Cartoon Distraction Alleviates Anxiety in Children

During Induction of Anesthesia

Jeongwoo Lee, MD,* Jihye Lee, MD,* Hyungsun Lim, MD,† Ji-Seon Son, MD, PhD,†
Jun-Rae Lee, MD, PhD,‡ Dong-Chan Kim, MD, PhD,† and Seonghoon Ko, MD, PhD§
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BACKGROUND: We performed this study to determine the beneficial effects of viewing an ani-
mated cartoon and playing with a favorite toy on preoperative anxiety in children aged 3 to 7
years in the operating room before anesthesia induction.
METHODS: One hundred thirty children aged 3 to 7 years with ASA physical status I or II were
enrolled. Subjects were randomly assigned to 1 of 3 groups: group 1 (control), group 2 (toy),
and group 3 (animated cartoon). The children in group 2 were asked to bring their favorite toy
and were allowed to play with it until anesthesia induction. The children in group 3 watched
their selected animated cartoon until anesthesia induction. Children’s preoperative anxiety was
determined by the modified Yale Preoperative Anxiety Scale (mYPAS) and parent-recorded anxi-
ety Visual Analog Scale (VAS) the night before surgery, in the preanesthetic holding room, and
just before anesthesia induction.
RESULTS: In the preanesthetic holding room, the group 2 mYPAS and parent-recorded anxiety
VAS scores were significantly lower than those of groups 1 and 3 (mYPAS: P = 0.007; parent-
recorded anxiety VAS: P = 0.02). In the operating room, the children in group 3 had the low-
est mYPAS and parent-recorded anxiety VAS scores among the 3 groups (mYPAS: P < 0.001;
parent-recorded anxiety VAS: P < 0.001). In group 3, the mYPAS and parent-recorded anxiety VAS
scores of only 3 and 5 children were increased in the operating room compared with their scores
in the preanesthetic holding room, whereas the anxiety scores of 32 and 34 children in group
1 and 25 and 32 children in group 2 had increased (P < 0.001). The number of children whose
scores indicated no anxiety (mYPAS score <30) in the operating room was 3 (7%), 9 (23%), and
18 (43%) in groups 1, 2, and 3, respectively (P < 0.001).
CONCLUSIONS: Allowing the viewing of animated cartoons by pediatric surgical patients is a
very effective method to alleviate preoperative anxiety. Our study suggests that this intervention
is an inexpensive, easy to administer, and comprehensive method for anxiety reduction in the
pediatric surgical population. (Anesth Analg 2012;115:1168–73)

M
any children undergoing surgery experience sub-
stantial anxiety in the preoperative holding area and
the operating room (OR) before induction of anesthe-
sia. In fact, approximately 50% of children experience anxiety
regarding an impending surgical experience.1–3 Preoperative
anxiety may be caused by separation from parents, unfamil-
iar environments and people, and negative anticipation of
surgical procedures. Children’s preoperative anxiety has been
observed to manifest in different ways, with many children
appearing fearful and agitated, breathing deeply, shivering,
crying, and stopping talking or playing. Children may protest,
fight, or try to escape, which may be emotionally traumatic
for the child and parents. Intense preoperative anxiety has
Author affiliations are provided at the end of the article.
Accepted for publication February 1, 2012.
Supported by departmental grant.
The authors declare no conflicts of interest.
This report was previously presented, in part, at the 88th Annual Scientific
Meeting of The Korean Society of Anesthesiologists, 2011, Seoul, South
Korea.
Reprints will not be available from the authors.
Address correspondence to Seonghoon Ko, MD, PhD, Department of
Anesthesiology and Pain Medicine and Research Institute of Clinical
Medicine, Chonbuk National University, 634-18 Keum-Am Dong, Jeonju,
Chonbuk 561-712, South Korea. Address e-mail to shko@jbnu.ac.kr.

