Effectiveness and safety of Tuina massage therapy for paediatric fever: a systematic review and meta-analysis of randomised controlled trials

Abstract

Objective

To systematically analyse the efficacy and safety of Tuina massage therapy for paediatric fever.

Methods and results

A search was conducted across PubMed, Embase, Cochrane Central Register of Controlled Trials and China National Knowledge Infrastructure databases, and it retrieved relevant randomised controlled trials (RCTs) up to November 2023. Fifteen trials (1,661 pediatric patients) were included, focusing on Tuina massage and tepid water massage. Studies were excluded due to: duplicate data, irrelevant types, incomplete outcomes and use of other interventions. The Cochrane RoB tool was employed to assess methodological quality, and the GRADE approach was used to evaluate the certainty of evidence. The review was registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY), registration number INPLASY202270041, following PRISMA 2020 guidelines. Massage treatment (120 min) showed a non-significant difference (standardized mean difference [SMD]: 0.68; 95% CI: − 0.31–1.67) compared with antipyretic medication. However, combining antipyretic medication and massage significantly reduced fever (SMD: 0.90; 95% CI: 0.50–1.30). Subgroup analysis indicated traditional Chinese Tuina massage significantly reduced pediatric fever (relative risk [RR]: 0.41; 95% CI: 0.26–0.65).

Conclusion

This meta-analysis suggests that traditional Chinese Tuina may be a promising adjunctive therapy for pediatric fever. Careful consideration of each child's specific conditions is necessary to ensure safety and comfort. Future research should enhance study design quality and broaden the scope of non-pharmacological treatment methods.

Introduction

Paediatric fever is a common physiological response in children, often resulting from infection or inflammation and leading to an elevated body temperature. Paediatric fever is prevalent in clinical practice, and it has diverse causes, such as colds, respiratory infections and other infectious diseases [1]. Fever is a focal point of clinical attention, and timely intervention is crucial, not only for clarifying the aetiology but also for symptom relief, prevention of complications and reduction of the risk of febrile seizures. Moreover, fever is closely correlated with age as infants are more susceptible to it due to their underdeveloped immune systems, which makes early intervention particularly critical [2]. Apart from causing discomfort, paediatric fever can lead to complications such as dehydration and electrolyte imbalances [3]. Furthermore, children are more prone to febrile seizures during fever episodes, causing anxiety for both parents and healthcare professionals [4].

The current treatment methods encompass both pharmaceutical and non-pharmaceutical interventions. Pharmaceutical treatments often involve antibiotics and antipyretic drugs, such as non-steroidal anti-inflammatory drugs like ibuprofen and acetaminophen, which are widely recognised as effective fever treatments. They inhibit prostaglandin synthesis, thereby exerting antipyretic and anti-inflammatory effects [5]. Studies indicate that these drugs can rapidly lower body temperature and alleviate discomfort in children, but they come with potential adverse side effects, including gastrointestinal discomfort and liver function impairment [6]. However, the use of medications in children poses several challenges. To avoid these problems, physical therapy has emerged as a notable alternative. Tepid water massage, often referred to as tepid sponging, is a non-pharmaceutical intervention that involves wiping or sponging the body with tepid water, which combines the physical effects of water with gentle massage-like movements. [7] This process not only aids in heat dissipation through evaporation but may also stimulate the body’s regulatory mechanisms through tactile stimulation, similar to massage techniques. Research suggests that tepid water massage can alleviate symptoms of paediatric fever, lower body temperature and exhibit fewer adverse reactions compared with drug therapy [7]. Furthermore, traditional Chinese Tuina massage, an ancient and unique treatment method, stimulates the body's meridians to promote the circulation of qi and blood. Its aim is to balance the yin and yang. Studies indicate that Tuina massage may not only alleviate fever symptoms but also modulate the immune system and enhance the body's resistance [8]. Despite their apparent differences, both tepid water massage and Tuina share common features of tactile stimulation and pressure application, potentially contributing to thermoregulation and physiological adjustments. This conceptual similarity provides the rationale for analyzing these two approaches together. However, despite the promising prospects of physical therapy in the treatment of paediatric fever, the effectiveness and safety of Tuina massage therapy remain contentious [9, 10]. Some studies support its positive role in relieving paediatric fever, while others raise concerns about its limitations and potential risks. Hence, a more in-depth investigation is needed to comprehensively clarify the mechanisms, scope of application and potential risks and benefits of these physical therapy methods.

