Anxiety and pain in children undergoing elective surgical procedures: a systematic review.

BACKGROUND: Anxiety and pain are two significant problems experienced by children undergoing elective surgical procedures, which may lead to suboptimal postoperative outcomes. Previous studies have shown a correlation between perioperative anxiety and pain in children.

OBJECTIVES: This review aimed to present the best available evidence on the correlation between perioperative anxiety and pain in children undergoing elective surgical procedures, and to determine the relationship between children's demographics, their anxiety and pain level in the perioperative period.

INCLUSION CRITERIA: Participants were children aged between five to 18 years old who were scheduled for an elective surgical procedure in the hospital setting.No specific intervention was of interest. So long as the primary studies examined correlation of children's anxiety and pain in the perioperative period, they were considered for inclusion.This review focused on children's preoperative level of anxiety; children's postoperative level of anxiety; children's postoperative pain intensity; and/or children's postoperative behavioural changes.This review included quantitative research studies, such as randomised-controlled trials, cohort studies, and descriptive studies which addressed the correlation between perioperative anxiety and perioperative pain in children undergoing elective surgical procedures.

SEARCH STRATEGY: A three-step search strategy was utilised in this review. The following databases were searched for articles published in English from the inception date of databases to December 2010: CINAHL, PubMed, Scopus, PsycINFO, Mednar, Trip Database, ProQuest Dissertations and Theses, Scirus ETD and Web of Science.

METHODOLOGICAL QUALITY: Papers selected for retrieval were assessed independently by two reviewers for methodological quality prior to inclusion in the review using standardised critical appraisal tools from Joanna Briggs Institute. There were no disagreements between the two reviewers, so the third reviewer was not required.

DATA EXTRACTION: Data were extracted using the standardised data extraction tools: the Joanna Briggs Institute Meta-Analysis Statistics Assessment and Review Instrument (JBI-MAStARI) for randomised-controlled trials, cohort studies, and descriptive/case series.

DATA SYNTHESIS: Since the ten included studies used various study designs and outcome measures for the levels of anxiety and pain, this made meta-analysis impossible and therefore the findings were summarised and presented in narrative form.

RESULTS: This review included two randomised-controlled trials, two cohort studies, five observational descriptive studies and one descriptive survey study. Eight studies revealed that children who had higher levels of pre- and post-operative anxiety experienced a higher level of post-operative pain. Pearson correlation coefficients of these eight studies were reported in the findings, with coefficients ranging between r = 0.29 (p < 0.05) to r = 0.57 (p < 0.001). There is no conclusive evidence supporting the relationships of children's demographics characteristics (i.e. gender, age and past surgical experience) and their perioperative anxiety and pain.

CONCLUSION: Children who had higher levels of pre- and post-operative anxiety experienced a higher level of post-operative pain. The review results inform healthcare providers of the role perioperative anxiety plays on paediatric postoperative pain.This evidence serves to generate implications for clinical practice and future studies in order to better manage children's perioperative anxiety and eventually improve their postoperative pain management. However, this review revealed insufficient evidence supporting the correlation between children's demographic data, namely gender, age and past surgical experience and their perioperative anxiety and pain.

IMPLICATIONS FOR PRACTICE: Children's perioperative anxiety should be routinely assessed prior to procedures in the clinical setting. This review also recommends that interventions be developed and implemented so as to reduce pain and anxiety for children during the perioperative period.

IMPLICATIONS FOR RESEARCH: Future studies are needed to examine the effectiveness of different interventions in reducing children's perioperative anxiety and pain, and to examine the relationship between anxiety and pain in other settings and countries. Future research should also be directed towards developing a reliable, shorter and practical anxiety assessment tool.