Copyright © 2012 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e31824fb469
DOI:
been associated with difficulty in anesthetic induction and the
development of postoperative agitation and negative behav-
iors.4–6 Common postoperative behavioral changes include
separation anxiety, nightmares, aggression toward authority,
and nocturnal enuresis.3,4 Kain et al.2 showed that 67% of chil-
dren had behavior changes the day after surgery, and this per-
sisted for 6 months in 20% and for 1 year in 7% of the children.
To reduce the incidence of preoperative anxiety in children,
anesthesiologists have used a number of prevention strategies,
including sedative premedication, parental presence during
anesthetic induction, behavioral preparation programs, music
therapy, hypnosis, and acupuncture.7 Some of these interven-
tions are used fairly frequently, whereas others are used less
frequently because of undesirable side effects, time constraints,
or increased health care costs. Although premedication with
oral midazolam is often used to alleviate childhood anxiety, its
use has been associated with side effects.8–10
Preschool children generally enjoy watching animated
cartoons, and they can become sufficiently engrossed to
become oblivious to their surroundings and disregard ver-
bal and tactile stimuli. Children may also be comforted by
familiar toys. Therefore, viewing an animated cartoon or
playing with a favorite toy seems likely to alleviate preop-
erative anxiety in children. There are no controlled trials
that have investigated the effects of viewing animated car-
toons on preoperative anxiety in children. This study was
performed to determine the beneficial effects of viewing an

