3.1 Selection of studies
The initial search detected 239 related publications, and EndNote X9 excluded 160 duplicate records. After reading the title and abstract, 13 records were excluded from the preliminary screening. After further screening, a total of 8 Tuina guidelines were included [12-19] for SR through AGREE Ⅱ. The literature search and screening process is shown in Figure 1.
3.2 General characteristics
As shown in Table 1, all the guidelines evaluated in this paper originated from China and were published from 2010 to 2020. Three of the guidelines [14-16] were published in 2010 and published in the same journal. However, a major shortcoming of the former three articles is that there is no evidence of the source of the guideline writing. Seven of the eight guidelines [12-16,18-19] aimed at clinicians or Tuina practitioners specifically. Seven [12-17,19] are from different Chinese Medicine universities or affiliated hospitals, and the remaining one  is from the China HQCC.
3.3 Quality assessment of guidelines and strength of recommendation
Table 2 shows the AGREE II standardization field score for each Tuina CPG and its overall recommendations. The scope and purpose of the field and the clarity and presentation achieved the highest average scores of 70% and 67% (ranges 60-82% and 51-82%, respectively). The average score for stakeholder participation in the domain was 51% (range 33-61%), and only one guide scored more than 60%. The largest score range is editorial independence (17-94%). 3 guides (37.5%) scored 17, and 5 guides (62.5%) scored less than 50%. Editorial independence and applicability produced the lowest average scores of 40% and 47% (ranges 17-94% and 21-64%, respectively). Unexpectedly, the four guidelines (26.7%) had the lowest score due to the failure to describe the criteria for selecting evidence and making recommendations clearly.
In general, the Practical Guidelines for Treating Prophylactic Diseases of Tuina Intervention of Spleen Deficiency  in Children Guide has high scores in all areas and is listed as "strongly recommended" in clinical practice, "recommendation of 3 types of Tuina CPG (37.5%)", and 3 types (37.5%) "Not recommended". The agreement of the overall reviewer is very good (ICC:0.901, 95% CI).
After a SR by four reviewers, we have obtained the AGREE Ⅱ scores and total scores in each field of the 8 guides in Table 3. Xiuzhen Chen  and Lunxue Qin  served as the first author's guide for the total score of more than 400, therefore, we can strongly recommend using these two Tuina guidelines. The guidelines with Jiangquan Li , Yanguo Wang , and Feng Liu  as the first authors have a total score of less than 300, so we do not recommend using these three guides. The guide, led by Longming Lei , Deren Sun , and Jun Pang  as the first author, scored between 300 and 400. These three guides can be recommended after upgrading and improving modifications.
The agreement between the four reviewers was measured by the intra-group correlation coefficient (ICC) and 95% confidence interval (CI). The degree of agreement between 0.01 and 0.20 is considered minor, the degree of proportionality between 0.21 and 0.40 is moderate, the degree of proportionality between 0.41 and 0.60, the substantive degree between 0.61 and 0.80, and the agreement between 0.81 and 1.00 is very good. P <0.05 indicates statistical significance. All tests are double-sided. Use SPSS version 25.0 for statistical analysis. By analyzing the intra-group correlation coefficients of the scores given by the four evaluators, we can see that the ICC value of each field is greater than 0.81 in Table 3. It can be considered that the scores given by the evaluators within the group are highly consistent.
3.4 Frequency statistics of disease
A total of 35 diseases were included, as showing in Figure 2, of which 13 diseases were specific to the child. Tuina is mainly used for alleviating pain as infantile Tuina for upper respiratory tract infection with the frequency of 2, 2 respectively.
A total of 35 diseases were included, as showing in Figure 2, of which 13 diseases were specific to the child.
For the Tuina guidelines included in this study, four guides for infantile Tuina, one for Tuina for children, three for adults Tuina.