To the Editor:—

Congratulations to the authors on a well-performed study in an area of particular interest to us. We are curious about one aspect of the methodology and would also like to discuss the results from a slightly different view point.

From a methodological standpoint, the pain assessments were performed by parental report by telephone, including the visual analog score (VAS) pain scale. Were the parents given a visual analog score scale to complete, which was then mailed back for measurement and recording, or were the parents responsible for measuring and reporting by telephone?

Historically, we have taken the position as a matter of course that presence of parents during induction is a useful technique. For the past 25 yr, it has been routine for us to bring one parent into the operating room during anesthetic induction. Therefore, we were pleased to see that the authors considered the presence of the parent to be their final recourse for children whose preoperative anxiety had not been treated with sedation. We wonder then, why this is not the routine for all patients because it is clearly accepted within the group in times of need?

In reviewing the data reported from the Post Hospitalization Behaviour Questionnaire (fig. 3), there are only two areas of significant difference between the groups: eating disturbances (on postoperative day 2 and separation anxiety (on postoperative days 2, 7, and 14). Because these were outpatient surgeries, the only separation events would have been the separation from parents at the time of anesthetic induction and the wait until parents returned when the child awoke (possibly in the postanesthetic care unit). Behavior indicative of separation anxiety is also the largest category of disturbed behaviour for both groups on all but postoperative day 2, and so the separation event is arguably the most significant contributor to the total behavioral disturbance. Therefore, it would seem that avoiding separation whenever possible would be likely to prevent anxiety and thus avoid behavioral disturbance.

It would seem that Kain et al.  1may be in an excellent position to evaluate this issue because they obviously have the evaluative tools and at least some acceptance from their group of the practice of the presence of parents during induction. Unfortunately from the standpoint of investigation, we enshrined parental presence in our dogma and so would have great difficulty in carrying out such an analysis.

Kain Z, Mayes L, Caramico L, Wang S, Hofstadter M: Postoperative behavioral outcomes in children: Effects of sedative premedication. A NESTHESIOLOGY 1999; 90: 758–65