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Easing children's minds about surgery

Yale Medicine Magazine, 1999 - Fall / 2000 - Winter


Imagine the operating room from the point of view of a child about to have surgery: bright lights, sharp instruments, a battery of imposing machines and a succession of strangers wearing gowns and masks. Last year, in this country alone, children underwent 3 million operations, prompting health care professionals such as Zeev N. Kain, M.D., HS ’92, to find better ways to prepare them psychologically for surgery and its aftermath.

“The overwhelming majority of kids in the United States who go into the operating room are awake, alone and crying,” said Kain, associate professor of anesthesiology, pediatrics and child psychiatry. But, he added, it doesn’t have to be that way.

After a yearlong study, Kain has found that sedating children 30 minutes before surgery can cut incidents of post-surgical anxiety by half. “The group that got the sedative manifested significantly less behavioral change after surgery than the group that did not get the sedative,” he said. Researchers found fewer incidents of nightmares, aggression towards authority, eating problems and separation anxiety.

Easing children’s fear may do more than simply reduce postoperative behavioral problems, researchers found. In studies of adults, Kain and his colleagues have shown that patients with low anxiety levels required less pain medication after surgery and healed faster. A reduction in stress, he said, resulted in lower levels of interleukin-6, a stress hormone that, in large quantities, can retard healing.

Kain began investigating fears about surgery in 1993 when he noticed gaps in the literature about surgical anxiety. Most research on the topic, he said, was done from a behavioral point of view. Assembling a team that included child development specialists, surgeons, anesthesiologists and a psychiatrist, Kain set out to address the ways children were prepared for surgery.

Kain’s study, published in March in the journal Anesthesiology, included 86 children, aged 2 through 7, who underwent elective surgery of the lower abdomen over a 12-month period. To eliminate other potential causes of psychological distress, children going through their parents’ divorce or the death of a loved one were removed from the study. Half the children received the sedative midazolam and those in the control group received no interventions, either behavioral or pharmacological. For two weeks following surgery, researchers interviewed parents, relying on a detailed survey with 27 questions about children’s behavior.

Kain emphasized that the sedative is only one element of peri-operative intervention. Anxiety also may be reduced by allowing parents into the operating room as anesthesia is administered, exposing children to the operating room before surgery, explaining what will happen to them during surgery, and playing music in the operating room. Kain believes the interventions not only will ease stress, but promote faster healing. “That,” he said, “is the ultimate outcome.”