Parental involvement for pediatric perioperative anxiety: A systematic review and implementation framework

Abstract

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.

Key Words: Child; Perioperative anxiety; Parental presence; Family-centered care; Anesthesia induction; Non-pharmacological intervention; Pediatric surgery; Parental involvement

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.

INTRODUCTION

Perioperative anxiety is among the most visible and clinically relevant sources of distress in pediatric surgical care. Children may experience fear related to separation from caregivers, unfamiliar staff and surroundings, loss of control, fasting, invasive procedures, operating room (OR) noise, monitors, masks, and the perceived threat of bodily harm[1-6]. The induction of anesthesia is a particularly sensitive moment because it combines sensory stimulation, perceived loss of control, and often separation from the parent at the point when the child most strongly seeks familiar attachment figures[1,2].

Untreated anxiety is not only an emotional problem. It may complicate induction, increase resistance and escape behaviors, reduce mask acceptance, intensify sympathetic activation, and contribute to postoperative pain, emergence delirium, sleep disturbance, feeding changes, separation anxiety, and other maladaptive behavioral responses after discharge[1-3,5,7]. These consequences affect both the child and the family, and they may shape future attitudes toward hospitals and surgery. Consequently, perioperative anxiety should be regarded as a patient-safety, experience-of-care, and family-systems issue rather than a narrow anesthesia inconvenience.

Sedative premedication, particularly midazolam, has long been used to reduce preoperative anxiety and facilitate induction. Pharmacological anxiolysis can be effective and predictable, but it may be associated with paradoxical reactions, respiratory depression, prolonged recovery, delayed discharge, impaired cooperation, or parental preference for non-drug approaches[3,8-10]. This has encouraged interest in non-pharmacological strategies such as preparation programs, distraction, play therapy, music, clowns, digital approaches, staff communication, and parental involvement[3,11-13]. Beyond the induction room, postoperative pediatric data also support the more extensive therapeutic relevance of parental presence: In a recent pediatric intensive care unit cohort from Kazakhstan, implementation of a parental-care protocol was associated with reduced diazepam prescribing, suggesting that family involvement may help reduce anxiety- or agitation-related sedative needs in selected pediatric settings[14].

Parental presence during induction of anesthesia (PPIA) is one of the most frequently studied non-pharmacological interventions in pediatric anesthesia[12,15]. It is commonly defined as the presence of a parent or caregiver in the OR or induction area until loss of consciousness or loss of eyelid reflex. However, the phrase “parental presence” may obscure major differences in what parents actually do. In some trials, the parent was a passive observer; in others, the parent actively held the child, provided verbal reassurance, helped apply the anesthesia mask, used distraction, or was prepared by structured coaching[11,16-19]. Virtual parental presence and recorded or real-time audiovisual contact add further variation[18].

Recent systematic reviews and meta-analyses have reached cautious conclusions. PPIA may reduce anxiety compared with no parental presence in some settings, but it is generally less effective than midazolam and does not consistently add benefit when combined with midazolam[15,20-22]. The unresolved clinical question has therefore shifted. Rather than asking whether parents should simply be allowed into the OR, pediatric perioperative teams need to know which children and families benefit, what type of parental role is therapeutic, when parental presence may be ineffective or unsafe, and how institutions can implement reproducible protocols.

Therefore, the present review is intentionally positioned between evidence synthesis and implementation analysis. The evidence synthesis focuses on randomized, prospective comparative studies of PPIA and closely related parental involvement strategies. The implementation component is author-derived and uses these data, together with perioperative clinical considerations, to propose careful practical considerations rather than trial-proven recommendations.

This distinction is important because the available evidence is narrower than the broad term “parental involvement” may imply. Most included trials evaluate parental presence during separation or induction, whereas comprehensive family-centered perioperative care remains a broader concept that has only partly been tested in randomized studies. Accordingly, this review does not treat parental presence as a simple binary exposure, but organizes the evidence along a spectrum from passive presence to active, coached, virtual, and multimodal parental involvement.

