In 1985, an ophthalmic surgeon, Adrian While, wrote in the British Medical Journal that he had not been allowed to accompany his 3-year-old daughter to the operating room for induction and argued that parents should be admitted to the operating room to help their child. Gauderer indicated that virtually all parents, given a choice, went into the operating room with their children; only two parents had a fainting spell. Nurses, anesthesiologists, and surgeons were excited about this new approach, which appeared to be safe, simple, and effective [13]. A study by Kain compared PPIA to drug preparation and demonstrated that children who were premedicated had a lesser degree of anxiety at the time of separation before induction compared to the control group and to the PPIA group [14]. In another study, the presence of a parent in the room did not reduce the anxiety of the child who had already received midazolam, while there was a reduction in the anxiety of the parents and their greater satisfaction [15].

Nevertheless, it seems that children aged older than 4 and anxious parents might get some benefit from PPIA [9].

Lerman believes that the presence of the parents is not an undeniable right but rather a therapeutic option to facilitate the induction of anesthesia to be used at the sole discretion of the anesthesiologist [16]. Despite this theory, there is no doubt that some children (such as those with special needs, very anxious, or subjected to multiple hospitalizations) may actually benefit from PPIA, which should ideally be preceded by a preparation program for parents.

In our experience, of over 15 years, we propose that one of the parents accompanies the child into the operating room for induction of anesthesia, excluding pregnant moms, parents with health problems, and anxious parents to whom we explain that their presence could increase the child’s anxiety and create problems for the staff. When the parent comes into the room, the preschoolers are normally premedicated with midazolam, while older children can choose, in agreement with the parent, whether or not to have premedication. They can also choose the type of induction of anesthesia, inhalation or intravenous, which helped in the choice by the anesthesiologist. A staff member accompanies the parent in every moment of his stay in the operating room.

Different “side effects” of PPIA have been described in the literature: parents taking their children out of the operating room, parents who faint, and even parents who want the anesthesiologist to discontinue anesthesia and awaken their child. Hence, it is important to select the right parents (excluding, e.g., those who are anxious) and possibly make them undergo a preparation process. In addition, it is important to have a staff member always close to the parent. This member will escort the parent outside the operating room at the end of induction or whenever the child’s condition changes and the parents’ presence might be distracting or disruptive to the induction of anesthesia.

Hospitalization before surgery and prolonged preoperative fasting represent for the child an additional source of discomfort. At our hospital, young patients can be admitted 1–2 h before surgery. Regarding preoperative fasting, it is necessary to minimize the fasting hours (especially in smaller patients) in accordance with the directions of the American Society of Anesthesiology for healthy pediatric patients undergoing elective surgery (see below). In particular, the reduction in fasting hours is not associated with an increased gastric residual volume, or indirect index of risk of aspiration pneumonia. Furthermore, a less restrictive fasting regimen reduces dehydration, increases hemodynamic stability during anesthesia, facilitates venous vascular access, guarantees glucose homeostasis, reduces irritability in the young patient, and increases the overall satisfaction of the child and parents.

The pain from venipuncture is one of the greatest fears of the hospitalized pediatric patient. The pain generated by venipuncture is classified as moderate to severe. The procedure should be reduced to the absolute minimum, such as preoperative blood tests prescribed only on the basis of anomalies detected in the patient history or by physical examination [17]. The intravenous line needed for the surgery is normally placed after induction of anesthesia when the child is asleep and the veins well dilated. However, if the child prefers an intravenous induction, it is recommended to apply an anesthetic cream over the skin of the most visible veins 40 minutes before the surgery.

The second part of this chapter will briefly review only the most widespread routes of administration of the most common drugs that are currently used for pharmacological preparation of children before surgery.

The goals of premedication in children are the reduction in anxiety, block of autonomic (especially vagal) reflexes, reduction of airway secretions, amnesia, prophylaxis against pulmonary aspiration of gastric contents, facilitation of induction of anesthesia, and possible analgesia and to potentially mitigate the stress response and prevent malignant cardiac arrhythmias [18].

A list, although not necessarily exhaustive, of the main indications for premedication in children includes:

Before examining the most frequently used drugs for premedication, it should be noted that its risks are respiratory depression, loss of airway reflexes, paradoxical response to the drug, and obviously potential allergic reactions. These risks are generally influenced not only by age but also by underlying medical conditions (furthermore in this chapter, we refer to elective surgery, but there are special circumstances such as full stomach, head or abdominal trauma, etc., that require different considerations). Although risks are mainly connected to a relative overdose (or coadministration of another drug) and can therefore be minimized using a high degree of attention, the conditions that may require close monitoring after premedication are:

The goal of premedication in children should be individualized: a mild sedation, while not able to eliminate anxiety completely, can be effective in a child who is not very agitated and could therefore make the induction mild and pleasant. Conversely, a heavier sedation may be necessary in the case of a very agitated child.

The factors to be considered when choosing the drug(s) are therefore age, weight, medication history of the patient (allergies), comorbidities, expectations of the child and family, level of psychological maturity, anxiety, and cooperativeness.

Another important point to consider is the route of administration of the drug. Although parenteral administration (especially intravenous) can be faster, can be more effective, and have a greater predictability in terms of clinical response, the majority of pediatric anesthesiologists refrain from this route of administration unless there is a venous access in place. In fact, most of the children reported needle puncture as their worst experience in hospital.

For this reason, enteral or transmucosal premedication is better accepted by the child, parents, and hospital staff. A noteworthy exception to this general rule (according to the experience of the authors) is for children born with spina bifida who generally do not have sensitivity in the buttock region. The same children on the other hand are often hostile to inhalation induction, often already have experience during previous surgeries. The doses of the two main drugs (midazolam and ketamine) used intramuscularly as premedication in Italy are disclosed in Table 3.1.

In spite of the relative abundance of literature about the different drugs/routes of administration, we can state that the ideal drug (or the ideal combination of drugs) for premedication in children has unfortunately yet to be invented. In this brief review, we will focus on oral, nasal, and rectal routes by examining midazolam, α-2 agonists, and ketamine.