Cartoon Distraction Alleviates Anxiety in Children

During Induction of Anesthesia

Jeongwoo Lee, MD,* Jihye Lee, MD,* Hyungsun Lim, MD,† Ji-Seon Son, MD, PhD,†
Jun-Rae Lee, MD, PhD,‡ Dong-Chan Kim, MD, PhD,† and Seonghoon Ko, MD, PhD§
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BACKGROUND: We performed this study to determine the beneficial effects of viewing an ani-
mated cartoon and playing with a favorite toy on preoperative anxiety in children aged 3 to 7
years in the operating room before anesthesia induction.
METHODS: One hundred thirty children aged 3 to 7 years with ASA physical status I or II were
enrolled. Subjects were randomly assigned to 1 of 3 groups: group 1 (control), group 2 (toy),
and group 3 (animated cartoon). The children in group 2 were asked to bring their favorite toy
and were allowed to play with it until anesthesia induction. The children in group 3 watched
their selected animated cartoon until anesthesia induction. Children’s preoperative anxiety was
determined by the modified Yale Preoperative Anxiety Scale (mYPAS) and parent-recorded anxi-
ety Visual Analog Scale (VAS) the night before surgery, in the preanesthetic holding room, and
just before anesthesia induction.
RESULTS: In the preanesthetic holding room, the group 2 mYPAS and parent-recorded anxiety
VAS scores were significantly lower than those of groups 1 and 3 (mYPAS: P = 0.007; parent-
recorded anxiety VAS: P = 0.02). In the operating room, the children in group 3 had the low-
est mYPAS and parent-recorded anxiety VAS scores among the 3 groups (mYPAS: P < 0.001;
parent-recorded anxiety VAS: P < 0.001). In group 3, the mYPAS and parent-recorded anxiety VAS
scores of only 3 and 5 children were increased in the operating room compared with their scores
in the preanesthetic holding room, whereas the anxiety scores of 32 and 34 children in group
1 and 25 and 32 children in group 2 had increased (P < 0.001). The number of children whose
scores indicated no anxiety (mYPAS score <30) in the operating room was 3 (7%), 9 (23%), and
18 (43%) in groups 1, 2, and 3, respectively (P < 0.001).
CONCLUSIONS: Allowing the viewing of animated cartoons by pediatric surgical patients is a
very effective method to alleviate preoperative anxiety. Our study suggests that this intervention
is an inexpensive, easy to administer, and comprehensive method for anxiety reduction in the
pediatric surgical population. (Anesth Analg 2012;115:1168–73)

M
any children undergoing surgery experience sub- been associated with difficulty in anesthetic induction and the
stantial anxiety in the preoperative holding area and development of postoperative agitation and negative behav-
the operating room (OR) before induction of anesthe- iors.4–6 Common postoperative behavioral changes include
sia. In fact, approximately 50% of children experience anxiety separation anxiety, nightmares, aggression toward authority,
regarding an impending surgical experience.1–3 Preoperative and nocturnal enuresis.3,4 Kain et al.2 showed that 67% of chil-
anxiety may be caused by separation from parents, unfamil- dren had behavior changes the day after surgery, and this per-
iar environments and people, and negative anticipation of sisted for 6 months in 20% and for 1 year in 7% of the children.
surgical procedures. Children’s preoperative anxiety has been To reduce the incidence of preoperative anxiety in children,
observed to manifest in different ways, with many children anesthesiologists have used a number of prevention strategies,
appearing fearful and agitated, breathing deeply, shivering, including sedative premedication, parental presence during
crying, and stopping talking or playing. Children may protest, anesthetic induction, behavioral preparation programs, music
fight, or try to escape, which may be emotionally traumatic therapy, hypnosis, and acupuncture.7 Some of these interven-
for the child and parents. Intense preoperative anxiety has tions are used fairly frequently, whereas others are used less
frequently because of undesirable side effects, time constraints,
or increased health care costs. Although premedication with
Author affiliations are provided at the end of the article. oral midazolam is often used to alleviate childhood anxiety, its
Accepted for publication February 1, 2012. use has been associated with side effects.8–10
Supported by departmental grant. Preschool children generally enjoy watching animated
The authors declare no conflicts of interest. cartoons, and they can become sufficiently engrossed to
This report was previously presented, in part, at the 88th Annual Scientific become oblivious to their surroundings and disregard ver-
Meeting of The Korean Society of Anesthesiologists, 2011, Seoul, South
Korea. bal and tactile stimuli. Children may also be comforted by
Reprints will not be available from the authors. familiar toys. Therefore, viewing an animated cartoon or
Address correspondence to Seonghoon Ko, MD, PhD, Department of playing with a favorite toy seems likely to alleviate preop-
Anesthesiology and Pain Medicine and Research Institute of Clinical erative anxiety in children. There are no controlled trials
Medicine, Chonbuk National University, 634-18 Keum-Am Dong, Jeonju,
Chonbuk 561-712, South Korea. Address e-mail to [email protected]. that have investigated the effects of viewing animated car-

