In Reply:—

We thank Drs. Buckley and Korz for their intersting comments involving the study performed by our group. 1 

Taking the methodological question first, home pain assessments were completed by the parent, who was given a visual analog scale (VAS) and asked to report the measurement from the scale to an investigator during telephone interviews.

As for the comments concerning parental presence, the readers of ANESTHESIOLOGY are well-aware that the issue of parental presence during induction of anesthesia is controversial. The experimental evidence to date does not support the routine use of parental presence during induction of anesthesia. 2–5Although early studies suggested anxiety reduction and increased cooperation if parents were present during induction, 6,7all recent investigations indicate that routine parental presence is not beneficial in terms of reduced anxiety or increased cooperation. 2–5The results of these studies should be interpreted, however, with caution. The design of a randomized controlled trial, although considered a ‘gold standard’ in research, may not reflect the practice of all anesthesiologists; that is, although a randomized controlled trial is applicable to centers that offer parental presence for all parents, it may not be applicable to centers that consider each request for parental presence based on the personality characteristics of each child and parent. Such centers may have different (better?) results with parental presence than were shown in experimental studies to date. We believe that research efforts in this area should shift toward an emphasis on what parents actually do during induction, rather than simply on their presence. Blount et al.  8reported that among children undergoing immunization, parents who were taught to be active in distracting the child by conversation and reading or in reassuring them through touch and eye contact were able to reduce the child's distress. It may be that effective methods of training can be developed for parental presence during induction of anesthesia. Therefore, in our center, we do not offer parental presence to all patients, but rather respond to each request based on the individual child, parent, and anesthesiologist.

We agree that separation anxiety is a major problem after surgery in children. This postoperative separation anxiety, however, is reflective of the behavioral response of the child to the entire perioperative experience and not only to the preoperative separation period. Therefore, to conclude that by preventing preoperative separation we will in fact prevent postoperative separation problems may be premature. Moreover, in two previous randomized controlled trials involving parental presence, we followed-up children for 2 weeks after surgery, 3,4measuring postoperative behavior with the Post Hospitalization Behavior Questionnaire. We demonstrated that children whose parents were present during induction of anesthesia were equally as likely to develop postoperative separation anxiety as children who were not accompanied by a parent. Therefore, we must deduce, based on the scientific data, that parental presence during induction of anesthesia does not decrease the incidence of postoperative behavioral changes in general, and postoperative separation anxiety in particular.

In conclusion, we believe that parental presence during induction of anesthesia may have a place in a child's perioperative experience, but significant work is needed to determine what role parents should play and how best to prepare parents to be most helpful to their children in the operating room setting. As it stands, parental presence increases parental satisfaction 9but does not affect a child's immediate perioperative anxiety or long-term behavior.

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