The Role of Anxiety in Acute Pain and Nausea-Vomiting in Children After Surgery

The Role of Anxiety in Acute Pain and Nausea-Vomiting in Children After Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Role of Anxiety in Acute Pain and Nausea-Vomiting in Children After Surgery Aytül Çoban, Zerrin CIGDEM, Melike YAVAŞ ÇELİK This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8910407/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 19 You are reading this latest preprint version Abstract Aim This study was conducted to examine the role of preoperative anxiety in postoperative acute pain and nausea and vomiting in children. Method In this study, FLAAC Pain Scale, modified Yale Preoperative Anxiety Scale and BARF Nausea Scale Score were used. Shapiro-Wilk test was used to evaluate the normal distribution of variables. Descriptive analysis used mean and standard deviation values for presentation purposes. Results A total of 77 patients were included in the study. The mean age of the patients was 9.84 ± 2.52 years and 74.03% were male. 24.68% of the children were attending second grade. The mean body weight of the children was 30.78 ± 9.88 kg, and their height was 132.19 ± 10.92 cm. 37.66% of the children had undergone surgery before and 46.75% had been hospitalized before. The mean hospitalization time was 3.37 ± 3.58. It was found that there was a relationship between the FLAAC Pain Scale, Yale Preoperative Anxiety Scale and Barf Nausea Scales, and as a result of the regression analysis, anxiety had a mediating role in the occurrence of pain and nausea. Conclusion These results showed that preoperative anxiety plays an important role in the prevention and treatment of postoperative pain and nausea-vomiting in children. Acute Pain Nausea-Vomiting Anxiety Introduction Considering the surgical processes, children face many health problems. Anxiety is one of these problems. Acute pain, nausea and vomiting that occur after surgery due to anxiety are serious problems. Children are generally more vulnerable than adults, and their individual control is weaker than adults. Anxiety occurs more frequently in children, especially in the younger age group (less than 15 years old) (Erden, 2021 ). Anxiety is generally a form of symbolic sign. Anxiety can trigger many problems. For this reason, in order to increase the comfort level of children after surgery and to help them cope with this situation, detailed evaluation of pain and nausea and vomiting should be made frequently and the treatment and care process should be planned according to the results of the evaluation (Conk et al., 2018 ). Acute pain occurs suddenly and can be defined as a sign of disease. The severity of the pain and how long it will last cannot be known with certainty. Acute pain, sometimes reaching unbearable levels, can cause many negative consequences by affecting other parts, systems and functions in the body. For this reason, it is known that acute pain is not a type of pain that should be ignored and that it is very difficult to cope with this situation (Yılmaz Koçak & Kaya, 2021 ). Acute pain, in addition to physical complaints in the child, also reveals some behavioral/mental states such as restlessness (Öztürk & Ayar, 2014 ). Anxiety is considered one of the most important causes of acute pain after surgery. It is suggested that high levels of anxiety and stress in the child further increase acute pain. This situation causes acute pain and other negative and undesirable conditions to develop (Bülbül & Arıkan, 2018 ). Nausea and vomiting are side effects of pain and anesthesia and are a condition that negatively affects children's quality of life (Durgut, 2021 ). Postoperative nausea and vomiting may reveal negative psychosocial problems such as patient dissatisfaction and discomfort. It may also cause physical consequences such as nausea and vomiting, fluid-electrolyte imbalance, aspiration pneumonia, esophageal rupture, and wound dehiscence. These situations may delay the child's discharge from the hospital and therefore increase healthcare costs (Aygın, 2016). Surgery is a challenging process for children, and this process must be managed effectively by parents, healthcare professionals, and other team members working in this field. Anxiety that can be effectively managed before surgery can prevent acute pain and nausea and vomiting that children may experience after surgery (Durgut, 2021 ). Therefore, this study aimed to evaluate the role of anxiety in children before surgery in the occurrence of acute pain and nausea and vomiting. Question of research What is the role of anxiety in children before surgery on acute pain and nausea and vomiting after surgery? Method Type of Research Relationship searching and descriptive. Population and Sample of the Research The G*Power 3.1.9.4 program was used to determine the sample size. The sample was calculated by taking into account the article written by Wang & Kain ( 2000 ), which has similar characteristics to the study (Wang & Kain, 2000 ). The effect size was taken as (ρ = 0.32) and the sample size was found to be 71 with 80% power. A total of 431 children were admitted to the Pediatric Surgery Clinic for surgery between 12.09.2022 and 20.01.2023, when the study was conducted. For the sample, 77 children who met the inclusion criteria listed below were included in the sample. Criteria for inclusion in the study : Be over 7 years old (required to be able to communicate while collecting data) Being hospitalized for surgery (clinic admission could be due to some different diseases) Volunteering to participate in the study Ability to read and write Turkish (some immigrants and Kurdish citizens in the region where the hospital where the research is conducted cannot speak Turkish) No diagnosed neurological or psychiatric disease Exclusion criteria from the study : Becoming a refugee Staying in hospital for less than 48 hours after surgery(Nausea and vomiting should have been evaluated within the 48th hour) Being brought in for emergency surgery Experiencing the recent death of a loved one Data Collection Tools Data were collected by the Descriptive Characteristics Form, Yale Preoperative Anxiety Scale, FLACC Pain Scale, and Baxter Animated Retching Faces/Baxter(BARF) Nausea Scale. Descriptive Characteristics Form This form was created by scanning studies related to the study (Yayan & Zengin, 2018; Bulut et al., 2020 ; Köse & Arıkan, 2020 ). It was created by descriptive characteristics of the children (Body Mass Index (BMI), height, body weight, gender, age, education level, economic status of the family, number of siblings) Yale Preoperative Anxiety Scale The scale is suitable for children aged 8–12. The Turkish validity and reliability study of the scale was conducted by Hatipoğlu et al. In 2019, Cronbach's alpha value was found to be 0.85. The scale consists of 22 items and 5 sub-dimensions. The subscales are Activity (4 items), Vocal Reactions (6 items), Emotional Expression (4 items), Degree of Arousal (4 items), and Parent-Related Reactions (4 items) (Topalel, 2018 ). While scoring the scale, the score obtained from each sub-dimension is divided by the highest score that can be obtained from that sub-dimension and the results are summed. This result is divided by the total number of sub-dimensions and multiplied by 100. As a result of this process, a total score ranging from 23.33 to 100 is obtained. A higher score from the scale indicates