TABLE 2.
Characteristics of the included studies (n = 26)
| Author, year, country | Design | Sample | Aim | Intervention a | Surgery | Anxiety and pain measured |
Results M (SD)/median (IQR) |
EL/RG |
|---|---|---|---|---|---|---|---|---|
| Al‐Nerabieah et al. (2020), Syria | RCT |
N = 64 Age 6–10 years n CG = 32 n IG = 32 |
To evaluate VR glasses in the dental waiting room |
CG: no intervention IG: a cartoon shows through VR eyeglasses in the waiting room (5 min play) Time before anaesthesia 20 min |
Dental surgery |
mYPAS‐SF WBFPRS |
Baseline mYPAS‐SF CG: 57.02 (7.53) IG: 37.31 (15.39) Induction mYPAS‐SF CG: 78.96 (8.24) IG: 45.89 (12.96) p ≤ .001 WBFPRS CG: 4.09 (0.85) IG: 1.56 (1.16) p ≤ .001 |
1b/A |
| Buffel et al. (2019), Belgium | RCT |
N = 20 Age 6–10 years n CG = 8 n IG = 12 |
To evaluate perioperative anxiety |
CG: no intervention IG: a serious game‐CliniPup® (2 days play prior to surgery) |
Ambulatory surgery (dental and ENT) | mYPAS |
Induction CG: 51.88 (15.57) IG: 31.67 (7.79) p = .01 |
1b/A |
| Buyuk et al. (2021), Turkey | RCT |
N = 78 Age 5–10 years n CG = 38 n IG = 40 |
To examine the effects of VR intervention on anxiety levels |
CG: no intervention IG: VR glasses (5 min play) |
Circumcision | CAM‐S | VR interventions were effective in reducing anxiety in the preoperative period | 1b/A |
| Chaurasia et al. (2019), India | RCT |
N = 80 Age 4–8 years n CG = 40 n IG = 40 |
To evaluate the efficacy of an incentive‐based game therapy in reducing preoperative anxiety |
CG: no intervention IG: incentive‐based game Time before anaesthesia 1 day |
Elective surgery (ophthalmology, urology, orthopaedic, general) | mYPAS |
Baseline CG: 27.1 (3.4) IG: 26.6 (3.5) Induction CG: 52.6 (11.4) IG: 32.4 (6.5) p < .001 |
1b/A |
| Clausen et al. (2021), Denmark | RCT |
N = 60 Age 3–6 years n CG = 30 n IG = 30 |
To evaluate anxiety level after a game on a tablet computer |
CG: no intervention IG: game on a tablet computer Time before anaesthesia 20 min |
Elective minor (abdominal and urologic surgery) | mYPAS |
Baseline CG: 39.0 (2.3) IG: 39.2 (3.0) Induction CG: 65.8 (3.4) IG: 55.7 (4.2) [95% CI, −0.63 to 20.8; p = .066] |
1b/A |
| Dehghan et al. (2019), Iran | RCT |
N = 40 Age 6–12 years n CG = 20 n IG = 20 |
To investigate the effect of VR technology on preoperative anxiety |
CG: no intervention IG: VR (5 min play) |
Abdominal surgery | YPAS | Intervention showed significant reduction in the preoperative anxiety score after therapeutic exposure using VR | 1b/A |
| Dwairej et al. (2020), Jordan | RCT |
N = 128 Age 5–11 years n CG = 64 n IG = 64 |
To evaluate the effectiveness of video game distraction on the preoperative anxiety |
CG: no intervention IG: videogame Time before anaesthesia 20 min |
Elective surgery (ENT, orthopaedic, dental, genital surgery) | mYPAS |
Baseline CG: 43.93 (12.04) IG: 43.49 (11.24) Induction CG: 63 (15.66) IG: 42.67 (13.91) p < .001 |
