Upcoming Pediatric Sedation Conference

Parental Presence:
The discussion

Literature Review:
Case-series of nurse-administered nitrous oxide for urinary catheterization
in children

Newsmakers Interview:
Judy Zier, MD
Children’s Hospital and Clinics of Minnesota

Parental Presence – The discussion

For those who are not aware, there is a listserve for pediatric sedation initiated by Mick Connors MD which is now a supported activity of the Society for Pediatric Sedation (SPS) – you can sign up at http://mailman.listserve.com/listmanager/listinfo/pediatric_sedation.

During November there was an interesting discussion among participants in the listserve on the current practice and appropriateness of parental presence during pediatric sedation for various procedures.  The discussion started with the question of what do providers allow (in terms of parental presence) for MRI scans and/or CT scans?  There were multiple answers given to this query.  I think I could summarize the discussion by stating that the majority of providers outside of anesthesiology felt that parents should be allowed to be present for the entire scan if they choose.  Many of those responding felt that parents should be present for the entirety of any procedure – including invasive minor procedures, cardiopulmonary resuscitation, and OR based surgery.  The anesthesiologists involved generally felt as though it was appropriate to have the parents present until the child went to sleep and when they woke up – but not needed actually during the scan.  

 Reasons given for allowing parents to be present with the sedated child during a procedure included (primarily) the fact that the parents feel reassured by being present and their satisfaction with the service provided is higher.  The thoughts behind not allowing presence centered primarily on the idea that there is no benefit to the child during the scan by having the parents present - and that parents need to be evaluated and educated before allowing presence. There were also reports of significant “push back” from MRI technologists concerning parental presence – including the fact that they do not want parents hanging around the MRI control area because of concerns for patient privacy. (They claim HIPPA violations by parents who see information on screens and hear discussion of patients by techs and MD’s).  There was also concern raised about the manner in which parents would respond if there was a problem that required resuscitation of the patient (simple or complex).  Do parents stay during the emergency?  Does someone usher them out of the scanner?  What if you want them to leave and they refuse?

This thread engendered a large number of testimonials from a wide variety of providers.  Most stated something to the effect of “we have parental presence for X years and have not had a problem to date”. Many respondents felt passionately that parents have a right to be present for any medical procedure their child goes through, and not allowing presence was actually violation of this right.  On the other side of the issue there were 3 contributors that reported various problems with parents who were present during MRI scans (mostly involving psychological trauma when a child needed some added sedation or airway manipulation during the scan) and subsequently stopped the practice of allowing parental presence. 

We were interested in this issue and tried to flesh out where the current opinions on parental presence were originating.  The AAP has clearly weighed in on this matter.  There is an entire statement from the Section on Hospital Care entitled Family Centered Care and the Pediatrician’s Role. [1] One of the recommendations in this policy statement reads “Parents and guardians should be offered the option to be present with their child during medical procedures and offered support before, during, and after the procedure.” Unfortunately the statement does not reference any prospective, controlled studies of this issue.  Another publication from the AAP “Death of a Child in the Emergency Department” quotes the Family Centered Care (above) statement concerning the fact that all parents should have the option to be present for procedures and encourages the idea that all parents should be “given the option” to be present during CPR for their child.[2]  This technical report references a number of retrospective and observational studies that have reviewed this issue and found that a majority of parents want the option to be present – and that those present during resuscitation show more “positive grieving behaviors” after the death of a child.

