Copyright © 2020 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.BACKGROUND: Pre-operative anxiety in children has been associated with adverse clinical outcomes such as difficulty in anaesthesia induction, emergence delirium and negative postoperative behavioural changes. Therefore, pre-operative anxiety should be alleviated in both children and clinicians. OBJECTIVE: We investigated the effect on pre-operative anxiety of premedication with midazolam, playing video games or watching a cartoon about anaesthesia. DESIGN: A prospective randomised trial. SETTING: Single-centre study performed between August 2018 and June 2019. PATIENTS: We enrolled 138 patients aged 5 to 8 years undergoing elective surgery. INTERVENTIONS: After evaluating baseline (T0) anxiety levels using the modified Yale Pre-operative Anxiety Scale (mYPAS) in the pre-operative holding area, 0.5 mg kg-1 oral midazolam was given to Group M, a tablet with videogame applications was given to Group T, and Group S watched the cartoon 'Şüko Is Being Operated'. mYPAS values were recorded a further three times: 20 min after the intervention (T1), while entering the operating room (T2), and during mask induction of anaesthesia (T3). MAIN OUTCOME MEASURES: The primary endpoint was the change in children's anxiety levels from baseline. The secondary endpoint was cooperation during mask induction. RESULTS: The baseline mYPAS scores were comparable (40.7, 42.6 and 40.7 in groups M, S and T respectively). The mean mYPAS scores at T1 were 32.6, 34.7, 26.8 and at T2 were 38.6, 42.7, 35 in groups M, S and T, respectively. There were significant differences between groups S and T at T1 and T2 (P < 0.001, P = 0.010). A significant decrease was found in Group T compared with both groups M and S from T0 to T1 (P = 0.002). mYPAS values at T3 were 38.3, 43.7, 39.5 in groups M, S and T, respectively, with no difference between the groups (P = 0.224). Mask acceptance scores were similar in all groups (P = 0.912). CONCLUSIONS: The passive teaching technique of watching a video for reducing anxiety levels was not effective. However, active distraction with videogames was found to be a valuable method to reduce pre-operative anxiety. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03530670.