1b/A |
| Eijlers, Dierckx, et al. (2019), Netherlands | RCT |
N = 191 Age 4–12 years n CG = 97 n IG = 94 |
To investigate if VR exposure is associated with lower levels of anxiety |
CG: no intervention IG: VR (15 min play) Time before anaesthesia 30–60 min |
Elective maxillofacial, dental or ENT | mYPAS |
Baseline Median (IQR) CG: 26.7 [23.3–32.5] IG: 28.3 [23.3–31.7] Induction CG: 38.3 [28.3–53.3] IG: 40.0 [28.3–58.3] p = .862 |
1b/A |
| Forouzandeh et al. (2020), Iran | RCT |
N = 172 Age 3–12 years n CG = 53 n IG1 = 64 n IG2 = 55 |
To analyse the effect of interactive games and painting on preoperative anxiety |
CG: no intervention IG1: interactive games IG2: painting Time before anaesthesia 20–30 min |
Elective surgery | mYPAS |
Baseline CG: 57.45 (17.93) IG1: 57.72 (17.60) IG2: 50.76 (19.20) Induction CG: 56.50 (15.63) IG1: 49.91 (13.21) p < .001 IG2: 42.21 (15.86) p < .001 |
1b/A |
| Gao et al. (2014), China | RCT |
N = 59 Age 3–6 years n CG = 30 n IG = 29 |
To evaluate the effect of games on reducing preoperative anxiety |
CG: no intervention IG: cartoons game Time before anaesthesia 15–20 min |
Elective surgery | mYPAS |
Baseline CG: 30.43 (3.27) IG: 30.81 (3.64) Induction CG: 58.89 (13.39) IG: 51.32 (11.34) p = .023 |
1b/A |
| Hashimoto et al. (2020), Japan | RCT |
N = 58 Age 4–12 years n CG = 29 n IG = 29 |
To determine the anxiolytic effect during the preoperative period in children |
CG: portable multimedia player IG: VR glasses Time before anaesthesia 1 day |
Elective surgery (ENT, ophthalmology, plastic/dermatology, orthopaedic, oral, digestive) | mYPAS |
Induction CG: 33.3 [23.3–44.2] IG: 23.3 [23.3–25.0] p = .001 |
|
| Hosseinpour and Memarzadeh (2010), Iran | RCT |
N = 200 Mean age 4.33 years n CG = 100 n IG = 100 |
To evaluate the efficacy of a playroom next to the operating room to reduce preoperative anxiety |
CG: no intervention IG: cartoons game Time before anaesthesia 30 min |
Elective surgery | mYPAS | Preoperative anxiety was significantly decreased for all categories of the anxiety score as assessed by mYPAS questionnaire | 1b/A |
| Huntington et al. (2018), England | RCT |
N = 176 Age 5–7 years n CG = 59 n IG1 = 60 n IG2 = 57 |
To evaluate if games improved children's anxiety |
CG: no intervention IG1: video game IG2: placebo‐video |
Dental surgery |
mYPAS VAS‐anxiety |
Baseline mYPAS CG: 45.1 (20.5) IG1: 47.6 (22.2) IG2: 43.2 (20.7) Induction mYPAS CG: 45.1 (20.5) IG1: 47.6 (22.2) [OR 1.02, 95% CI 0.61 to 2.6, p = .97] IG2: 43.2 (20.7) [OR 1.38, 95% CI 0.87 to 3.81; p = .49] VAS CG: 3.5 (2.5) IG1: 3.5 (2.6) [OR 2.0, 95% CI −0.6 to 1.3 p = .42] IG2: 3.7 (2.4) [OR 1.53, 95% CI −0.8 to 1.1; p = .65] |
1b/A |
| Jung et al. (2021), USA | RCT |
N = 70 Age 5–12 years n CG = 37 n IG = 33 |
To evaluate VR to reduce preoperative anxiety |
CG: no intervention IG: VR (5 min play) |
Elective surgery | mYPAS |
