their toy into the theatre.

The complexity of interpreting this study’s results is increased because of a number of anaesthetic-related factors: There was no specified anaesthetic protocol (this decision was left to the anaesthetist responsible for the case); the pre-operative visit may have been performed a day prior to surgery or on the day of surgery; the option of using other non-pharmacological anxiolytic techniques (at the attending anaesthetist’s prerogative); and the anaesthetist who performed the pre-operative assessment may or may not have been the same person who introduced the face mask to the participant.

The surgical factors include: Many surgical disciplines were included in order to obtain a broad range of participants; the potential sedating side-effects of certain pain medications; and some participants who may have had prior theatre exposures, which can either elevate their anxiety or lessen it (gathering these data was beyond the scope of this article).

The participant factors include: A broad age range (including adolescents) beyond that which is usually found in pre-operative anxiety studies; the variability of caregiver presence in theatre; and different waiting times between arrival in the waiting area, offering the soft toy, and entering the operating theatre (these data were not feasible to gather). In addition, the potential Hawthorne effect (observer bias) from the investigator’s presence during the mYPAS scoring may have affected the participants’ scores.

For children who did not have a caregiver with them, and for those whose caregivers chose not to enter the theatre, the mYPAS domain for ‘use of parents’ was scored with respect to the adult who acted in place of the child’s caregiver while in the theatre. This was most often an anaesthetist or an anaesthetic nurse. The authors acknowledge that this non-caregiver relationship likely affected the participants’ anxiety, but still chose to include these participants as they represent a significant portion of the children presenting for surgery at CHBAH.

During data collection, it was incidentally noted that children booked for orthopaedic procedures had fewer distractions and fewer play opportunities as a function of the location of the orthopaedic theatre. These children waited on a transport bed in the corridor outside the theatre. On the other hand, children booked for non-orthopaedic procedures waited in a dedicated paediatric waiting area on the opposite side of the theatre complex. This room has toys, books, and videos available to all children. There are also many children waiting together in this room, which adds to the distraction. It will be valuable to consider its impact on pre-operative anxiety as an area of further research.

Conclusion

This study found that children presenting for elective surgery had high levels of pre-operative anxiety. Offering a soft toy to children was associated with decreased anxiety prior to entering the theatre, but it is not sufficient to show an associated decrease in anxiety at face mask introduction for induction of anaesthesia. In the real-world context of this study, this is significant because it highlights the importance of using multiple anxiolytic strategies to maximise effectiveness. In low- and middle-income countries, non-pharmacological anxiolysis is often more accessible and safer than techniques that require technology (e.g., virtual reality), additional staff (e.g., child life specialists), or extended monitoring (e.g., pharmacological anxiolysis). Further research is recommended to identify combinations of non-pharmacological techniques that can reduce anxiety across various age groups.

Acknowledgements

The research presented in this article formed part of Katherine R. Drennan’s postgraduate studies and was originally conducted as part of her Master’s thesis titled ‘Pre-operative anxiety and the effect of soft toys in children at an academic hospital in Johannesburg, South Africa’, submitted to the Faculty of Health Sciences, University of the Witwatersrand in 2025, under the supervision of Grace Manjooran and Cara Redelinghuys. The thesis was submitted in partial fulfilment of the requirements for the Master’s degree. Portions of the thesis have been revised, updated, and adapted for publication as a journal article. The original thesis is currently unpublished and was not publicly available online at the time of publishing this article.

This article is based on research previously presented in abstract form at the Paediatric Anaesthesia Congress of South Africa, held in Umhlanga, South Africa, 07–09 November 2025. The abstract has since been developed into a full article, which has been expanded and revised for journal publication. This republication is done with permission from the conference organisers.