MATERIALS AND METHODS

Design and reporting

This systematic review was designed and reported in accordance with PRISMA 2020[23]. The review focused on randomized and prospective comparative evidence evaluating PPIA and closely related parental-involvement strategies for reducing perioperative anxiety in children. The review was registered in International Prospective Register of Systematic Reviews under registration number CRD420251111399. Because the included studies differed substantially in intervention design, comparator structure, timing of outcome assessment, and measurement instruments, a narrative synthesis was planned rather than a meta-analysis. Evidence-derived findings were summarized separately from the author-derived clinical interpretation. The taxonomy and implementation pathway were developed as interpretive tools after extraction; they were not treated as trial-proven outcomes or validated recommendations.

Eligibility criteria

The eligibility framework was structured around population, intervention, comparator, outcomes, and study design. Eligible populations were children undergoing elective procedures under general anesthesia. No narrower age range was imposed a priori beyond study-defined pediatric status and the use of pediatric anxiety or behavioral-distress outcomes; however, the included studies ultimately enrolled children aged approximately 18 months to 12 years. When reported, children were generally healthy or American Society of Anesthesiologists physical status I-II. Studies involving major developmental delay, significant chronic systemic disease, prematurity, emergency surgery, or contexts in which anxiety measurement would be unreliable were excluded when this information was available.

Eligible interventions included physical PPIA, virtual parental presence, parental accompaniment, active parental participation during induction, coached parental involvement, and family-centered preparation programs that incorporated parents as part of the intervention. Comparators included parental absence, standard care, sedative premedication, parental presence combined with sedatives, active vs passive parental involvement, one-parent vs two-parent presence, and virtual vs physical parental presence.

The primary outcome was child perioperative anxiety or behavioral distress measured during separation, transfer to the OR, mask introduction, or induction of anesthesia. The induction time point was prioritized when multiple measurements were reported. Secondary outcomes included parental state anxiety, induction cooperation, emergence agitation or delirium, postoperative maladaptive behavior, pain, satisfaction, sedative requirements, staff workload, and implementation-related safety or workflow outcomes.

Information sources and search strategy

PubMed/MEDLINE, Scopus, and Web of Science were searched from database inception to June 1, 2026. Inclusion was restricted to studies published from 2000 onward to represent contemporary anesthesia practice and perioperative care. The search combined controlled vocabulary and free-text terms associated with children, surgery, anesthesia induction, parental presence or accompaniment, family-centered care, anxiety, distress, cooperation, and emergence agitation or delirium. The reference lists of included studies and relevant reviews were manually screened to identify additional eligible reports.

The core search concept was: (Child OR children OR pediatric OR paediatric OR infant OR adolescent) AND (surgery OR surgical OR anesthesia OR anaesthesia OR anesthetic induction OR induction of anesthesia OR preoperative OR perioperative) AND (parental presence OR parent presence OR parental accompaniment OR parent accompaniment OR family-centered preparation OR family-centered care OR active parental participation OR virtual parental presence) AND (anxiety OR preoperative anxiety OR perioperative anxiety OR distress OR cooperation OR emergence agitation OR emergence delirium).

Study selection and data extraction

Titles and abstracts were screened by predefined eligibility criteria. Full texts of potentially eligible reports were then assessed for inclusion. Two reviewers independently screened titles and abstracts and assessed full-text reports for eligibility. Disagreements were resolved by discussion and, when necessary, consultation with a third reviewer.

Data were extracted using a structured form covering country, design, sample size, age range, sex distribution when reported, ASA status when reported, surgical setting or procedure type, intervention characteristics, comparator, parental role, anxiety instrument, timing of outcome assessment, numerical outcomes, and key secondary outcomes. Particular attention was given to whether parental presence was passive, active, coached, virtual, or embedded in a multimodal preparation pathway. This classification was used to support clinical interpretation because parental presence is not a uniform intervention and its mechanism plausibly depends on the quality of parental behavior rather than physical proximity alone.

Risk of bias assessment

Risk of bias was assessed using the Cochrane RoB 2 framework for randomized trials[24]. The domains were: Randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selection of reported results. Each study was rated as low risk, some concerns, or high risk overall. Blinding limitations were interpreted cautiously because participant and staff blinding are intrinsically difficult in parental-presence trials.