1168 www.anesthesia-analgesia.org November 2012 • Volume 115 • Number 5

 
animated cartoon or playing with a favorite toy on preop-
erative anxiety in children aged 3 to 7 years in the OR before
anesthesia induction.
METHODS
This prospective, randomized trial examined the effects of
2 behavioral interventions on preoperative anxiety in chil-
dren undergoing general anesthesia for elective surgery.
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The study was approved by the IRB of Chonbuk National
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University Hospital in South Korea. Written informed
parental consent was obtained for all participants.
One hundred and thirty children, aged 3 to 7 years, ASA
physical status I or II, were enrolled. Children having emer-
gency surgery and those with previous anesthetic experi-
ence, developmental delays, mental retardation, or chronic
illnesses were excluded from the study. Subjects were ran-
domly assigned by computer-generated random number to
1 of 3 groups: group 1 (control), group 2 (toy), and group 3
(animated cartoon).
Patients were admitted the evening before surgery. The
research team anesthesiologist visited the pediatric ward
to conduct preoperative interviews and measure base-
line anxiety scores. The patients were allocated to 1 of 3
groups before preoperative assessment of baseline anxiety.
Demographic data were collected from the parents and the
medical charts. The children in group 2 were asked to bring
their favorite toy with them to the preoperative holding
room.
Children’s preoperative anxiety was determined by the
modified Yale Preoperative Anxiety Scale (mYPAS) and the
parent-recorded anxiety Visual Analog Scale (VAS). The
mYPAS contains 22 items in 5 categories qualifying anxi-
ety in young children: activity, emotional expressivity, state
of arousal, vocalization, and use of parents. This observa-
tional measurement has shown good-to-excellent inter-
and intraobserver reliabilities and validity for measuring
children’s anxiety in the preoperative holding area, upon
entrance to the OR, and during induction of anesthesia in
children aged 2 to 12 years. The score range is 23.3 to 100,
with a score of ltequ30 indicating that the subject does not
have anxiety; a score mt30 indicates that the subject does
have anxiety.11 The parent-recorded anxiety VAS measures
children’s anxiety assessed by the accompanying parents
using a 10-cm scale. In the current study, the mYPAS and
parent-recorded anxiety VAS scores were used to measure
the children’s anxiety levels the night before surgery, when
they were in the preanesthetic holding room, and just before
anesthesia induction.
All operations were performed in morning sessions. A
24-gauge catheter was inserted into a peripheral vein the
night before surgery or the morning of surgery after EMLA
(Eutectic Mixture of Local Anesthetics) cream application,
and the time was recorded. When the children were trans-
ported from the pediatric ward to the preanesthetic hold-
ing room, the children in group 2 brought their favorite
toys and were allowed to play with them until anesthesia
induction. After the second measurement of anxiety scores,
in the preanesthetic holding room, the children in group 3
chose 1 from a selection of 10 movies. The preselected 10
movies were 4 action movies (Beyblade®, Power Ranger®,
Power Ranger Jungle Force®, and Robocar Poli®), 4 comics
November 2012 • Volume 115 • Number 5
(Chiro®, Crayon Shin-chan®, Doraemon®, and Pororo®), 1
science fiction (Keroro®), and Cinderella. The children in
group 3 watched their selected movie using a notebook or
tablet personal computers (PCs) until anesthesia induction.
When the children fell asleep after administration of IV
anesthetics, the movie was stopped. When the patients were
transported from the preanesthetic holding room to the OR,
they were accompanied by their parent and a research team
member. When they entered the OR, the parent was dressed
in scrubs, hat, and mask. After monitor placement of elec-
trocardiogram and pulse oximetry, the final mYPAS and
parent-recorded anxiety VAS measurements were taken just
before anesthesia induction. The mYPAS scores were mea-
sured by 1 anesthesiologist to exclude interrater bias.
Standard anesthetic regimens and techniques were used
for all patients. IV anesthetic induction was performed
using 4 to 6 mg/kg thiopental or 1 to 2 mg/kg ketamine,
and patient arterial blood pressure was noninvasively
monitored with an anesthesia workstation (Zeus®; Dräger
Medical, Lübeck, Germany). For facilitation of tracheal intu-
bation, the patients received 0.6 mg/kg rocuronium. After
tracheal intubation, temperature was monitored at the naso-
pharynx or rectum. Anesthesia was maintained with 50%
nitrous oxide in oxygen and 1.5% to 3.0% sevoflurane. Fresh
gas flow rate was maintained at 3 L/min during the opera-
tion. End-tidal carbon dioxide partial pressure was main-
tained at 30 to 35 mm Hg. Arterial blood pressure and heart
rate were kept within 20% of preanesthetic values. At the end
of surgery, sevoflurane and nitrous oxide administration was
discontinued, and the patients received pyridostigmine and
glycopyrrolate for reversal of neuromuscular blockade. At
skin closure, patients received 1 mg/kg ketorolac or 1 µg/kg
fentanyl for postoperative pain control.
Sample Size Determination and
Statistical Analysis
A pilot study of 18 children in the OR had mean (SD) mYPAS
scores of 62 (18), 49 (23), and 30 (12) in group 1, 2, and 3,
respectively. We considered a clinically significant decrease
in mYPAS score to be ≥15 points. It was ascertained that 35
patients were required in each group to show a difference
in mean mYPAS scores of 15 for an expected standard devi-
ation of 20 with a significance level of 0.05 (α = 0.05) and
a power of 80% (β = 0.20). Sample size was calculated by
1-way analysis of variance (ANOVA) using SigmaStat 3.5
(Systat Software Inc., San Jose, CA). To allow for attrition,
sample size was enlarged to 130.
Data are presented as mean ± SD or median and inter-
quartile range. Patient characteristics and anxiety scores
among groups were analyzed using 1-way ANOVA fol-
lowed by the Tukey test for multiple comparisons for vari-
ables that were normally distributed or the Kruskal-Wallis
test followed by Dunn’s method for variables that had non-
parametric data or were not normally distributed. Anxiety
scores within groups were analyzed using repeat-measures
ANOVA followed by the Holm-Sidak test for multiple com-
parisons. A P value <0.05 was regarded as significant.
RESULTS
Of the 130 enrolled children, 4 children in group 2 were
excluded for data analysis because they did not bring a
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 Cartoon Alleviates Pediatric Preoperative Anxiety

Table 1. Patient Characteristics

Group 1 Group 2 Group 3 P values
No. of patients 44 44 42
Age (y) 4.8 ± 1.5 4.4 ± 1.2 4.6 ± 1.3 0.378
Height (cm) 112.4 ± 10.8 108.7 ± 8.8 109.6 ± 11.4 0.223
Weight (kg) 20.7 ± 4.9 19.0 ± 3.7 20.5 ± 5.9 0.211
Gender (male/female) 30/14 29/15 28/14 0.974
ASA physical status (I/II) 40/4 41/3 41/1 0.422
Fasting time (h) 11.8 ± 1.8 11.8 ± 2.0 12.0 ± 1.7 0.846
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Time from catheterization to induction (min) 176.6 ± 265.0 177.3 ± 238.1 177.8 ± 236.4 0.994
Catheterization timing (evening/morning) 10/34 13/31 12/30 0.739
Guardian (F/M/GP) 8/35/1 9/34/1 7/34/1 0.995
Surgery — — — 0.966
Tonsillectomy 17 19 17 —
Herniorrhaphy 11 11 10 —
Eye surgery 6 6 6 —
Hand surgery 3 2 5 —
Others 7 6 4 —
Group 1 (control), Group 2 (toy), Group 3 (animated cartoon). Guardian (F = father; M = mother; GP = grandparents). Catheterization timing (evening = the evening
before the operation; morning = the morning of the operation day).

