Introduction
The World Health Organization (WHO) identifies complementary and alternative medicine (CAM) as medical systems, practices and products that are separate from conventional medicine [1]. The national center for CAM describes CAM as a group of medical systems, practices, and products that are not normally found in conventional medicine [2]. This center categorizes complementary and alternative medical practices into five areas: Alternative medical systems, mind-body therapies, biologically based therapies, and manipulative and body-based therapies. Each area offers distinct therapeutic modalities, including traditional Eastern medicine, acupuncture, Ayurveda, naturopathy, and homeopathy [3], [4, 5]. Popular CAM therapies include acupuncture, aromatherapy, yoga, and herbal supplements [6]. 
In various countries, the use of CAM among children is prevalent, particularly for managing chronic illnesses and enhancing quality of life. For example, 6% to 91% of children with cancer globally report using CAM [7, 8]. Research on children’s CAM use in Europe shows 56% used traditional and complementary medicine [9], while surveys conducted in Turkey revealed that traditional and complementary medical treatments were used by 56.5% to 87% of children [10]. Studies from Australia [11], Switzerland [12], and Saudi Arabia [13] suggest that using CAM is prevalent for addressing various health conditions. In Iran, CAM is particularly significant due to cultural influences that encourage traditional and herbal remedies [14]. However, despite its widespread use, CAM practices are often not disclosed to healthcare providers, either due to beliefs in the harmlessness of these treatments, fear of medical disapproval, or assumptions about healthcare providers’ limited knowledge of CAM [15]. 
The rationale for this review is to address the limited research on CAM use specifically among Iranian pediatric populations. Although studies indicate that CAM use is high among children in Iran [16], especially for chronic conditions, comprehensive data on the forms of CAM used, reasons for use, and perceived efficacy are lacking. This gap highlights the need for a systematic review to consolidate and synthesize existing evidence. This review provides insights that can inform healthcare policy, guide educational efforts in healthcare training programs, and support healthcare providers in advising parents on CAM practices. Ultimately, this information may help optimize CAM use, prevent potential misuse, and improve pediatric care in Iran.

Methods
To comprehensively evaluate the evolving landscape of the use of CAM in the treatment of children’s diseases in Iran, a systematic approach was crucial, given the burgeoning literature in this area. We used the preferred reporting items for systematic reviews and meta-analyses checklist to ensure that the systematic review’s reporting was of high quality [17]. The checklist, which includes four sequential processes (identification, screening, eligibility and inclusion) and 27 elements, was intended to help writers perform more effective systematic reviews (Figure 1).
Research questions and objectives
Research question 1: What are the main types of CAM methods used in the treatment of children’s diseases in Iran?
Research question 2: What are the primary reasons for using CAM among pediatric patients in Iran?
The objective of this systematic review is to provide a comprehensive understanding of the various forms, uses, and perceptions of CAM in treating pediatric patients in Iran. By systematically evaluating the existing literature, this review aims to investigate the following items:
Identify and classify the CAM methods used for treating children’s diseases in Iran; assess the reasons for CAM use among caregivers and healthcare providers for pediatric patients; develop evidence-based recommendations to inform healthcare professionals, policymakers, and educators on integrating CAM safely and effectively within pediatric healthcare settings in Iran.

Search technique
An investigation was done into published clinical trials, observational, quasi-experimental and qualitative investigations from January 1, 2020, to January 3, 2023, in nine scientific research databases, namely PubMed, ScienceDirect, Wiley Online, Scopus, SciELO, LILACS and Google Scholar, as well as several Persian databases including Magiran and SID. The following keywords were used in English and Persian: ([“complementary medicine” OR “alternative medicine” OR “CAM” OR “integrative medicine” OR “traditional medicine” OR “herbal medicine” OR “acupuncture” OR “homeopathy” OR “cupping therapy” OR “massage therapy” OR “aromatherapy” OR “naturopathy” OR “spiritual healing” OR “larval practice” OR “music therapy” OR “reflexology”] AND [“pediatric” OR “child” OR “children” OR “adolescent” OR “infant”] AND [“Iran”] AND [“prevalence” OR “epidemiology” OR “frequency” OR “usage” OR “utilization” OR “incidence”]). The initial search yielded 865 articles, out of which 808 were removed for not meeting the inclusion criteria, leaving 26 articles for analysis. 

Inclusion criteria
Studies were eligible for inclusion criteria if they passed the following criteria: 1) Clinical trials, observational, quasi-experimental, and qualitative studies; 2) Use of any type of CAM; 3) Studies focused on children and adolescents under 18 years of age; 4) Published from January 1, 2020 to January 3, 2023; 5) Studies published in English and Persian and 6) Studies with a code of ethics. 

