Comment on ‘Effectiveness of Nurse‐Led Interventions on Emergence Delirium in Pediatric Patients: A Systematic Review and Meta‐Analysis’

We read with great interest the systematic review and meta-analysis by (Fu et al. 2025). To examine the effectiveness of nurse-led interventions on emergence delirium in the ED of paediatric patients. The authors address a clinically significant and increasingly prioritised area in perioperative paediatric care and provide a comprehensive synthesis of evidence supporting the role of nurse-led, non-pharmacological strategies in mitigating emergence delirium and related outcomes. Beyond consolidating a heterogeneous body of literature, this review prompts an important reflection on how nurse-led interventions should be conceptualised, evaluated and implemented within contemporary paediatric perioperative practice. A notable strength of this review lies in its explicit framing of nurses as primary agents of intervention rather than ancillary contributors to anaesthetic or surgical care. By defining nurse-led interventions as those initiated, implemented and supervised by nurses across the perioperative trajectory, the authors implicitly advanced a professional model in which nursing judgement, continuity and relational care constitute core therapeutic mechanisms. This perspective is particularly relevant in paediatric emergence delirium, a condition shaped not only by pharmacological exposure but also by developmental vulnerability, environmental unfamiliarity and emotional dysregulation (Ul Huda et al. 2025). The aggregated reduction in delirium incidence and severity, preoperative anxiety and postoperative pain collectively reinforces the clinical salience of nursing-led approaches that address these dimensions. At the same time, the magnitude of heterogeneity reported across most pooled outcomes warrants careful interpretive caution, not merely as a statistical limitation, but as a signal of conceptual diversity within the intervention category itself. The included studies encompassed a wide range of strategies, including virtual reality exposure, parental presence, maternal voice recordings, distraction technologies and preparatory education. Although these approaches share a common nursing leadership component, they differ substantially in terms of intensity, timing, theoretical underpinnings and action mechanisms. Pooling such interventions under a single analytical umbrella risks obscuring the elements that are most influential for specific outcomes and developmental stages. From a clinical standpoint, distinguishing between interventions that primarily modulate anxiety, pain perception, sensory overload and attachment security is essential for targeted implementation. Relatedly, the review highlights an important dissociation between improvements in subjective or behavioural outcomes and the absence of measurable effects on post-anaesthesia care unit length of stay or anaesthesia induction compliance. Rather than interpreting these findings as evidence of limited effectiveness, it may be appropriate to question whether these operational metrics adequately capture the value of nurse-led interventions. The length of stay in the post-anaesthesia care unit is influenced by anaesthetic protocols, institutional discharge criteria and staffing patterns that may be only marginally responsive to changes in delirium severity. Similarly, induction compliance reflects a narrow temporal window that may not fully benefit from interventions delivered earlier in the perioperative period. These observations underscore the need to align outcome selection more closely with the mechanisms and timing of nursing interventions. This review also raises important questions regarding measurement consistency in paediatric emergence delirium research. Although the Pediatric Anaesthesia Emergence Delirium Scale predominates, several studies employ alternative instruments, each with distinct thresholds and behavioural emphases (Yang et al. 2025). Variability in scale selection and scoring practices complicates cross-study comparisons and may contribute to the high heterogeneity observed. More importantly, it challenges the assumption that emergence delirium represents a unitary construct across age groups and clinical contexts. Younger children, for example, may manifest distress through behaviours that overlap with normative developmental responses, whereas older children may express delirium in subtler cognitive or affective terms. Advancing the field will require greater consensus not only on measurement tools but also on age-appropriate operational definitions of emergence delirium. From an implementation perspective, the findings invite a deeper consideration of how nurse-led interventions can be sustainably integrated into routine practice. Many of the evaluated interventions required additional time, training or technological resources, such as virtual reality equipment or structured preparatory programs. Although the review affirms their effectiveness, it does not fully address the feasibility challenges faced by busy perioperative units, particularly in resource-constrained settings. Future research could benefit from explicitly examining implementation outcomes, including acceptability to families and staff, workflow integration and cost-effectiveness. Such data are critical for translating evidence synthesis into scalable practice changes. An additional contribution of this review is its implicit challenge to pharmacocentric models of delirium prevention. By demonstrating that nurse-led, non-pharmacological interventions can meaningfully reduce delirium incidence and severity, the authors reinforced a paradigm in which behavioural, relational and environmental modifications function as primary preventive strategies rather than adjuncts (Hoch et al. 2025). This shift has ethical and safety implications, particularly in paediatric populations, where off-label medication use and adverse drug effects remain concerns. However, advancing this paradigm will require a clearer articulation of how nurse-led interventions interface with anaesthetic decision-making and postoperative pain management protocols, ensuring that non-pharmacological and pharmacological strategies operate synergistically rather than in isolation. The international scope of the included studies further strengthens the review but also introduces contextual variability that merits closer examination. Cultural norms regarding parental presence, child autonomy and communication style may influence both the delivery and effectiveness of nurse-led interventions. Similarly, differences in nursing roles and scope of practice across health systems may affect intervention fidelity. Although the review appropriately synthesises outcomes across regions, future analyses exploring contextual moderators could enhance the understanding of how cultural and organisational factors shape intervention success. Importantly, this review advances the professional visibility of nursing research by positioning nurse-led interventions as evidence-based contributors to perioperative outcomes traditionally dominated by anaesthetic and surgical metrics. This positioning has implications for education, policy and interdisciplinary collaboration. Embedding these findings into clinical guidelines and training curricula could strengthen nurses' roles as leaders in delirium prevention and perioperative psychosocial care. Moreover, recognising nursing interventions as discrete, testable entities encourages more rigorous trial design and theory-driven intervention development. In conclusion, Fu et al. provided a timely and methodologically rigorous synthesis that affirms the effectiveness of nurse-led interventions in reducing paediatric emergence delirium and related outcomes. This review contributes substantively by consolidating evidence, elevating the conceptual role of nursing leadership and identifying gaps that warrant further investigation. Moving forward, the field would benefit from greater intervention specificity, harmonised outcome measurements, and explicit attention to implementation and contextual factors. Such efforts will ensure that the benefits of nurse-led interventions translate into consistent and equitable improvements in perioperative paediatric care. C.L. conceptualised the commentary, drafted the manuscript and serves as the corresponding author. G.G. contributed to nursing contextualisation, literature interpretation and manuscript review. All authors reviewed, edited and approved the final version of the manuscript. The authors have nothing to report. The authors have nothing to report. Generative AI tools were used solely for language refinement and formatting assistance. All scientific interpretation, critique and conceptual analysis were independently developed by the authors. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.