Over five million children undergo surgery in the US each year and it is reported that up to 50 percent of these children develop significant fear prior to surgery. As a result, about 20 percent of children who undergo surgery are subsequently forcefully restrained while crying, kicking and screaming throughout the induction of anesthesia process. Preoperative sedatives and parental presence during induction of anesthesia (PPIA) are available at the current time to help children during this extremely stressful period. However, preoperative sedatives, although effective, are associated with significant increases in operational costs; thus, many hospitals actively discourage their routine use. As a result, PPIA is currently used to a varying degree by about 50 percent of all anesthesiologists in the US. Interestingly, whereas initial observational studies suggested that PPIA reduces children's anxiety, recent randomized trials indicate that PPIA is not reliably beneficial. All PPIA research to date, however, only deals with one question - whether or not parents should be present in the or during induction of anesthesia. It is our opinion that the question we need to address is not that of parental presence or absence, but rather what parents actually do while in the OR. In fact, previous preliminary investigations involving children with cancer who underwent painful procedures indicate that parental and health care provider behaviors significantly influence children's anxiety during painful procedures. It is because PPIA as practiced today is ineffective, and because the use of PPIA is on the rise, that we call for the development of an intervention that will convert parental presence in the OR into an effective, clinically applicable, low-cost modality that reduces anxiety and improves postoperative outcomes. To convert PPIA into an effective intervention, however, it is of utmost importance to first empirically identify the specific parent and health-care personnel behaviors that increase or decrease children's anxiety during induction of anesthesia and the postoperative period. This will be achieved by obtaining a preoperative sequential process-oriented view of parent-child-health care provider behavioral interaction and by using robust sequential analysis techniques. As the next step we will develop data-driven behavioral preparation programs that will train parents, nurses, anesthesiologists and surgeons in how to reduce children's distress during the preoperative process.
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