BACKGROUND Pre-operative anxiety in children has been associated with adverse clinical outcomes such as difficulty in anaesthesia induction, emergence delirium and negative postoperative behavioural changes. Therefore, pre-operative anxiety should be alleviated in both children and clinicians. OBJECTIVE We investigated the effect on pre-operative anxiety of premedication with midazolam, playing video games or watching a cartoon about anaesthesia. DESIGN A prospective randomised trial. SETTING Single-centre study performed between August 2018 and June 2019. PATIENTS We enrolled 138 patients aged 5 to 8 years undergoing elective surgery. INTERVENTIONS After evaluating baseline (T0) anxiety levels using the modified Yale Pre-operative Anxiety Scale (mYPAS) in the pre-operative holding area, 0.5 mg kg−1 oral midazolam was given to Group M, a tablet with videogame applications was given to Group T, and Group S watched the cartoon ‘Şüko Is Being Operated’. mYPAS values were recorded a further three times: 20 min after the intervention (T1), while entering the operating room (T2), and during mask induction of anaesthesia (T3). MAIN OUTCOME MEASURES The primary endpoint was the change in children's anxiety levels from baseline. The secondary endpoint was cooperation during mask induction. RESULTS The baseline mYPAS scores were comparable (40.7, 42.6 and 40.7 in groups M, S and T respectively). The mean mYPAS scores at T1 were 32.6, 34.7, 26.8 and at T2 were 38.6, 42.7, 35 in groups M, S and T, respectively. There were significant differences between groups S and T at T1 and T2 (P < 0.001, P = 0.010). A significant decrease was found in Group T compared with both groups M and S from T0 to T1 (P = 0.002). mYPAS values at T3 were 38.3, 43.7, 39.5 in groups M, S and T, respectively, with no difference between the groups (P = 0.224). Mask acceptance scores were similar in all groups (P = 0.912). CONCLUSIONS The passive teaching technique of watching a video for reducing anxiety levels was not effective. However, active distraction with videogames was found to be a valuable method to reduce pre-operative anxiety. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03530670.

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