Clinicians should: identify the resources available to patients and families to allow for a smooth perioperative experience; understand the long-term effects and potential maladaptive changes associated with an anxiety-provoking perioperative period; understand the most common parental and patient concerns and misconceptions regarding surgery; understand the most common and up-to-date perioperative anesthesia practices; understand the indication for referral to the preoperative anesthesia clinic for patient evaluation to avoid unnecessary cancellation.Pediatricians are often tasked with preparing children and their families for the preoperative period and dealing with questions related to postoperative issues and concerns. Instruction based on current practice and new research and techniques may help patients and families cope with the stressors of surgery. Determining which patients may benefit from a medical or child life preoperative visit is of crucial importance.After completing this article, the reader should be able to:The period of time surrounding a planned surgical procedure can be tumultuous and anxiety provoking for both pediatric patients and their parents. The “mysterious place” that is the operating room often remains a mystery to many health care providers, including those tasked with caring for patients both before and after a procedure. As the health care provider most familiar to patients and their families, the pediatrician is in a unique position to allay many of the fears of a pending surgery, as well as initiate the perioperative preparation. This article provides a background for common pediatric operating room practices to refresh providers with the latest in pediatric perioperative care. The most commonly encountered parental and general concerns are presented as they relate to preoperative, intraoperative, and postoperative periods.The perioperative period can be a highly intense and anxiety-provoking period for children and parents, with more than 60% of children experiencing anxiety during this period. (1) More than 50% of children undergoing general anesthesia and surgery exhibit negative behaviors (eg, regression of milestones, tantrums, bed-wetting) up to 2 weeks after the procedure. In 20% and 7% of children, respectively, these behaviors persist at 6 months and 1 year. (2) Additionally, the degree of anxiety expressed by parents is directly related to the anxiety levels noted in children. (3)(4) Numerous studies have demonstrated a direct correlation between a child’s perioperative anxiety and the incidence of postoperative emergence delirium, increased analgesic consumption, development of maladaptive behaviors, and a slower, more painful recovery. (5)(6)(7) Deliberate patient and parental preparation may help to minimize anxiety and prevent untoward perioperative issues. Parents who received more preoperative information and preparation report lower anxiety levels surrounding the event than those who were unprepared. (8)Anesthesia practices vary dramatically between institutions. Certainly, it would be beneficial for pediatric providers to familiarize themselves with local practices, especially with respect to induction of anesthesia, allowing for the most accurate information based on regional practice. Tips and resources for surgical preparation are available in both English and Spanish to share with patients and families, free of charge. (9)(10)A common question from parents is, “Should I prepare my child for surgery?” Children, when prepared for what to expect before hospital visits and procedures, cope better emotionally during the hospital visit. (11) Children between the ages of 1½ and 3 years develop a sense of autonomy and a desire to complete tasks independently and maintain some control over their environment. In the hospital setting, much of their control is taken away, causing many patients to react by protesting and being noncompliant. (12) Providing age-appropriate choices can enhance their experience and encourage compliance (eg, choosing a flavor for the anesthesia mask). Fortier et al demonstrated that children aged 7 to 17 years have a strong desire to receive perioperative preparation, especially with respect to postoperative pain management. (8) Children were noted to have less anxiety with preoperative preparation, including children who had undergone surgical procedures in the past. (8) A great deal of research on recognizing the benefits of reducing perioperative pediatric anxiety and stress has resulted in allocation of resources for perioperative emotional support, especially by child life specialists (CLSs).CLSs are part of the multidisciplinary health care team and promote positive coping skills to help minimize stress and anxiety in the hospital setting through education, procedural preparation, and play-based therapeutic activities. CLSs are a resource provided free of charge by the hospital for patients and their families.A CLS may be consulted to help provide developmentally appropriate preparation for surgery. CLSs use age-appropriate and specifically tailored preparation methods based on the child’s chronological and developmental age, anxiety levels, and prior hospital experiences. The medical procedure is described