The Takeaway

Delivering prerecorded, repeated maternal voice orientation via noise cancelling headphones decreased emergence agitation in pediatric patients undergoing tonsillectomy and adenoidectomy

Study Design

• Double-blinded, randomized controlled trial with 360 participants
• ASA Class 1 or 2
• Children aged 5–12 years, scheduled for elective tonsillectomy with or without adenoidectomy
• Exclusion criteria: "(1) developmental or neurological disorders; (2) hearing impairment or deafness; (3) neuromuscular disorders; (4) inability to provide the mother's recordings as required; (5) previous surgery history; (6) recent use of any sedative medication within a week, and (7) parental refusal"
• 3 Arms: maternal voice orientation (Group O), maternal voice awakening (Group A), and control (Group C).

Abstract

Study objective: Evaluate the efficacy of repeated maternal voice orientation in reducing the incidence of emergence agitation (EA) in pediatric patients undergoing elective tonsillectomy and adenoidectomy.

Design: Randomized controlled trial.

Setting: A tertiary hospital.

Patients: 360 children aged 5-12 years undergoing elective tonsillectomy and adenoidectomy.

Interventions: Patients were randomized into three groups: maternal voice orientation group (Group O), maternal voice awakening group (Group A), and a control group (Group C) receiving silent recordings.

Measurements: The primary outcome was the incidence of EA, defined by a Pediatric Anesthesia Emergence Delirium (PAED) score of 12 or higher. Secondary outcomes included the severity of EA (PAED score > 14), postoperative pain (assessed using FLACC and NRS scales), and recovery profiles in the Post-Anesthesia Care Unit (PACU).

Main results: Maternal voice orientation (Group O) significantly reduced the incidence of EA compared to the control group and Group A, especially notable in the 5-8 year subgroup. Group O showed the lowest PAED scores immediately post-extubation and at 10 min.

Conclusions: Repeated maternal voice orientation effectively reduces the incidence and severity of EA among pediatric patients, supporting its inclusion in pediatric anesthesia recovery protocols to improve postoperative outcomes.

Excerpts

Emergence agitation (EA) is a prevalent and troubling complication for pediatric patients recovering from general anesthesia, with an incidence reported in up to 80 % of children, particularly after procedures like tonsillectomy and adenoidectomy.

Various strategies to manage EA include pharmacological options such as midazolam and dexmedetomidine, which, while effective in reducing agitation, may also cause adverse effects such as sedation and respiratory depression

auditory stimuli, particularly the sound of a mother's voice, have been recognized for their soothing effect and effectiveness in mitigating EA without the side effects associated with medications.

Repeated orientation reminders involve providing patients with continuous information about their surroundings, location, and the people around them, which can help alleviate disorientation and confusion.

noise-cancelling headphones were placed on the child, and the maternal voice recording was played.

Group O, children received repeated orientation reminders from their mothers' recordings: ‘(Child's name), you are in the operating room, surrounded by doctors, the surgery is over, take a deep breath and open your eyes.’ In Group A, children were provided with their mothers' awakening recordings: ‘(Child's name), take a deep breath and open your eyes.’ In the Control Group, subjects received no auditory stimulation, only a silent recording.

This study demonstrates that repeated maternal voice orientation significantly decreases both the incidence and severity of EA. By employing specific orientation cues delivered in a maternal voice as patients awaken from anesthesia, we observed a smoother recovery process.

Research indicates that a mother's voice activates key brain areas such as the amygdala and hippocampus, triggering positive emotional responses and improving how auditory cues are received and understood [[23], [24], [25]]. Although the anesthetic sevoflurane can initially dampen how these auditory signals are processed, it does not entirely shut down these pathways. As the effects of sevoflurane decrease, the auditory cortex and related emotional and memory regions gradually regain their full functionality

noise-cancelling headphones, equipped with active noise cancellation technology, help mitigate ambient noise in the PACU by producing sound waves that neutralize background sounds. This technology not only minimizes sensory overload and cognitive strain but also ensures that the maternal voice is transmitted clearly to the child, significantly enhancing the calming effect

our subgroup analysis included children aged 5–12 years. The intervention in Group O was effective across both age groups, with greater effectiveness observed in the older subgroup (9–12 years). In contrast, the intervention in Group A was only effective in the younger subgroup (5–8 years), with no significant effect observed in the older children

The orientation intervention not only reduced EA but also expedited the overall recovery process. Both Groups O and A experienced quicker awakenings, shorter extubation times, and reduced durations in the PACU compared to Group C. This suggests that mitigating agitation not only improves behavioral outcomes but may also facilitate a more efficient physiological recovery

Citation

Wang Z, Wang X, Yang Y, He X, Jia W, Yao X, Sheng X, Jiao H. The effect of repeated maternal voice orientation on postoperative emergence agitation in children following tonsillectomy and adenoidectomy: A randomized controlled trial. J Clin Anesth. 2025 May 2;104:111851. doi: 10.1016/j.jclinane.2025.111851. Epub ahead of print. PMID: 40318514.

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