Interactive Distraction Techniques Versus Midazolam in Anxiolysis In Pediatric Patients: A Systematic Review and Meta-Analysis

Background: Many pediatric patients experience high levels of anxiety prior to undergoing surgery. Midazolam is currently one of the most commonly used sedative drugs in the pediatric preoperative environment. A number of studies have evaluated the use of non-pharmacological methods of relaxing pediatric patients prior to surgery, known as ‘Interactive Distraction’. These techniques involve using various methods of distracting the child from the preoperative anesthetic procedures. Some examples of these methods involve giving the patient an iPad with which they can play video games. There have yet to be any systematic reviews comparing the usage of Midazolam alone against utilizing interactive distraction alone techniques to mitigate pediatric anxiolysis in the preoperative setting. We hypothesize that interactive distraction could be noninferior in reducing anxiety levels in these patients. Purpose: This systematic review and meta analysis compared the preoperative anxiolytic effects of Midazolam to interactive distraction techniques on a pediatric population. Methods: The systematic review and meta analysis followed the 2020 PRISMA guidelines. Six online databases were surveyed (Pubmed, Embase, Scopus, Cochrane, Web of Science). The analysis included randomized controlled trials (RCTs) in which pediatric patients received .3 mg/kg Midazolam alone or interactive distraction. Patient anxiety levels were measured using the modified Yale Perioperative Anxiety Scale (myPAS). MyPAS scores were evaluated at two distinct time marks, the first being arrival to the surgical ward whilst the other time mark measured was during induction of anesthesia. Two RCTs fit the inclusion criteria for the review, yielding 217 distinct evaluations. The average patient age was 6.79 ± 2.13. Results: The results portray clinically significant results as there was a low, but apparent difference in mean effect size with a difference of Cohen’s d = 0.21, in favor of utilizing the Midazolam. However, there was no statistical significance (p = 0.57) between utilizing Midazolam alone versus utilizing the interactive distraction techniques. Discussion: Utilization of .3 mg/kg Midazolam had clinically superior anxiolysis compared to the interactive distractions. A main limitation of our study is the relatively small sample size of 217 patients. Conducting additional RCTs with larger sample sizes would be beneficial in reinforcing our findings.