Synthesis approach

A meta-analysis was not performed because the trials evaluated heterogeneous interventions and comparators, including unstructured parental presence, active parental participation, coached involvement, virtual parental presence, sedative premedication, dexmedetomidine, oral midazolam, clown therapy, and family-centered preparation programs. The timing of anxiety measurement also varied across separation, operating-room entry, mask presentation, and induction. The synthesis therefore prioritized intervention type, direction, and consistency of effect; risk of bias; certainty of evidence; and implementation implications. Author-derived interpretation is explicitly labeled in the Results and Discussion to avoid presenting conceptual frameworks as direct empirical findings.

Certainty of evidence

Because a meta-analysis was not performed, certainty judgments followed Grading of Recommendations Assessment, Development and Evaluation principles for narrative synthesis and non-pooled bodies of evidence[25,26]. Certainty was considered separately for the following evidence categories: Unstructured parental presence vs parental absence or standard care; parental presence vs sedative premedication; active or coached parental involvement vs passive parental presence; parental involvement combined with pharmacological or behavioral adjuncts; and virtual parental presence. Certainty ratings were interpreted as high, moderate, low, or very low.

RESULTS

Study selection

The database search identified 1168 records across three databases. After removing 341 duplicate records, 827 records remained for screening. Following title and abstract screening, 112 reports were retrieved; 105 full-text reports were assessed for eligibility, and 12 randomized trials were included in the qualitative synthesis (Figure 1).

Figure 1  PRISMA 2020 flow diagram for study selection.

Characteristics of included studies

Twelve randomized or prospective comparative trials were included, representing 1104 parent-child dyads[11,16-19,27-33]. Sample sizes ranged from 41 dyads to 204 dyads. The age range across included studies was approximately 18 months to 12 years, with most trials enrolling preschool or school-age children. Most studies involved elective procedures under general anesthesia and, when reported, generally healthy children or ASA physical status I-II. Surgical settings included adenotonsillectomy or tonsillectomy/adenoidectomy in several otolaryngology trials, outpatient or day-case surgery, and mixed minor elective pediatric procedures. No included trial specifically evaluated emergency surgery, high-risk airway management, hemodynamic instability, medically complex children, or children with severe developmental delay. These demographic and procedural characteristics limit generalizability to urgent or high-risk pediatric anesthesia (Table 1).

Table 1 Characteristics of included randomized trials.

Ref.	Country	Design	Population	Surgical setting/procedure as reported	Comparator/intervention	Main outcomes
Yarımoglu et al[19], 2026	Turkey	RCT	80 children, 5-12 years	Elective adenotonsillectomy	Both parents vs one preferred parent	mYPAS, STAI, PAED
Matava et al[18], 2024	Canada	Pilot 2 × 2 factorial RCT	41 dyads, 1.5-12 years	Elective pediatric surgery under general anesthesia	Virtual vs physical presence, with/without coaching	mYPAS, STAI, PAED, ICC
Jain et al[27], 2023	India	Randomized comparative study	60 children, 4-12 years	Elective surgery under general anesthesia; mixed pediatric procedures	PPIA vs intravenous midazolam	mYPAS, STAI
Ismail and Mahrous[28], 2022	Egypt	RCT	120 children, 3-8 years	Elective surgery under general anesthesia; mixed pediatric procedures	Active participation vs presence only	mYPAS, PAED, parental anxiety
Yao et al[29], 2022	China	RCT	124 children, 2-6 years	Tonsillectomy and/or adenoidectomy	Control vs PPIA vs dexmedetomidine vs PPIA + dexmedetomidine	mYPAS, STAI, PAED, ICC, VAS
Rasti-Emad-Abadi et al[30], 2017	Iran	Randomized clinical trial	60 children, 2-10 years	Elective surgery under general anesthesia; mixed pediatric procedures	PPIA vs no parental presence	mYPAS, STAI
Sadeghi et al[31], 2017	Iran	Randomized clinical trial	96 children, 4-10 years	Elective minor surgery	Midazolam + PPIA vs midazolam alone	mYPAS, STAI, ICC, satisfaction
Vagnoli et al[32], 2010	Italy	Randomized prospective study	75 children, 5-12 years	Elective pediatric surgery under general anesthesia; mixed procedures	PPIA + clown vs PPIA + midazolam vs PPIA alone	mYPAS, STAI
Wright et al[17], 2010	Canada	Randomized clinical trial	61 children, 3-6 years	Outpatient pediatric surgery	PPIA vs parental absence	mYPAS at multiple time points
Kain et al[11], 2007	United States	Four-arm RCT	204 dyads, 2-10 years	Elective outpatient surgery under general anesthesia	Control vs PPIA vs ADVANCE vs midazolam	mYPAS, STAI, emergence outcomes
Kain et al[33], 2003	United States,	RCT	80 dyads, 2-10 years	Elective surgery under general anesthesia	PPIA vs control vs PPIA + midazolam	mYPAS, STAI, physiological markers
Kain et al[16], 2000	United States	Randomized comparative trial	103 children, 2-8 years	Elective surgery under general anesthesia	Midazolam vs midazolam + PPIA	mYPAS, STAI

