Effect of transportation method on preoperative anxiety in children: a randomized controlled trial.

BACKGROUND: This study was performed to evaluate the effect of a wagon as a transport vehicle instead of the standard stretcher car to reduce children's anxiety of separation from parents. The secondary goal was to evaluate whether this anxiolytic effect was related to age. METHODS: We divided 80 children (age 2-7 years) into two groups. The stretcher group was transferred to the operating room on a conventional stretcher car, whereas the wagon group was transferred using a wagon. The level of anxiety was evaluated three times using the Modified Yale Preoperative Anxiety Scale (mYPAS): in the waiting area (T0), in the hallway to the operating room (T1), and before induction of anesthesia (T2). RESULTS: The mYPAS score was significantly lower in the wagon group (36.7 [31.7, 51.7]) than in the stretcher group (51.7 [36.7, 83.3]) at T1 (P = 0.007). However, there was no difference in the mYPAS score between the two groups at T2 (46.7 [32.5, 54.2] vs. 51.7 [36.7, 75.0], respectively, P = 0.057). The baseline anxiety tended to be lower with increasing age (r = -0.248, P = 0.031). During transportation to the operating room, the increase in the mYPAS score (T1-T0) was greater as the age of children decreased in the stretcher group (r = -0.340, P = 0.034). However, no correlation was observed in the wagon group (r = -0.053, P = 0.756). CONCLUSION: The wagon method decreased preoperative anxiety, suggesting that it may be a good alternative for reducing preoperative anxiety in children.

Pre-medication before dental procedures: A randomized controlled study comparing intranasal dexmedetomidine with oral midazolam.

BACKGROUND: This study aimed to determine if intranasal dexmedetomidine is a superior pre-medication to oral midazolam in older, difficult children. METHODS: This was conducted as a prospective, single-blind randomized control trial in a tertiary care center. Seventy-five children, age >5 years and weight >20 kg, who needed general anesthesia for dental procedures were randomly assigned to be pre-medicated with either oral midazolam at a dose of 0.5 mg/kg (max 15 mg) or intranasal dexmedetomidine at a dose of 2 mcg/kg (max 100 mcg). The primary outcome studied was the patients' level of sedation when separated from their parents, which was assessed using a 5-point University of Michigan Sedation Scale. Secondary outcome studied was the level of anxiolysis assessed by the acceptance of mask induction using a 4-point scale. All assessments were made by one research person blinded to the study drug. RESULTS: The two groups were similar in age, sex, weight, pre-anesthetic behavior, time from pre-medication to anesthesia induction, and surgical time. A significantly higher proportion of patients who received dexmedetomidine had satisfactory sedation at separation from parents (69.4% vs 40.5%, P = .03) compared to those who received midazolam. There were no significant differences in the rate of acceptance of mask induction (80.6% vs 78.4%, P = 1.00). Intranasal dexmedetomidine was tolerated well when administered using a mucosal atomizer and without any clinically significant effect on heart rate or systolic blood pressure. CONCLUSIONS: Intranasal dexmedetomidine provides higher success rate in sedation and parental separation compared to oral midazolam, in older, difficult children.

Adolescent escitalopram prevents the effects of maternal separation on depression- and anxiety-like behaviours and regulates the levels of inflammatory cytokines in adult male mice.

There is little research on the effects of adolescent administration of antidepressants on behavioural function and inflammation in early-life stressed adult mice. Using maternal separation (MS), a paradigm of early adversity, we investigated the effects of adolescent (PND 33-54) escitalopram (ES; 10mg/kg) exposure on depression- and anxiety-like behaviours and the levels of inflammatory cytokines (interleukin [IL]-1ß, tumor necrosis factor [TNF]-α, and IL-10) in the ventral hippocampus (HPV), prefrontal cortex (PFC), and serum in adult (PND 61) male offspring mice. The results showed that MS has no effect on locomotor activity, but increased depression-like behaviours in the saccharin preference test and increased anxiety-like behaviours in the social preference and elevated plus maze tests. MS increased the levels of IL-1ß in the HPV, PFC, and serum, while decreasing the level of IL-10 in the HPV. Furthermore, adolescent ES treatment inhibited these depression- and anxiety-like behaviours, decreased the levels of IL-1ß, and increased the level of IL-10 in the HPV. The results also showed that there are no effects of chronic escitalopram administration on normal behaviour in control mice. Taken together, the current data provide experimental evidence that MS increases depression and anxiety levels in adult male offspring. Additionally, the findings support the idea that early pharmacological intervention with ES may be an effective treatment for reducing the behavioral abnormalities induced by early adversity and regulating the underlying inflammatory mechanisms involved.