The authors acknowledge Dr Clarence Yah for his assistance with sample size estimation and Mr Brian Brummer for his assistance with statistical analysis. While their contributions were important, they did not meet the criteria for authorship. The authors acknowledge the individuals and organisations who donated soft toys to the hospital’s Department of Anaesthesia.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

CRediT authorship contribution

Katherine R. Drennan: Conceptualisation, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Visualisation, Writing – original draft, Writing – review & editing. Grace Manjooran: Conceptualisation, Methodology, Project administration, Supervision, Visualisation, Writing – review & editing. Cara Redelinghuys: Conceptualisation, Methodology, Project administration, Supervision, Visualisation, Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The data that support the findings of this study are available from the corresponding author, Katherine R. Drennan, upon reasonable request.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or the publisher. The authors are responsible for the article’s results, findings, and content.

References

  1. Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviours. Anesth Analg. 2004;99:1648–1654. https://doi.org/10.1213/01.ANE.0000136471.36680.97
  2. Jones MT, Kirkendall M, Grissim L, Daniels S, Boles JC. Exploration of the relationship between a group medical play intervention and children’s preoperative fear and anxiety. J Pediatr Health Care. 2021;35(1):74–83. https://doi.org/10.1016/j.pedhc.2020.08.001
  3. Clausen NG, Madsen D, Rosenkilde C, Hasfeldt-Hansen D, Larsen LG, Hansen TG. The use of tablet computers to reduce preoperative anxiety in children before anesthesia: A randomized controlled study. J Perianesth Nurs. 2021;36(3):275–278. https://doi.org/10.1016/j.jopan.2020.09.012
  4. Gold JI, Annick ET, Lane AS, Ho K, Marty RT, Espinoza JC. ‘Doc McStuffins: Doctor for a Day’ Virtual Reality (DocVR) for pediatric preoperative anxiety and satisfaction: Pediatric medical technology feasibility study. J Med Internet Res. 2021;23(4):e25504. https://doi.org/10.2196/25504
  5. Ahmed MI, Farrell MA, Parrish K, Karla A. Preoperative anxiety in children risk factors and non-pharmacological management. Middle East J Anaesthesiol [serial online]. 2011 [cited 2023 Mar 10];21(2):153–164. Available from https://www.aub.edu.lb/fm/Anesthesiology/meja/Documents/Preoperative%20Anxiety%20In%20Children%20-%20Risk%20Factors%20And%20Non%20-%20Pharmacological%20Management.pdf
  6. De Moura LA, Dias IMG, Pereira LV. Prevalence and factors associated with preoperative anxiety in children aged 5–12 years. Rev Latino-Am Enfermagem. 2016;24:e2708. https://doi.org/10.1590/1518-8345.0723.2708
  7. Bedaso A, Mekonnen N, Duko B. Prevalence and factors associated with preoperative anxiety among patients undergoing surgery in low-income and middle-income countries: A systematic review and meta-analysis. BMJ Open. 2022;12(3):e058187. https://doi.org/10.1136/bmjopen-2021-058187
  8. Torlutter M. A cross sectional survey investigating the prevalence of preoperative anxiety in children, and if this is associated with cultural and socio-economic background at Rahima Moosa Mother and Child Hospital, South Africa [homepage on the Internet] [Master’s thesis]. Stellenbosch University; 2012 [cited 2025 Jan 17]. Available from https://scholar.sun.ac.za/items/8cf1e074-9e83-4514-9bfb-d80b4bb1ffb8
  9. Dale E, Scribante J, Perrie H, Jooma Z. Audiovisual distraction for preoperative anxiety in paediatric patients at a regional hospital. South Afr J Anaesth Analg. 2024;30(6):185–189. https://doi.org/10.36303/SAJAA.3173
  10. Jooma Z, Perrie H, Scribante J, Kleyenstuber T. Emergence delirium in children undergoing dental surgery under general anesthesia. Pediatr Anesth. 2020;30(9):1020–1026. https://doi.org/10.1111/pan.13937