This study conducts a systematic review and meta-analysis to comprehensively assess the effectiveness and safety of Tuina massage therapy in paediatric fever. Relevant randomised controlled studies are collected and integrated to evaluate the cooling effects of Tuina massage on paediatric fever. Furthermore, its performance in symptom alleviation, temperature reduction and potential adverse reactions are analysed.

Methods

Search strategy and literature selection

This study conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines recommended by the Cochrane Collaboration [11]. Searches were performed in four electronic databases: PubMed, Embase, Cochrane Central Register of Controlled Trials and China National Knowledge Infrastructure (CNKI), from their inception until November 2023. The language was limited to English or Chinese. Moreover, the search strategy combined MeSH/Emtree terms and free-text terms, with relevant keywords such as fever, children, massage, tepid, sponge in titles and abstracts (see the Supplementary material). Additionally, this study manually searched reference lists of relevant studies, reviews and meta-analyses to expand the search scope. Literature records were exported to EndNote X9.3.3 software, and automated deduplication was followed by manual deduplication. Furthermore, two researchers independently conducted electronic record and publication screening based on predefined inclusion and exclusion criteria. In cases of discrepancies, mutual discussion and full-text reading were employed to resolve them, with final decisions made by a senior researcher if consensus could not be reached (see the Supplementary material). The protocol for this systematic review and meta-analysis was registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY), registration number INPLASY202270041. The registration can be accessed at https://inplasy.com/.

Inclusion and exclusion criteria

The inclusion criteria were based on the Participants, Intervention, Comparison, Outcome and Study principle. The inclusion criteria were as follows: 1) children (< 18 years) with fever symptoms; 2) intervention group receiving tepid water massage or traditional Chinese Tuina massage; 3) control group receiving antipyretic drugs, other medications or placebos; 4) at least one treatment outcome related to fever, including absolute temperature reduction, antipyretic treatment effectiveness or adverse reactions; and 5) only randomised controlled trials (RCTs) were included. The exclusion criteria were as follows: 1) duplicate or redundant data; 2) irrelevant study types such as animal studies, case reports, literature reviews or conference abstracts; 3) studies with incomplete data or unreported outcome measures, such as those using self-control groups; and 4) studies using other interventions or control methods.

Data extraction and risk of bias assessment

After excluding irrelevant studies, two researchers independently extracted features and data from the chosen studies. These included basic study information (e.g. author, publication date, study design, follow-up time, sample size and population characteristics), intervention and control group settings, ambient temperature at the study location, temperature measurement site, temperature measurement tools and study results. Following the recommendations of the Cochrane Handbook for Systematic Reviews (version 5.1), two researchers independently assessed the risk of bias in the included studies. In cases of disagreement, discrepancies were resolved through discussion or consultation with a third party. Bias risk assessment covered aspects such as 1) random sequence generation; 2) allocation concealment; 3) blinding of participants and personnel; 4) blinding of outcome assessors; 5) completeness of outcome data; 6) selective reporting; and 7) other sources of bias. Each aspect was classified into three levels: ‘low risk’, ‘high risk’ and ‘unclear’. Low risk indicated that the implementation method was correct or had no impact on outcome measurement; high risk indicated errors in the implementation method, which affected outcome measurement; ‘unclear’ indicated that the study did not provide relevant information. This assessment system aided in comprehensively clarifying the credibility and risk of bias levels in the included studies.

Statistical analysis

This study used the RevMan 5.4 software (Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark) for meta-analysis. For continuous variables, the standard mean differences (SMD) and the 95% confidence interval (CI) were used as statistical analysis indicators. For categorical variables, the risk ratio (RR) was selected as a statistical analysis indicator. To assess the heterogeneity between the study results, Cochran’s Q test and the I² statistic were used. When statistical heterogeneity between the results was low (P > 0.1 or I² < 50%), a fixed-effects model was used for the analysis. When statistical heterogeneity was present (P < 0.1 or I² > 50%), a random-effects model was used for meta-analysis, and the significance level was set at α = 0.05. To assess the potential for publication bias, a funnel plot was drawn. However, if the number of included studies is small, generally fewer than 10–15, funnel plots may not accurately detect publication bias and are not recommended for assessing bias in these cases. Moreover, sensitivity analysis was conducted to evaluate the impact of individual studies on the overall effect and heterogeneity, observing changes in effect size and I² value after excluding individual studies. Additionally, subgroup analysis was performed to separately explore the therapeutic effects of tepid water massage and traditional Chinese Tuina massage on paediatric fever. This detailed analysis contributed to a deeper understanding of the efficacy of different intervention methods, providing a more comprehensive perspective for interpreting study results. We assessed the certainty of evidence for the primary outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Literature selection