Copyright © 2012 International Anesthesia Research Society toons on preoperative anxiety in children. This study was
DOI: 10.1213/ANE.0b013e31824fb469
DOI: performed to determine the beneficial effects of viewing an

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animated cartoon or playing with a favorite toy on preop- (Chiro®, Crayon Shin-chan®, Doraemon®, and Pororo®), 1
erative anxiety in children aged 3 to 7 years in the OR before science fiction (Keroro®), and Cinderella. The children in
anesthesia induction. group 3 watched their selected movie using a notebook or
tablet personal computers (PCs) until anesthesia induction.
METHODS When the children fell asleep after administration of IV
This prospective, randomized trial examined the effects of anesthetics, the movie was stopped. When the patients were
2 behavioral interventions on preoperative anxiety in chil- transported from the preanesthetic holding room to the OR,
dren undergoing general anesthesia for elective surgery. they were accompanied by their parent and a research team
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The study was approved by the IRB of Chonbuk National member. When they entered the OR, the parent was dressed
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University Hospital in South Korea. Written informed in scrubs, hat, and mask. After monitor placement of elec-
parental consent was obtained for all participants. trocardiogram and pulse oximetry, the final mYPAS and
One hundred and thirty children, aged 3 to 7 years, ASA parent-recorded anxiety VAS measurements were taken just
physical status I or II, were enrolled. Children having emer- before anesthesia induction. The mYPAS scores were mea-
gency surgery and those with previous anesthetic experi- sured by 1 anesthesiologist to exclude interrater bias.
ence, developmental delays, mental retardation, or chronic Standard anesthetic regimens and techniques were used
illnesses were excluded from the study. Subjects were ran- for all patients. IV anesthetic induction was performed
domly assigned by computer-generated random number to using 4 to 6 mg/kg thiopental or 1 to 2 mg/kg ketamine,
1 of 3 groups: group 1 (control), group 2 (toy), and group 3 and patient arterial blood pressure was noninvasively
(animated cartoon). monitored with an anesthesia workstation (Zeus®; Dräger
Patients were admitted the evening before surgery. The Medical, Lübeck, Germany). For facilitation of tracheal intu-
research team anesthesiologist visited the pediatric ward bation, the patients received 0.6 mg/kg rocuronium. After
to conduct preoperative interviews and measure base- tracheal intubation, temperature was monitored at the naso-
line anxiety scores. The patients were allocated to 1 of 3 pharynx or rectum. Anesthesia was maintained with 50%
groups before preoperative assessment of baseline anxiety. nitrous oxide in oxygen and 1.5% to 3.0% sevoflurane. Fresh
Demographic data were collected from the parents and the gas flow rate was maintained at 3 L/min during the opera-
medical charts. The children in group 2 were asked to bring tion. End-tidal carbon dioxide partial pressure was main-
their favorite toy with them to the preoperative holding tained at 30 to 35 mm Hg. Arterial blood pressure and heart
room. rate were kept within 20% of preanesthetic values. At the end
Children’s preoperative anxiety was determined by the of surgery, sevoflurane and nitrous oxide administration was
