Research Supporting PreOpApp Kids
Why Pediatric Preoperative Preparation Needs Modernization
Mask Induction Reimagined
The way we start anesthesia for kids (called inhalation induction, using a mask) has basically been done the same way – for 200 years! This can be one of the most unfamiliar and anxiety-provoking moments of a child’s surgical day, and using the mask often involves a large amount of fear and discomfort. [4]
PreOpApp™ Kids introduces a new way to prepare children for that experience by actively engaging them in the process. The app allows children to practice breathing, interact with playful visual tools, and become more familiar with the anesthesia mask experience in a child-centered way both prior to their day of surgery, and also at the time of inhalation induction.
The app currently has two games available in the Kid Zone: Little Hottie™ and Mandala Sync™. They can be used in three locations: at home, in the preop waiting area, and in the operating room at the time of starting anesthesia.
Little Hottie™ is an interactive game that uses innovative technology to help children practice blowing and breathing, making mask induction feel more familiar, playful, less intimidating – and actually FUN!
Mandala Sync™ builds on this idea with new innovative technology in the form of a meditative induction challenge game. The child makes their own Mandala art in the app, puts on their pulse oximeter – then the game connects the child’s heartbeat to their art – into one calming visual experience. Their art begins to move in sync with their heart, and playful characters also emerge from their art. This creates a new way for children to participate in their own mask induction through focus, breathing, and visual engagement.
Unlike virtual reality (VR) approaches that require large or expensive headsets, that may be scary for the child to wear on their day of surgery, PreOpApp™ Kids is designed around accessible mobile-based preparation and interactive technology that can be used before surgery and within the perioperative environment – on any phone or mobile device.
Through breathing games, calming visuals, and child-friendly preparation, PreOpApp™ Kids helps transform mask induction from something unfamiliar and intimidating into something children can explore, practice, and willingly (and happily!) participate in.
Effects of Preoperative anxiety in Pediatric Patients
Research Supporting PreOpApp Kids
It is associated with delays and cancellations. In the UK PINEAPPLE multicenter study, children with anxiety had a 20.8% delay/cancellation rate, compared with 3.6% in children
without anxiety
Research Supporting PreOpApp Kids
It is associated with:
- increased postoperative pain,
- emergence delirium,
- maladaptive postoperative behaviors, and
- greater perioperative distress.
Effects of NPO fasting misunderstandings in pediatric patients
Clinical implications of preoperative anxiety
- Over-fasting, which increases discomfort, dehydration, irritability, physiologic stress, electrolyte abnormalities, risk of hypotension and
- Under-fasting, which can result in day-of-surgery delays or cancellations [2]. Under-
fasting can also lead to aspiration during induction of anesthesia if not properly recognized prior.
The American Society of Anesthesiologists emphasizes that perioperative teams should
make efforts to minimize prolonged fasting, particularly in children
The Pediatric Preoperative Assessment: Is it happening?
Frequency and Timing
Too late?
In a U.S. pediatric preoperative needs assessment across 17 children’s hospitals:
- Fewer than 25% of children received formal preoperative assessment before the day of surgery, and over 40% of assessments occurred the day before or day of surgery.
When the preoperative assessment is too late, there is minimal time for patient optimization, specialist interdepartmental communication about medical issues, time to obtain any outside medical records, or time for the parent to use the information in the call to emotionally prepare their child for surgery.
Too early?
Similarly, in the PINEAPPLE study, only 60.1% of children received preassessment, meaning nearly 40% did not.
Intercurrent illness in the PINEAPPLE study was the top reason for delays and cancelations on the day of surgery. Most of the preoperative assessments were done atleast 2 weeks before the day of surgery. This shows that if communication with the parents is too early – then screening for intercurrent illness subsequently proves difficult.
Method of Communication
Phone calls
In a U.S. pediatric preoperative needs assessment across 17 children’s hospitals, preoperative screening was predominantly completed through screening phone calls.
In the PINEAPPLE study, the majority of patients received preoperative assessment via
phone calls.
Many locations migrated to phone call assessments since the pandemic.
Digital Communication Is Feasible, Effective, and Welcome
Digital implementation has already shown promise in pediatric preoperative care.
A randomized clinical trial demonstrated that an app-based educational intervention reduced children’s preoperative anxiety [5].
A qualitative study of parents whose children underwent pediatric day surgery or MRI found that parents wanted more guidance, support, and child involvement throughout the care pathway. The study also identified a need for a digital gaming solution to support preparation, communication, gamification, and connection for children and families [8].
A pediatric preoperative quality improvement initiative at the Children’s Hospital of Georgia in Augusta, Georgia, US, implemented a layered digital communication strategy including:
- a preoperative instructional video,
- a caregiver-facing website,
- a reminder text sent the day before surgery with a direct link to website, and
- Direct caregiver access for questions via email address on website.
- a children’s educational storybook was printed and disseminated
This initiative showed that:
- Parents were reliably reached through text-based communication (75% of parents reached), and
- The majority of surveyed caregivers were satisfied with and valued that communication (91% of parents highly satisfied with receiving text message reminder)[6].