Table 2. Modified Yale Preoperative Anxiety Scale

(mYPAS) and Parent-Recorded Anxiety Visual
Analog Scale (VAS) Scores
Preanesthetic Preanesthetic Operating
visit holding room room
mYPAS scores
Group 1 27.3 ± 8.4 48.0 ± 15.8 57.4 ± 18.1*
Group 2 27.3 ± 7.6 38.3 ± 11.5† 43.6 ± 16.1*†
Group 3 25.8 ± 4.2 45.7 ± 15.5 31.8 ± 8.8*†
Parent-recorded
anxiety VAS
scores
Group 1 1.6 ± 2.2 5.0 ± 3.0 6.1 ± 2.7*
Group 2 1.8 ± 2.4 3.7 ± 2.6† 5.2 ± 2.6*
Group 3 1.8 ± 1.3 5.3 ± 2.5 3.2 ± 2.4*†
*P < 0.05 versus preanesthetic holding room.
†P < 0.05 versus group 1.
Figure 1. The number of patients who had changes in their modi-
fied Yale Preoperative Anxiety Scale (nonhatched stacked bars) and
parent-recorded anxiety Visual Analog Scale (hatched stacked bars)
toy. The number of patients with analyzed anxiety scores scores in the operating room (OR) compared with the preanesthetic
was 44 in group 1, 40 in group 2, and 42 in group 3. The holding room. Green, blue, and red colors represent the number
3 study groups were comparable with respect to demo- of patient who had decreased, unchanged, and increased anxiety
graphic data, ASA physical status, fasting time, times from scores in the OR compared with scores in the preanesthetic holding
room, respectively. Groups 1, 2, and 3 are represented as control, a
peripheral IV catheter placement to anesthesia induction, a
group who played with a toy, and a group who watched an animated
guardian who accompanied the child to the OR, and type cartoon, respectively. *P < 0.001 compared with groups 1 and 2.
of surgery (Table 1). The most common surgical procedure
in all groups was tonsillectomy. Other common procedures
were herniorrhaphy and eye surgery. The mother was the scores among the 3 groups, and group 2 had the next lowest
most likely parent to accompany the child into the OR. scores (Table 2). In the OR, the mYPAS scores of only 3 chil-
The toys brought by children in group 2 were dolls, robots, dren in group 3 were increased compared with the preanes-
mobile phones, and portable video games (VGs), in order of thetic holding room, whereas 32 children in group 1 and 25
decreasing frequency. In group 3, the selected animated car- children in group 2 had increased anxiety scores (P < 0.001).
toons by children and the number of patients who selected Similarly, for the parent-recorded anxiety VAS, 34 children
the cartoon were Power Ranger (15 children), Pororo (10 in group 1 and 32 children in group 2 had increased anxiety
children), Doraemon (5 children), and Keroro (5 children), scores in the OR compared with the preanesthetic holding
Chiro (3 children), Cinderella (2 children), Power Ranger room, whereas only 5 children in group 3 demonstrated an
Jungle Force (1 child), and Robocar Poli (1 child). increase (P < 0.001) (Fig. 1). The number of children whose
There were no significant differences among the 3 groups scores indicated no anxiety (mYPAS score ≤30) in the OR was
in the initial mYPAS and parent-recorded VAS scores on the 3 (7%), 9 (23%), and 18 (43%) in groups 1, 2, and 3, respec-
pediatric ward. In the preanesthetic holding room, in group tively. Within groups in the OR, there was no significant dif-
2, the mYPAS and parent-recorded VAS scores were signifi- ference in mYPAS scores of children who were accompanied
cantly lower than in groups 1 and 3. In the OR, the children by their mothers compared with their fathers. The mYPAS
in group 3 had the lowest mYPAS and parent-recorded VAS and parent-recorded VAS scores within-patient changes