ICC: Induction Compliance Checklist; mYPAS: Modified Yale Preoperative Anxiety Scale; PAED: Pediatric Anesthesia Emergence Delirium Scale; PPIA: Parental presence during induction of anesthesia; RCT: Randomized controlled trial; STAI: State-Trait Anxiety Inventory; VAS: Visual analogue scale.

For synthesis, we first classified the empirical interventions as reported in each study: Physical parental presence, one-parent vs two-parent presence, active participation, coaching, virtual parental presence, and parental presence combined with pharmacological or behavioral adjuncts. On that basis, we developed an author-derived taxonomy to organize clinical interpretation and implementation planning. This taxonomy should not be read as a validated classification system or as evidence-graded recommendations. It is a heuristic framework for discussing how differences in parental roles may explain heterogeneity and guide future implementation research (Table 2).

Table 2 Author-derived taxonomy of parental-involvement strategies and implementation considerations.

Strategy	Definition	Likely clinical value	Implementation implications
Passive physical presence	Parent is physically present but has no clearly defined therapeutic role	May reduce separation distress in selected children, but effects at induction are inconsistent	Low resource, but vulnerable to anxiety transmission and staff distraction
Active parental participation	Parent provides touch, eye contact, calm verbal reassurance, distraction, or helps with mask acceptance	More plausible mechanism; active participation outperformed passive presence in one RCT	Requires brief training, role scripting, and staff agreement
Coached or prepared presence	Parent receives behavioral guidance before induction and is instructed in coping-promoting behaviors	Appears more promising than unstructured presence; aligns with ADVANCE and virtual coaching evidence	Requires standardized preoperative education and staff time
Multimodal parental involvement	Presence combined with sedative premedication, dexmedetomidine, clown therapy, preparation, or distraction	May be useful as part of individualized pathways; not consistently additive to midazolam	Should be protocolized to avoid duplicative or unnecessary interventions
Virtual parental presence	Parent provides real-time or recorded audiovisual presence without entering the OR	Feasible and potentially useful when physical presence is impractical; evidence remains pilot-level	May reduce infection-control and workflow barriers; needs technology reliability

RCT: Randomized controlled trial; OR: Operating room.

Effects on child perioperative anxiety

The effect of parental involvement on child anxiety was heterogeneous. Trials comparing unstructured PPIA with parental absence or standard care reported mixed results. Some studies showed lower anxiety scores when parents were present, while others found no clinically significant difference at induction (Table 3). Wright et al[17] observed that parental presence was most helpful during separation rather than at induction, suggesting that the mechanism may be strongest at the point of attachment rupture rather than during the technical phase of anesthesia.

Table 3 Summary of key quantitative findings and clinical interpretation.