in terms of the child’s sensory experience (including all 5 senses) and sequence of events. Medical equipment may be used for demonstration while encouraging the child to handle and explore the equipment, promoting understanding, comfort, and familiarity, as well as an opportunity to demystify the encounter. Together with the parents, a plan is composed for effective coping strategies during the procedure. The CLS may also accompany the child to the operating room or procedure to provide a consistent and nonthreating presence.Parents may choose to schedule an appointment with the child life department prior to the day of surgery. The CLS can provide appropriate information in advance to clarify many of the child’s misconceptions (Table 1). The CLS may also provide a tour of the surgical facility or procedural area (eg, the magnetic resonance imaging [MRI] room) to allay fear of the unknown for both child and parent. In some institutions, a mock operating room may be available to allow the child to simulate his or her role on the day of the procedure (Figure 1). After preparation, the CLS will encourage the child and family to ask questions and express feelings while determining if a formal plan for anxiety management is appropriate.For children with anxiety beyond the normal range for their developmental level, the CLS can provide alternative interventions, such as distraction with play, watching a movie, listening to music, or involving the child in conversation to divert their attention from the hospital setting. Children with chronic illnesses and those requiring staged surgeries may benefit from an ongoing relationship with a particular CLS to provide consistency and continued strategies for anxiety reduction and coping.Hospital visits can be stressful for anyone, and this holds especially true for children with autism. Traversing the crowded facility and meeting a host of unfamiliar people can be particularly difficult and even traumatic for these children. For children with autism, the stress of going to the hospital is heightened because of their sensory sensitivities, speech and social deficits, and need for routine. In addition to the environmental sensitivities, not being able to eat or drink for a period of time can add to their stress levels.Many hospitals provide services to adapt and modify the perioperative processes that help to minimize stressors or triggers for children with special needs, including autism. Parents should be instructed to communicate specific needs (eg, low-stimulation room) and past anesthetic experiences ahead of time to facilitate a smooth and uneventful perioperative experience. At many pediatric institutions, a parent questionnaire is administered to gather detailed information about the child’s triggers, stressors, preferred ways of communicating, and preferred mode of comfort. By using this questionnaire, the multidisciplinary team can develop a coping plan to customize the surgical process to the child’s individualized needs. When appropriate, providers can instruct parents to contact the hospital, including child life and or anesthesia departments, prior to the day of surgery.For certain procedures (eg, MRI) and in patients who are appropriately cooperative, distraction techniques can be used, which obviate the need for general anesthesia. (13)(14) Distraction techniques have been used to mitigate procedural distress that may be associated with long-term maladaptive effects, including behavioral changes and emotional issues (eg, nightmares, separation anxiety, eating problems, and increased fear of physicians). Distraction is designed to shift attention from procedure-related pain and can be in the form of cognitive techniques (eg, counting, listening to music, non–procedure-related talk) or behavioral techniques (eg, breathing techniques, emotive imagery, reimagination of pain). (15) The theorized mechanism of action for distraction is based on the brain’s limited immediate processing capacity to process stimuli and by “distracting” the brain (ie, with music). By doing so, there is reduced ability to focus on and process other stimuli, such as pain. Distraction for procedural relaxation is guided by the patient’s emotional maturity, with younger children often responding better to task-oriented distractors (eg, use of interactive devices or video games), whereas older children can use breathing strategies and reimagination of pain.A meta-analysis of distraction in children showed that the use of distraction techniques during painful procedures resulted in a significant decrease in self-reported pain and behavioral measures of distress. (16) Specifically, audiovisual distractors have proven successful in reducing distress for children who are undergoing painful procedures. (17)(18)(19) Active distraction strategies, such as music and engaging with interactive technologies, including tablet devices and video goggles, have been shown to decrease procedural distress and pain scores, all while increasing procedural tolerability. (20)(21)(22)(23) The choice of distraction method is based on the child’s developmental age and cognitive ability, while considering the practicality of use for the specific procedure. (15) The plan for distraction and