higher anxiety (Topalel, 2018 ). The Modified Yale Preoperative Anxiety Scale was filled out by the investigator 1 hour before the surgery, while the patient was at the patient's bed with his/her parent next to him/her. children were evaluated twice. Analyzes were made by taking the average of two evaluations. FLAAC Pain Scale FLACC pain assessment scale is a scale used to evaluate postoperative pain in pediatric patients. It was developed by Merkel and colleagues in 1997. Its Turkish translation was made in 2006. The two-way cross-stratification method was used to examine the agreement among pediatric surgeon, anesthetist and nurse raters independently of each other, and it was reported that the Kappa Value was found to be significant (Şenaylı et al., 2006 ). The scale consists of a total of 5 sections evaluated between 0 and 2. These sections; Face, Legs, Activity, Cry, Consolability. Application of the scale requires observing the child every 10 minutes for 50 minutes and giving a score between 0–2 for each section. The total score varies between 0 and 10. A score of 0 indicates that the child is calm and comfortable, a score of 1–3 indicates that the child is slightly uncomfortable, scores between 4–6 indicate that the child is in moderate pain, and scores between 7–10 indicate that the child is significantly uncomfortable and in pain. When the total pain score is 4 or above, additional analgesics are recommended (Şenaylı et. al., 2006 ). In this study, all children were evaluated for pain by observing the Flacc pain scale immediately after being taken to their postoperative rooms, and by observing them 5 times at 10-minute intervals for a total of 50 minutes. Analyzes were carried out by taking the average of these evaluations. The children's parents were also with the children during this evaluation process. In the practice of the clinic where our study was conducted, routine analgesia was not applied to every child, and analgesia prescribed by the physician was administered to children who complained of pain after the first ten minutes and whose scale score was four or more. BARF Nausea Scale It was developed by William Baxter in 2010 to evaluate postoperative nausea in children over the age of seven. The scale is a visual evaluation scale consisting of six facial expressions scored between 0 and 10. Turkish validity and reliability was conducted by Şişman et al. in 2015. There are a total of six items in the BARF Scale and six facial expressions that define each item (Şişman, 2015). This scale was applied at the 2nd hour after surgery. Children were asked to choose which face shape suits them at that moment using the BARF Scale. Since no patient was administered antiemetics within the last half hour before the evaluation, nausea and vomiting were not evaluated again. Statistical Analysis of Data Statistical analyzes were performed with SPSS version 25.0 program. The suitability of the variables for normal distribution was examined with the Shapiro-Wilk test. Mean and standard deviation values were used when presenting descriptive analyses. Frequency and percentage values of the variables were used when presenting categorical variables. Relationships between quantitative variables were examined with Pearson Correlation Analysis. Correlation coefficient r*, very strong correlation between 0.81 and 1.0; Strong correlation between 0.60 and 0.79; moderate correlation between 0.40 and 0.59; Between 0.20 and 0.39 was considered a weak correlation, and between 0 and 0.19 was considered a very weak correlation. Additionally, Hayes mediation analysis was performed and Model 4 was used to determine the mediating role of preoperative anxiety level in the effect of postoperative acute pain on nausea and vomiting complaints in children. Additionally, Hayes mediation analysis was performed and Model 4 was used to determine the mediating role of preoperative anxiety level in the effect of postoperative acute pain on nausea and vomiting complaints in children. Cases where the p-value was below 0.05 were considered statistically significant. Ethical aspects The study was granted ethical clearance by the institution’s General Human Research Ethics Committee. The research was conducted with children who were allowed to participate in the research by legally protected individuals (mother, father, grandfather, uncle). Informed consent was obtained from the participants and their relatives. The research was conducted by the Principles of the Declaration of Helsinki. To protect the interests of the participants, the researcher complied with ethical standards throughout the study. Results The average age of the children was 9.84 ± 2.52 years. It was found that 74.03% (n = 57) of the children, were boys and 24.68% (n = 19) of the children were attending second grade.The average body weight of the children was 30.78 ± 9.88 kg and the average height of the children was 132.19 ± 10.92 cm. It was determined that 44.16% (n = 34) of the mothers were illiterate and 87.01% (n = 67) were not working. It was determined that 32.47% (n = 25) of the fathers had secondary education level and 64.94% (n = 50) were working. It was observed that the income of 71.43% (n = 55) of the children's families did not cover their expenses and the average number of siblings was 5.17 ± 2.20 (Table 1 ). Table 1 Distribution of Descriptive Characteristics of Children Data Mean ± S.D n = 77 Median Min-Max (%) Age 9,84 ± 2,52 9 (7–16) Sex Female Male 20 57 25,97 74,03 School No school 1.class 2.class 3.class 4.class 5. class 6. class 7. class 8. class 9. class 6 12 19 9 12 5 7 5 1 1 7,79 15,58 24,68 11,69 15,58 6,49 9,09 6,49 1,30 1,30 Weight (kg) 30,78 ± 9,88 28 (18–65) Height (cm) 132,19 ± 10,92 130 (110–160) Body mass index 17,21 ± 2,85 16,85 (12,5–25,4) Mother's education level Illiterate Literate Secondary education High school education University education 34 22 7 13 1 44,16 28,57 9,09 16,88 1,30 Mother's working status No Yes 67 10 87,01 12,99 Father's education level Illiterate Literate Secondary education High school education University education 7 20 25 22 3 9,09 25,97 32,47 28,57 3,90 Father's working status No Yes 27 50 35,06 64,94 Income income is lower than expenses Income equals expenses Income exceeds expenses 55 20 2 71,43 25,97 2,60 Number of siblings (Mean) 5,17 ± 2,20 5 (2–12) The total Yale Preoperative Anxiety Scale and the total score averages of the subscales were as follows; Activity: 1.97 ± 1.16, Vocal reactions: 2.53 ± 1.54, Emotional Expression: 2.36 ± 1.12, Degree of Arousal: 2.31 ± 1.17, Parent-Related Reactions: 2.23 ± 1.05 and the total points: 11.42 ± 5.42 (Table 2 ). Table 2 Children's Mean Scores of the Yale Preoperative Anxiety Scale, FLACC Pain Scale, and BARF Nausea Scale Ölçek Adı Mean ± S.D n = 77 Median (Min. Mak) %=100 Yale Preoperative Anxiety Scale Activity 1,97 ± 1,16 2 (1–4) Vocal Reactions 2,53 ± 1,54 2 (1–6) Emotional Expression 2,36 ± 1,12 3 (1–4) Degree of Arousal 2,31 ± 1,17 3 (1–4) Parent-Related Reactions 2,23 ± 1,05 2 (1–4) Total score 11,42 ± 5,42 11 (5–22) FLACC Pain Scale Calm and confortable 5 6,49 Slightly uncomfortable 9 11,69 Moderate pain 36 46,75 Significantly Uncomfortable and in pain 27 35,06 Total score 5,68 ± 2,88 5 (0–10) BARF Nausea Scale Total score 2,23 ± 3,21 2 (0–10) According to the FLACC Pain Scale classification, 6.49% (n = 5) of the children were calm and comfortable, 11.69% (n = 9) were slightly uncomfortable, 46.75% (n = 36) were moderately uncomfortable. 