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

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.

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.

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.

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.

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.

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.