Remembering the Classics: Emotional Trauma in Pediatric Patients Undergoing Anesthesia -A Thing of the Past Still Present
Alan Jay Schwartz, MD, MSEd
Remember when you were 3-8 years old? So many experiences were still new and unknown! Thank goodness Mom and Dad were there to protect you! Doctors were unfamiliar intruders into your life. Mom and Dad’s presence with you during the Doctor’s office visit was reassuring.
And then the pronouncement, you “had to have your tonsils and adenoids (T&A) removed”. On the day of your surgery, the OR surroundings were unfamiliar and uninviting, the nurses joined the Doctors as unfamiliar characters, you had to take your clothes off and the decisive action commenced, the induction of general anesthesia! In the distant past it was the noxious pungent odor of ether emanating from the claustrophobic mask slapped upon your face that you so distinctly remember!
Is it any wonder that this scenario, that has been repetitively conducted around the world, fostered psychological trauma to the young “victims”? Adding anesthesia to T&A surgery was a compassionate advance from the surgery that was being conducted “awake”! Comprehend the account of awake T&A surgery declared by the famous children’s author, Roald Dahl.1
“A visit to the doctor
I have only one unpleasant memory of the summer holidays…‘We are going to the doctor this afternoon. He wants to look at your nose and mouth.’ I think I was eight at the time. ‘What’s wrong with my nose and mouth?’ I asked. ‘Nothing much,’ my mother said. ‘But I think you’ve got adenoids.’…I was too young to realize that something out of the ordinary was going to happen…‘Open your mouth,’ the doctor said…He spoke gently, and I was seduced by his voice. Like an ass, I opened my mouth…That was in 1924, and taking out a child’s adenoids, and often the tonsils as well, without any anaesthetic was common practice in those days. I wonder, though, what you would think if some doctor did that to you today.”1
A classic article describing the commonly accepted lore of the 1940s was written by David M Levy.2 Record review of 124 children to identify behavioral issues after undergoing a surgical procedure (the majority undergoing T&A) identified 25 children who displayed emotional issues. The psychologic upset was most common in children <3 years old (50%). Levy characterized the emotional upset:
“The most frequent fears were of the dark, of physicians and nurses and of strange men. The total fear reaction was to strange people, strange places and hurtful objects. There were various modifications of total specific fears. When prolonged, the general fears left, and a specific fear relating to the operative procedure remained. Otherwise, fears of the dark outlasted all others.
When considered in accordance with general psychiatric nosology the emotional sequelae were classified as follows:
1. Conditioned fear
night terrors
2. Dependency fears and regressions
clinging to the mother, refusing to be out of earshot of her, insisting on knowing exactly where she will go at night and when she will come home, wanting the mother to help in dressing, bedwetting…more frequent after an operation than it had been before
3. Latent fear
fears of the dark, of crowds and of sickness
4. Phobias
fear of closed rooms after an operation
5. Anxiety states
more or less constant state of emotional tension that broke out at times in acute states of panic with, also, suicidal impulses
6. Hostility reactions
spiteful reactions against a parent or parents and were manifested as disobedience, temper tantrums, defiance and destructive behavior
7. Obsessions
patient made a scene whenever his ritual of arranging his clothes at night was disturbed in any detail, anxiety following the operation took the form of strong self protection, possessions being used as symbols to preserve self integration
8. Hysteria
feeling of numbness was found to be directly related to the feeling when going under the anesthetic, fear of vomiting and of choking”2
Levy recommended:
“The prevention of postoperative fears is thought to consist of the following steps:
1. Postponement of the operation, if possible, to at least the age of 3 years, especially if evidence of anxiety or undue dependency on the mother is evident.
2. An explanation to the child of what is to take place, to overcome reactions to the strange or surprising event.
3. Contact with the mother before and after the operation.
4. Preparatory sedative and anesthetic in the bedroom, to spare the child the experiences of seeing instruments and the operating room and riding through the corridors.”2
The pediatric literature fretted over the same concern of emotional trauma when children experienced medical care.3,4 The anesthesiology literature’s response to Levy’s categorization of emotional consequences children may manifest after undergoing general anesthesia concurred with the recommended strategies to prepare a child for anesthesia.5 Jackson noted that pharmacologic (sedative medication) and psychologic (diverting the child’s attention by telling stories, playing music or flavoring the mask and describing directly to the child what will take place removing a majority of the unknown aspects of general anesthetic induction) preanesthetic preparation of the child in the presence of the parent whenever possible have distinct benefits.5
Eighty years have transpired since Levy described emotional upset of children associated with anesthesia. Have we made progress in solving this concern? Perhaps yes. Perhaps not enough. We still debate appropriateness of preanesthetic anxiolytic medications and psychologic techniques.6-9
What is your “special sauce” for reducing the emotional trauma children may experience during anesthesia care? Send your recipes and suggestions to Myron (myasterster@gmail.com) for publication in PAAD reader response.
PS from Myron: The late great and sorely missed pediatric anesthesiologist, Dr. Chris Abajian, advocated for the use of simple magic tricks like the Magic coloring book and the Incredible Traffic Light Traffic Light Cards Magic Trick to ease his patients into unconsciousness. He conducted workshops in the use of magic at many Society for Pediatric Anesthesia meetings where I learned these really easy and simple tricks from the master. I quickly became a true believer using both of these tricks on an almost daily basis in my practice. I would introduce these magic tricks in the preoperative prep area and teach the amazed child to take a deep breath and say abracadabra as loudly as they could. Once in the OR and using a primed anesthesia circuit. I would repeat the trick and most kids lost consciousness amazingly quickly and atraumatically. Thank you Chris and Rest in Peace!
References
1. Dahl R: Boy-Tales of Childhood. Puffin Books, the Penguin Group, New York 1986, pp 68-70
2. Levy DM. Psychic Trauma of Operations in Children: and a Note on Combat Neurosis. Am J Dis Child. 1945; 69 (1): 7–25. doi:10.1001/archpedi.1945.02020130014003
3. Jackson K, Winkley R, Faust OA, Cermak EG, MM; Behavior Changes Indicating Emotional Trauma in Tonsillectomized Children: Final Report. Pediatrics July 1953; 12 (1): 23–28. https://doi.org/10.1542/peds.12.1.23
4. Jackson K, Winkley R, Faust OA. Problem of Emotional Trauma in Hospital Treatment of Children. JAMA. 1952;149 (17): 1536-1538. doi:10.1001/jama.1952.02930340020007
5. Jackson, K. Psychologic Preparation as a Method of Reducing the Emotional Trauma of Anesthesia in Children. Anesthesiology. 1951;12 (3): 293-300. Cited in: Journals@Ovid Full Text at https://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=ovfta&NEWS=N&AN=00000542-195105000-00004.
6. Zuckerberg A. Perioperative Approach to Children. Pediatric Clinics of North America 1994; 41(1):15-29. DOI:10.1016/S0031-3955(16)38689-8
7. Maclaren J. and Kain ZN. Pediatric preoperative preparation: a call for evidence-based practice. Pediatric Anesthesia, 2007; 17: 1019-1020. https://doi-org.proxy.library.upenn.edu/10.1111/j.1460-9592.2007.02319.x
8. Reddy SK, Deutsch N. Behavioral and Emotional Disorders in Children and Their Anesthetic Implications. Children 2020; 7(12):253. https://doi.org/10.3390/children7120253
9. Yun, R, Caruso, T. Identification and Treatment of Pediatric Perioperative Anxiety. Anesthesiology. 2025; 16 (1): 973-983. doi:10.1097/ALN.0000000000005105.