Evaluation of effects of olfactory and auditory stimulation on separation anxiety by salivary cortisol measurement in dogs.

Separation anxiety (SA) is a serious behavioral problem in dogs. In this study, salivary cortisol was studied to determine if the owner's odor or voice could reduce SA in dogs. Twenty-eight dogs with SA were divided into three groups: group 1 (control), group 2 (with owner's clothes during the separation period; SP) and group 3 (a recording of the owner's voice was played during SP). The dog's saliva was collected after the owner and their dog were in the experimental room for 5 min (PRE). The dog was then separated from the owner for 20 min and saliva collected four times at intervals of 5 min (SP1-4). Finally, the owner was allowed back into the room to calm the dog for 5 min, after which saliva was collected (POST). Evaluation of salivary cortisol concentrations by ELISA revealed that the ratios of SP1 concentration to PRE or POST concentrations were significantly higher in group 1 than in group 2 or 3. Additionally, the concentrations of SP1-PRE and SP1-POST among groups differed significantly. These findings indicate that the owner's odor or voice may be helpful to managing stress in dogs with SA.

The effect of nasal midazolam premedication on parents-child separation and recovery time in dental procedures under general anaesthesia.

AIM: For many children medical and dental procedures, unfamiliar dental staff and treatment places are disturbing and stressful. Stress in children often makes them uncooperative. General anaesthesia is indicated for anxious uncooperative children or those who are disabled, immature or too young to undergo dental treatment by other means. Moreover parents' separation while entering the operative room is a traumatic experience for children. Thus premedication such as midazolam is recommended to decrease child's stress. In these situations the increased recovery time was considered as one of the midazolam side effects. There is no study that evaluated the effect of midazolam both in parents-child separation and recovery time in long dental procedure. The purpose of this study was to evaluate the effect of nasal midazolam premedication with placebo on parents-child separation and recovery times in uncooperative paediatric patients undergoing long-lasting general anaesthesia for dental procedures. STUDY DESIGN: This randomised, double-blind study was done on 60 uncooperative patients (ASA physical status I or II) aged 2-4 years who were scheduled for general anaesthesia for dental treatment. Group A received 0.2 mg/kg intranasal midazolam as premedication, and group B received the same volume of intranasal placebo 20 minutes before entering the operating room for general anaesthesia. General anaesthesia was done with the same method for all patients, then parent-child separation and recovery times were compared between the two groups. STATISTICAL ANALYSIS: Statical significance was set at P≤0.05. Statically analysis was performed using SPSS version17.Chi-squared and student t-tests were applied to analyse the data. RESULTS: We found significant differences in parents- child separation assessment between two groups. Nasal midazolam premedication had a positive effect on parents-child separation; but there was no significant difference between the two groups in terms of recovery time. CONCLUSION: Premedication of nasal midazolam before induction of general anaesthesia did not prolong recovery time but made the separation of children from their parents easier by showing a better behaviour.

[School refusal and dropping out of school: positioning regarding a Swiss perspective]. / Schulverweigerung und Schulabbruch: Eine Standortbestimmung unter Berücksichtigung von Perspektiven aus der Schweiz.

This article deals with refusal to attend school and dropping out of school from the point of view of child and adolescent psychiatry and psychology, in German speaking countries and from the perspective of Swiss schools and their administrative bodies. General epidemiological data on refusal to attend school show that approximately 5% of children and adolescents are likely to try to avoid attending school at some point. There is very little data available on the frequency of school drop-out. In the past two years (2011 and 2012), approximately 2% of all patients seen for the first time at the department of Child and Adolescent Psychiatry, University Zurich, were referred because of failure to attend school, making this phenomenon one of the most common reasons for referral in child and adolescent psychiatry. After a discussion of the epidemiology, symptomatology, causes and its risk factors, the article presents examples drawn from practice and guidelines for intervention in cases of refusal to attend school, and discusses ways of preventing school drop-out from the point of view of schools, hospitals and bodies such as educational psychology services in Switzerland.