modified Yale Preoperative Anxiety Scale (mYPAS) and the discontinued, and the patients received pyridostigmine and
parent-recorded anxiety Visual Analog Scale (VAS). The glycopyrrolate for reversal of neuromuscular blockade. At
mYPAS contains 22 items in 5 categories qualifying anxi- skin closure, patients received 1 mg/kg ketorolac or 1 µg/kg
ety in young children: activity, emotional expressivity, state fentanyl for postoperative pain control.
of arousal, vocalization, and use of parents. This observa-
tional measurement has shown good-to-excellent inter- Sample Size Determination and
and intraobserver reliabilities and validity for measuring Statistical Analysis
children’s anxiety in the preoperative holding area, upon A pilot study of 18 children in the OR had mean (SD) mYPAS
entrance to the OR, and during induction of anesthesia in scores of 62 (18), 49 (23), and 30 (12) in group 1, 2, and 3,
children aged 2 to 12 years. The score range is 23.3 to 100, respectively. We considered a clinically significant decrease
with a score of ltequ30 indicating that the subject does not in mYPAS score to be ≥15 points. It was ascertained that 35
have anxiety; a score mt30 indicates that the subject does patients were required in each group to show a difference
have anxiety.11 The parent-recorded anxiety VAS measures in mean mYPAS scores of 15 for an expected standard devi-
children’s anxiety assessed by the accompanying parents ation of 20 with a significance level of 0.05 (α = 0.05) and
using a 10-cm scale. In the current study, the mYPAS and a power of 80% (β = 0.20). Sample size was calculated by
parent-recorded anxiety VAS scores were used to measure 1-way analysis of variance (ANOVA) using SigmaStat 3.5
the children’s anxiety levels the night before surgery, when (Systat Software Inc., San Jose, CA). To allow for attrition,
they were in the preanesthetic holding room, and just before sample size was enlarged to 130.
anesthesia induction. Data are presented as mean ± SD or median and inter-
All operations were performed in morning sessions. A quartile range. Patient characteristics and anxiety scores
24-gauge catheter was inserted into a peripheral vein the among groups were analyzed using 1-way ANOVA fol-
night before surgery or the morning of surgery after EMLA lowed by the Tukey test for multiple comparisons for vari-
(Eutectic Mixture of Local Anesthetics) cream application, ables that were normally distributed or the Kruskal-Wallis
and the time was recorded. When the children were trans- test followed by Dunn’s method for variables that had non-
ported from the pediatric ward to the preanesthetic hold- parametric data or were not normally distributed. Anxiety
ing room, the children in group 2 brought their favorite scores within groups were analyzed using repeat-measures
toys and were allowed to play with them until anesthesia ANOVA followed by the Holm-Sidak test for multiple com-
induction. After the second measurement of anxiety scores, parisons. A P value <0.05 was regarded as significant.
in the preanesthetic holding room, the children in group 3
chose 1 from a selection of 10 movies. The preselected 10 RESULTS
movies were 4 action movies (Beyblade®, Power Ranger®, Of the 130 enrolled children, 4 children in group 2 were
Power Ranger Jungle Force®, and Robocar Poli®), 4 comics excluded for data analysis because they did not bring a

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 Cartoon Alleviates Pediatric Preoperative Anxiety