child preparation should be discussed with family and may be best performed with the assistance of a CLS. (13)Since not all hospitals have readily available devices, parents may be instructed to bring these items on the day of surgery (eg, a tablet, gaming devices, or headphones). Use of these devices may also be helpful in distracting a child who does not understand the nil per os (nothing by mouth) guidelines. With the implementation of technological devices, such as video goggles, children can choose their own videos as a distraction during the MRI session (Figure 2).When assessing a child preoperatively or ordering an MRI, cooperative age and developmentally appropriate children should be considered for scheduling without anesthesia in centers in which this technology is used. Avoidance of anesthesia precludes the nil per os time, reduces distress related to anesthesia, and prevents the ill effects of pharmacological agents. One caveat to suggesting avoidance of anesthesia is for children who require MRI with contrast material, for which an intravenous (IV) catheter must be placed while the child is awake.The American Society of Anesthesiology has imposed strict nil per os guidelines for nonemergent cases that require general anesthesia, which serves as a great source of concern for parents preoperatively. Current nil per os guidelines can be found in Table 2. (24) Generally, younger patients are preferentially scheduled early in the day. To avoid dehydration, especially in young children, parents can be advised to provide clear liquids on the morning of surgery, 3 hours prior to their scheduled procedure. Children who are breastfed can be fed at a defined interval prior to their surgery or, alternatively, a solution that contains glucose (eg, Pedialyte; Abbott Laboratories, Abbott Park, Illinois) may be substituted. Numerous studies in adults have demonstrated the benefits of providing carbohydrate-rich drinks to patients preoperatively and showed consistently decreased anxiety, hunger, malaise, and thirst, without any evidence of increasing gastric volumes. (25) In situations of unforeseen delays, parents should serve as advocates and inquire about allowing clear liquids to be given. Avoidance of prolonged nil per os times has been associated with improved postoperative outcomes, decreased postoperative nausea and vomiting, reduced recovery stays, and greater patient satisfaction. (26) However, children with certain conditions (eg, polycythemia, sickle cell disease) may receive preoperative IV fluids or solutions that contain dextrose solutions, as indicated by their disease process.Aside from usual surgeon referral to the perioperative anesthesia clinic, a perioperative evaluation may be initiated by the pediatrician or the patient’s family. The perioperative clinic assessment best allows for coordination of patient care and reduces the likelihood for procedure delays or cancellation on the day of surgery. Assessment of the patients’ medical optimization prior to surgery is performed, as well as identification of the need for additional workup or subspecialty recommendations. Examples of situations where subspecialty recommendations would be indicated might include any organ system and could range from hemophilia to a metabolism plan for a patient with an underlying inborn error of metabolism. General conditions that require consideration for preoperative referrals to the perioperative anesthesia clinic are summarized in Table 3. The preoperative assessment aids in facilitating postoperative disposition planning and multispecialty care coordination. The perioperative clinic, in conjunction with the anesthesiologist, will indicate the appropriate venue for the surgical intervention (eg, the main operating room vs an outpatient surgical center). Inappropriate surgical site scheduling is an avoidable cause of day of surgery cancellation that may be prevented, given appropriate preoperative evaluation.In addition, parents may request evaluation by the perioperative anesthesia clinic, especially in cases of past family or personal history of surgical or anesthesia-related complications. Patients with a family history of severe reactions to anesthesia (eg, malignant hyperthermia) and those with myopathies should also be considered for evaluation.Not uncommonly, parents arrive on the day of surgery expecting additional procedures that are unanticipated and not previously scheduled (ie, “The neurologist said the next time my child has anesthesia, he should get an MRI”), which can result in dissatisfaction. The pediatrician and/or parent should communicate these needs or schedule a visit to the preoperative clinic so that arrangements for combined procedures may be facilitated in advance.Despite being one of the most common reasons for preoperative cancellation in children, guidelines for the management of perioperative upper respiratory infections are lacking. (27) The variability in practice for patients with upper respiratory infections stems from the heterogeneity in both patient symptoms and comfort level of the anesthesia provider. Elective surgical procedures are nearly universally cancelled for patients who are acutely ill. The gray area consists of patients with mild symptoms, especially