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Figure 2. Modified Yale Preoperative Anxiety Scale (mYPAS) (A) and
parent-recorded (PR) anxiety Visual Analog Scale (VAS) (B) within-
patient scores change from the preanesthetic holding room to the
OR. Box represents the interquartile range from 25th to 75th per-
centile. Upper and lower whiskers indicate range of scores. Line
within the box indicates the median. *P < 0.05 compared with
group 1. Groups 1, 2, and 3 are represented as control, a group who
played with a toy, and a group who watched an animated cartoon,
respectively.
from the preanesthetic holding room to the OR were also
significantly lower in group 3 than in groups 1 and 2 (Fig.
2). There were significant correlations between mYPAS and
parent-recorded VAS scores in all groups in the OR (group 1:
r = 0.670, P < 0.001; group 2: r = 0.760, P < 0.001; group 3: r =
0.634, P < 0.001; overall: r = 0.789, P < 0.001).
DISCUSSION
The principal finding of this investigation is that the chil-
dren who watched animated cartoons in the OR had signifi-
cantly lower anxiety scores (mYPAS and parent-recorded
VAS) than the children in the control and toy groups.
Furthermore, mYPAS and parent-recorded VAS scores of
the majority of group 3 (animated cartoon) children were
decreased or unchanged in the OR compared with the
preanesthetic holding room, whereas the scores of most
children in group 1 (control) and group 2 (toy) were signifi-
cantly increased. This is the first study to show that view-
ing animated cartoons can prevent or alleviate preoperative
anxiety in 3- to 7-year-old children.
November 2012 • Volume 115 • Number 5
Most preschool- and elementary school-aged children
very much enjoy watching animated cartoons. Many ani-
mated cartoons are in the public domain, so popular car-
toons can be downloaded without cost in many countries.
In this study, we downloaded 10 popular animated cartoons
in South Korea for free or with low cost and played them
for the children on PCs. Therefore, the intervention of view-
ing animated cartoons to reduce preoperative anxiety can
be used without increasing health care costs. Most mobile
devices can be used to play animated cartoons, includ-
ing notebook and tablet PCs, portable multimedia play-
ers (PMPs), digital camcorders, and mobile phones. PMPs
are less expensive and more convenient for this purpose
than notebook or tablet PCs. Although display screens of
smart phones are small, they are very convenient for view-
ing cartoons. Many anesthesiologists in our hospital use
their smart phone or a PMP to show an animated cartoon
for alleviating anxiety of pediatric patients. When the chil-
dren watched an animated cartoon in the OR, they usually
became engrossed in the cartoon, oblivious to the unfamil-
iar people and OR environment. Therefore, we suggest that
viewing animated cartoons is a very simple and effective
intervention to reduce preoperative anxiety in children.
A number of other preoperative preparation programs
have been examined for their ability to prevent or allevi-
ate anxiety, including sedative premedication, hypnosis,
parental presence, behavioral preparation programs, music
therapy, and acupuncture. Some of these programs are used
frequently for pediatric surgical patients (i.e., midazolam,
parental presence, and behavioral preparation programs),
and others are used less frequently (i.e., acupuncture, hyp-
nosis, and interactive music therapy).7 Although pharma-
cologic intervention with a sedative (i.e., midazolam) is
an effective method to alleviate children’s anxiety, it has
been associated with delays in hospital discharge8,12 and
maladaptive behavioral changes.9,10,13 Additionally, the
administration of oral premedication to children is not
easy because of their reluctance or refusal. However, view-
ing animated cartoons has no side effects, and it is easy
to administer. One of the frequently used interventions to
treat preoperative anxiety is parental presence. Although
the effects of parental presence on preoperative anxiety are
controversial, many pediatric anesthesiologists believe that
parental presence alleviates children’s preoperative anxiety
in the OR. Kain et al.14 reported that there was an increas-
ing trend toward allowing parental presence from 1995 to
2002. Because this practice is routine in our hospital, all chil-
dren in this study were accompanied by their parent during
anesthesia induction.
Patel et al.15 found that children aged 4 to 12 years who
played with a handheld VG had less anxiety at induction
of anesthesia than children who had only their parents
present. Children can play with VG consoles anywhere,
and children may be as engrossed in playing VGs as when
watching an animated movie. Therefore, VGs can be applied
in health care for distraction and behavior modification