Table 1. Patient Characteristics

Group 1 Group 2 Group 3 P values
No. of patients 44 44 42
Age (y) 4.8 ± 1.5 4.4 ± 1.2 4.6 ± 1.3 0.378
Height (cm) 112.4 ± 10.8 108.7 ± 8.8 109.6 ± 11.4 0.223
Weight (kg) 20.7 ± 4.9 19.0 ± 3.7 20.5 ± 5.9 0.211
Gender (male/female) 30/14 29/15 28/14 0.974
ASA physical status (I/II) 40/4 41/3 41/1 0.422
Fasting time (h) 11.8 ± 1.8 11.8 ± 2.0 12.0 ± 1.7 0.846
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Time from catheterization to induction (min) 176.6 ± 265.0 177.3 ± 238.1 177.8 ± 236.4 0.994
Catheterization timing (evening/morning) 10/34 13/31 12/30 0.739
Guardian (F/M/GP) 8/35/1 9/34/1 7/34/1 0.995
Surgery — — — 0.966
Tonsillectomy 17 19 17 —
Herniorrhaphy 11 11 10 —
Eye surgery 6 6 6 —
Hand surgery 3 2 5 —
Others 7 6 4 —
Group 1 (control), Group 2 (toy), Group 3 (animated cartoon). Guardian (F = father; M = mother; GP = grandparents). Catheterization timing (evening = the evening
before the operation; morning = the morning of the operation day).

Table 2. Modified Yale Preoperative Anxiety Scale

(mYPAS) and Parent-Recorded Anxiety Visual
Analog Scale (VAS) Scores
Preanesthetic Preanesthetic Operating
visit holding room room
mYPAS scores
Group 1 27.3 ± 8.4 48.0 ± 15.8 57.4 ± 18.1*
Group 2 27.3 ± 7.6 38.3 ± 11.5† 43.6 ± 16.1*†
Group 3 25.8 ± 4.2 45.7 ± 15.5 31.8 ± 8.8*†
Parent-recorded
anxiety VAS
scores
Group 1 1.6 ± 2.2 5.0 ± 3.0 6.1 ± 2.7*
Group 2 1.8 ± 2.4 3.7 ± 2.6† 5.2 ± 2.6*
Group 3 1.8 ± 1.3 5.3 ± 2.5 3.2 ± 2.4*†
*P < 0.05 versus preanesthetic holding room.
†P < 0.05 versus group 1.
Figure 1. The number of patients who had changes in their modi-
fied Yale Preoperative Anxiety Scale (nonhatched stacked bars) and
parent-recorded anxiety Visual Analog Scale (hatched stacked bars)
toy. The number of patients with analyzed anxiety scores scores in the operating room (OR) compared with the preanesthetic
was 44 in group 1, 40 in group 2, and 42 in group 3. The holding room. Green, blue, and red colors represent the number
3 study groups were comparable with respect to demo- of patient who had decreased, unchanged, and increased anxiety
graphic data, ASA physical status, fasting time, times from scores in the OR compared with scores in the preanesthetic holding
room, respectively. Groups 1, 2, and 3 are represented as control, a
peripheral IV catheter placement to anesthesia induction, a
group who played with a toy, and a group who watched an animated
guardian who accompanied the child to the OR, and type cartoon, respectively. *P < 0.001 compared with groups 1 and 2.
of surgery (Table 1). The most common surgical procedure
in all groups was tonsillectomy. Other common procedures
were herniorrhaphy and eye surgery. The mother was the scores among the 3 groups, and group 2 had the next lowest
most likely parent to accompany the child into the OR. scores (Table 2). In the OR, the mYPAS scores of only 3 chil-
The toys brought by children in group 2 were dolls, robots, dren in group 3 were increased compared with the preanes-
mobile phones, and portable video games (VGs), in order of thetic holding room, whereas 32 children in group 1 and 25
decreasing frequency. In group 3, the selected animated car- children in group 2 had increased anxiety scores (P < 0.001).
toons by children and the number of patients who selected Similarly, for the parent-recorded anxiety VAS, 34 children
the cartoon were Power Ranger (15 children), Pororo (10 in group 1 and 32 children in group 2 had increased anxiety
children), Doraemon (5 children), and Keroro (5 children), scores in the OR compared with the preanesthetic holding
Chiro (3 children), Cinderella (2 children), Power Ranger room, whereas only 5 children in group 3 demonstrated an
Jungle Force (1 child), and Robocar Poli (1 child). increase (P < 0.001) (Fig. 1). The number of children whose
There were no significant differences among the 3 groups scores indicated no anxiety (mYPAS score ≤30) in the OR was
in the initial mYPAS and parent-recorded VAS scores on the 3 (7%), 9 (23%), and 18 (43%) in groups 1, 2, and 3, respec-
pediatric ward. In the preanesthetic holding room, in group tively. Within groups in the OR, there was no significant dif-
2, the mYPAS and parent-recorded VAS scores were signifi- ference in mYPAS scores of children who were accompanied
cantly lower than in groups 1 and 3. In the OR, the children by their mothers compared with their fathers. The mYPAS
in group 3 had the lowest mYPAS and parent-recorded VAS and parent-recorded VAS scores within-patient changes

