To the Editor:—

I agree with Professor Lerman in his recent editorial on parental presence at induction of anesthesia (PPIA) 1when he states that an evidence-based scientific approach is needed in examining this issue, but I disagree with some of the conclusions he draws from current research in this area.

Reviewing the literature on PPIA, three studies show a reduction of child anxiety at anesthesia induction with parental presence. 2–4However, these were not all randomized trials, confounding factors existed, and the measures of anxiety used were not all validated. Two more recent randomized controlled trials show no benefit for children in the PPIA groups compared with controls; however, there was no increase in child anxiety in the PPIA groups. 5,6The study by Kain et al.  5was randomized, excluded confounding factors, and used a validated measure of child anxiety—the Yale Preoperative Anxiety Scale. No significant difference in child anxiety was seen between the control group and the PPIA group. However, some subgroups of children benefited from PPIA. Anxiety measured by serum cortisol level was reduced in children older than 4 yr, children with calm parents, and shy, inhibited children.

I suggest a more positive view of parental presence is appropriate. It can be effective in alleviating the anxiety of some children. We need to examine how parental presence can be made more effective as an intervention instead of denying this useful resource. Reduced parental anxiety is associated with reduced child anxiety, 5whereas children accompanied by anxious parents are more anxious themselves. 6Preparation of parents and providing them with more information is useful in reducing their anxiety, 7so studies examining the effect of parental preparation for PPIA on child anxiety would be interesting. Identifying anxious parents and relieving their anxiety may be important.

Study of the interaction between parent and child at anesthesia induction would be useful. Encouraging more involvement of the parent with use of distraction or by teaching coping methods has been shown to be beneficial in other medical settings. 8,9 

Distraction may be particularly useful for intravenous induction of anesthesia. Also, we should listen to parents because they are good predictors of their children’s distress at induction 10—certainly better predictors than anesthetists. 11 

The risks of PPIA are discussed in the editorial. The potential for “serious cardiac dysrhythmias” of the parent is discussed without citation of evidence. PPIA has proved to be exceptionally safe, without major problems for the child or parent, in several studies. 2,3,5,12In the literature, only one anecdotal report exists of a problem in which no harm resulted. 13It seems that the editorial overstates the risks. The nurse who accompanies the parent and child can accompany the parent back to the ward after induction of anesthesia. Anxiety levels of anesthetists are not increased by PPIA, as demonstrated by Kain et al.  5 

Sedative premedication is effective in reducing child anxiety, but, in unpremedicated children, parental presence has a role and should not be discouraged. Further studies on methods of improving the effectiveness of parental presence are needed in this contentious area.

Lerman J: Anxiolysis: By the parent or for the parent? Anesthesiology 2000; 92: 925–7
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Kain ZN, Mayes LC, Caramico LA, Silver D, Spieker M, Nygren MN, Anderson G, Rimar S: Parental presence during induction of anesthesia: A randomized controlled trial. Anesthesiology 1996; 84: 1060–7
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