Clowns for the prevention of preoperative anxiety in children: a randomized controlled trial G. GOLAN PhD *, P. TIGHE MD MD †, N. DOBIJA MD MD †, A. PEREL MD MD * AND I. KEIDAN MD MD *† *Department of Anesthesia and Intensive Care, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel and †Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA Summary Objective: To determine if specially trained professional clowns allayed preoperative anxiety and resulted in a smooth anesthetic induction compared to the use of midazolam or no intervention. Methods: This was a randomized, controlled, and blinded study conducted with children 3–8 years of age undergoing general anes- thesia and elective outpatient surgery. Patients were assigned to one of three groups: Group 1 did not receive midazolam or clown presence; group 2 received 0.5 mgÆkg )1 oral midazolam 30 min before surgery up to a maximum of 15 mg; and group 3 had two specially trained clowns present upon arrival to the preoperative holding area and throughout operating room (OR) entrance and mask application for inhalation induction of anesthesia. The children were videotaped for later grading. Results: The clown group had a statistically significant lower modi- fied-Yale Preoperative Anxiety Scale score in the preoperative holding area compared to the control and midazolam group. The clowns’ effect on anxiety reduction continued when the children entered the OR but was equal at this point to the midazolam group. Upon application of the anesthesia mask no significant differences were detected between the groups. Conclusions: This study found that the use of preoperative medically trained clowns for children undergoing surgery can significantly alleviate preoperative anxiety. However, clowns do not have any effect once the anesthesia mask is introduced. Keywords: clowns; perioperative anxiety; pediatric surgery Introduction The perioperative environment, often anxiety- provoking for adults, may be quite frightening for children. Anxiety during induction of anesthesia is correlated with increased distress in the postopera- tive period (1–4). Many preoperative systems allow parental, pharmacologic, and anticipatory interven- tions to facilitate a relaxed perioperative environ- ment for children. Unfortunately, scheduling conflicts, side effects, and limited resources conspire to limit their use- fulness. For example, only 10% of respondents in a Correspondence to: I. Keidan MD, Department of Anesthesia and Intensive Care, Sheba Medical Center, Tel Hashomer 52366, Israel (email: ikeidan@anest.ufl.edu). Pediatric Anesthesia 2008 doi:10.1111/j.1460-9592.2008.02903.x Ó 2008 The Authors Journal compilation Ó 2008 Blackwell Publishing Ltd 1