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Most preschool- and elementary school-aged children

very much enjoy watching animated cartoons. Many ani-
mated cartoons are in the public domain, so popular car-
toons can be downloaded without cost in many countries.
In this study, we downloaded 10 popular animated cartoons
in South Korea for free or with low cost and played them
for the children on PCs. Therefore, the intervention of view-
ing animated cartoons to reduce preoperative anxiety can
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be used without increasing health care costs. Most mobile

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devices can be used to play animated cartoons, includ-

ing notebook and tablet PCs, portable multimedia play-
ers (PMPs), digital camcorders, and mobile phones. PMPs
are less expensive and more convenient for this purpose
than notebook or tablet PCs. Although display screens of
smart phones are small, they are very convenient for view-
ing cartoons. Many anesthesiologists in our hospital use
their smart phone or a PMP to show an animated cartoon
for alleviating anxiety of pediatric patients. When the chil-
dren watched an animated cartoon in the OR, they usually
became engrossed in the cartoon, oblivious to the unfamil-
iar people and OR environment. Therefore, we suggest that
viewing animated cartoons is a very simple and effective
intervention to reduce preoperative anxiety in children.
A number of other preoperative preparation programs
have been examined for their ability to prevent or allevi-
ate anxiety, including sedative premedication, hypnosis,
parental presence, behavioral preparation programs, music
therapy, and acupuncture. Some of these programs are used
frequently for pediatric surgical patients (i.e., midazolam,
parental presence, and behavioral preparation programs),
and others are used less frequently (i.e., acupuncture, hyp-
nosis, and interactive music therapy).7 Although pharma-
Figure 2. Modified Yale Preoperative Anxiety Scale (mYPAS) (A) and cologic intervention with a sedative (i.e., midazolam) is
parent-recorded (PR) anxiety Visual Analog Scale (VAS) (B) within-
patient scores change from the preanesthetic holding room to the an effective method to alleviate children’s anxiety, it has
OR. Box represents the interquartile range from 25th to 75th per- been associated with delays in hospital discharge8,12 and
centile. Upper and lower whiskers indicate range of scores. Line maladaptive behavioral changes.9,10,13 Additionally, the
within the box indicates the median. *P < 0.05 compared with administration of oral premedication to children is not
group 1. Groups 1, 2, and 3 are represented as control, a group who
played with a toy, and a group who watched an animated cartoon,
easy because of their reluctance or refusal. However, view-
respectively. ing animated cartoons has no side effects, and it is easy
to administer. One of the frequently used interventions to
treat preoperative anxiety is parental presence. Although
from the preanesthetic holding room to the OR were also the effects of parental presence on preoperative anxiety are
significantly lower in group 3 than in groups 1 and 2 (Fig. controversial, many pediatric anesthesiologists believe that
2). There were significant correlations between mYPAS and parental presence alleviates children’s preoperative anxiety
parent-recorded VAS scores in all groups in the OR (group 1: in the OR. Kain et al.14 reported that there was an increas-
r = 0.670, P < 0.001; group 2: r = 0.760, P < 0.001; group 3: r = ing trend toward allowing parental presence from 1995 to
0.634, P < 0.001; overall: r = 0.789, P < 0.001). 2002. Because this practice is routine in our hospital, all chil-
dren in this study were accompanied by their parent during
DISCUSSION anesthesia induction.
The principal finding of this investigation is that the chil- Patel et al.15 found that children aged 4 to 12 years who
dren who watched animated cartoons in the OR had signifi- played with a handheld VG had less anxiety at induction
cantly lower anxiety scores (mYPAS and parent-recorded of anesthesia than children who had only their parents
VAS) than the children in the control and toy groups. present. Children can play with VG consoles anywhere,
Furthermore, mYPAS and parent-recorded VAS scores of and children may be as engrossed in playing VGs as when
the majority of group 3 (animated cartoon) children were watching an animated movie. Therefore, VGs can be applied
decreased or unchanged in the OR compared with the in health care for distraction and behavior modification
preanesthetic holding room, whereas the scores of most therapy.16–18 However, older children may benefit more than
children in group 1 (control) and group 2 (toy) were signifi- younger children because VG playing requires hand skill.
cantly increased. This is the first study to show that view- Furthermore, most children are familiar with only a few
ing animated cartoons can prevent or alleviate preoperative VGs and cannot play others. It is also difficult to prepare
anxiety in 3- to 7-year-old children. many VG consoles in the OR. In contrast, viewing animated