The search strategy yielded a total of 2,679 electronic records, with 989 from PubMed, 1,035 from Embase, 542 from Cochrane and 113 from CNKI. After removing 1,321 duplicate records and excluding 1,316 irrelevant articles based on a title and abstract review, 27 articles were further excluded after full-text reading due to various reasons, such as non-human studies, non-RCTs, failure to compare according to the set criteria or being abstracts/conference papers. References for the 27 excluded studies are provided in the supplementary file. Finally, 15 articles were included in the systematic review, with 13 articles entering quantitative meta-analysis and the remaining two articles excluded due to a lack of extractable data. The literature screening flowchart is presented in Fig. 1.

Fig. 1

PRISMA 2020 flow diagram of study selection. Note: this diagram is derived from the PRISMA 2020 statement (Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. Published 2021 Mar 29. https://doiorg.publicaciones.saludcastillayleon.es/10.1136/bmj.n71)

Basic characteristics of the included studies

This study included 15 RCTs with a total of 1,661 paediatric patients [12,13,14,15,16,17,18,19,20,21,22,23,24,25,26]. The basic characteristics of the included literature are shown in Table 1. Among these studies, five were conducted in China, while others were conducted in various regions like the United States, India, the United Kingdom, Australia, Canada, Thailand, Brazil and Turkey. Most of the studies (93.3%) had a single-centre randomised controlled design. The interventions included tepid water massage (10 studies) and traditional Chinese Tuina massage (five studies). The control group primarily received antipyretic drugs such as ibuprofen and acetaminophen, with a few studies using aspirin or dipyrone. Moreover, the specific parameters for the intervention and control groups varied across the studies, but most Tuina massage studies adopted methods targeting specific body areas, such as Qingtianhe water and Qingfeijing, to help children sweat. Tepid water massage interventions mostly involved using a wet cloth to massage the child's body, except the scalp. Five studies covered the entire body, one study focused on the trunk and limbs and the remaining studies provided detailed descriptions of body areas. The duration of most massage interventions was around 15–20 min, with water temperatures ranging between 20 °C and 37.8 °C.

Table 1 Characteristics of the included studies

The characteristics of the paediatric patients in the included studies are presented in Table 2. Among them, six studies (40%) explicitly stated that the children were diagnosed with upper respiratory tract infections, and their age range was between 3 months and 12 years. The temperature ranges for fever measurement in the axilla, rectum and oral cavity were above 37.8 °C, 38.5 °C and 39.5 °C, respectively. Six studies reported the duration of fever illness, ranging between 12 h and 23 days. Rectal, oral and axillary temperature measurement methods were used in four, five and one study, respectively. Moreover, mercury thermometers were used in three studies, digital thermometers were used in three studies and an infrared thermometer was used in one study, while eight studies did not specify the type of thermometer used. Most studies had room temperatures ranging between 21.0 °C–32.0 °C, but one study had a room temperature of − 0.5 °C. In the 15 studies, the longest duration of temperature monitoring was 5 days, with the majority of studies (8 out of 15, 53%) using a 120-min time point.

Table 2 Characteristics of included subjects

Risk of bias assessment

Detailed information regarding the risk of bias is shown in Fig. 2. The Cochrane Collaboration’s tool was used to assess the quality of the literature. Most studies (80%) clearly reported the method of random sequence generation, but two studies (13.3%) described the method of allocation concealment. Some studies obtained an unclear or high risk of bias due to not blinding the participants and personnel, with only two studies explicitly implementing double blinding. Moreover, most studies did not blind or clearly describe the blinding of the outcome assessors. Overall, the included studies had an exact random process, but there were some methodological flaws at other levels.

Fig. 2

Methodological quality of included studies

Temperature reduction difference

Five studies reported the impact of massage and Tuina on the temperature reduction difference (Fig. 3). Among them, four studies indicated that simple massage or Tuina massage had no statistically significant difference in SMD at 120 min compared with the use of antipyretic drugs (SMD = 0.68, 95% CI: − 0.31–1.67; P < 0.00001; I² = 95%; P = 0.18). One study reported that the combination of antipyretic drugs and massage or Tuina massage was effective in reducing the temperature of febrile children at 120 min, with an SMD of 0.90 (95% CI: 0.50–1.30). The overall effect value after combining several studies was 0.73 (95% CI: − 0.01–1.47; P < 0.0001; I² = 93%), and the difference was statistically significant (P = 0.05). For the five studies assessing this outcome, one exhibited a high risk of bias related to the blinding of participants and outcomes. The other four studies showed an unclear risk of bias across several domains.

