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The primary purpose of this study was to compare the effect of active distraction to midazolam as a non-pharmacological method of reducing preoperative anxiety in preschool children. A secondary purpose was to compare emergence delirium, sedation/agitation, and length of stay between groups. Preschool children (N = 99) scheduled for elective surgery participated in this 2-group randomized controlled trial: the active distraction (tablet) group (n = 52) had unlimited playtime with a tablet and the midazolam group (n = 47) were medicated approximately 10 min before mask induced anesthesia. Data were collected using the modified Yale Preoperative Anxiety Scale, Pediatric Anesthesia Emergence Delirium scale, and Richmond Agitation Sedation Score. Length of stay (LOS) was measured in minutes from PACU admission to discharge. Wilcoxon rank sum, Pearson's chi square, and Fischer's exact tests were used in analysis. Preschool children (3–5 years old), predominantly male (61%) and White (85%) presented for ear, nose, throat, ophthalmology, urology, and general surgery at a pediatric surgical center within a large Midwestern hospital. There was no significant difference in anxiety, emergence delirium, or sedation/agitation scores between midazolam and tablet groups. Children assigned to the tablet group had shorter LOS (p = 0.021). Active distraction with a tablet as an anxiolytic was as effective as midazolam for pre-school aged children with no side effects and reduced length of stay. Preoperatively, non-pharmacological methods such as active distraction with a tablet should be considered for preschool children as an alternative to medication. • Preschool children are at high risk for preoperative anxiety. • Tablet is equally effective at reducing preoperative anxiety compared to midazolam. • Active distraction resulted in shorter length of stay. • Parents prefer their children have less medicine preoperatively. [ABSTRACT FROM AUTHOR]