Reducing Children's Preoperative Fear with an Educational Pop-up Book: A Randomized Controlled Trial

Otolaryngol Head Neck Surg. 2022 Aug;167(2):366-374. doi: 10.1177/01945998211053197. Epub 2021 Oct 26.


Objective: Preoperative education empowers children to approach surgery with positive expectations, and providers need efficient, child-focused resources. This study aimed to evaluate an interactive pop-up book as a tool for explaining surgery, managing preoperative anxiety, and strengthening coping strategies.

Study design: Prospective randomized controlled trial.

Setting: Pediatric outpatient surgery center.

Methods: Patients ages 5 to 12 undergoing outpatient surgery read a pop-up book about anesthesia (intervention) or received standard care (control). Patients self-reported their preoperative fear, pain expectations, views of the procedure and preoperative explanations, and coping strategies. Outcomes also included observer-rated behavioral anxiety and caregiver satisfaction.

Results: In total, 148 patients completed the study. The pop-up book had a significant, large effect in reducing patients' fear of anesthesia induction (Cohen's d effect size = 0.94; P < .001). Intervention patients also expected less pain than control patients from the anesthesia mask and during surgery (d = 0.60-0.80; P < .001). The book encouraged more positive views of the procedure and preoperative explanations (P < .005). Furthermore, the book prepared patients to cope adaptively: intervention patients were significantly more likely to generate positive active coping strategies, distraction strategies, and support-seeking strategies (P < .001). Observer-rated behavioral anxiety at anesthesia induction did not differ between groups (P = .75). Caregivers in the intervention group were significantly more satisfied with each aspect of the surgical experience (P≤ .02).

Conclusion: The educational pop-up book offers a child-focused resource that helps alleviate children's preoperative fears, encourages positive coping, and improves caregivers' perceptions of the experience. This study was registered at (NCT04796077).

Keywords: ambulatory surgical procedures; anxiety; coping; general anesthesia; patient education; pediatrics; preoperative care.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Anxiety* / prevention & control
  • Books
  • Child
  • Child, Preschool
  • Fear*
  • Humans
  • Pain
  • Preoperative Care / methods
  • Prospective Studies

Associated data