July 10, 2019

Study Examines Nonpharmacologic Methods to Reduce Anxiety in Preoperative Pediatric Patients

Comparing midazolam to tablet device use


In 2015, the pediatric post-anesthesia care unit (PACU) at Cleveland Clinic’s main campus began giving iPads to pediatric patients with unexpected long wait times prior to surgery. “We soon noticed the children were so happily playing with the iPads that they were no longer complaining about being hungry or thirsty,” says Michelle Levay, MSN, RN, CPN, assistant nurse manager of the pediatric PACU. “They were occupied, and parents were content to see that their children were no longer crying and upset.”


Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

That led Levay and two of her colleagues in the PACU, TeNeasha Billingsley, MSN, RN, and Megan Sumser, BSN, RN, to question the unit’s preoperative medication standard of care. Children were given midazolam orally prior to surgery to induce sedation and minimize anxiety. Nurses wondered if patients might benefit from an equally effective nonpharmacologic intervention. Their curiosity led to a research study under the tutelage of Sandra L. Siedlecki, PhD, RN, APRN-CNS, a senior nurse scientist in Cleveland Clinic’s Office of Nursing Research and Innovation.

The study purpose and design

The purpose of the study was to compare the effects of midazolam (standard care) and use of an interactive tablet-like electronic distraction device in 3- to 5-year-old children preoperatively. Levay and her team of co-investigators sought to ascertain if there was a difference in anxiety, incidence of emergence delirium, pre- and postoperative sedation/agitation, and length of stay.

The randomized controlled trial included 99 patients recruited between April 2017 and March 2019. Patients were classified as American Society of Anesthesiologists Class I (a normal healthy patient) and Class II (a patient with mild systemic disease) who were scheduled for elective surgeries within the otolaryngology, urology, ophthalmology and general surgery areas. Preoperatively, children were randomly assigned to one of two groups: 48 received midazolam (control group) and 51 received an interactive tablet-like electronic distraction device (intervention group). Children were excluded if the anesthesia provider determined it was in the best interest of the child to be pre-medicated with midazolam before surgery.


The nurses utilized the following outcomes and measurement for their study:

  • Anxiety: Modified Yale Pre-operative Anxiety Scale (higher scores indicated greater anxiety).
  • Emergence delirium: Pediatric Anesthesia Emergence Delirium scale (scores greater than 12 indicated emergence delirium).
  • Agitation and sedation: Richmond Agitation Sedation Scale (to code as agitated, sedated or neither).
  • Length of stay: By review of medical record data (based on days from PACU admission to discharge).

Results of the study

“In preliminary analysis, there was no significant difference between emergence delirium, agitation, sedation, anxiety or length of stay between groups,” says Levay. “We were actually pleased with these results, as it means that providers have options in relation to preoperative care. Medicating children prior to surgery may not be necessary, as an anti-anxiety medication was not superior to the interactive tablet-like electronic distraction device.”

Levay acknowledges that midazolam is an excellent medication when children are extremely anxious. If a child walks into the unit crying and afraid, then midazolam may be the best option. However, children who are relatively calm and cooperative are ideal candidates for the interactive tablet-like electronic distraction device intervention. Anecdotally, parents seemed to prefer the interactive tablet-like electronic distraction device intervention to medication: 21 families opted out of the study after randomization to the control group (midazolam) because they preferred the experimental treatment.


“Technology is constantly evolving, and there are many different tools available to help distract children from the stress of being in the hospital,” concludes Levay. “The most important takeaway of the study is that nonpharmacological methods for reducing anxiety are equally as effective as midazolam.”

All medications have side effects; using sedative/anti-anxiety medications can cause respiratory depression and, in rare cases, a paradoxical reaction where children become excessively agitated. “Parents told us that they wanted their children to have less medicine overall, including during the preoperative period,” says Levay. “Our intervention may not only be a great distractor for children; it may minimize preoperative over-sedation.”

Related Articles

Nurse laughing with elderly patient
February 21, 2024
What to Consider When Choosing a Wound, Ostomy and Continence Nursing Education Program

Advice for those pursuing a WOC nursing career

December 26, 2023
Nurse-Led Effort Pays Off by Reducing CLABSIs

Redesigned protocols enhance infection-prevention measures

December 13, 2023
Study Highlights Gap Between Real and Perceived Diabetes Knowledge in Outpatient Nurses

Longevity in healthcare, personal experiences may provide caregivers with false sense of confidence

November 22, 2023
Behind Closed Doors: Forensic Nurses Approach Victims With Empathy and Precision

Specialized team prioritizes trauma-informed care and evidence collection

November 20, 2023
Improving Teamwork, Morale and Outcomes with Plan-of-Care Visits

Collaborative approach leans on expertise of nurses

October 30, 2023
Nurses Champion New Patient-Centric Model of Labor and Delivery Care

TeamBirth aims to improve outcomes by facilitating collaboration between patients and caregivers

October 26, 2023
Nurse Anesthesia School Trains Specialized Team of Critical Caregivers

Nurses describe challenges and joys of caring for hospital’s most vulnerable patients

October 23, 2023
Nurses Reap Career-Affirming Rewards of Hospital Credentialing

Magnet status ensures improved caregiver satisfaction, professional growth opportunities