Parental involvement for pediatric perioperative anxiety: A systematic review and implementation framework

Table 5 Summary of certainty of evidence by comparison category

Comparison category	Direction of findings	Main limitations	Certainty of evidence
Unstructured PPIA vs parental absence or standard care	Mixed; some trials showed reduced anxiety, while others showed no clinically meaningful induction benefit	Heterogeneity in timing, comparator, parental role, and outcome measurement; limited blinding	Low to moderate
PPIA vs sedative premedication	Sedative premedication generally produced more reliable reduction in induction anxiety	Limited number of direct comparisons; different sedative protocols	Moderate
Active or coached parental involvement vs passive presence	Active/coached approaches appeared more favorable than passive presence	Few trials; intervention protocols differed; limited precision	Low
Multimodal parental involvement	Potential benefit when combined with preparation, behavioral support, or selected pharmacological anxiolysis	Difficult to isolate effect of parental involvement from adjunctive intervention	Low
Virtual parental presence	Feasible and promising, especially when combined with coaching	Pilot-level evidence; small sample size; technology and implementation variability	Very low to low

PPIA: Parental presence during induction of anesthesia.