Exclusion criteria
The exclusion criteria were as follows: 1) Lack of access to full texts; 2) Individual case reports, systematic reviews, and meta-analyses and 3) Unrelated objectives. 

Quality assessment of the articles
A critical appraisal was performed according to the study design of the articles. The critical appraisal skills program was used for analysis. The critical appraisal skills program is a 10-item questionnaire with three possible answers: “Yes,” “no” and “cannot tell.” If ≥8 of the criteria on the checklist were met, the study was rated as “good” quality. If 5 to 7 were met, it was rated as “fair” quality. If < 5 were met, it was scored as “poor” quality. To ensure consistency and reliability in the critical appraisal process, two independent reviewers conducted the assessments. Any discrepancies in their evaluations were resolved through consensus, guaranteeing a thorough and unbiased analysis. Data were extracted from all papers that met the eligibility and inclusion criteria for the review. 

Data extraction
Two authors performed the literature search also independently followed the application of the inclusion and exclusion criteria and screened the studies based on the titles and abstracts. Adhering to the preferred reporting items for systematic reviews and meta-analyses checklist ensured a rigorous and transparent review process. The screening process was carried out for duplicates using EndNote software, version X7 (clarivate analytics). After initial screening, the full text of the studies was obtained and examined to ensure eligibility for the development of the data extraction table. Data was extracted from the final set of included full texts, encompassing information such as the first author, the year of publication, study design, purpose, sample size, participant demographics, study setting, type of CAM intervention, and duration of intervention, instruments and measurement time used and description of outcomes associated with CAM use (Table 1).











Results
Figure 1 presents an overview of the search strategy’s outcomes. Initially, 865 articles were identified and after removing 26 duplicates, 839 references remained. A total of 31 articles met the initial inclusion criteria based on their titles, abstracts, and full texts in both English and Persian. The inclusion and exclusion criteria were then carefully reviewed for the full texts of these 31 articles, resulting in the exclusion of five papers. Ultimately, 26 papers were included in our systematic review, and information was systematically extracted from each paper, as presented in Table 1 which includes data on trial intervention, study design, participant demographics, outcome measurements, follow-up timeline, and key findings. The studies included in this review were conducted in various pediatric wards and child and adolescent outpatient clinics. Of the 26 studies included, 18 were randomized controlled trials; additionally, one study used a quasi-experimental design [18]. Other clinical trial designs were used to benefit seven additional articles. 
The CAM therapies used in the included studies varied, with none of the articles utilizing energy therapy or CAM intervention. Six studies employed mind-body CAM interventions, including one relaxation method [19], one yoga [18], two congestive behavioral therapy [20, 21] and two music therapy [22, 23]. A total of 9 articles used a variety of manipulative method categories including the following items: Three acupressure [24-26], three reflexology [27-29] and four massage therapy [30]. Most of the articles (n=11) used biologically based therapies including the following items: 11 articles on herbal medicine in the form of oil, syrup, and topical. The 26 other publications also noted a significant impact of CAM therapies on patient improvement. The studies utilized a variety of CAM therapies, with notable findings on their effectiveness as follows.

Pain and anxiety reduction
The majority of articles (9 out of 26) demonstrated significant reductions in pain and anxiety among pediatric patients. CAM therapies such as acupressure, massage therapy, and herbal remedies were commonly used and consistently yielded improvements in comfort and emotional well-being.

Symptom management in attention deficit hyperactivity disorder
Four studies reported favorable outcomes in managing ADHD symptoms using mind-body CAM interventions such as yoga, relaxation methods, and cognitive-behavioral therapy. These therapies contributed to enhanced focus, reduced hyperactivity and improved behavioral control.

Management of other health conditions
 Regarding diarrhea and vomiting, two studies applied herbal and nutritional CAM therapies, which helped alleviate symptoms, contributing to faster recovery. Regarding respiratory distress syndrome, one study showed improvements in breathing and reduced distress in patients receiving herbal and massage therapy interventions. In terms of diabetes and gastrointestinal disorders, conditions such as diabetes, functional constipation, gastroesophageal reflux and nephritis syndrome saw improved symptom control and quality of life in individual studies through the use of dietary and herbal CAM interventions. regarding cancer and sleep disorders, CAM methods, including relaxation techniques and herbal treatments, were beneficial in managing sleep disorders, cancer-related symptoms and overall quality of life.

