Banca de DEFESA: ISABELE GOUVEIA MUNIZ DE ALENCAR

Non-pharmacological therapies for pain management in pediatric and neonatal intensive care units: a scoping review update

Pain Management; Pediatric Intensive Care
Units; Complementary Therapies; Music Therapy;
Music; Evidence-Based Nursing; Scoping Review.

MUNIZ, I.G. Non-pharmacological therapies for pain
management in pediatric and neonatal intensive care
units: an updated scoping review. 2026, 145p. Thesis
(PhD in Nursing in Health Care) — Health Sciences
Center, Federal University of Rio Grande do Norte,
Natal, 2026.
Introduction: Pain in children admitted to the Pediatric
Intensive Care Unit (PICU) is a complex and prevalent
clinical phenomenon, even when pharmacological
protocols are in place. Evidence on non-pharmacological
therapies (NPTs) in this setting remains fragmented and
insufficiently systematized. Objective: To map NPTs
used for pain management in the PICU, identifying

patterns, advances, gaps, and implications for evidence-
based nursing practice. Method: This thesis was

structured in three stages: (1) a scoping review protocol,
prospectively registered on the Open Science Framework
(DOI: 10.17605/OSF.IO/DZHKT) and published in BMJ
Open (2024); (2) a scoping review conducted using JBI
methodology and reported according to PRISMA-ScR
guidelines, with a comprehensive search of nine
electronic databases (PubMed/MEDLINE, CINAHL,
Embase, Scopus, Web of Science, LILACS, Academic
Search Premier, ScienceDirect, and the Cochrane
Library) and grey literature, with no language
restrictions; and (3) an update of the scoping review.
Data were organized using the PAGER framework
(Patterns, Advances, Gaps, Evidence for Practice and

Research Recommendations). Ethical aspects: This
study used publicly available secondary data and was
exempt from ethics committee review (Brazilian
Resolution CNS No. 510/2016). The protocol was
prospectively registered. No conflicts of interest were
declared. Main results: The original scoping review
included 28 studies from 780 records; the update
included 56 studies from 1,002 records. Music-based
interventions (recorded classical music, live music
therapy, and recorded maternal voice) were the most
frequently reported NPTs, with sessions ranging from 10
to 60 minutes. Also identified were acupuncture,
massage, therapeutic touch, aromatherapy, guided
imagery, hypnosis, storytelling, virtual reality,
positioning, and parental presence. Most studies reported
reductions in pain scores (FLACC, Revised FLACC,
COMFORT-B, Wong-Baker FACES, Numeric Rating
Scale). Recurring limitations included protocol
heterogeneity, lack of outcome standardization, small
sample sizes, and co-administration of sedatives.
Evidence on mechanical ventilation duration and length
of stay was inconclusive. PAGER analysis revealed
underrepresentation of low- and middle-income
countries, limited integration of NPTs into care protocols,
and a critical conceptual gap: recorded music and live
music therapy were indiscriminately grouped under the
generic term "music interventions," compromising the
interpretability of findings. Conclusion: NPTs are
feasible and potentially beneficial as adjuncts to analgesia
in the PICU. Robust clinical recommendations require
methodological standardization and multicenter trials.
The primary contribution of this thesis is making explicit
the distinction between live music therapy and recorded
music — non-interchangeable modalities whose
conflation undermines the validity of evidence syntheses
and clinical decision-making. Research outputs: The
protocol was published in BMJ Open (2024), ensuring
traceability and reproducibility. This thesis strengthens
the theoretical and practical framework of pediatric
critical care nursing, with applications to the NANDA-I
classifications (Acute Pain 00132; Impaired Comfort
00214; Anxiety 00146), NIC (Music Therapy 4400), and
NOC (Pain Control 1605; Comfort Level 2100; Anxiety
Level 1211). Social impact: This research aligns with

SDG 3 (Good Health and Well-Being) of the 2030
Agenda, particularly target 3.8. By mapping feasible,
low-cost NPTs, it contributes to reducing unnecessary
suffering in critically ill children across different
socioeconomic contexts. Distinguishing between
modalities of varying complexity and cost promotes
equitable adoption of these strategies. The findings
reinforce children's right to dignified, family-centered
care and support the development of evidence-based
policies and protocols for pediatric critical care.