Maternal depressive symptoms and children's emotional problems: can early child care help children of depressed mothers?

IMPORTANCE: Maternal depression is a major risk factor for the development of children's mental health problems. No population-based study to date has examined whether early child care spanning the full preschool period from infancy onward is protective for children of depressed mothers. OBJECTIVE: To examine whether early child care moderates associations between maternal depressive symptoms (MDSs) and child internalizing problems (emotional problems [EPs], separation anxiety symptoms, and social withdrawal symptoms [SWSs]) during the preschool period. DESIGN AND SETTING: Population-based prospective cohort study within the Québec Longitudinal Study of Child Development. PARTICIPANTS: Québec Longitudinal Study of Child Development participants (n = 1759) assessed repeatedly between ages 5 and 60 months. MAIN OUTCOMES AND MEASURES: High-level trajectories of EPs, SWSs, and separation anxiety symptoms between ages 17 and 60 months. RESULTS: Child care age at entry moderated associations between MDSs and child internalizing problems. Among children of mothers with elevated MDSs, reduced odds ratios for EPs and SWSs were found for those entering child care early (0.24; 95% CI, 0.09-0.66 for EPs and 0.29; 95% CI, 0.09-0.92 for SWSs) or late (0.29; 95% CI, 0.11-0.77 for EPs and 0.21; 95% CI, 0.07-0.65 for SWSs) compared with those remaining in maternal care. Child care type moderated the association between MDSs and child EPs; children of mothers with elevated MDSs who received group-based child care had lower odds ratios for EPs than those who remained in maternal care (0.21; 95% CI, 0.09-0.48) or those who were cared for by a relative or babysitter (0.40; 95% CI, 0.17-0.94). CONCLUSIONS AND RELEVANCE: Regulated early child care services reduced the risks for internalizing problems for children of mothers with elevated MDSs. Regulated child care services may be used as a public health intervention to buffer the negative effect of maternal depression on children's internalizing problems.

A journey filled with emotions--mothers' experiences of breastfeeding their preterm infant in a Swedish neonatal ward.

The study took place in a 10-bed neonatal ward in a hospital in the south of Sweden and includes mothers having given birth to a preterm infant born before the 37th week of gestation. The aim of the study was to illuminate mothers' experiences of breastfeeding a preterm infant in a neonatal ward. Data collection includes written protocols from twelve mothers. These protocols were analysed thematically. The results indicate that the mothers should be offered a private place where they can breastfeed or express breastmilk, and that the breastmilk should not be placed in a shared area. The mothers described that they did not want to be separated from their preterm infant during the night. Finally, they also pointed out the importance of support from the health professionals for establishing an exclusive breastfeeding regime.

A comparison of two different doses of rectal ketamine added to 0.5 mg x kg(-1) midazolam and 0.02 mg x kg(-1) atropine in infants and young children.

In some circumstances, a high degree of sedation that results in a child being unconscious at the time of parental separation is desirable. We set out to investigate the efficacy and safety of a rectal premedication regimen designed to produce this increased level of sedation. Sixty-seven children aged two to 24 months were randomised into two groups. Group MK received 4 mg x kg(-1) ketamine, 0.5 mg x kg(-1) midazolam and 0.02 mg x kg(-1) atropine and group MKK received 8 mg x kg(-1) ketamine, 0.5 mg x kg(-1) midazolam and 0.02 mg x kg(-1) atropine per rectum. The sedation score at the time of parental separation 30 minutes after drug administration and the response to intravenous cannulation were evaluated on a four-point scale. Respiratory rate, heart rate and arterial oxygen saturation were recorded immediately before parental separation. More patients in group MKK were asleep during separation (62 vs 35%, P < 0.05). Fewer patients in group MKK cried during intravenous cannulation (37 vs 68%, P < 0.05). Sedation scores were significantly increased at both time points. There was no difference between groups in vital signs at the time of parental separation and no adverse respiratory events occurred during the study period. In cases where a high degree of sedation following premedication in infants and toddlers is desired, the addition of 8 mg x kg(-1) ketamine to 0.5 mg x kg(-1) midazolam and 0.02 mg x kg(-1) atropine administered rectally is more efficacious than 4 mg x kg(-1) ketamine.

Psychosocial considerations of perioperative care in children, with a focus on effective management strategies.