35.06% (n = 27) were significantly uncomfortable and the mean scale score was 5.68 ± 2.88 (Tablo 2). The mean BARF Nausea Scale score of the children at the 2nd hour after surgery was evaluated as 2.23 ± 3.21 (Table 2 ). A positive and moderate (r = 0.602, p < 0.001) statistically significant relationship was detected between the Yale Preoperative Anxiety Scale and FLACC Pain Scale scores. A positive and moderate (r = 0.414, p < 0.001) statistically significant relationship was found between Yale Preoperative Anxiety Scale and BARF Nausea Scale. A positive and moderate (r = 0.384, p < 0.001) statistically significant relationship was found between FLACC Pain Scale and BARF Nausea Scale (Table 3 ). Table 3 Relationship Between Scales FLACC Pain Scale YALE FLACC BARF *r 0,602 1 p < 0,001 - BARF Nausea Scale r 0,414 0,384 1 p < 0,001 < 0,001 - *r: pearson correlation coefficient Regression analysis based on the bootstrap method was performed to test whether preoperative anxiety had a mediating role in the relationship between postoperative acute pain and nausea and vomiting in children. Accordingly, it was determined that the indirect effect of postoperative pain on nausea and vomiting in children was significant, and that preoperative anxiety mediated the relationship between acute pain and nausea and vomiting (Table 4 ). Table 4 The Mediating Role of Preoperative Anxiety in the Relationship Between Postoperative Acute Pain and Nausea and Vomiting in Children Result Variables M (Pre-op Anxiety) Y (Post-op Nausea-Vomiting) Estimated Variables b S.H. b S.H. X (Post-op Pain) a 5,148** 0,804 c’ 0,209 0,131 M (Pre-op Anxiety) - - - b 0,033* 0,015 Fix i M 24,871** 5,064 i Y -1,027 0,762 R 2 =0,363 R 2 =0,200 F (1, 72) = 41,026, p < 0,001 F (2, 71) = 8,847, p < 0,001 b S.H. t p LLCI ULCI Total impact (c path) 0,379 0,107 3,528 < 0,001 0,165 0,593 Direct impact (c path) 0,209 0,131 1,589 0,117 -0,053 0,470 Indirect impact(a.b path) 0,170 0,090 - - 0,015 0,366 * Statistically significant results at p < 0.05 and **p < 0.001 levels, S.H.: Standard Error, Unstandardized beta coefficients (b) are reported Discussion In this study, which we conducted to evaluate the role of anxiety in children before surgery on acute pain and nausea and vomiting after surgery, it was found that anxiety before surgery is a very effective factor on acute pain and nausea and vomiting after surgery. A similar study revealed that there is a relationship between preoperative anxiety and postoperative pain, and that different factors, along with anxiety, play a role in the formation of postoperative pain (Vaughn et al., 2007 ). In another study, it was determined that there was a statistically significant positive relationship between pre- and postoperative anxiety score averages and pain score averages (Çiftçi, 2019 ). According to the FLACC Pain Scale classification, 6.49% (n = 5) of the children were calm and comfortable, 11.69% (n = 9) were slightly uncomfortable, 46.75% (n = 36) were moderately uncomfortable. 35.06% (n = 27) were significantly uncomfortable and the mean scale score was 5.68 ± 2.88 (Şenaylı et al., 2006 ). A positive and moderate (r = 0.602, p < 0.001) statistically significant relationship was detected between the Modified Yale Preoperative Anxiety Scale score and the FLACC Pain Scale of Postoperative Pain in Children score. Anxiety causes differences in physiological and psychological variables in children. Physiological changes cause changes in cardiac and respiratory functions due to the suppression of immunity and increased sensitivity to pain due to the release of stress hormones such as cortisol (Çalışır & Karataş, 2019 ). As a result of children experiencing anxiety and fear in the preoperative period, the following psychological problems occur: nausea, restlessness, and angry and aggressive behavior behavioral and physiological traumas (Bizzio et al., 2020 ; Fortier et al., 2010 ). Studies have revealed that especially children experience nausea and vomiting in the second hour after surgery, that the rate of postoperative nausea and vomiting in children may be 5% in infancy and 20% in the preschool period, and that it may reach even higher rates as age progresses, especially in adolescence (Klemetti et al., 2009 ; Morrison & Wilmshurst, 2019 ; Bizzio et al., 2020 ). The average age of the children in this study was 9.84 ± 2.52 and it was determined that scored of BARF Nausea Scale of the children was 2.23 ± 3.21. BARF Bulantı According to the evaluation of the scale, this score was interpreted as children not having many problems with nausea and vomiting (Şişman, 2015). Additionally, a positive and moderate (r = 0.414, p < 0.001) statistically significant relationship was detected between the Yale Preoperative Anxiety Scale and the BARF Nausea Scale (BARF). Wiggins and Foster ( 2007 ) evaluated the pain of children after tonsillectomy and adenoidectomy operations. As a result of this study, it was found that children's pain rates were mostly between 3.1–3.3 and that 64.7% of children woke up at night due to their pain and 52.9% of children experienced nausea (Wiggins & Foster, 2007 ). Conclusion Preoperative anxiety generally reflected children's fear, anxiety and stress levels regarding surgery. These emotions can affect children's perception of pain, their ability to tolerate pain, and increase their physiological and behavioral reactions to pain. In this study, it was found that preoperative anxiety had a strong effect on postoperative acute pain and nausea and vomiting. This finding proved how valuable it is to reduce anxiety and stress before surgery. For this reason, it is important to prepare children before surgery and adapts to the hospital environment. Family-centered care, therapeutic play, holistic care and primary nursing care may be beneficial in preventing anxiety in children and helping the child adapt to the situation it is experiencing. Declarations C onflict of interest: The authors declare that they have no competing interests. Acknowledgements: We thank the participants who participated in the research Consent for publication : There is no objection to publishing the study. Funding: The study did not receive any funding support. Data availability: The original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding authors. Ethical considerations: Ethics committee permission was obtained from the Ethics Committee of Hasan Kalyoncu University (IRB number: 2022/078, date: 22.08.2022). Consent to participate : Consent was obtained from the legal guardians/family members of all participants. Author contributions: Conceptualization, Z.C, A.Ç; methodology, Z.C. and M.Y.C.; software, A.Ç. and M.Y.C.; validation, Z.C. and M.Y.C.; formal analysis, M.Y.C.; investigation, Z.C. and M.Y.C.; resources, Z.C., A.Ç., and M.Y.C.; data curation, Z.C., A.Ç and M.Y.C.; writing—original draft preparation, Z.C., A.Ç., and M.Y.C.; writing—review and editing, M.Y.C.; visualization, Z.C., A.Ç and M.Y.C.; supervision, Z.C., A.Ç. and M.Y.C.; project administration, M.Y.C.; funding acquisition, Z.C., A.Ç and M.Y.C. 