Background Acute pain management in children during the postoperative period is challenging. Poor pain management causes physiological changes and impacts on various systems that contribute to physical and psychological adverse effects. Objectives To evaluate the best available evidence related to the use and effectiveness of non-pharmacological interventions as an adjunct therapy to pharmacological interventions and the perceptions and/or pain behaviours in infants, children and adolescents who had undergone a major surgery. Inclusion criteria Types of participants This systematic review considered studies whose participants were children aged 0-19 years who received non-pharmacological pain management interventions before or after receiving a major surgery. Types of intervention(s)/phenomena of interest Non-pharmacological pain management interventions before or after receiving a major surgery. Types of studies This review considered any randomized clinical trials and quasi-experimental design studies. Types of outcomes The outcome measure of interest was pain assessment using measurement scales with established validity and reliability. This review considered any randomized clinical trials and quasi-experimental design studies. Search strategy The search sought to identify both published and unpublished studies between January 1990 and December 2011. The databases searched for published studies included: PubMed, CINAHL, EMBASE, Science Direct, ProQuest Dissertations and Theses, Medical Library, Cochrane Database, Blackwell Synergy, Journals@Ovid, EBSCO Host Research Databases, Thai Thesis Database, Digital Library of Thailand Research Fund, and Research of National Research Council of Thailand. Methodological quality Two reviewers independently assessed the methodological quality of all the articles using a standardized critical appraisal checklist developed by the Joanna Briggs Institute. Data collection Data were extracted from studies using a standardized data extraction tool from the Joanna Briggs Institute. Data synthesis Statistical pooling of results in meta-analysis was not appropriate, so the findings were summarized in narrative form. Results Eight of the nine studies included in this review indicated a significant positive effect of non-pharmacological pain management. Four interventions improved postoperative pain in both school-age and adolescent patients using guided imagery, parent-child-nurse mutual participation, foot massage and play activities. Touching the forehead, shoulder and the skin above the wound alleviated postoperative pain in school-age patients. Fowler's position alleviated postoperative pain in infant patients. Conclusions A combination of pharmacological and non-pharmacological interventions is usually effective in postoperative pain management. No single pain relief intervention is effective across ages or types of pain; therefore, nurses should select an appropriate non-pharmacological intervention for each patient. Implications for practice A pre-operative preparation session should be conducted with school-age and adolescent patients. Guided imagery and parent-child-nurse mutual participation are effective interventions to be used in these sessions for management of postoperative pain relief. In the postoperative care period, especially the first three days after surgery, play activities as a distraction strategy have proven to be effective for relieving pain and enhancing coping behaviors among school-age and adolescent patients. Positioning the patient in the Fowler's position could be used to relieve pain in infant patients. In addition, touching the forehead, shoulder and skin above the operative wound could be used for school-age patients and foot massages could be used for both school-age and adolescent patients. Implications for research The studies identified in this review only focused on infants, school-age children and adolescents. Additional research is needed to fully understand postoperative pain management in children of all age groups. Other non-pharmacological interventions such as thermal regulation, presence of parents, helping in daily activities, and creating a comfortable environment could be included in further studies.