Effectiveness of parental presence during induction of anaesthesia in managing perioperative anxiety in children: a GRADE-assessed systematic review and meta-analysis of randomized controlled trials

Preoperative anxiety in children is common and may negatively affect anesthetic management and postoperative recovery. Parental Presence during Induction of Anesthesia (PPIA) is widely used as a non-pharmacological strategy, but its effectiveness remains uncertain. This systematic review and meta-analysis evaluated the effect of PPIA on perioperative anxiety in children. Randomized and quasi-randomized trials comparing PPIA with no parental presence or alternative interventions for perioperative anxiety in children undergoing elective procedures under general anesthesia were systematically reviewed. Five electronic databases were searched from inception to June 30, 2025. Study quality was assessed using the Cochrane Collaboration’s Risk-of-Bias tool and GRADE framework. Data were pooled using a random-effects meta-analysis, with effect sizes reported as Weighted Mean Differences (WMDs) or Standardized Mean Differences (SMDs). The primary outcome was perioperative anxiety assessed at follow-up time points, and the secondary outcome was the change in perioperative anxiety from baseline to each follow-up time point. A total of 24 studies were included, evaluating four intervention comparisons: PPIA versus no parental presence, PPIA versus sedative premedication, PPIA combined with sedative premedication versus sedative premedication alone, and PPIA versus other non-pharmacological interventions. Compared with no parental presence, PPIA was associated with reductions in children’s anxiety and heart rate from baseline to induction (SMD= ˗1.13, P = 0.022; WMD= ˗8.74, P = 0.004). In contrast, PPIA alone was less effective than midazolam in reducing anxiety at induction and from baseline to induction (SMD = 1.06, P = 0.022; SMD = 2.15, P = 0.004), and combining PPIA with midazolam offered no additional benefit over midazolam alone at induction (SMD: ˗0.40, P = 0.402). One study suggested that video distraction may be more effective than PPIA. The certainty of evidence ranged from low to moderate, and only five studies were rated as high quality. PPIA modestly reduces perioperative anxiety and heart rate in children compared with no parental presence but is less effective than midazolam and provides no additional benefit when combined with it. Therefore, high-quality studies are needed to clarify the clinical relevance of PPIA and to optimize its implementation in pediatric anesthesia. CRD42024596457