those scheduled for potentially beneficial surgery (eg, ear tube placement for chronic otitis media or adenotonsillectomy for recurrent tonsillitis) and patients who are recovering from illness. Common considerations amongst anesthesiologists for determining procedure cancellation include temperature (>100.4°F [>38.0°C] and certainly >100.9°F [>38.3°C]), abnormal lower respiratory auscultation findings, productive cough, copious airway secretions, purulent mucus production, and reduced room air oxygen saturation. (28) Procedures scheduled at outpatient locations may influence the decision to proceed with surgery, as the ability to admit the patient postoperatively is not plausible. While an increase in overall respiratory adverse events in children with recent or active upper respiratory infections exists, the incidence of clinically significant respiratory complications is not greater and does not preclude anesthesia. (27)(28)(29) When in doubt, instruct the parent to contact the preoperative clinic or the surgeon’s office directly (during business hours) or the anesthesia provider on call (if after hours via the hospital operator) to determine if the procedure should be preemptively cancelled to avoid unnecessary arrival at the hospital with a sick child.Despite being one of the most common childhood illnesses, there are no formal consensus guidelines for the preoperative management of asthma. (30) While there is an increased risk of laryngospasm and bronchospasm with anesthesia in patients with reactive airway disease, it rarely precludes safe anesthetic administration. (31) In general, patients with moderate to severe asthma should be considered for a preoperative evaluation; recommendations from their managing provider should be obtained. Patients with more clinically significant asthma may not be appropriate candidates for surgery in the outpatient setting.The general recommendation is for the patient to continue the medication regimen or advance 1 level on their asthma action plan. Those using β-agonists as needed are often instructed to use their inhalers daily for 2 days before surgery, on the morning of surgery, and continue after surgery as needed. (32) Patients should bring their inhalers on the day of surgery. Pulmonary function tests performed specifically for preoperative assessment are generally unnecessary. Patients with poorly controlled symptoms should be optimized prior to scheduling elective surgery.In general, obstructive sleep apnea (OSA) in children is multifactorial, with a greater incidence of non–obesity-related obstruction than in adults. Preoperative evaluation for children with severe OSA (most often due to adenotonsillar hypertrophy) is variable with respect to polysomnography. (33) While polysomnography is not indicated as a perioperative test, some ear, nose, and throat surgeons will obtain these data for help in postoperative disposition planning. Children with severe OSA are at high risk for postoperative apnea or hypopnea, which does not immediately improve with tonsillectomy. These children are often sensitive to opioids and other sedatives with respect to respiratory depression. Patients at high risk are often admitted for observation and continuous pulse oximetry. The criteria for determining the procedure location and postoperative disposition at The Children’s Hospital of Philadelphia are highlighted as an example in Table 4; however, these criteria vary by institution.With the increase in childhood obesity, many children are using home continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) machines. Other indications for preoperative CPAP use include children with neuromuscular disorders and those with tracheostomies. Obtaining the patient’s baseline CPAP or BiPAP settings is helpful in planning a perioperative ventilation plan, as are the results of the patient’s previous polysomnogram, specifically the apnea-hypopnea index and saturation nadir. Generally, children with CPAP or BiPAP use should be considered for evaluation by the perioperative anesthesia clinic, as well as instructed to bring their home CPAP machine on the day of surgery. These patients are generally not appropriate candidates for procedures at the outpatient surgical center, as they are often kept overnight for monitoring. Regional anesthesia may be beneficial in select patients to decrease the opioid-induced respiratory depression.Indications for the administration of perioperative antibiotics, specifically for the prophylaxis of infective endocarditis, have changed dramatically over the past 20 years. (34)(35) Routine administration of antibiotics for genitourinary or gastrointestinal procedures is no longer recommended for the sole prevention of infective endocarditis. Additionally, antibiotic administration is recommended for patients deemed to be at high risk for the development of infective endocarditis (past endocarditis). Patients with congenital heart disease that required infective endocarditis prophylaxis should be considered for preprocedural evaluation by a cardiologist and/or the anesthesiology preoperative clinic.The method by which the pediatric patient is ushered into the operating room varies by institution. Induction of anesthesia is reported