Fig. 3

Forest plot comparing temperature difference values between the massage group and control group. SD: standard deviation; IV: inverse variance

Antipyretic effectiveness

Ten studies reported data on the effectiveness of massage and Tuina massage in reducing fever. As shown in Fig. 4, compared with the use of antipyretic drugs, simple massage or Tuina massage alone had no significant effectiveness in reducing fever in children (RR = 1.21, 95% CI: 0.41–3.54; P < 0.0001; I² = 84%). For the six studies assessing this subgroup, two had a high risk of bias related to blinding or allocation concealment. The remaining studies mostly exhibited an unclear risk of bias across several domains. However, massage or Tuina massage combined with antipyretic drugs significantly improved the efficacy of reducing fever in children, with an RR of 0.38 (95% CI: 0.20–0.71; P = 0.003; I² = 47%). For the seven studies assessing this subgroup, two also had a high risk of bias concerning blinding or allocation concealment. The overall effect value after combining the two subgroups was 0.63 (95% CI: 0.35–1.14; P < 0.0001; I² = 74%), and the difference was not statistically significant (P = 0.13).

Fig. 4

Forest plot comparing antipyretic effectiveness between the massage group and control group. SD: standard deviation; IV: inverse variance

Subgroup analysis

To separately analyse the efficacy of tepid water massage and Chinese Tuina massage, this study conducted a subgroup analysis of treatment effectiveness, as shown in Table 3. Compared with the use of antipyretic drugs alone, the efficacy of tepid water massage did not reach statistical significance (RR = 4.86, 95% CI: 0.71–33.41), while Chinese Tuina massage significantly reduced the proportion of febrile children (RR = 0.41, 95% CI: 0.26–0.65). Similarly, the combined use of tepid water massage and antipyretic drugs did not reach statistical significance (RR = 0.46, 95% CI: 0.22–0.94), whereas Chinese Tuina massage combined with antipyretic drugs achieved better efficacy (RR = 0.22, 95% CI: 0.08–0.61). However, due to the limited number of studies included in each subgroup, it was not feasible to use subgroup analyses to explore potential sources of heterogeneity.

Table 3 Subgroup analysis of antipyretic effectiveness

Adverse reactions

In the included studies, adverse reactions related to fever were mainly crying, convulsions and chills, with no adverse reactions reported in Chinese Tuina massage-related studies. Regarding crying, one study reported a higher incidence in the intervention group (51.9%) compared with the control group (0.0%). Regardless of whether tepid water massage was used alone or combined with antipyretic drugs, the incidence of chills and discomfort in the intervention group was higher than in the control group. Additionally, regarding convulsions, one study reported an incidence rate of approximately 2.5% in the intervention group, with no occurrences in the control group (see Table 4).

Table 4 Summary results of adverse events

Publication bias and sensitivity analysis

Given that the number of studies included in the analysis was relatively small, funnel plots may have limited reliability in detecting publication bias and thus may not be applicable in this context. In addition, a sensitivity analysis of the summary results was performed. After excluding one study at a time, the heterogeneity between studies remained relatively high. For example, in the analysis of temperature difference outcomes, excluding Newman 1985 [22] reduced the overall heterogeneity (I²) from 93 to 75%, with a total effect size of SMD 1.05 (95% CI 0.56–1.54) (Figure S1). Excluding other studies did not significantly change heterogeneity, which remained above 90%. For the effectiveness analysis, removing Agbolosu 1997 [12] decreased the overall heterogeneity (I²) from 74 to 55%, with a total effect size of RR 0.50 (95% CI 0.31–0.79), test for overall effect (P = 0.003) (Figure S2). Excluding other studies did not markedly alter heterogeneity, which stayed around 70%.