Ref.	Country	Child anxiety at induction	P value	Clinical interpretation
Yarımoglu et al[19], 2026	Turkey	Both parents: 25.8 (23.3-35.8) vs one parent: 33.3 (28.3-46.7)	0.009	Two-parent presence may reduce choice-related distress in selected children
Matava et al[18], 2024	Canada	vPPIA + coaching: 25.3 ± 2.3 vs baseline 27.7 ± 5.3	0.10	Pilot data; coaching and virtual support are promising but not definitive
Jain et al[27], 2023	India	PPIA: 63.19 ± 25.31 vs midazolam: 31.30 ± 12.04	0.001	Standalone PPIA underperformed compared with pharmacological anxiolysis
Ismail and Mahrous[28], 2022	Egypt	Active participation: 42.07 ± 4.93 vs presence only: 49.87 ± 5.36	< 0.001	Active parental role was superior to passive presence
Yao et al[29], 2022	China	PPIA: 31.45 (IQR 10) vs control: 89.3	< 0.001	PPIA reduced anxiety; combined PPIA + dexmedetomidine had strongest overall profile
Rasti-Emad-Abadi et al[30], 2017	Iran	PPIA: 67.83 ± 16.78 vs control: 70.39 ± 20.93	0.621	No significant reduction in child anxiety
Sadeghi et al[31], 2017	Iran	PPIA + midazolam: 35.5 ± 16.6 vs midazolam alone: 59.8 ± 22.4	< 0.001	Improved induction anxiety and cooperation in this trial; differs from older midazolam-addition data
Vagnoli et al[32], 2010	Italy	PPIA alone: 65.40 ± 24.97 vs PPIA + midazolam: 49.72 ± 22.86	< 0.001	Medication or clown-based adjuncts outperformed PPIA alone
Wright et al[17], 2010	Canada	PPIA: 54.18 ± 27.90 vs absence: 52.75 ± 24.27 at induction	0.001 across time pattern	Benefit was greatest at separation, not induction
Kain et al[11], 2007	United States	PPIA: 50 ± 26 vs control: 52 ± 26; ADVANCE: 43 ± 23	0.07 for PPIA vs control; 0.018 for ADVANCE effect	Structured preparation outperformed simple presence
Kain et al[33], 2003	United States,	PPIA: 35 ± 17 vs control: 42 ± 20	0.024	Some child-anxiety benefit, but parental physiological stress increased
Kain et al[16], 2000	United States	No significant difference between midazolam + PPIA and midazolam alone	0.28	PPIA was not additive to midazolam for child anxiety

vPPIA: Virtual parental presence during induction of anesthesia; PPIA: Parental presence during induction of anesthesia; IQR: Interquartile range.

When PPIA was compared with sedative premedication, pharmacological anxiolysis generally produced lower anxiety scores. Jain et al[27] reported substantially lower Modified Yale Preoperative Anxiety Scale (mYPAS) scores with midazolam compared with parental presence alone. Kain et al[16] found no additional reduction in child anxiety when PPIA was added to midazolam, although parental outcomes differed. These data are consistent with recent meta-analytic conclusions that PPIA may be modestly better than no parental presence but less effective than midazolam and not consistently additive to midazolam[22].

More favorable signals were observed when parental involvement was structured, but these data should be interpreted cautiously, as they came from only a few heterogeneous trials. Active participation, including parental involvement in mask acceptance and reassurance, reduced anxiety more than passive presence in the trial by Ismail and Mahrous[28]. The ADVANCE, a family-centered behavioral preparation program, produced better perioperative outcomes than unstructured parental presence in the Kain et al’s trial[11]. Virtual parental presence, combined with coaching, demonstrated feasibility and favorable directional effects in the pilot trial by Matava et al[18]. The study by Yarımoglu et al[19] suggested that the presence of both parents, when feasible, may reduce anxiety compared with requiring the child to choose one parent. These data supports further evaluation of structured parental roles, but they do not prove that all forms of parental involvement are effective.

Values are presented as reported in the original studies. Because the timing of anxiety assessment, comparator groups, scale versions, and statistical approaches differed across trials, values should not be interpreted as directly comparable effect estimates. Where available, induction or mask-introduction anxiety was prioritized. Between-group comparisons were preferred over within-group baseline-to-induction comparisons.

Effects on parental anxiety and family experience

Parental outcomes were also heterogeneous. Some studies reported lower parental anxiety or higher satisfaction when parents were allowed to remain with their child[16,29,31]. However, parental anxiety was not uniformly reduced. Physiological stress responses among parents increased at several time points in the Kain et al[33] physiological study, and midazolam-based child premedication reduced parental state anxiety more than PPIA alone in some comparisons[27,32].