to be the most psychologically challenging time for the child during the perioperative period. (3) Children without IV access undergo induction of anesthesia by using inhalational gases. At some institutions, a parent (generally only one) is allowed to accompany their child to the operating room during the time of mask induction. While this process is not painful, parents should be informed that children often cry because of the unpleasant smell of the gas and their lack of control of the situation. Additionally, strange eye movements (nystagmus) and nonpurposeful limb movements are often observed, which, while expected, may be psychologically traumatic for parents. While favorable amongst parents, parental presence at induction has not been shown to alleviate anxiety in children. (36) Alternatively, patients may be given premedication, most commonly oral midazolam or IV midazolam, if IV access exists. A common misconception by parents is the thought that their child will be anesthetized prior to leaving them. While many children will become relaxed and even sleep, the goal of premedication, especially with midazolam, is to induce amnesia. Anxiolysis and amnesia are especially important for children who require multiple future interventions.Use of premedication has been shown to be most effective at reducing patient anxiety when compared with parental presence and should be considered, especially in cases with highly anxious children or parents. (12) Premedication with midazolam has also been shown to reduce poor cooperation with induction of anesthesia, as well as appearance of postoperative behavioral changes. (12) In contrast, parental presence, while viewed positively amongst parents, has not been shown to be as beneficial for the child. (12)(37)A common and avoidable “surprise” amongst parents for which they are unprepared is the required overnight stay for neonates after anesthesia. While institutional policies on postoperative discharge vary, there is generally a required overnight observational period where neonates are monitored for apnea after undergoing anesthesia. The basis for this is data from the meta-analysis by Coté et al, who demonstrated an increase in postoperative apnea in children on the basis of postconceptual age, as well as neonates with anemia (hematocrit level <30%). (38) At Texas Children’s Hospital, term neonates younger than 4 weeks and preterm neonates younger than 52 weeks’ postconceptual age are monitored overnight for apneic events. The monitoring period at The Children’s Hospital of Philadelphia is extended until 60 weeks’ postconceptual age.One of the most common anesthesia-related issues is postoperative nausea and vomiting, which serves as a substantial cause of patient dissatisfaction. Postoperative nausea and vomiting may last as long as 24 to 48 hours after surgery and may be exacerbated by the use of opioids postoperatively. Nausea and vomiting for durations longer than 48 hours after surgery should raise suspicion for other causes, including surgical and/or medication-related issues.Commonly attributed risk factors include previous postoperative nausea and vomiting; motion sickness; ear, nose, and throat procedures; strabismus surgery; gastrointestinal and genitourinary procedures; age older than 3 years; female sex; dehydration; opioid use; and use of inhalation agents. (39) Concerned parents should alert their anesthesiology provider about a past history of postoperative nausea and vomiting so that prophylactic agents may be pre-emptively administered and/or triggering agents prophylactically avoided. (40) High-risk children can be instructed to consume clear liquids up to 2 hours prior to surgery. Prophylactic scopolamine patches, while infrequently used in pediatric patients, can be placed on the morning of surgery and may be appropriate for older children and adolescents.A less frequently encountered postoperative concern is hoarseness. Most often, hoarseness is self-limited and caused by irritation of the vocal cords or surgical manipulation itself (eg, ear, nose, and throat procedures). In extremely rare cases, vocal cord or arytenoid cartilage damage has been reported after anesthesia. Injury to the recurrent laryngeal nerve during neck surgery (eg, thyroid surgery) and, more commonly, after cardiac surgery (eg, patent ductus arteriosus ligation) may result in hoarseness. Prolonged duration of hoarseness (>1–2 weeks) that does not abate with conservative treatment may necessitate a dynamic vocal cord evaluation by an otolaryngologist.Postoperative emergence delirium is an anesthetic-induced phenomenon that can be potentially self-injurious to patients and traumatic for parents to observe. (41) The incidence of emergence delirium varies greatly in the literature on the basis of the criteria for diagnosis but occurs in approximately 12% to 18% of children and is related to the patients’ age, the surgical procedure, and the anesthetic type. Emergence delirium occurs after exposure to inhalation agents (eg, sevoflurane) and manifests with uncontrolled and erratic behavior, flailing, and a state of delirium, at which time the child is dissociated from his or her surroundings. Emergence delirium is self-limiting; however, during the time