As standardised outcomes will support benchmarking and pooling (meta-analysis) of trials, one or more of these recommended endpoints should be considered for inclusion in clinical trials assessing patient comfort and pain after surgery.

Background Induction of general anaesthesia can be distressing for children. Non‐pharmacological methods for reducing anxiety and improving co‐operation may avoid the adverse effects of preoperative sedation. Objectives To assess the effects of non‐pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their co‐operation. Search strategy We searched CENTRAL (The Cochrane Library 2009, Issue 1). We searched the following databases from inception to 14th December 2008: MEDLINE, PsycINFO, CINAHL, DISSERTATION ABSTRACTS, Web of Science and EMBASE. Selection criteria We included randomized controlled trials of a non‐pharmacological intervention implemented on the day of surgery or anaesthesia. Data collection and analysis Two authors independently extracted data and assessed risk of bias in trials. Main results We included 17 trials, all from developed countries, involving 1796 children, their parents or both. Eight trials assessed parental presence. None showed significant differences in anxiety or co‐operation of children during induction, except for one where parental presence was significantly less effective than midazolam in reducing children's anxiety at induction. Six trials assessed interventions for children. Preparation with a computer package improved co‐operation compared with parental presence (one trial). Children playing hand‐held video games before induction were significantly less anxious than controls or premedicated children (one trial). Compared with controls, clown doctors reduced anxiety in children (modified Yale Preoperative Anxiety Scale (mYPAS): mean difference (MD) 30.75 95% CI 15.14 to 46.36; one trial). In children undergoing hypnosis, there was a nonsignificant trend towards reduced anxiety during induction (mYPAS < 24: risk ratio (RR) 0.59 95% CI 0.33 to 1.04 ‐ 39% versus 68%: one trial) compared with midazolam. A low sensory environment improved children's co‐operation at induction (RR 0.66, 95% CI 0.45 to 0.95; one trial) and no effect on children's anxiety was found for music therapy (one trial). Parental interventions were assessed in three trials. Children of parents having acupuncture compared with parental sham‐acupuncture were less anxious during induction (mYPAS MD 17, 95% CI 3.49 to 30.51) and more children were co‐operative (RR 0.63, 95% CI 0.4 to 0.99). Parental anxiety was also significantly reduced in this trial. In two trials, a video viewed preoperatively did not show effects on child or parental outcomes. Authors' conclusions This review shows that the presence of parents during induction of general anaesthesia does not reduce their child's anxiety. Promising non‐pharmacological interventions such as parental acupuncture; clown doctors; hypnotherapy; low sensory stimulation; and hand‐held video games needs to be investigated further. Plain Language Summary Non‐pharmacological interventions for assisting the induction of anaesthesia in children The initial process of giving general anaesth...

6. Frank NC, Blount RL, Smith AJ, Manimala MR, Martin JK. Parent and staff behavior, previous child medical experience, and maternal anxiety as they relate to child procedural distress and coping.

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Summary Recent evidence suggests that how anaesthesia information is presented may influence patient treatment outcomes. We conducted an observational study of anaesthetic‐based patient information leaflets across NHS Trusts in England for their nocebo terms vs. therapeutic terms, and how adverse effects were presented. In this study, ‘nocebo’ is wording that may predispose the patient to expect adverse events such as pain or nausea. Data were extracted and analysed for word frequency, weighted proportion and thematic analysis. In total, 42 patient information leaflets from 61 NHS Trusts were analysed. ‘Pain’ was the second most common word across the leaflets, median (IQR [range]) 0.82 (0.50–1.0 [0.12–1.47]) per 100 words, second only to ‘anaesthesia’. In comparison, ‘safe’ was the most common positively valanced word which featured eight times less frequently than ‘pain’ 0.10 (0.07–0.18 [0.0–0.84]) and ‘comfort’ featured 16.5 times less than ‘pain’ 0.02 (0.0–0.05 [0.0–0.13]). Multiple examples of phrasing that could have potential nocebo effects included, ‘you will need strong painkillers’ suggesting ‘strong pain’ and the need for ‘painkillers’ rather than using therapeutic terms focusing on ‘comfort’, ‘healing’ and ‘recovery’. Our results suggest a dominance of phrases with negative content in the presentation of anaesthesia information provided to patients. Clinicians need to be aware of inadvertent generation of nocebo‐weighted vs. comfort‐weighted communication with patients. Our study findings suggest an opportunity for more emphasis to be placed on therapeutic outcomes and effective mitigation strategies of anaesthesia risks to avoid potential unintended nocebo effects of anaesthesia information leaflets or websites.

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