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Anxiety is one of these problems. Acute pain, nausea and vomiting that occur after surgery due to anxiety are serious problems. Children are generally more vulnerable than adults, and their individual control is weaker than adults. Anxiety occurs more frequently in children, especially in the younger age group (less than 15 years old) (Erden, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnxiety is generally a form of symbolic sign. Anxiety can trigger many problems. For this reason, in order to increase the comfort level of children after surgery and to help them cope with this situation, detailed evaluation of pain and nausea and vomiting should be made frequently and the treatment and care process should be planned according to the results of the evaluation (Conk et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAcute pain occurs suddenly and can be defined as a sign of disease. The severity of the pain and how long it will last cannot be known with certainty. Acute pain, sometimes reaching unbearable levels, can cause many negative consequences by affecting other parts, systems and functions in the body. For this reason, it is known that acute pain is not a type of pain that should be ignored and that it is very difficult to cope with this situation (Yılmaz Ko\u0026ccedil;ak \u0026amp; Kaya, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Acute pain, in addition to physical complaints in the child, also reveals some behavioral/mental states such as restlessness (\u0026Ouml;zt\u0026uuml;rk \u0026amp; Ayar, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Anxiety is considered one of the most important causes of acute pain after surgery. It is suggested that high levels of anxiety and stress in the child further increase acute pain. This situation causes acute pain and other negative and undesirable conditions to develop (B\u0026uuml;lb\u0026uuml;l \u0026amp; Arıkan, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNausea and vomiting are side effects of pain and anesthesia and are a condition that negatively affects children's quality of life (Durgut, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Postoperative nausea and vomiting may reveal negative psychosocial problems such as patient dissatisfaction and discomfort. It may also cause physical consequences such as nausea and vomiting, fluid-electrolyte imbalance, aspiration pneumonia, esophageal rupture, and wound dehiscence. These situations may delay the child's discharge from the hospital and therefore increase healthcare costs (Aygın, 2016).\u003c/p\u003e \u003cp\u003eSurgery is a challenging process for children, and this process must be managed effectively by parents, healthcare professionals, and other team members working in this field. Anxiety that can be effectively managed before surgery can prevent acute pain and nausea and vomiting that children may experience after surgery (Durgut, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Therefore, this study aimed to evaluate the role of anxiety in children before surgery in the occurrence of acute pain and nausea and vomiting.\u003c/p\u003e \u003cp\u003e \u003cb\u003eQuestion of research\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat is the role of anxiety in children before surgery on acute pain and nausea and vomiting after surgery?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cstrong\u003eType of Research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRelationship searching and descriptive.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003ePopulation and Sample of the Research\u003c/h2\u003e\n\u003cp\u003eThe G*Power 3.1.9.4 program was used to determine the sample size. The sample was calculated by taking into account the article written by Wang \u0026amp; Kain (\u003cspan class=\"CitationRef\"\u003e2000\u003c/span\u003e), which has similar characteristics to the study (Wang \u0026amp; Kain, \u003cspan class=\"CitationRef\"\u003e2000\u003c/span\u003e). The effect size was taken as (\u0026rho;\u0026thinsp;=\u0026thinsp;0.32) and the sample size was found to be 71 with 80% power. A total of 431 children were admitted to the Pediatric Surgery Clinic for surgery between 12.09.2022 and 20.01.2023, when the study was conducted. For the sample, 77 children who met the inclusion criteria listed below were included in the sample.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCriteria for inclusion in the study\u003c/em\u003e:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eBe over 7 years old (required to be able to communicate while collecting data)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eBeing hospitalized for surgery (clinic admission could be due to some different diseases)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eVolunteering to participate in the study\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eAbility to read and write Turkish (some immigrants and Kurdish citizens in the region where the hospital where the research is conducted cannot speak Turkish)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eNo diagnosed neurological or psychiatric disease\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eExclusion criteria from the study\u003c/em\u003e:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eBecoming a refugee\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eStaying in hospital for less than 48 hours after surgery(Nausea and vomiting should have been evaluated within the 48th hour)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eBeing brought in for emergency surgery\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eExperiencing the recent death of a loved one\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/div\u003e\n\u003ch3\u003eData Collection Tools\u003c/h3\u003e\n\u003cp\u003eData were collected by the Descriptive Characteristics Form, Yale Preoperative Anxiety Scale, FLACC Pain Scale, and Baxter Animated Retching Faces/Baxter(BARF) Nausea Scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescriptive Characteristics Form\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis form was created by scanning studies related to the study (Yayan \u0026amp; Zengin, 2018; Bulut et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e; K\u0026ouml;se \u0026amp; Arıkan, \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). It was created by descriptive characteristics of the children (Body Mass Index (BMI), height, body weight, gender, age, education level, economic status of the family, number of siblings)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYale Preoperative Anxiety Scale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe scale is suitable for children aged 8\u0026ndash;12. The Turkish validity and reliability study of the scale was conducted by Hatipoğlu et al. In 2019, Cronbach's alpha value was found to be 0.85. The scale consists of 22 items and 5 sub-dimensions. The subscales are Activity (4 items), Vocal Reactions (6 items), Emotional Expression (4 items), Degree of Arousal (4 items), and Parent-Related Reactions (4 items) (Topalel, \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). While scoring the scale, the score obtained from each sub-dimension is divided by the highest score that can be obtained from that sub-dimension and the results are summed. This result is divided by the total number of sub-dimensions and multiplied by 100. As a result of this process, a total score ranging from 23.33 to 100 is obtained. A higher score from the scale indicates higher anxiety (Topalel, \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). The Modified Yale Preoperative Anxiety Scale was filled out by the investigator 1 hour before the surgery, while the patient was