of delirium, the patient is at risk for self-injury and disruption of IV lines, surgical drains, and dressings. (7) Emergence delirium is generally “treated” by allowing passage of a brief period of time, but administration of medications returning the patient to the hypnotic state (propofol, dexmedetomidine, midazolam) may be attempted. The occurrence of emergence delirium is likely to result in poor parental satisfaction with the perioperative experience. (42) Therefore, aside from treating the patient, it is important to address parental concerns after an episode of emergence delirium, as it can be traumatizing for a parent to witness. Providers should reassure parents that emergence delirium is self-limiting and a “normal” phenomenon that may occur after anesthesia and does not preclude the patient from receiving future anesthetic.It is well known that after surgery, children may exhibit new-onset maladaptive behaviors and milestone regression. Described in up to 50% of children postoperatively, these behaviors include anxiety, enuresis, nighttime crying and/or night terrors, separation anxiety, and temper tantrums. (5) Increased levels of preoperative anxiety and presence of emergence delirium have been noted to increase the incidence of postoperative maladaptive behaviors. (3) Patients identified to be at risk for developing postoperative maladaptive behavior may be advised to request a premedication from the anesthesia provider to reduce preoperative anxiety.A major area of concern amongst parents is the question of neurodevelopmental effects of anesthesia drugs. With recent national media attention, parents frequently inquire about the effects of anesthesia on their young children. In December 2016, the United States Food and Drug Administration issued a warning against the prolonged and repeated use of anesthetics for longer than 3 hours in duration in children younger than 3 years of age. (43) Thankfully, while most anesthetics in children are far shorter in duration, this is certainly a concern shared by many parents and providers. At present, studies in animals are concerning for the development of neuroapoptosis after prolonged exposure to inhalation agents. Prospective neurocognitive development studies in children are ongoing, to attempt to conduct long-term neurodevelopmental analysis. Most studies, but not all, have thus far failed to solidify these findings in humans. Exposure to single and short-duration anesthetics prior to the age of 2 years did not demonstrate increased risk of learning disabilities. (44) A recently published landmark study on neurodevelopmental outcomes in anesthesia reported no evidence of adverse neurological outcomes by the age of 2 years after a single hour of anesthesia during infancy. (45) While it may be advisable to delay completely elective surgical procedures (eg, circumcision) until completion of these studies, most pediatric surgery that is longer than 3 hours in duration is medically necessary (eg, craniofacial and cardiac surgery). Single anesthetics of short duration in children under the age of 3 years has not been proven to result in long-term neurodevelopmental effects. Consensus statements regarding the safety of anesthetics in children are available for providers and parents from the SmartTots organization. (46) Certainly, pediatricians are in a unique position to discuss these concerns with parents and consider the potential risks of anesthetics when ordering certain tests. (47) Concerned parents should be advised to discuss this with the surgeon and/or contact the anesthesiology department prior to the day of surgery.A major concern of parents is safely administering opioids to their children after they leave the hospital. (48) Despite many pediatric patients experiencing moderate to severe pain after postsurgical discharge, there is substantial variability in the information provided to parents regarding analgesic dosing. (49)(50) While parents can generally assess their child’s pain, there is lack of understanding regarding the effectiveness of analgesics, which often leads to undertreatment of pain. (11)(51)(52) Many parents report using less than the prescribed dose of opioids, switching to a less potent analgesic, or administering medication only for severe pain. (11)(50)(51)(52)(53) Untreated acute postoperative pain is a main risk factor in the development of chronic pain in children. (54)(55) Parents worry about side effects from opioids and the potential for addiction with exposure to these medications. (53) Opioids, which are given for a short duration and as prescribed, along with multimodal analgesia (eg, acetaminophen, ibuprofen) and nonpharmacological modalities where appropriate (eg, ice or heat, massage, distraction, relaxation) should adequately treat acute postsurgical pain. Additionally, this may help to prevent chronic pain and maladaptive pain syndromes and may aid in mobility and recovery postoperatively. In addition to the use of multimodal analgesia, improvements in postoperative pain management are also likely to occur with providing standardized written discharge instructions with respect to pain management and using surgery-specific pediatric analgesia guidelines when available. (56) When used