 After a pretty complete review of the literature we could find few well controlled prospective, randomized trials that addressed the issue of parental presence during sedated procedures or resuscitation. Almost all of the studies are small, retrospective and address awake procedures or CPR in moribund patients.  Probably the most complete review of the subject is from Piira et. al.[3] This study evaluated all possible studies looking at parental presence for any type of procedure (dental, hem/onc, radiological etc.) – a total of 28 studies met their very basic inclusion criteria and a total of only 15 were randomized in a reasonable manner. There was no specific mention made of sedated/awake status of patients but it is clear from some of the descriptions in the Methods section that most of these studies involve patients who were awake during these procedures. The results of this review are complex and need to be read in their entirety. Many of these studies use anxiety and satisfaction measurement tools without proven validity and reliability. In summary however, the results showed that there was no convincing evidence that parental presence was beneficial to the child/patient – either in the short term (during the procedure) or in the longer term (post hospitalization behaviors).  Seventeen studies were found that evaluated parental satisfaction and distress. Parents were found to be more satisfied if they were allowed to be present in seven of these studies while ten studies found no difference between parents who were allowed to be present and those who were not allowed presence.  The exact relevance of this review to the issue of presence during sedated procedures is uncertain.

The skeptical opinions concerning parental presence that characterize anesthesiologists may be due to the environment they work in, and are almost certainly influenced by the work of Zeev Kain MD and his coworkers at Yale University.  Dr. Kain’s group has spent the past fifteen years evaluating the impact of various interventions on the anxiety, satisfaction levels, and post hospitalization behavior of parents and children undergoing induction of anesthesia in the operating room. [4-8] This group has been funded through the NIH and all of the studies are rigorously performed with validated measures and appropriate blinding and control groups. There is no way to briefly summarize all of the findings from this series of studies.  Individuals should peruse these studies in all their detail. Suffice it to say the evidence shows that there are many factors that determine whether or not a particular patient/parent grouping will benefit from parental presence.  In fact, many parents show signs of significant stress both physiologically and emotionally when presence is allowed - while others clearly benefit and are highly satisfied by the experience.  The lesson for the anesthesiology community has been that any program wishing to pursue a program allowing parental presence must focus on the preparation that is provided for parents prior to their experience in the operating room.  Physicians must also recognize that any policy concerning parental presence must appreciate that there is significant differences between parents in terms of their likelihood to benefit from presence and some assessment should take place to determine whether or not the parent/child combination is appropriate in a particular instance. Finally, these investigators showed that sedation of patients prior to the experience of induction greatly changes the stress and satisfaction of parents.  Once again the applicability of these findings is uncertain with respect to the question of parental presence during sedated procedures, but it may help explain the thinking of the anesthesia community.

Conclusion: Few things are completely clear with respect to parental presence during sedated procedures other than the fact that there are no studies to direct our practice.  We would suggest that this issue is ripe for a prospective, multi-centered, collaborative study of the impact of parental presence – we invite interested parties to contact us and we will attempt to start putting together a study group for this issue.

1. Committee on Hospital Care, Family-Centered care and the pediatrician's role. Pediatrics, 2003. 112(3): p. 691-696.
2. Knapp, J. and D. Mulligan-Smith, Death of a child in the emergency department. Pediatrics, 2005. 115(5): p. 1432-1437.
3. Piira, T., et al., The role of parental presence in the context of children's medical procedures: a systematic review. Child: Care, Health & Development, 2005. 31(2): p. 233-43.
4. Kain, Z.N., et al., 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 national survey. Anesthesia & Analgesia. 98(5): p. 1252-9.
5. Kain, Z.N., et al., Predicting which child-parent pair will benefit from parental presence during induction of anesthesia: a decision-making approach. Anesthesia & Analgesia, 2006. 102(1): p. 81-4.
6. Kain, Z.N., et al., Parental presence during induction of anesthesia: physiological effects on parents. Anesthesiology, 2003. 98(1): p. 58-64.
7. Kain, Z.N., et al., Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology, 2007. 106(1): p. 65-74.
8. Kain, Z.N., et al., Predicting which children benefit most from parental presence during induction of anesthesia. Paediatric Anaesthesia, 2006. 16(6): p. 627-34.

Editors:
Joseph Cravero MD
George Blike MD

Departments of Anesthesiology
and Pediatrics,
Children’s Hospital
at Dartmouth,
Dartmouth Hitchcock
Medical Center,
Lebanon, NH