at the patient's bed with his/her parent next to him/her. children were evaluated twice. Analyzes were made by taking the average of two evaluations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFLAAC Pain Scale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFLACC pain assessment scale is a scale used to evaluate postoperative pain in pediatric patients. It was developed by Merkel and colleagues in 1997. Its Turkish translation was made in 2006. The two-way cross-stratification method was used to examine the agreement among pediatric surgeon, anesthetist and nurse raters independently of each other, and it was reported that the Kappa Value was found to be significant (Şenaylı et al., \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). The scale consists of a total of 5 sections evaluated between 0 and 2. These sections; Face, Legs, Activity, Cry, Consolability. Application of the scale requires observing the child every 10 minutes for 50 minutes and giving a score between 0\u0026ndash;2 for each section. The total score varies between 0 and 10. A score of 0 indicates that the child is calm and comfortable, a score of 1\u0026ndash;3 indicates that the child is\u003c/p\u003e\n\u003cp\u003eslightly uncomfortable, scores between 4\u0026ndash;6 indicate that the child is in moderate pain, and scores between 7\u0026ndash;10 indicate that the child is significantly uncomfortable and in pain. When the total pain score is 4 or above, additional analgesics are recommended (Şenaylı et. al., \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn this study, all children were evaluated for pain by observing the Flacc pain scale immediately after being taken to their postoperative rooms, and by observing them 5 times at 10-minute intervals for a total of 50 minutes. Analyzes were carried out by taking the average of these evaluations. The children's parents were also with the children during this evaluation process. In the practice of the clinic where our study was conducted, routine analgesia was not applied to every child, and analgesia prescribed by the physician was administered to children who complained of pain after the first ten minutes and whose scale score was four or more.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBARF Nausea Scale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt was developed by William Baxter in 2010 to evaluate postoperative nausea in children over the age of seven. The scale is a visual evaluation scale consisting of six facial expressions scored between 0 and 10. Turkish validity and reliability was conducted by Şişman et al. in 2015. There are a total of six items in the BARF Scale and six facial expressions that define each item (Şişman, 2015).\u003c/p\u003e\n\u003cp\u003eThis scale was applied at the 2nd hour after surgery. Children were asked to choose which face shape suits them at that moment using the BARF Scale. Since no patient was administered antiemetics within the last half hour before the evaluation, nausea and vomiting were not evaluated again.\u003c/p\u003e\n\u003ch3\u003eStatistical Analysis of Data\u003c/h3\u003e\n\u003cp\u003eStatistical analyzes were performed with SPSS version 25.0 program. The suitability of the variables for normal distribution was examined with the Shapiro-Wilk test. Mean and standard deviation values were used when presenting descriptive analyses. Frequency and percentage values of the variables were used when presenting categorical variables. Relationships between quantitative variables were examined with Pearson Correlation Analysis. Correlation coefficient r*, very strong correlation between 0.81 and 1.0; Strong correlation between 0.60 and 0.79; moderate correlation between 0.40 and 0.59; Between 0.20 and 0.39 was considered a weak correlation, and between 0 and 0.19 was considered a very weak correlation. Additionally, Hayes mediation analysis was performed and Model 4 was used to determine the mediating role of preoperative anxiety level in the effect of postoperative acute pain on nausea and vomiting complaints in children.\u003c/p\u003e\n\u003cp\u003eAdditionally, Hayes mediation analysis was performed and Model 4 was used to determine the mediating role of preoperative anxiety level in the effect of postoperative acute pain on nausea and vomiting complaints in children. Cases where the p-value was below 0.05 were considered statistically significant.\u003c/p\u003e\n\u003ch3\u003eEthical aspects\u003c/h3\u003e\n\u003cp\u003eThe study was granted ethical clearance by the institution\u0026rsquo;s General Human Research Ethics Committee. The research was conducted with children who were allowed to participate in the research by legally protected individuals (mother, father, grandfather, uncle). Informed consent was obtained from the participants and their relatives. The research was conducted by the Principles of the Declaration of Helsinki. To protect the interests of the participants, the researcher complied with ethical standards throughout the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe average age of the children was 9.84\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52 years. It was found that 74.03% (n\u0026thinsp;=\u0026thinsp;57) of the children, were boys and 24.68% (n\u0026thinsp;=\u0026thinsp;19) of the children were attending second grade.The average body weight of the children was 30.78\u0026thinsp;\u0026plusmn;\u0026thinsp;9.88 kg and the average height of the children was 132.19\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92 cm. It was determined that 44.16% (n\u0026thinsp;=\u0026thinsp;34) of the mothers were illiterate and 87.01% (n\u0026thinsp;=\u0026thinsp;67) were not working. It was determined that 32.47% (n\u0026thinsp;=\u0026thinsp;25) of the fathers had secondary education level and 64.94% (n\u0026thinsp;=\u0026thinsp;50) were working. It was observed that the income of 71.43% (n\u0026thinsp;=\u0026thinsp;55) of the children's families did not cover their expenses and the average number of siblings was 5.17\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Descriptive Characteristics of Children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eData\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003cp\u003eMin-Max\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,84\u0026thinsp;\u0026plusmn;\u0026thinsp;2,52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (7\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25,97\u003c/p\u003e \u003cp\u003e74,03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSchool\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo school\u003c/p\u003e \u003cp\u003e1.class\u003c/p\u003e \u003cp\u003e2.class 3.class\u003c/p\u003e \u003cp\u003e4.class\u003c/p\u003e \u003cp\u003e5. class\u003c/p\u003e \u003cp\u003e6. class\u003c/p\u003e \u003cp\u003e7. class\u003c/p\u003e \u003cp\u003e8. class\u003c/p\u003e \u003cp\u003e9. class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e19\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7,79\u003c/p\u003e \u003cp\u003e15,58\u003c/p\u003e \u003cp\u003e24,68\u003c/p\u003e \u003cp\u003e11,69\u003c/p\u003e \u003cp\u003e15,58\u003c/p\u003e \u003cp\u003e6,49\u003c/p\u003e \u003cp\u003e9,09\u003c/p\u003e \u003cp\u003e6,49\u003c/p\u003e \u003cp\u003e1,30\u003c/p\u003e \u003cp\u003e1,30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight (kg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30,78\u0026thinsp;\u0026plusmn;\u0026thinsp;9,88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (18\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e132,19\u0026thinsp;\u0026plusmn;\u0026thinsp;10,92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130 (110\u0026ndash;160)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17,21\u0026thinsp;\u0026plusmn;\u0026thinsp;2,85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16,85 (12,5\u0026ndash;25,4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMother's education level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate Literate Secondary education High school education University education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003cp\u003e22\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44,16\u003c/p\u003e \u003cp\u003e28,57\u003c/p\u003e \u003cp\u003e9,09\u003c/p\u003e \u003cp\u003e16,88\u003c/p\u003e \u003cp\u003e1,30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMother's working status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87,01\u003c/p\u003e \u003cp\u003e12,99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFather's education level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate Literate Secondary education High school education University education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e22\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9,09\u003c/p\u003e \u003cp\u003e25,97\u003c/p\u003e \u003cp\u003e32,47\u003c/p\u003e \u003cp\u003e28,57\u003c/p\u003e \u003cp\u003e3,90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFather's working status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35,06\u003c/p\u003e \u003cp\u003e64,94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eincome is lower than expenses Income equals expenses Income exceeds expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71,43\u003c/p\u003e \u003cp\u003e25,97\u003c/p\u003e \u003cp\u003e2,60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of siblings\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Mean)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,17\u0026thinsp;\u0026plusmn;\u0026thinsp;2,20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (2\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe total Yale Preoperative Anxiety Scale and the total score averages of the subscales were as follows; Activity: 1.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16, Vocal reactions: 2.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54, Emotional Expression: 2.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12, Degree of Arousal: 2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17, Parent-Related Reactions: 2.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05 and the total points: 11.42\u0026thinsp;\u0026plusmn;\u0026thinsp;5.42 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChildren's Mean Scores of the Yale Preoperative Anxiety Scale, FLACC Pain Scale, and BARF Nausea Scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026Ouml;l\u0026ccedil;ek Adı\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian (Min. Mak)\u003c/p\u003e \u003cp\u003e%=100\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eYale Preoperative Anxiety Scale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,97\u0026thinsp;\u0026plusmn;\u0026thinsp;1,16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocal Reactions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,53\u0026thinsp;\u0026plusmn;\u0026thinsp;1,54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional Expression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,36\u0026thinsp;\u0026plusmn;\u0026thinsp;1,12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDegree of Arousal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,31\u0026thinsp;\u0026plusmn;\u0026thinsp;1,17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParent-Related Reactions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,23\u0026thinsp;\u0026plusmn;\u0026thinsp;1,05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11,42\u0026thinsp;\u0026plusmn;\u0026thinsp;5,42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (5\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eFLACC\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ePain Scale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCalm and confortable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6,49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSlightly uncomfortable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11,69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46,75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSignificantly Uncomfortable and in pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35,06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,68\u0026thinsp;\u0026plusmn;\u0026thinsp;2,88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBARF\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNausea Scale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,23\u0026thinsp;\u0026plusmn;\u0026thinsp;3,21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to the FLACC Pain Scale classification, 6.49% (n\u0026thinsp;=\u0026thinsp;5) of the children were calm and comfortable, 11.69% (n\u0026thinsp;=\u0026thinsp;9) were slightly uncomfortable, 46.75% (n\u0026thinsp;=\u0026thinsp;36) were moderately uncomfortable. 35.06% (n\u0026thinsp;=\u0026thinsp;27) were significantly uncomfortable and the mean scale score was 5.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88 (Tablo 2).\u003c/p\u003e \u003cp\u003eThe mean BARF Nausea Scale score of the children at the 2nd hour after surgery was evaluated as 2.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA positive and moderate (r\u0026thinsp;=\u0026thinsp;0.602, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) statistically significant relationship was detected between the Yale Preoperative Anxiety Scale and FLACC Pain Scale scores. A positive and moderate (r\u0026thinsp;=\u0026thinsp;0.414, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) statistically significant relationship was found between Yale Preoperative Anxiety Scale and BARF Nausea Scale. A positive and moderate (r\u0026thinsp;=\u0026thinsp;0.384, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) statistically significant relationship was found between FLACC Pain Scale and BARF Nausea Scale (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationship Between Scales\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFLACC Pain Scale\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYALE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFLACC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBARF\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e*r\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,602\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBARF Nausea Scale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0,414\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,384\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*r: pearson correlation coefficient\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegression analysis based on the bootstrap method was performed to test whether preoperative anxiety had a mediating role in the relationship between postoperative acute pain and nausea and vomiting in children. Accordingly, it was determined that the indirect effect of postoperative pain on nausea and vomiting in children was significant, and that preoperative anxiety mediated the relationship between acute pain and nausea and vomiting (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Mediating Role of Preoperative Anxiety in the Relationship Between Postoperative Acute Pain and Nausea and Vomiting in Children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"11\" nameend=\"c12\" namest=\"c2\"\u003e \u003cp\u003eResult Variables\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eM (Pre-op Anxiety)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e \u003cp\u003eY (Post-op Nausea-Vomiting)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEstimated Variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eS.H.