Children are not just 'small adults'. They have specific physical, psychological and social requirements that must be identified and addressed to optimise their well-being in the perioperative period. The healthcare practitioner should be trained to understand the needs of the paediatric patient in hospital, including the ever increasing need to take into account cultural differences. Hospital policy should include a preoperative preparation programme, specially aimed at the paediatric population, where parental involvement is encouraged throughout.

Audiovisual interventions to reduce the use of general anaesthesia with paediatric patients during radiation therapy.

Clinical audiovisual interventions were implemented to avoid the use of general anaesthesia with children undergoing radiation therapy treatment. A retrospective audit and case study review was conducted to evaluate the utility of distraction interventions aimed at improving immobilisation and reducing separation anxiety for children aged between 2 and 6 years old who received radiation therapy. A simple, inexpensive audiovisual system was established using commercially available equipment. Paediatric patients could elect to (i) use a closed-circuit TV system that allowed them to see their carer(s); (ii) watch a DVD movie; or (iii) listen to carer(s) on a microphone during their treatment. Over a 2-year period (March 2007-May 2009), 37 paediatric patients aged 2-6 years received radiation therapy at the centre. Twenty-four children participated in audiovisual interventions, and 92% (n = 22) of these children did not require the use of general anaesthesia for some or all of their treatment. Case study review illustrates the utility and limitations of the system. The audit and case studies suggest that the audiovisual interventions provided supportive care and reduced the need to anaesthetise children undergoing radiation therapy treatment.

Premedication with oral midazolam with or without parental presence.

BACKGROUND AND OBJECTIVE: In this study, we aimed to investigate whether the combination of low-dose (0.25 mg kg(-1)) midazolam premedication with parental presence can effectively reduce anxiety at induction as well as provide a smoother emergence. METHODS: Institutional ethics committee approval and informed consent from one of the parents were obtained prior to the study. Sixty ASA grade I or II children undergoing surgery were enrolled in the study. Children were randomized to receive either 0.5 mg kg(-1) midazolam orally (group M) or 0.25 mg kg(-1) midazolam orally with parental presence (group MP) or parental presence alone (group P). The child's anxiety and sedation scores were evaluated as 1-4 points on the Anxiety Scale and as 0-4 points on the University of Michigan Sedation Scale (UMSS), respectively, at the entrance to the operating room and for tolerance to the face mask. Heart rate, the mean arterial blood pressure and O2 saturation (%) were assessed at repeated intervals before and after induction. At the end of surgery, the child's Anxiety Scale score, UMSS score, Observer's Pain Scale (OPS) score and FLACC score were also assessed. RESULTS: There were no differences between groups in demographic variables and duration of surgery or anaesthesia. Mean blood pressure changes were similar between groups at measured intervals, but the heart rate was higher in group M before and after induction of anaesthesia (P<0.05). UMSS score was greater in both midazolam groups (groups M and MP) in the preoperative period (P<0.05). Anxiety Scale scores for anxiolysis were higher in groups M and MP than in group P (less anxious and more sedated) at 20 min after premedication, at the entrance to the operating room and at mask tolerance time points (P<0.05). During recovery there was no significant difference in sedation, recovery scores or behavioural anxiety assessment between groups, Anxiety Scale score, UMSS score, FLACC score, Visual Analog Scale (VAS) score and Observer's Pain Scale score in groups MP, M and P. CONCLUSION: Preoperative administration of midazolam 0.5 mg kg(-1) for premedication alone, without parental presence at induction, and that of low-dose midazolam 0.25 mg kg(-1) for premedication with parental presence at induction are both equally effective in reducing separation anxiety and providing a smooth emergence. However, parental presence alone, without midazolam for premedication, is not an adequate approach for this outcome. If the environment for parental presence is convenient, the dose of midazolam may be reduced and induction and emergence conditions may still be of high quality.

A comparison of intranasal dexmedetomidine and oral midazolam for premedication in pediatric anesthesia: a double-blinded randomized controlled trial.

