Child's Temperament as Risk Factor for Preoperative Anxiety-A Secondary Analysis of the ALPAKA Trial

Preoperative anxiety is common in young children and may impair cooperation during anesthesia induction. Some temperament traits have been associated with higher anxiety levels in the preoperative phase. While midazolam is widely used for anxiolysis, individual responses vary and may be influenced by underlying psychological characteristics such as temperament.

This study aimed to examine the association between specific temperament traits and preoperative anxiety in young children and to determine whether these associations persist after midazolam administration.

This secondary analysis of the ALPAKA trial examined associations between temperament and perioperative anxiety in children aged 2-8 years undergoing elective surgery. Temperament was assessed using the parent-reported Integrative Child Temperament Inventory (ICTI). Anxiety was rated at two time points before (T1) and after (T2) midazolam administration using the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Additional variables included the Strengths and Difficulties Questionnaire (SDQ) scores, baseline characteristics and prior emotional distress. Spearman correlation (r_s), multivariable and univariate logistic regression analyses were conducted to identify predictors of elevated anxiety (defined as mYPAS-SF > 30).

Eighty-nine children were included in the final analysis. Behavioral inhibition was associated with anxiety at both T1 (r_s = 0.35, 95% CI 0.15-0.53, p = 0.001) and T2 (r_s = 0.46, 95% CI 0.28-0.62, p < 0.001). No significant associations were found for other IKT or SDQ subscales. Logistic regression showed that male sex (OR 3.16, 95% CI 1.36-7.19, p = 0.011) and prior anesthesia experience (OR 4.28, 95% CI 1.78-10.39, p = 0.001) were independently associated with elevated anxiety at T1. A multivariable logistic regression for behavioral inhibition adjusted by sex and prior anesthesia showed for T1 a positive association with elevated anxiety (OR 1.02, 95% CI 1.00-1.05). For T2, the corresponding model showed limited explanatory power.

Behavioral inhibition is a robust predictor of perioperative anxiety in young children, both before and after midazolam administration. Brief screening for inhibition may help identify children at increased risk and guide individualized, risk-adapted strategies in pediatric anesthesia.

German Clinical Trial Registration number: DRKS00025411. Principal investigator: Armin Sablewski (15/02/2022, https://drks.de/search/en/trial/DRKS00025411).