The results are clinically plausible. For some parents, exclusion from induction may be experienced as forced separation and loss of control. For others, witnessing induction, mask application, agitation, or loss of consciousness may be distressing. Parental presence, therefore, has a dual potential: It may support both the child and the parent when the parent is calm and prepared, but it may amplify family distress when the parent is anxious, uninformed, or unable to maintain coping-promoting behaviors[34-37].

Risk of bias

The risk-of-bias profile was mixed. Randomization and intervention delivery were generally acceptable, but blinding was difficult, and outcome measurement was vulnerable to observer and performance bias. Five studies were judged to have low overall risk of bias, five to have some concerns, and two to have high risk. The main concerns were missing outcome data, incomplete reporting, and subjective measurement of anxiety (Table 4).

Table 4 Cochrane RoB 2 assessment of included studies.

Ref.	D1	D2	D3	D4	D5	Overall
Yarımoglu et al[19], 2026	Low	Low	Low	Some concerns	Low	Some concerns
Matava et al[18], 2024	Low	Low	High	Low	Low	High
Jain et al[27], 2023	Low	Low	Low	Some concerns	Low	Some concerns
Ismail and Mahrous[28], 2022	Low	Low	Some concerns	Low	Low	Some concerns
Yao et al[29], 2022	Low	Low	Low	Low	Low	Low
Rasti-Emad-Abadi et al[30], 2017	Low	Low	Low	High	High	High
Sadeghi et al[31], 2017	Low	Low	Low	Some concerns	Low	Some concerns
Vagnoli et al[32], 2010	Low	Low	Low	Low	Low	Low
Wright et al[17], 2010	Low	Low	Low	Some concerns	Some concerns	Some concerns
Kain et al[11], 2007	Low	Low	Low	Low	Low	Low
Kain et al[33], 2003	Low	Low	Low	Low	Low	Low
Kain et al[16], 2000	Low	Low	Low	Low	Low	Low

D1: Randomization; D2: Deviations from intended interventions; D3: Missing outcome data; D4: Measurement of outcome; D5: Selection of reported result.

Certainty of evidence

The certainty of evidence was limited by heterogeneity in intervention structure, comparator groups, timing of anxiety assessment, and difficulty blinding participants, staff, and outcome assessors. Overall, the evidence was judged to be low to moderate for unstructured parental presence compared with no parental presence or standard care, moderate for the finding that sedative premedication is more reliable than unstructured parental presence for reducing induction anxiety, low for active or coached parental involvement compared with passive presence, low for multimodal parental involvement, and very low to low for virtual parental presence because of pilot-level evidence (Table 5).

Table 5 Summary of certainty of evidence by comparison category.

Comparison category	Direction of findings	Main limitations	Certainty of evidence
Unstructured PPIA vs parental absence or standard care	Mixed; some trials showed reduced anxiety, while others showed no clinically meaningful induction benefit	Heterogeneity in timing, comparator, parental role, and outcome measurement; limited blinding	Low to moderate
PPIA vs sedative premedication	Sedative premedication generally produced more reliable reduction in induction anxiety	Limited number of direct comparisons; different sedative protocols	Moderate
Active or coached parental involvement vs passive presence	Active/coached approaches appeared more favorable than passive presence	Few trials; intervention protocols differed; limited precision	Low
Multimodal parental involvement	Potential benefit when combined with preparation, behavioral support, or selected pharmacological anxiolysis	Difficult to isolate effect of parental involvement from adjunctive intervention	Low
Virtual parental presence	Feasible and promising, especially when combined with coaching	Pilot-level evidence; small sample size; technology and implementation variability	Very low to low

PPIA: Parental presence during induction of anesthesia.

DISCUSSION

This review supports a careful and clinically refined interpretation. In randomized and prospective comparative studies, parental presence during anesthesia induction showed inconsistent effects when used as an unstructured standalone intervention. It was generally less reliable than sedative premedication for induction anxiety, while active, coached, multimodal, or virtual forms of parental involvement showed more favorable signals. These signals should be interpreted conservatively because they are based on a few trials, small samples, heterogeneous comparators, and mostly low-certainty evidence.