Baseline Median (IQR) CG: 28.3 [23.3–28.3] IG: 28.3 [23.3–28.3] Induction CG: 45.0 [33.3–56.7] IG: 28.3 [23.3–33.3] p < .0001 |
1b/A |
| Lee et al. (2012), South Korea | RCT |
N = 130 Age 3–7 years n CG = 44 n IG1 = 44 n IG2 = 42 |
To determine the effects of gamification on preoperative anxiety in children |
CG: no intervention IG1: game IG2: cartoon |
Elective surgery (ENT, ophthalmology, orthopaedic) | mYPAS |
Baseline CG: 27.3 (8.4) IG1: 27.3 (7.6) IG2: 25.8 (4.2) Induction CG: 57.4 (18.1) IG1: 43.6 (16.1) p < .05 IG2: 31.8 (8.8) p < .05 |
1b/A |
| Marechal et al. (2017), France | RCT |
N = 115 Age 4–11 years n CG = 55 n IG = 60 |
To compare the effects of midazolam with tablet‐games for children anxiety |
CG: midazolam IG: tablet‐game Time before anaesthesia 20 min |
Ambulatory surgery (urology, ENT, orthopaedic, ophthalmology) | mYPAS |
Baseline CG: 37.1 (14.0) IG: 34.6 (13.6) Induction CG: 40.5 (18.6) IG: 41.8 (20.7) p = .99 |
1b/A |
| Matthyssens et al. (2020), Belgium | RCT |
N = 72 Age 5–11 years n CG = 25 n IG1 = 25 n IG2 = 22 |
To evaluate the effectiveness of the serious game on anxiety and pain |
CG: no intervention IG1: serious game‐CliniPup® IG2: empty game without educational information |
Ambulatory surgery (dental, ENT or urologic) | VAS‐anxiety and pain |
Baseline Anxiety CG: 4.5 IG1: 2.8 IG2: 2.5 Pain CG: 1.6 IG1: 0.5 IG2: 1.4 Induction Anxiety CG: 4.5 IG1: 1.9 p = .044 IG2: 2.7 Pain CG: 1.12 IG1: 0.4 p = .09 IG2: 1.1 |
1b/A |
| Park et al. (2019), South Korea | RCT |
N = 80 Age 4–10 years n CG = 40 n IG = 40 |
To evaluate the effect of VR on preoperative anxiety of children |
CG: VR video + parents watching the same video via the mirroring display IG: VR video (4 min) |
Elective surgery (ENT, ophthalmology, orthopaedic, dental) | mYPAS |
Baseline CG: 36.7 (23.3–47.5) IG: 32.5 (23.3–47.5) Induction CG: 38.3 (23.3–44.2) IG: 28.3 (23.3–36.7) p = .025 |
1b/A |
| Patel et al. (2006), USA | RCT |
N = 112 Age 4–12 years n CG =38 n IG1 = 38 n IG1 = 36 |
To evaluate the efficacy of a video game in reducing preoperative anxiety in children |
CG: midazolam IG1: parent presence + hand‐held video game IG2: parent presence |
Outpatient surgery | mYPAS |
Baseline CG: 45.2 (3.1) IG1: 37.4 (2.3) IG2: 34.3 (2.0) Induction CG: 53.9 (2.7) IG1: 41.7 (4.1) p = .04 IG2: 51.5 (4.0) |
1b/A |
| Rodriguez et al. (2019), USA | RCT |
N = 52 Age 4–10 years n CG = 25 n IG = 27 |
To determine if a large projection‐based video screen mounted to a patient's bed decreased anxiety when compared to a tablet |
CG: bedside entertainment and relaxation theatre IG: tablet game (1.17–7.64 min play) |
Outpatient surgery (ENT, plastics, urology, ophthalmology, orthopaedics, rheumatology, general) | mYPAS |
Baseline CG: 26.3 (6.5) IG: 25.5 (5.7) Induction CG: 35.0 (14.3) p = .001 IG: 30.6 (14.6) p = .037 |
1b/A |
| Ryu et al. (2019), South Korea | RCT |
N = 80 Age 4–10 years n CG = 39 n IG = 41 |