Biologically-based CAM therapies
The most frequently employed interventions were biologically-based, with herbal medicine featured in 11 studies in forms such as oils, syrups, and topical applications. Across these studies, herbal therapies were shown to alleviate symptoms, improve comfort and support recovery, especially in managing pain, anxiety, and gastrointestinal complaints.

Discussion
Our findings demonstrate that CAM use is widespread among Iranian children and adolescents, with a diverse range of modalities employed. Specifically, the most frequently utilized CAM methods identified in this review included herbal medicine (in the forms of oil, syrup, and topical treatments), massage therapy, reflexology, acupressure, music therapy, relaxation therapy, yoga and cognitive-behavioral therapy, respectively. Our results largely support those of previous Iranian studies [44, 45] which indicated that dietary supplements, prayer, and herbal medicines are the most commonly used CAM above 17 years of age. Similarly, Moeini et al. in 2021 have reported that in Babol, a major city in northern Iran, 30% of residents reported using herbs and herbal remedies in the previous year. The most often used techniques included music therapy, water treatment, herbal medicine, and Persian medicine [16]. These findings are consistent with those of other studies on this topic. Herbal therapy and natural products were the most frequently used treatments for children in Palestine [46], Turkey [47] and Saudi Arabia [48]. The main advantages of using herbal medicines were their ease of use, safety, satisfaction with symptom relief, and lack of concern about drug interactions [49]. Furthermore, Iranians favor herbal remedies, with manipulation body therapies like massage, reflexology, and body wrapping being the most popular CAM modalities, followed by biologically based therapies for postpartum mothers in Malaysia [50]. In contrast, in a study conducted in Brazil, acupuncture and homeopathy, as well as medicinal plants and herbal remedies, were the most frequently used CAM modalities among adult Brazilians [51]. The utilization of particular CAM modalities varies greatly across nations. These variations may be attributable to methodological issues as well as sociodemographic differences in CAM utilization among nations. This review reveals that participants most commonly used CAM modalities to alleviate pain and anxiety, which may be due to the high prevalence of pain and anxiety among children [52-54]. Similarly, Shaharban in 2022 reported that Reiki therapy is effective in controlling anxiety among children undergoing surgery [55]. These findings are consistent with those of earlier studies on this subject [56-58]. The study justifies CAM use for treating persistent illnesses like ADHD, diabetes, constipation, sleep disorders, cancer, and nephritis. Our discovery is supported by research by Pazoki et al. who found Saffron combined with Ritalin therapy can significantly reduce ADHD patients’ symptoms [59]. Another Iranian study found that practicing super brain yoga helped school-age children with hyperactivity disorder experience fewer symptoms [60]. Our results partly confirm the findings of a study in Iran [61], which reported that the quality of life of type 2 diabetic patients was improved by utilizing CAM. Additionally, some research has reported combining CAM techniques with traditional medical therapies. For example, according to Mofid et al., meditation practice lessens the weariness experienced by breast cancer patients receiving chemotherapy. As a result, in addition to medication, meditation is recommended for these individuals [5]. These findings concur with those of earlier studies on this subject [62, 63]. However, it is important to note that most of these applications are used by families without the knowledge of health personnel. While CAM techniques can have positive effects, they can also cause negative interactions [6]. Therefore, careful consideration is needed when choosing CAM techniques for children, as parents often have high expectations for treatment, including symptom relief and full recovery from illnesses like cancer.

Conclusion
This systematic review underscores the widespread use of CAM among Iranian children, with popular modalities including herbal remedies, massage therapy, acupressure, and mind-body practices for managing pain, anxiety, and conditions like ADHD. The strong cultural preference for herbal treatments highlights their perceived safety and effectiveness, though unmonitored use raises concerns about interactions with conventional treatments. Future research should focus on CAM’s safety and efficacy in pediatric care, establish guidelines for its integration into clinical practice, and explore the sociocultural factors influencing CAM use to better understand family preferences.

Study limitations
This study had several limitations. First, access to full articles was sometimes restricted by subscription-based journals, making it challenging to include certain studies in the analysis. Where possible, open-access articles and institutional library resources were used to gather comprehensive data. Additionally, the study was limited by inclusion criteria, heterogeneity of data, and a specific focus on research conducted within Iran, which may affect the generalizability of the findings to other cultural or geographic settings. Furthermore, inadequate reporting of conditions and outcomes in some of the included studies reduced their applicability to real-world settings, limiting the strength of our overall conclusions.

Ethical Considerations
Compliance with ethical guidelines
There were no ethical considerations to be considered in this research. 

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors contributions
All authors equally contributed to preparing this article.

Conflicts of interest
The authors declared no conflict of interest.


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