The scope of the evidence is narrower than the term “parental involvement” may imply. Most included studies evaluated PPIA at the point of separation or induction; only a limited subset evaluated active participation, coaching, virtual presence, or family-centered preparation. Therefore, this review does not establish a comprehensive family-centered perioperative pathway as an evidence-proven intervention. Rather, the pathway proposed below is an author-derived implementation framework generated from the trial evidence, risk-of-bias and certainty assessment, and relevant clinical considerations.

A key practical inference is that physical proximity alone is unlikely to be the active ingredient. Trials of passive or unstructured presence were inconsistent[16,17,22,27,35,37], whereas studies in which parents had a defined role or preparation suggested more favorable effects[11,18,19,28]. This interpretation is biologically and behaviorally plausible: Calm parental behavior, distraction, touch, and predictable communication may support child regulation, whereas visible distress, repeated reassurance, apologizing, or inability to follow staff instructions may amplify anxiety[34,35,37-39]. However, this remains an inference requiring direct testing in future trials.

Family-centered perioperative care should not be equated with unrestricted parental access to the OR. Pediatric care highlights the importance of partnership and respect for families[13,40-44], but induction of anesthesia remains a high-risk clinical phase with constraints related to sterility, space, team communication, airway management, infection control, and rapid response to complications[36,41,43]. In this context, parental presence should be considered only when it can be delivered without compromising patient safety or workflow.

The following practical considerations should therefore be presented as expert-informed suggestions rather than high-level evidence recommendations. Parental presence may be reasonable for selected children undergoing elective, stable, low- or moderate-complexity procedures, particularly when the child is separation-sensitive and the parent is calm, willing, prepared, and able to follow instructions[37,43]. It may be less appropriate when the parent is highly anxious, ambivalent, likely to panic or faint, unable to follow staff direction, or when the child appears to become more distressed in response to parental emotion. When physical parental presence is unsuitable, structured child-life preparation may be considered as an alternative or adjunct where available[45,46]. It may also be inappropriate during emergency surgery, anticipated difficult airway management, hemodynamic instability, high-risk induction, strict infection-control restrictions, or severe workflow constraints[36,43,47,48].

When parental presence is used, the intervention should be made explicit. Families can be told that parental involvement is one of several anxiety-reduction options rather than an entitlement or obligation. A brief parent script may specify where to stand, how to touch or hold the child, what language to use, how to provide distraction, when to stop talking, and how the parent will leave after induction. Staff may also define a stop rule allowing the anesthesiologist or perioperative nurse to discontinue parental presence if safety or workflow is threatened[36,43]. These components are proposed implementation safeguards; they require prospective evaluation.

Virtual parental presence may offer a practical alternative when operating-room entry is not feasible, but current evidence remains pilot-level[18]. Future studies should test whether virtual contact or parent coaching improves child anxiety, parental anxiety, staff workload, device hygiene, privacy, and workflow outcomes in adequately powered trials.

Parental involvement and pharmacological premedication should be viewed as complementary rather than competing strategies. Midazolam and dexmedetomidine act pharmacologically[8-10,29], whereas parental involvement may provide attachment security and support family engagement[42,44]. The pediatric intensive care unit evidence cited in this review supports only the broader plausibility of family involvement as a non-pharmacological adjunct; it should not be extrapolated directly to anesthesia induction[14]. A tiered pathway may therefore be most appropriate: Universal preparation, optional coached parental involvement for suitable families, and pharmacological anxiolysis when predicted anxiety or poor cooperation is high.

Author-derived implementation pathway

Based on this synthesis, we propose the following author-derived pathway as a pragmatic template for local adaptation and future evaluation (Table 6). It should not be interpreted as a validated clinical guideline; each step requires local governance, staff agreement, and prospective audit before routine implementation.

Table 6 Author-derived practical considerations for structured parental involvement in pediatric perioperative care.

