Comparative efficacy of non-pharmacological interventions on emergency delirium in postoperative children: a systematic review and Bayesian network meta-analysis

Background: Emergence delirium (ED) is a distressing complication in pediatric patients following general anesthesia, often resulting in self-injury, extended hospitalization, and emotional distress for families. Although non-pharmacological interventions are being increasingly utilized, their effectiveness remains uncertain. Methods: We conducted a systematic review and Bayesian network meta-analysis. PubMed, EMBASE, Cochrane CENTRAL, and Web of Science databases were searched from inception to 17 November 2024, with an updated search performed on 24 July 2025. Randomized controlled trials (RCTs) evaluating non-pharmacological interventions in children (<18 years) undergoing general anesthesia were included. Studies involving pharmacological co-interventions were excluded. Two reviewers independently extracted data and assessed the risk of bias using the Cochrane Risk of Bias 2.0 (RoB 2.0) tool. Bayesian random-effects models were applied, and effectiveness of interventions was ranked using surface under the cumulative ranking curve (SUCRA) values. Results: A total of 56 RCTs involving 6183 pediatric participants were included. Among 37 non-pharmacological strategies, virtual reality (VR) and ice popsicles were the most effective in reducing ED [VR: risk ratios (RR) = 0.082, 95% credible interval (CrI) 0.010–0.311; ice popsicle: RR = 0.157, 95% CrI 0.057–0.388]. VR also ranked highest for postoperative pain reduction (standardized mean difference = −2.68, 95% CrI −3.47 to −1.88). For anxiety outcomes, parental active participation in anesthesia induction (PAPIA) was most effective in reducing children’s perioperative anxiety (SUCRA = 86.1%), while parental educational programs (EP) ranked highest for reducing caregiver anxiety (SUCRA = 78.3%). No intervention significantly improved compliance on the Induction Compliance Checklist. Conclusions: This Bayesian network meta-analysis provides low-to-moderate certainty evidence suggesting that VR and simple oral cold stimulation (ice popsicles) may reduce ED and early postoperative pain in children. PAPIA may modestly reduce children’s perioperative anxiety, while EP appears most effective in alleviating parental anxiety. However, no intervention demonstrated significant improvement in induction compliance.