BACKGROUND
Perioperative anxiety is common in children and may contribute to difficult separation, poor cooperation during induction of anesthesia, postoperative pain, emergence delirium, maladaptive behavioral changes, and distress among parents. Parental presence during induction of anesthesia has traditionally been evaluated as a discrete anesthesia intervention. However, contemporary pediatric practice increasingly conceptualizes parental involvement as part of family-centered perioperative care, where the relevant question is not simply whether parents are present, but how parental presence is selected, structured, prepared, and integrated into clinical pathways.
AIM
To synthesize randomized evidence on parental presence and related parental-involvement strategies for reducing pediatric perioperative anxiety, and to identify clinical and implementation conditions under which parental involvement appears most likely to benefit children, families, and perioperative teams.
METHODS
We performed a PRISMA 2020-compliant systematic review of randomized and prospective comparative studies. PubMed/MEDLINE, Scopus, and Web of Science were searched from inception to June 1, 2026, with inclusion limited to studies published from 2000 onward. Eligible studies enrolled children undergoing elective procedures under general anesthesia; the included trials ultimately represented children aged 18 months to 12 years. Interventions included physical or virtual parental presence, parental accompaniment, active or coached parental participation, or family-centered preparation in which parents had a defined role. The primary outcome was child anxiety or behavioral distress during separation, transfer to the operating room, mask introduction, or induction. Secondary outcomes included parental anxiety, induction cooperation, emergence delirium, postoperative behavior, pain, satisfaction, sedative requirements, and implementation aspects. Risk of bias was assessed with the Cochrane RoB 2 framework. Because the studies differed in intervention structure, comparator, timing of assessment, and anxiety scale, we used narrative synthesis rather than meta-analysis.
RESULTS
Twelve randomized or prospective comparative trials involving 1104 child-parent dyads were included. The evidence was dominated by parental presence during induction of anesthesia; broader parental-involvement models were represented by fewer active, coached, multimodal, or virtual interventions. Unstructured parental presence alone produced inconsistent effects on child anxiety and was generally less reliable than sedative premedication. Active participation, coaching, family-centered preparation, selected pharmacological combination, and virtual parental presence showed more favorable signals, but certainty was low because these data came from few heterogeneous trials. Calm and prepared parents may support child coping, whereas high parental anxiety may transmit distress or increase staff workload. Implementation issues identified from the evidence and related clinical literature included parent selection, emotional preparation, role assignment, infection-control constraints, workflow, and safety stop criteria.
CONCLUSION
Parental involvement should be viewed as a potentially useful, context-dependent adjunct rather than a universal substitute for pharmacological anxiolysis. The trial evidence mainly supports a careful approach to structured parental presence during induction in selected elective cases; it does not demonstrate comprehensive family-centered perioperative protocols as proven interventions. Institutions that use parental presence may consider structured, locally adapted processes for selecting and preparing parents, defining their role, protecting operating-room safety, and combining parental involvement with behavioral or pharmacological strategies when indicated.
Core Tip: Randomized evidence does not support unstructured parental presence during anesthesia induction as a consistently effective substitute for sedative premedication. More structured forms of parental involvement, including active participation, coaching, multimodal preparation, or virtual contact, appear more promising but are supported by limited and heterogeneous evidence. This review, therefore, separates evidence-based findings from an author-derived implementation framework. The proposed pathway should be read as a practical template for local adaptation and future evaluation, not as a validated clinical guideline.