  11. Ramkisson U. The influence of a play intervention on pre-operative anxiety in children at an academic hospital: A pilot study [homepage on the Internet] [Master’s thesis]. Johannesburg: University of the Witwatersrand; 2020 [cited 2023 Oct 8]. Available from https://wiredspace.wits.ac.za/items/705baa7e-9d85-4819-9746-e2d116642499
  12. Liu W, Xu R, Jia J, Shen Y, Li W, Bo L. Research progress on risk factors of preoperative anxiety in children: A scoping review. Int J Environ Res Public Health. 2022;19(16):9828. https://doi.org/10.3390/ijerph19169828
  13. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale preoperative anxiety scale: How does it compare with a ‘gold standard’? Anesth Analg. 1997;85(4):783–788. https://doi.org/10.1097/00000539-199710000-00012
  14. Jenkins BN, Fortier MA, Kaplan SH, Mayes LC, Kain ZN. Development of a short version of the modified Yale Preoperative anxiety scale. Anesth Analg. 2014;119(3):643–650. https://doi.org/10.1213/ANE.0000000000000350
  15. Hussain A, Khan FA. Effect of two techniques of parental interaction on children’s anxiety at induction of general anaesthesia – A randomized trial. Turk J Anaesthesiol Reanim. 2018;46(4):305–310. https://doi.org/10.5152/TJAR.2018.66750
  16. Malik R, Yaddanpudi S, Panda NB, Kohli A, Mathew PJ. Predictors of pre-operative anxiety in Indian children. Indian J Pediatr. 2018;85(7):504–509. https://doi.org/10.1007/s12098-018-2606-3
  17. Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics. 2006;118(2):651–658. https://doi.org/10.1542/peds.2005-2920
  18. Bromfalk Å, Myrberg T, Walldén J, Engström Å, Hultin M. Preoperative anxiety in preschool children: A randomized clinical trial comparing midazolam, clonidine, and dexmedetomidine. Pediatr Anesth. 2021;31(11):1225–1233. https://doi.org/10.1111/pan.14279
  19. Aytekin A, Doru Ö, Kucukoglu S. The effects of distraction on preoperative anxiety level in children. J Perianesth Nurs. 2016;31(1):56–62. https://doi.org/10.1016/j.jopan.2014.11.016
  20. Dionigi A, Gremigni P. A combined intervention of art therapy and clown visits to reduce preoperative anxiety in children. J Clin Nurs. 2017;26(5–6):632–640. https://doi.org/10.1111/jocn.13578
  21. Golden L, Pagala M, Sukhavasi S, Nagpal D, Ahmad A, Mahanta A. Giving toys to children reduces their anxiety about receiving premedication for surgery. Anesth Analg. 2006;102(4):1070–1072. https://doi.org/10.1213/01.ane.0000198332.51475.50
  22. Ghabeli F, Moheb N, Hosseini Nasab SD. Effect of toys and preoperative visit on reducing children’s anxiety and their parents before surgery and satisfaction with the treatment process. J Caring Sci. 2014;3(1):21–28. https://doi.org/10.5681/jcs.2014.003
  23. Weber FS. The influence of playful activities on children’s anxiety during the preoperative period at the outpatient surgical center. J Pediatr (Rio J). 2010;86(3):209–214. https://doi.org/10.2223/JPED.2000
  24. South Africa. Children’s Act No. 38 of 2006 [homepage on the Internet]. 2006 [cited 2023 Dec 20]. Available from: https://www.gov.za/sites/default/files/gcis_document/201409/a38-053.pdf
  25. Berghmans JM, Poley MJ, Van der Ende J, et al. A visual analog scale to assess anxiety in children during anesthesia induction (VAS-I): Results supporting its validity in a sample of day care surgery patients. Pediatr Anesth. 2017;27(9):955–961. https://doi.org/10.1111/pan.13206
  26. Fortier MA, Del Rosario AM, Martin SR, Kain ZN. Perioperative anxiety in children. Pediatr Anesth. 2010;20(4):318–322. https://doi.org/10.1111/j.1460-9592.2010.03263.x
  27. Eijlers R, Staals LM, Legerstee JS, et al. Predicting intense levels of child anxiety during anesthesia induction at hospital arrival. J Clin Psychol Med Settings. 2021;28(2):313–322. https://doi.org/10.1007/s10880-020-09716-6


Crossref Citations

No related citations found.