The Gap that PreOpApp™ Kids Fills
Current systems often prepare families too late, rely heavily on last-minute phone communication, and do not consistently reinforce:
- fasting instructions
- illness guidance, or
- child-friendly preparation before surgery [1][3
At the same time, evidence suggests that earlier preassessment is associated with less anxiety in children, and therefore less cancelations and delays [1]. There are very limited tools available for parents to help prepare their child for surgery at home – which we know can help to decrease the child’s anxiety [5]. Decreasing the child’s anxiety would improve clinical outcomes, and decrease cancelation and delays [1][4]. PreOpApp™ Kids is specifically designed to help children understand and become familiar with the hospital, the equipment, and the process that will happen to them on their day of surgery. The app uses innovative technology, games, and a storybook that is easily available on anyone’s phone, anywhere in the world.
Other than PreOpApp™ Kids, there is no other such tool available to help empower parents and caregivers to accurately follow fasting guidelines. This app allows for operationalize of the fasting instructions beyond the preoperative clinic, beyond the electronic medical record, and beyond the verbal instructions said to the parent on a preoperative screening phone call.
“Future research should focus on interventions to improve adherence to fasting guidelines and to shorten preoperative fasting duration in children.” [7]
PreOpApp™ Kids does just this. The app allows the parent to enter their arrival time, which then automatically produces:
- A Personalized preparation schedule
- An Up to date in app alert banner
- Timed push alerts for NPO fasting times overnight
PreOpApp™ Kids is a perioperative digital platform designed to address this gap in pediatric healthcare by bringing together:
- Caregiver-facing reminders for NPO fasting and illness reporting,
- Earlier, repeated communication before the day of surgery, and
- Developmentally appropriate preparation tools for children
This approach is meant to support families in the period before the day of surgery, when confusion is common, communication is often insufficient and last minute, and opportunities to reduce anxiety and avoid preventable delays are often missed.
Clinicians such as child life staff and anesthesiologists can use the app in the preoperative waiting area, and in the OR/OT during induction of anesthesia.
Global Digital Health Alignment and Access
Modernizing pediatric preoperative preparation means moving beyond one-time phone calls and static instructions toward accessible, family-centered digital support.
The use of digital tools in health care had grown enough that in 2018 the World Health Organization (WHO) developed a shared classification system to describe how digital technologies support health systems, patients, families, clinicians, researchers, and public health programs. The WHO framework includes patient-facing digital health functions that PreOpApp™ Kids supports: such as patient and caregiver communication, providing prompts and alerts based according to protocol, and on-demand access to health information. [9]
PreOpApp™ Kids Fasting Alert System is free and available worldwide – helping to address these global concerns of equity in care to pediatric patients coming for surgery. By making pediatric surgery preparation available through a mobile platform, PreOpApp™ Kids supports broader global digital health priorities: improving access to reliable health information, supporting family engagement, reducing preparation confusion, and using scalable digital tools to help patients and caregivers prepare for care.
The app supports families through parent guidance, child-friendly education, a three-part fasting alert system, visual familiarization, interactive games, and calming tools.
Core preparation tools, including fasting guidance and alerts, are designed to be accessible to families without adding cost barriers. Translations to additional languages are underway.
Lauren Welsh, MD
Founder, PreOpApp™ Kids
Pediatric Anesthesiologist
Download PreOpApp™ Kids Free here:
Works Cited
[1] Bennett T, Lewis H, Riley C, Lee AJ, Raja EA, Arnold P; Paediatric Anaesthetic Trainee Research Network (PATRN); Brooks P. PaedIatric caNcelation ratEs And PerioPerative clinicaL Evaluation (PINEAPPLE): A UK Prospective Multi-Center Observational Cohort Study. Pediatric Anesthesia. 2026;36(4):388-395.
[2] American Society of Anesthesiologists. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2023.
[3] Pediatric Preoperative Management (P-POM) Special Interest Group. Society of Pediatric Anesthesia, U.S. pediatric preoperative needs assessment.
[4] Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioral recovery in children undergoing surgery. Pediatrics. 2006.
[5] Liguori S, Stacchini M, Ciofi D, et al. Effectiveness of an App for Reducing Preoperative Anxiety in Children: A Randomized Clinical Trial. JAMA Pediatrics. 2016.
[6] Welsh L, et al. Improving Preoperative Communication with Patients in CHOG. Wellstar MCG Health Quality Improvement Symposium, 2025.
[7] Zhang B, Pan S, Zheng J, Li B, Miao Y, Liu G. Optimizing pediatric preoperative fasting management: a survey of practices and real durations in Chinese hospitals. BMC Anesthesiology. 2025;25:204.
[8] Rantala A, Jansson MM, Helve O, Lahdenne P, Pikkarainen M, Pölkki T. Parental Experiences of the Pediatric Day Surgery Pathway and the Needs for a Digital Gaming Solution: Qualitative Study. JMIR Medical Informatics. 2020;8(11)
[9] World Health Organization. Classification of Digital Health Interventions v1.0: A shared language to describe the uses of digital technology for health. Geneva: WHO; 2018.
For more information: www.PreOpApp.com