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eS.H.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eX (Post-op Pain)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ea\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5,148**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0,804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003ec\u0026rsquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e0,209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0,131\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eM (Pre-op Anxiety)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eb\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e0,033*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0,015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFix\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ei\u003c/em\u003e\u003csub\u003e\u003cem\u003eM\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e24,871**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e5,064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003ei\u003c/em\u003e\u003csub\u003e\u003cem\u003eY\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e-1,027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0,762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e=0,363\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e \u003cp\u003e\u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e=0,200\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eF (1, 72)\u0026thinsp;=\u0026thinsp;41,026, p\u0026thinsp;\u0026lt;\u0026thinsp;0,001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e \u003cp\u003e\u003cem\u003eF (2, 71)\u0026thinsp;=\u0026thinsp;8,847, p\u0026thinsp;\u0026lt;\u0026thinsp;0,001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eS.H.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003et\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eLLCI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003e\u003cb\u003eULCI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal impact (c path)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0,379\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0,107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e3,528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0,165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003e0,593\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect impact (c path)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0,209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0,131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1,589\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0,117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0,053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003e0,470\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect impact(a.b path)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0,170\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,090\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0,015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0,366\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003e* Statistically significant results at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and **p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 levels, S.H.: Standard Error, Unstandardized beta coefficients (b) are reported\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, which we conducted to evaluate the role of anxiety in children before surgery on acute pain and nausea and vomiting after surgery, it was found that anxiety before surgery is a very effective factor on acute pain and nausea and vomiting after surgery. A similar study revealed that there is a relationship between preoperative anxiety and postoperative pain, and that different factors, along with anxiety, play a role in the formation of postoperative pain (Vaughn et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). In another study, it was determined that there was a statistically significant positive relationship between pre- and postoperative anxiety score averages and pain score averages (\u0026Ccedil;ift\u0026ccedil;i, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). According to the FLACC Pain Scale classification, 6.49% (n\u0026thinsp;=\u0026thinsp;5) of the children were calm and comfortable, 11.69% (n\u0026thinsp;=\u0026thinsp;9) were slightly uncomfortable, 46.75% (n\u0026thinsp;=\u0026thinsp;36) were moderately uncomfortable. 35.06% (n\u0026thinsp;=\u0026thinsp;27) were significantly uncomfortable and the mean scale score was 5.68\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88 (Şenaylı et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). A positive and moderate (r\u0026thinsp;=\u0026thinsp;0.602, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) statistically significant relationship was detected between the Modified Yale Preoperative Anxiety Scale score and the FLACC Pain Scale of Postoperative Pain in Children score.\u003c/p\u003e \u003cp\u003eAnxiety causes differences in physiological and psychological variables in children. Physiological changes cause changes in cardiac and respiratory functions due to the suppression of immunity and increased sensitivity to pain due to the release of stress hormones such as cortisol (\u0026Ccedil;alışır \u0026amp; Karataş, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). As a result of children experiencing anxiety and fear in the preoperative period, the following psychological problems occur: nausea, restlessness, and angry and aggressive behavior behavioral and physiological traumas (Bizzio et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Fortier et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudies have revealed that especially children experience nausea and vomiting in the second hour after surgery, that the rate of postoperative nausea and vomiting in children may be 5% in infancy and 20% in the preschool period, and that it may reach even higher rates as age progresses, especially in adolescence (Klemetti et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Morrison \u0026amp; Wilmshurst, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Bizzio et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The average age of the children in this study was 9.84\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52 and it was determined that scored of BARF Nausea Scale of the children was 2.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21. BARF Bulantı\u003c/p\u003e \u003cp\u003eAccording to the evaluation of the scale, this score was interpreted as children not having many problems with nausea and vomiting (Şişman, 2015). Additionally, a positive and moderate (r\u0026thinsp;=\u0026thinsp;0.414, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) statistically significant relationship was detected between the Yale Preoperative Anxiety Scale and the BARF Nausea Scale (BARF).