More than 3 million children in the United States have major surgery every year, and these procedures often require them to undergo general anesthesia. The prospect of surgery is stressful regardless of the patient’s age, but doctors need to be particularly sensitive when patients are children. The entire surgical team should work closely together and with the child’s parents to minimize the stress and trauma that they may face before and after surgery.

The preoperative process is particularly critical. Much of the anxiety and trauma children experience after surgery is because of the procedures we put them through prior to their operation, from giving them shots to putting masks on their faces to deliver the anesthetics. It’s estimated that 50% of children who have major surgery suffer some sort of postoperative behavioral changes after their operation, including night terrors and other longer-lasting emotional issues.

Make Efforts to Minimize Impact

Doctors can take simple steps toward minimizing the emotional distress that children face before and after surgery:

1. Spend time with parents before the surgery. Explain precisely what will happen and when it will happen. Include details on when and how anesthesia will be administered, and how it could affect their child’s behavior after the operation. Many children experience “emergence delirium,” where they are thrashing, crying, and inconsolable, which can be terrifying for parents. To circumvent this, describe details on expectations to alleviate postoperative stress. Also ensure that parents are active participants preoperatively.

2. Minimize trauma from needles and anesthesia masks. If possible, give children oral midazolam about 30 minutes prior to surgery so that they are comfortable and relaxed prior to separation from their parents and induction of anesthesia. Permit parents into the operating room so they can comfort children before surgery begins and keep them relaxed as anesthesia is administered. While this may not reduce anxiety, it can increase parent and child satisfaction significantly.

3. Talk to parents about possibly using melatonin before surgery to minimize emergence delirium. A study my colleagues and I published in Anesthesiology looked at how preoperative melatonin affected children (ages 2 to 8). About 25% of children who underwent surgery with general anesthesia had an episode of emergence delirium, but that percentage dropped to 5% if children received melatonin prior to their operation.

4. Ensure that parents are allowed into the recovery room immediately after surgery. This allows parents to be present when their child wakes up. Seeing familiar faces, even in an unfamiliar and painful setting, may help minimize postoperative anxiety for both parents and children.

5. Counsel parents on pain management for their children. Doctors should ensure that parents understand how much pain their child might experience and how they can tell if pain medication should be adjusted. Children cannot always communicate about the pain they are experiencing, and many parents are afraid to give them the medication they may need. Children shouldn’t have to suffer unnecessarily—a simple, straightforward conversation with parents about how they can minimize their child’s pain can make a significant difference.

Although these steps may seem simple, physicians too often do not take the time that’s needed to implement these strategies. Doing so will not only help make the surgical process easier for parents, children, and the surgical team, but it will also minimize the long-term negative effects that can result from postoperative trauma.


Kain Z, MacLaren J, Herrmann L, et al. Preoperative melatonin and its effects on induction and emergence in children undergoing anesthesia and surgery. Anesthesiology. 2009;111:44-49. Abstract available at: .

Kain ZN, Caldwell-Andrews A, Maranets I, et al. Preoperative anxiety, emergence delirium and postoperative maladaptive behaviors: are they related? A new conceptual framework. Anesth Analg. 2004;99:1648-1654.

Kain ZN, Wang SM, Mayes LC, Caramico LA, Hofstadter MB. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg. 1999;88:1042-1047.

Kain ZN, Caldwell-Andrews AA, Krivutza DM, LoDolce ME, Wang SM, Gaal D. Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative premedication in the United States, 1995-2002: results of a follow up study. Anesth Analg. 2003;98:1252-1259.

Kain ZN, MacLaren J, McClain BC, et al. Effects of age and emotionality on the effectiveness of midazolam administered preoperatively to children. Anesthesiology. 2007;107:545-552.