GRADE assessment

For temperature difference, the evidence from five randomized trials was rated as moderate certainty (Table 5). While risk of bias, indirectness, and imprecision were not serious concerns, there was some inconsistency among studies. Overall, Tuina or tepid massage resulted in a moderate effect on temperature reduction, with a SMD of 0.73 higher compared to antipyretic drugs (95% CI: 0.01 lower to 1.47 higher). For efficacy, based on ten randomized trials, the certainty of evidence was also rated as moderate. There were no serious concerns regarding risk of bias, indirectness, or imprecision, though inconsistency was noted. The RR was 0.63 (95% CI: 0.35 to 1.14), suggesting that massage may reduce the incidence of fever, with 92 fewer cases per 1,000 compared to antipyretic drugs, although confidence intervals included both fewer and slightly more cases.

Table 5 GRADE assessment of the evidence in the meta-analysis

Discussion

This meta-analysis systematically analysed the effectiveness and safety of Tuina massage as a non-pharmacological physical therapy for treating fever in children. Moreover, methodological quality assessment was conducted for the included studies. The main findings of this study are as follows: 1) compared with antipyretic drugs, Tuina massage alone showed no significant difference in reducing body temperature in febrile children after 120 min; 2) compared with the use of antipyretic drugs alone, Tuina massage alone was not significantly effective in treating fever in children; 3) combined therapy of Tuina massage and antipyretic drugs significantly improved the efficacy of fever reduction in children and reduced the risk of persistent fever; 4) subgroup analysis indicated that warm water massage did not show superiority over antipyretic drugs, but traditional Chinese Tuina techniques enhanced the antipyretic effect on the basis of antipyretic drugs; and 5) compared with antipyretic drugs, warm water massage may increase the occurrence of crying, convulsions and shivering in children.

As a non-pharmacological fever-reducing method, warm water massage has gained attention in the treatment of paediatric fever. The meta-analysis results suggest that warm water massage may have no significant difference in temperature reduction compared with antipyretic drugs. However, it is important to note that the control group in this study was treated with antipyretic drugs rather than a placebo, indicating that warm water massage was not inferior to antipyretic drugs in terms of fever reduction. The subgroup analysis revealed additional insights into the comparative efficacy of tepid water massage and Chinese Tuina massage. Specifically, the analysis showed that tepid water massage, whether used alone or in combination with antipyretic drugs, did not achieve statistically significant effects in reducing fever. In contrast, Chinese Tuina massage, both independently and combined with antipyretic drugs, demonstrated significant effectiveness in lowering febrile rates among children. These findings suggest that while both methods aim to modulate physiological responses, their mechanisms may differ substantially.

The mechanism of fever reduction by warm water massage may be related to its physiological effects, such as promoting blood circulation, dilating blood vessels, and increasing surface blood flow. Warm water massage increases skin temperature, leading to vasodilation, enhanced blood flow, and accelerated heat dissipation. In addition, warm water massage involves wiping and gently massaging the skin surface, which may stimulate mechanoreceptors and enhance thermoregulatory and metabolic responses. This tactile stimulation activates sensory pathways and may modulate autonomic nervous system activity, thereby improving thermal regulation and producing antipyretic effects. [27, 28] Furthermore, the use of tepid water may assist in dissipating heat through evaporation, providing a cooling effect complementary to the massage's physiological impact. In contrast, Tuina massage, rooted in traditional Chinese medicine, focuses on stimulating acupoints and meridians to regulate the flow of Qi and blood. This approach aims to restore the balance of yin and yang, promoting systemic regulation rather than focusing solely on local temperature reduction. Tuina’s effects may involve deeper neurohumoral regulation by stimulating peripheral nerves and influencing endocrine and immune responses. Studies suggest that the stimulation of specific acupoints may enhance immune function, promote anti-inflammatory pathways, and support homeostasis, contributing to fever relief. Unlike warm water massage, which primarily relies on surface-level effects and temperature modulation, Tuina massage may exert broader physiological impacts by integrating mechanical stimulation with traditional therapeutic concepts. However, it should be noted that the heterogeneity in the included studies may be related to specific implementation factors of warm water massage, such as the method, water temperature, and massage duration. Given the limited number of studies included in the subgroup analysis, caution should be exercised when interpreting these findings, and additional high-quality research is necessary to draw definitive conclusions.