\u003c/p\u003e \u003cp\u003eWiggins and Foster (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) evaluated the pain of children after tonsillectomy and adenoidectomy operations. As a result of this study, it was found that children's pain rates were mostly between 3.1\u0026ndash;3.3 and that 64.7% of children woke up at night due to their pain and 52.9% of children experienced nausea (Wiggins \u0026amp; Foster, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePreoperative anxiety generally reflected children's fear, anxiety and stress levels regarding surgery. These emotions can affect children's perception of pain, their ability to tolerate pain, and increase their physiological and behavioral reactions to pain. In this study, it was found that preoperative anxiety had a strong effect on postoperative acute pain and nausea and vomiting. This finding proved how valuable it is to reduce anxiety and stress before surgery. For this reason, it is important to prepare children before surgery and adapts to the hospital environment. Family-centered care, therapeutic play, holistic care and primary nursing care may be beneficial in preventing anxiety in children and helping the child adapt to the situation it is experiencing.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003cstrong\u003eonflict of interest:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e We thank the participants who participated in the research\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication :\u0026nbsp;\u003c/strong\u003eThere is no objection to publishing the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The study did not receive any funding support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eThe original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations:\u003c/strong\u003e Ethics committee permission was obtained from the Ethics Committee of Hasan Kalyoncu University (IRB number: 2022/078, date: 22.08.2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate :\u003c/strong\u003e Consent was obtained from the legal guardians/family members of all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e Conceptualization, Z.C, A.Ç; methodology, Z.C. and M.Y.C.; software, A.Ç. and M.Y.C.; validation, \u0026nbsp;Z.C. and M.Y.C.; formal analysis, M.Y.C.; investigation, Z.C. and M.Y.C.; resources, Z.C., A.Ç., and M.Y.C.; data curation, Z.C., A.Ç and M.Y.C.; writing—original draft preparation, Z.C., A.Ç., and M.Y.C.; writing—review and editing, M.Y.C.; visualization, Z.C., A.Ç and M.Y.C.; supervision, Z.C., A.Ç. and M.Y.C.; project administration, M.Y.C.; funding acquisition, \u0026nbsp; Z.C., A.Ç and M.Y.C. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAygin D. Bulantı ve kusma. Yoğun Bakım Hemşireliği Dergisi. 2016;20(1):44\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBulut M, Alemdar DK, Bulut A, Şalcı G. The effect of music therapy, hand massage, and kaleidoscope usage on postoperative nausea and vomiting, pain, fear, and stress in children a randomized controlled trial. 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Sel\u0026ccedil;uk Sağlık Dergisi. 2021;2(2):197\u0026ndash;213.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute Pain, Nausea-Vomiting, Anxiety","lastPublishedDoi":"10.21203/rs.3.rs-8910407/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8910407/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis study was conducted to examine the role of preoperative anxiety in postoperative acute pain and nausea and vomiting in children.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eIn this study, FLAAC Pain Scale, modified Yale Preoperative Anxiety Scale and BARF Nausea Scale Score were used. Shapiro-Wilk test was used to evaluate the normal distribution of variables. Descriptive analysis used mean and standard deviation values for presentation purposes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 77 patients were included in the study. The mean age of the patients was 9.84\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52 years and 74.03% were male. 24.68% of the children were attending second grade. The mean body weight of the children was 30.78\u0026thinsp;\u0026plusmn;\u0026thinsp;9.88 kg, and their height was 132.19\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92 cm. 37.66% of the children had undergone surgery before and 46.75% had been hospitalized before. The mean hospitalization time was 3.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.58. It was found that there was a relationship between the FLAAC Pain Scale, Yale Preoperative Anxiety Scale and Barf Nausea Scales, and as a result of the regression analysis, anxiety had a mediating role in the occurrence of pain and nausea.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese results showed that preoperative anxiety plays an important role in the prevention and treatment of postoperative pain and nausea-vomiting in children.\u003c/p\u003e","manuscriptTitle":"The Role of Anxiety in Acute Pain and Nausea-Vomiting in Children After Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 17:49:21","doi":"10.21203/rs.3.rs-8910407/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-03T16:48:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T09:53:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32384018874187141776355402225277432309","date":"2026-04-23T10:46:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-17T17:06:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104404127490408594092294647382873175897","date":"2026-04-17T11:48:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-17T11:32:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-17T06:42:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224462125662547785005658408296663687096","date":"2026-04-09T05:47:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-08T17:22:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165788029428600189462308886634354765114","date":"2026-04-08T16:12:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206776694578413988043094501864303243688","date":"2026-04-08T06:02:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91832807914129387509928491747160468471","date":"2026-04-08T03:52:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169423485710048157741313151498370702217","date":"2026-04-08T02:00:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120389472806917979325646854458004022747","date":"2026-04-07T19:10:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-07T17:00:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-25T14:42:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-25T03:20:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-25T03:18:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-02-18T14:41:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6aa02bd9-b0e7-41ac-b342-b1be2fac74ce","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-03T16:48:27+00:00","index":82,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T17:49:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 17:49:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8910407","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8910407","identity":"rs-8910407","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}