appropriately in these settings, the concern for addiction postoperatively is extremely low. Persistent postsurgical pain, present despite treatment after an adequate time to allow for surgical healing (dependent on the surgical procedure and preoperative factors such as presurgical pain), should prompt evaluation by the surgeon. Untreated or inadequately managed pain may result in the development of behavioral and psychological consequences, as well as development of chronic pain. (53)(54) One opioid, however—codeine—is no longer recommended for use in children, especially after surgical procedures. (57) Evaluation of postoperative codeine-related fatalities has allowed identification of some patients to be “rapid metabolizers” of codeine. As dispensed, codeine is an inactive prodrug that requires metabolism to the active form, morphine. In some patients, genetic variability results in upregulation of cytochrome CYP2D6, which leads to a more rapid conversion of codeine to morphine, resulting in an effective overdose and the ensuing adverse effects (respiratory depression). (57)Keeping children safe and comfortable at home is a challenge and concern of parents in the era of widespread addiction and abuse, especially given that the risks for prescription opioid abuse are highest in adolescents and young adults. (58) Aside from the risk to the patient, the presence of unsecured and unsupervised opioids in a home with teenagers places highly addictive and potentially deadly medications within reach of these at-risk adolescents. (58) Additionally, unused and unsecured prescription opioids could be fatal if ingested by toddlers or young children.Evaluation of the epidemic of nonmedical use of prescription opioids has shown that many adolescents and young adults have used and/or abused prescription pain medications dispensed by medical providers (often prescribed for a family member or friend but also kept in the home because of medications being unused). (58) These unused (and unsecured or unsupervised) opioid medications that remain after surgical recovery pose a danger of accidental ingestion for very young patients and deliberate experimental ingestion in adolescents. Providers should instruct their patients and families about the safe disposal of these unused and unneeded medications. In 2010, the Drug Enforcement Administration (DEA) started a national drug “Take Back” campaign as a temporary means of collecting medications while legislative and regulatory action was being considered to develop more permanent and accessible disposal methods. DEA regulations allow registered law enforcement officials (eg, local law enforcement personnel) to take possession of and destroy controlled substances at any time. Whereas national “Take Back” days occur infrequently (biannually), permanent drug donation boxes serve as a means by which medications can be disposed of in a consistently accessible manner. Regional drop boxes are often available at police stations, and individual pediatrician offices should learn their locations. Additionally, mail-back programs are widely available, and materials can be purchased at local pharmacies or made available to patients in the office for a minimal fee (Figure 3). The DEA and the Food and Drug Administration have discouraged discarding unused or unneeded medications by flushing these down the toilet, as new and expanding evidence has demonstrated the environmental effects, specifically contamination of the water table. Patients and their families should be instructed not to flush or discard their medications but to call their local city or county government household trash and recycling service and ask if a drug take-back program is available in your community. Some counties hold household hazardous waste collection days, where prescription and over-the-counter drugs are accepted at a central location for proper disposal.If no hazardous waste collection program is available, the Environmental Protection Agency recommends the following steps for household drug disposal: (a) Take your prescription drugs out of their original containers. (b) Mix the drugs with an undesirable substance, such as cat litter or used coffee grounds. (c) Put the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag. (d) Conceal or remove any personal information, including prescription number, on the empty containers by covering the information with a permanent marker or duct tape or by scratching it off. (e) The sealed container with the drug mixture and the empty drug containers can now be placed in the trash. Information sheets from the U.S. Environmental Protection Agency on safe and proper medication disposal are available for distribution to your patients. (59)The perioperative period can be daunting for pediatric patients and families and can lead to anxiety and potentially maladaptive postoperative behavioral changes. Clinicians who can provide up-to-date and accurate information regarding perioperative issues from technical and emotional preparation to answering postoperative concerns may help allay these fears while addressing concerns appropriately.To view teaching slides that accompany this article, visit http://pedsinreview.aappublications.org/content/39/1/13.supplemental.