Compared with a previous meta-analysis [10], this study updated the scope by not only covering warm water massage but also including an analysis of traditional Chinese Tuina techniques. This update allowed for a more comprehensive understanding of the effects of different non-pharmacological treatments in paediatric fever. Regarding warm water massage, this study found no significant difference in temperature reduction compared with analgesic drugs, which was consistent with previous research. This may imply that warm water massage has similar effects to some conventional drug treatments in terms of antipyresis. However, the analysis of traditional Chinese Tuina techniques in this study showed their superiority over analgesic drugs. The potential reasons and mechanisms for this may be as follows. 1) Physiological regulatory effects: as a traditional Chinese medical treatment, Chinese Tuina techniques may regulate the body temperature at a physiological level by stimulating meridians. Traditional Chinese theory suggests that Tuina massage on meridians can promote the flow of Qi and blood, helping restore normal body functions [29, 30]. 2) Immune system regulation: traditional Chinese Tuina may regulate the function of the immune system by stimulating specific acupoints. Enhanced immune system function can help resist infection and alleviate symptoms caused by diseases. This mechanism may make traditional Chinese Tuina relatively superior in the treatment of paediatric fever [31]. 3) Scope of action and technique: While warm water massage primarily targets localized areas for heat dissipation through water evaporation and tactile stimulation, Tuina massage applies broader pressure and focuses on acupoints along meridians to improve systemic regulation. This difference highlights Tuina’s potential to address underlying physiological imbalances rather than just reducing surface temperature. 4) Individual differences: different children may react differently to warm water massage and traditional Chinese Tuina. The superiority of this method may be more apparent in specific individuals or aetiologies, requiring further research to clarify this effect. 5) Safety considerations and adverse effects: While both methods are considered relatively safe, adverse reactions such as skin irritation or excessive cooling with warm water massage need to be considered. Tuina massage, focusing on energy flow and meridians, may carry fewer risks but requires skilled practitioners for proper execution. Additionally, non-pharmacological massage emphasises the overall physical conditioning of children, providing a more comprehensive therapeutic effect. It is important to note that the efficacy and mechanisms of traditional Chinese Tuina are still uncertain in current research and more high-quality studies are required for verification and clarification. Moreover, clinicians should consider the specific conditions of children, including age, aetiology and medical history, when choosing treatment methods. Future research could explore integrating the strengths of both methods to develop hybrid techniques that combine the thermal effects of water massage with the systemic benefits of Tuina massage, potentially offering more effective and safer treatment strategies for paediatric fever.

This study has some limitations that warrant careful consideration. First, the number of included studies was relatively small (fewer than ten), which limits the feasibility of subgroup analyses for exploring sources of heterogeneity. Once more data become available, future studies could potentially explain this heterogeneity more effectively. Additionally, several of these studies are relatively old and may not fully reflect the latest treatment advancements, potentially affecting the generalizability of this study's findings. Second, sensitivity analyses showed notable variability in outcomes when excluding specific studies. For instance, removing Agbolosu 1997 [12] in the effectiveness analysis notably reduced heterogeneity and shifted the effect from negative to positive, suggesting potential effectiveness of Tuina. However, from a conservative perspective, this result should not be taken as confirmation of effectiveness but rather as an indication of individual variation, warranting further investigation. Third, some studies exhibited lower methodological quality, such as small sample sizes, inadequate random sequence generation, and lack of allocation concealment, introducing potential biases that could affect efficacy assessment. Future research should emphasize study design and quality control to enhance overall evidence credibility. Fourth, as this study primarily focused on traditional Chinese Tuina therapy, which is more commonly practiced in China, its applicability in other regions may be limited due to cultural and healthcare system differences, warranting cautious interpretation when applied to other settings. Fifth, this study did not address other non-pharmacological massage therapies or Tuina techniques, requiring further exploration to provide a more comprehensive evaluation of these treatments. Lastly, as this study is based on published literature, potential publication bias may exist if unpublished or negative results were not adequately reported. Future research should strive to address these limitations to offer a more comprehensive and accurate assessment of the effectiveness of non-pharmacological massage and Tuina therapy in treating pediatric fever.

In summary, this study provided a systematic evaluation of the effectiveness of non-pharmacological massage and Tuina therapy in the treatment of paediatric fever. Although valuable conclusions have been obtained, they should be interpreted with caution. Traditional Chinese Tuina therapy showed certain superiority in the treatment of paediatric fever compared with warm water massage, especially in demonstrating a significant effect compared with analgesic drugs. This provided a potentially safe and effective option for non-pharmacological treatment. However, future research should focus more on the diversity of treatment methods, improve the quality of study design and broaden the scope of research to more comprehensively understand the actual effects of non-pharmacological massage and Tuina therapy in the treatment of paediatric fever. Overall, while this study found that traditional Chinese Tuina may be a promising treatment option, its application in practice should still consider the specific conditions of the child, carefully selecting the most suitable treatment method to ensure their safety and comfort.