To evaluate whether gamification with VR gaming reduce preoperative anxiety in children |
CG: no intervention IG: VR (4 min play) |
Elective surgery (ENT, ophthalmology, orthopaedics, dental) | mYPAS |
Baseline CG: 51.7 (31.7–61.7) IG: 46.7 (32.5–55.9) Induction CG: 46.7 (33.3–63.3) IG: 38.3 (23.3–50.9) [Mean difference 95% CI 9.2 (0.3–18.2), p = .022] |
1b/A |
| Scarano et al. (2021), Italy | RCT |
N = 50 Age 4–12 years n CG = 25 n IG = 25 |
To evaluate how playing can help to reduce preoperative anxiety of children |
CG: no intervention IG: playing room Time before anaesthesia 30 min |
Elective surgery | mYPAS |
Baseline CG: 30.86 (16.57) IG: 25.12 (4.3) Induction CG: 43.45 (24.30) IG: 28.92 (9.32) p < .05 |
1b/A |
| Seiden et al. (2014), USA | RCT |
N = 108 Age 1–11 years n CG = 51 n IG = 57 |
To compare the effects of a tablet‐based interactive distraction tool on perioperative anxiety |
CG: midazolam IG: tablet‐game |
Outpatient surgery (ENT, urology, gastrointestinal, ophthalmology, gynaecologic, dental, orthopaedics, general) | mYPAS |
Baseline Median (IQR) CG: 28 (23–45) IG: 32 (23–45) Induction IG vs CG mean difference (95% CI) (favour intervention): −14.0 (−6.1 to −22.0), p < .001 |
1b/A |
| Stewart et al. (2019), USA | RCT |
N = 102 Age 4–12 years n CG = 51 n IG = 51 |
To compare effects of tablet‐based interactive distraction with oral midazolam on preoperative anxiety |
CG: midazolam IG: tablet‐game Time before anaesthesia 20 min |
Ambulatory surgery (urology, ENT, ophthalmology, general) | mYPAS‐SF |
Baseline CG: 24.4 (3.7) IG: 25.3 (5.0) Induction CG: 35.7 (16.4) IG: 28.6 (11.6) p < .001 |
1b/A |
| Ünver et al. (2020), Turkey | RCT |
N = 94 Age 7–12 years n CG = 47 n IG = 47 |
To determine the effect of a game intervention on the preoperative anxiety levels |
CG: no intervention IG: game Jenga® |
Elective minor surgery (circumcision, inguinal hernia repair) | VFAS |
Baseline CG: 1.48 (0.99) IG: 1.82 (1.27) Postintervention CG: 2.42 (1.13) IG: 0.70 (0.80) p < .001 |
1b/A |
| Uyar et al. (2020), Turkey | RCT |
N = 134 Age 5–8 years n CG = 46 n IG1 = 43 n IG2 = 45 |
To analyse the change in children's anxiety levels |
CG: midazolam IG1: playing a videogame IG2: watch cartoon Time before anaesthesia 20 min |
Elective surgery (ENT) | mYPAS |
Baseline CG: 40.7 IG1: 40.7 IG2: 42.6 Induction CG: 38.3 IG1: 39.5 IG2: 43.7 p = .224 |
1b/A |
Abbreviations: CAM‐S, Children's Anxiety metre scale; CG, Control group; EL, Evidence level; ENT, Ears, Nose and Throat surgery; IG, Intervention group; IQR, Interquartile range; mYPAS, Modified Yale Preoperative Anxiety Scale; mYPAS‐SF, Modified Yale Preoperative Anxiety Scale‐Short Form; RG, Recommendation grade; VAS, Visual analogue scale; VFAS, Visual Facial Anxiety Scale; VR, Virtual reality; WBFPRS, Wong–Baker Faces Pain Rating Scale; YPAS, Yale Preoperative Anxiety Scale questionnaire.
No intervention = no distraction aids or usual medication.