therapy.16–18 However, older children may benefit more than
younger children because VG playing requires hand skill.
Furthermore, most children are familiar with only a few
VGs and cannot play others. It is also difficult to prepare
many VG consoles in the OR. In contrast, viewing animated
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 Cartoon Alleviates Pediatric Preoperative Anxiety
cartoons is an inexpensive, easy to administer, and compre-
hensive method for anxiety reduction in the younger pedi-
atric surgical population.
There are several limitations to this study. First, observer
bias is a limitation of studies that use an observer tool for
anxiety measurement with interventions such as paren-
tal presence and distraction techniques.19–21 The observer
could not be blinded to treatment group for obvious rea-
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sons. In this study, also, parent-recorded VAS for anxi-
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ety could have been biased by the parent’s perception of
their child’s behavior, although there is good correlation
between mYPAS and parent-recorded VAS. Second, all
children had peripheral venous catheters placed before
the start of anesthesia. There were no differences in mean
times from IV catheterization to the start of the operation
among the 3 groups. Third, all children in this study had
their anesthesia induced with IV drugs because IV induc-
tion has been the usual pediatric practice in our hospital.
Thus, these results may not be applicable to children under-
going inhaled inductions of anesthesia. Fourth, the children
were admitted the evening before the operation because
outpatient surgery is not popular in Korea. Although anxi-
ety levels could be markedly influenced by the child’s pre-
operative hospitalization, baseline levels were similar for
all 3 groups.
In conclusion, allowing the viewing of animated cartoons
by pediatric surgical patients is a very effective method to
alleviate preoperative anxiety. The study suggests that this
intervention is an inexpensive, easy to administer, and com-
prehensive method for anxiety reduction in the pediatric
surgical population. E
AUTHOR AFFILIATIONS
From the *Department of Anesthesiology and Pain Medicine,
Chonbuk National University Hospital; †Department of
Anesthesiology and Pain Medicine, Chonbuk National
University Medical School and Hospital; ‡Department of
Anesthesiology and Pain Medicine, Chonbuk National
University Dental School and Hospital; and §Department of
Anesthesiology and Pain Medicine and Research Institute
of Clinical Medicine, Chonbuk National University Medical
School and Hospital, Jeonbuk, South Korea.
DISCLOSURES
Name: Jeongwoo Lee, MD.
Contribution: This author helped conduct the study and write
the manuscript.
Attestation: Jeongwoo Lee has seen the original study data,
reviewed the analysis of the data, approved the final manuscript,
and is the author responsible for archiving the study files.
Name: Jihye Lee, MD.
Contribution: This author helped conduct the study.
Attestation: Jihye Lee has seen the original study data, reviewed
the analysis of the data, approved the final manuscript, and is
the author responsible for archiving the study files.
Name: Hyungsun Lim, MD.
Contribution: This author helped conduct the study and
analyze the data.
Attestation: Hyungsun Lim has seen the original study data,
reviewed the analysis of the data, approved the final manuscript,
and is the author responsible for archiving the study files.
1172   
www.anesthesia-analgesia.org
Name: Ji-Seon Son, MD, PhD.
Contribution: This author helped conduct the study and
analyze the data.
Attestation: Ji-Seon Son has seen the original study data,
reviewed the analysis of the data, approved the final manuscript,
and is the author responsible for archiving the study files.
Name: Jun-Rae Lee, MD, PhD.
Contribution: This author helped conduct the study.
Attestation: Jun-Rae Lee has seen the original study data,
reviewed the analysis of the data, approved the final manuscript,
and is the author responsible for archiving the study files.
Name: Dong-Chan Kim, MD, PhD.
Contribution: This author helped design the study.
Attestation: Dong-Chan Kim has seen the original study
data, reviewed the analysis of the data, approved the final
manuscript, and is the author responsible for archiving the
study files.
Name: Seonghoon Ko, MD, PhD.
Contribution: This author designed the study, analyzed the
data, and wrote the manuscript.
Attestation: Seonghoon Ko has seen the original study
data, reviewed the analysis of the data, approved the final
manuscript, and is the author responsible for archiving the
study files.
This manuscript was handled by: Peter J. Davis, MD.
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