Step	Characteristics
Step 1	Preoperative screening: Consider assessing child’s age, developmental needs, previous healthcare trauma, expected separation anxiety, baseline parental anxiety, language needs, and family preference
Step 2	Eligibility triage: Consider parental involvement for elective, stable, low- to moderate-complexity inductions where the anesthesia team agrees that parental presence will not compromise safety
Step 3	Parent preparation: Provide a short verbal or written script explaining the induction sequence, expected child behavior, parent position, coping-promoting phrases, distraction options, and exit procedure
Step 4	Role prescription: Assign the parent a simple active role, such as maintaining eye contact, holding the child's hand, coaching breathing, telling a story, or assisting with mask familiarization when appropriate
Step 5	Staff coordination: Define who escorts the parent, who observes parent distress, and who has authority to stop the intervention
Step 6	Alternatives: Offer virtual parental presence, preoperative preparation, child-life support, distraction, or pharmacological anxiolysis when physical parental presence is unsuitable
Step 7	Audit and feedback: Collect data on child anxiety, induction cooperation, parental anxiety or satisfaction, induction time, staff workload, adverse events, and protocol adherence

This author-derived framework is intended as a set of expert-informed practical considerations for local adaptation, implementation research, and prospective evaluation. It should not be interpreted as an evidence-based recommendation or validated clinical guideline.

Strengths and limitations

This review has several strengths. It focused on randomized, prospective comparative studies, used a PRISMA-informed approach, assessed risk of bias using the Cochrane RoB 2 framework, and interpreted findings according to the certainty of the evidence. It also explicitly separates evidence-derived findings from author-derived implementation interpretation, which improves transparency and clinical applicability.

The review also has important limitations. First, the included studies were heterogeneous in intervention intensity, comparator structure, timing of outcome assessment, and measurement instruments, which precluded meta-analysis. Second, anxiety was often measured using observational tools, and blinding of parents, staff, and outcome assessors was difficult or impossible in many trials. Third, several studies were small and single-center, limiting precision and generalizability. Fourth, details on surgical procedure, baseline child anxiety, parental anxiety, and parent behavior were not consistently reported, limiting subgroup interpretation. Fifth, the taxonomy and implementation pathway are author-derived and have not been prospectively validated. Sixth, the search was limited to English-language and accessible full-text studies and did not include all potentially relevant databases such as CENTRAL, EMBASE, CINAHL, or PsycINFO. Finally, because most evidence concerns elective procedures in relatively healthy children, the findings should not be generalized to emergency surgery, medically complex children, or high-risk inductions without caution.

Future research

Future trials should move beyond recording parental presence as a binary exposure and should specify the parent role, preparation method, staff training, eligibility criteria, and safety stop rules. Two priorities are particularly important. First, multicenter randomized trials with adequate power should compare structured or coached parental involvement with passive parental presence, standard care, and pharmacological anxiolysis pathways. These trials should use standardized anxiety time points and validated outcome measures. Second, implementation studies should evaluate the safety, equity, and reproducibility of parental-presence protocols in real-world pediatric surgical settings. This evaluation should include the effects on staff workload, induction time, workflow disruption, parent distress, adverse events, and protocol adherence. Future studies should stratify or adjust for child age, baseline anxiety, temperament, previous healthcare exposure, parental anxiety, surgical complexity, and type of anesthetic induction. Common outcomes should include mYPAS or mYPAS-SF at standardized time points, parental STAI scores, compliance with induction, emergence delirium, postoperative maladaptive behavioral changes, pain levels, parental satisfaction, induction time, staff workload, and adverse events.

CONCLUSION

Parental involvement in pediatric perioperative care is best understood as a context-sensitive, family-centered adjunct rather than a simple substitute for sedative premedication. The available randomized and prospective comparative evidence mainly concerns parental presence during the induction of anesthesia. Unstructured presence has inconsistent effects on child anxiety, whereas active, coached, multimodal, and virtual approaches appear more promising but remain supported by limited and heterogeneous evidence. The proposed pathway is therefore an author-derived implementation framework, not a validated guideline. Pediatric institutions that use parental presence may consider structured processes for selecting suitable children and parents, preparing caregivers for a defined role, protecting operating-room safety, and integrating parental involvement with behavioral or pharmacological strategies when clinically indicated. The central clinical question is not whether parents should always be present, but how family involvement can be safely and effectively tailored to the child, parent, procedure, and perioperative system.