BACKGROUND: Midazolam is the most commonly used premedication in children. It has been shown to be more effective than parental presence or placebo in reducing anxiety and improving compliance at induction of anesthesia. Clonidine, an alpha(2) agonist, has been suggested as an alternative. Dexmedetomidine is a more alpha(2) selective drug with more favorable pharmacokinetic properties than clonidine. We designed this prospective, randomized, double-blind, controlled trial to evaluate whether intranasal dexmedetomidine is as effective as oral midazolam for premedication in children. METHODS: Ninety-six children of ASA physical status I or II scheduled for elective minor surgery were randomly assigned to one of three groups. Group M received midazolam 0.5 mg/kg in acetaminophen syrup and intranasal placebo. Group D0.5 and Group D1 received intranasal dexmedetomidine 0.5 or 1 microg/kg, respectively, and acetaminophen syrup. Patients' sedation status, behavior scores, blood pressure, heart rate, and oxygen saturation were recorded by an observer until induction of anesthesia. Recovery characteristics were also recorded. RESULTS: There were no significant differences in parental separation acceptance, behavior score at induction and wake-up behavior score. When compared with group M, patients in group D0.5 and D1 were significantly more sedated when they were separated from their parents (P < 0.001). Patients from group D1 were significantly more sedated at induction of anesthesia when compared with group M (P = 0.016). CONCLUSIONS: Intranasal dexmedetomidine produces more sedation than oral midazolam, but with similar and acceptable cooperation.

The relationship of military imposed marital separations on maternal acceptance of pregnancy.

The effect of military deployment and perceived availability and source of community support on women's acceptance of pregnancy were examined in each trimester of pregnancy at four military bases. The sample was 503 primigravida or multigravida women eligible for care in the military medical system. Military deployment and community support had a statistically significant effect on pregnancy acceptance. Gravidas with deployed husbands had higher conflict for accepting pregnancy than gravidas without deployed spouses. Community support had a significant positive effect on pregnancy acceptance. Women perceiving support predominantly from off-base versus on-base communities had significantly higher conflict with acceptance of pregnancy. Findings point to improved maternal acceptance of pregnancy with paternal presence and community support in the event of military deployment.

Supporting breastfeeding mothers in hospital: part 2a.

The first article in this series highlighted the challenges that mothers face in establishing breastfeeding (Wallis and Harper 2007). Breastfeeding a sick infant in hospital presents additional challenges such as small, sleepy babies, babies who may be nil by mouth for prolonged periods and babies who may find breastfeeding difficult due to mechanical problems. There is very little published abut the needs of babies with complex medical or surgical conditions who may have had significant delays in their feeding or numerous starts and stops along the way. This article and Part 2b in the November issue illustrate some of the common challenges and propose principles of care that are transferable to caring for other sick babies with similar problems.

Preventing and treating homesickness.

Homesickness is a normative pathology that ranges from benign to severe. It is defined as the distress or impairment caused by an actual or anticipated separation from home and attachment objects. Symptoms of homesickness, including preoccupying thoughts of home, can be predicted, prevented, and treated. This article summarizes the latest clinical research and practice surrounding homesickness in children and adolescents. Equipped with this knowledge, health care providers can train and consult with summer camp directors and staff to properly prepare and treat new and returning campers.

Preventing and treating homesickness.

Homesickness is the distress and functional impairment caused by an actual or anticipated separation from home and attachment objects such as parents. It is characterized by acute longing and preoccupying thoughts of home. Almost all children, adolescents, and adults experience some degree of homesickness when they are apart from familiar people and environments. Pediatricians and other health care professionals are in a unique position to assist families in understanding the etiology, prevention, and treatment of homesickness. In the case of planned separations, such as summer camp, techniques are provided that may aid in prevention. In the case of unanticipated or traumatic separations, such as hospitalization, effective treatment strategies are available.

Children's experiences of hospitalization.

This article reports on children's experiences of hospitalization. Data were collected via semi-structured interviews with 11 children aged between seven and 14 years from four paediatric units in England. The children identified a range of fears and concerns, which included: separation from parents and family; unfamiliar environment; investigations and treatments; and loss of self-determination. The children's loss of self-determination over personal needs exacerbated their fears and concerns. It needs to be recognized that compliance with hospital routines is a variable, which influences children's reaction to hospitalization. The findings clearly indicate that children need adequate information tailored to their needs, that their views are sought in the planning and delivery of their care and that hospital environments need to be made more child-centred. Interventions designed to reduce children's stress during hospitalization are not only likely to decrease their stress at the time, but also likely to influence how future experiences are appraised and managed.