Effects of non-pharmacological interventions on preoperative anxiety in children: a systematic literature review and meta-analysis

Background: Preoperative anxiety is a common response in children undergoing anaesthesia. It is defined as a feeling of fear and worry related to perceived threat. Anxiety can negatively affect the perioperative process and lead to increased pain, behavioural changes, and prolonged recovery time. Children are particularly vulnerable due to limited cognitive development and dependence on secure attachment figures. This may increase feelings of uncertainty and loss of control. Common causes of anxiety include separation from parents, fear of pain, and anaesthesia. Interventions may be pharmacological or non-pharmacological, both of which have varying effects and limitations. Person-centred and age-appropriate care is essential to reduce children’s preoperative anxiety and promote a sense of safety during induction of anaesthesia. Aim: To map non-pharmacological interventions and assess their effect compared to standard care regarding preoperative anxiety in children using the Modified Yale Preoperative Scale. Method: A systematic literature review with a quantitative approach. Database searches were performed in PubMed and Scopus, including randomised controlled trials (RCTs) published in the last five years were included. Quality assessment was performed using the Critical Appraisal Skills Programme (CASP). A meta-analysis was performed using a random-effects model to evaluate the effect of non-pharmacological interventions measured with mYPAS during anaesthesia induction. Heterogeneity was assessed using I² statistics. Data were analysed using SPSS Statistics. Results: A total of eight RCTs from different parts of the world published between 2022 and 2025 were included. The results showed that non-pharmacological interventions, mainly video-based methods and parental presence or assistance, reduced preoperative anxiety in children compared to standard care. The pooled effect demonstrated a statistically significant reduction in mYPAS scores (mean difference -16.33; 95% confidence interval –24.57 to –8.10, p <0.001). High heterogeneity was observed between the studies (I²=98%). Conclusion: Non-pharmacological interventions such as video distraction and parental presence or assistance may reduce preoperative anxiety in children compared with standard care. However, the results should be interpreted with caution due to the high heterogeneity between studies and limited generalisability. The choice of intervention should therefore be tailored based on a person-centred approach. Key words: paediatrics, preoperative anxiety, mYPAS, non-pharmacological interventions, systematic literature review, meta-analysis