November 2012 • Volume 115 • Number 5 www.anesthesia-analgesia.org 1171

 Cartoon Alleviates Pediatric Preoperative Anxiety

cartoons is an inexpensive, easy to administer, and compre- Name: Ji-Seon Son, MD, PhD.
hensive method for anxiety reduction in the younger pedi- Contribution: This author helped conduct the study and
atric surgical population. analyze the data.
There are several limitations to this study. First, observer Attestation: Ji-Seon Son has seen the original study data,
bias is a limitation of studies that use an observer tool for reviewed the analysis of the data, approved the final manuscript,
anxiety measurement with interventions such as paren- and is the author responsible for archiving the study files.
Name: Jun-Rae Lee, MD, PhD.
tal presence and distraction techniques.19–21 The observer
Contribution: This author helped conduct the study.
could not be blinded to treatment group for obvious rea-
Attestation: Jun-Rae Lee has seen the original study data,
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sons. In this study, also, parent-recorded VAS for anxi-

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reviewed the analysis of the data, approved the final manuscript,

ety could have been biased by the parent’s perception of and is the author responsible for archiving the study files.
their child’s behavior, although there is good correlation Name: Dong-Chan Kim, MD, PhD.
between mYPAS and parent-recorded VAS. Second, all Contribution: This author helped design the study.
children had peripheral venous catheters placed before Attestation: Dong-Chan Kim has seen the original study
the start of anesthesia. There were no differences in mean data, reviewed the analysis of the data, approved the final
times from IV catheterization to the start of the operation manuscript, and is the author responsible for archiving the
among the 3 groups. Third, all children in this study had study files.
their anesthesia induced with IV drugs because IV induc- Name: Seonghoon Ko, MD, PhD.
tion has been the usual pediatric practice in our hospital. Contribution: This author designed the study, analyzed the
Thus, these results may not be applicable to children under- data, and wrote the manuscript.
going inhaled inductions of anesthesia. Fourth, the children Attestation: Seonghoon Ko has seen the original study
were admitted the evening before the operation because data, reviewed the analysis of the data, approved the final
outpatient surgery is not popular in Korea. Although anxi- manuscript, and is the author responsible for archiving the
ety levels could be markedly influenced by the child’s pre- study files.
This manuscript was handled by: Peter J. Davis, MD.
operative hospitalization, baseline levels were similar for
all 3 groups. REFERENCES
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