Socio-demographic data and classification of healers

In this study, 86 participants were interviewed on the five studied islands. Among them, 36 (41.9%) were from the Windward islands, and 50 (58.1%) were from the Leeward islands (Table 1).

Table 1 Socio-demographic characteristics of the 86 participants interviewed in the five islands from the Society archipelago

The age range of the participants was between 20 and 77 years old with a mean age of 53.9 years old and a median of 56 years old. Most of participants were females (78, 90.7%) and stopped their education before high school (61, 70.9%). The most represented religion was Protestantism with 49 participants (56.9%).

In our study, a high proportion of women were interviewed. Most ethnobotanical studies in French Polynesia have already found this predominance of females over males [1, 2, 5]. Indeed, women (i.e., mothers and grand-mothers) have the role of health careers in the community, especially for children. And they are often in charge of the pharmacopeia dedicated to the care of persons living in their family [14]. Following the Polynesian healers classification previously described [1], 38 (44.2%) participants were categorized as non-specialists, 26 (30.2%) were classified as knowledgeable, and 22 (25.6%) as specialists. Among the specialists, 16 (72.7%) were experts in herbalism only, two (9.1%) were experts in massage only, one (4.5%) was expert in apitherapy only, two (9.1%) were experts in herbalism and massage, and one (4.5%) was expert in herbalism, apitherapy and massage. Out of these 22 specialists, three reported that they were specialized in the treatment of children. Among the knowledgeable persons, eight (30.8%) reported to treat all types of patients (and not just family members), seven (26.9%) were known by other people in the area for being able to heal, four (15.4%) mentioned to treat all types of patients and had a reputation of healing people, four others (15.4%) were in the process of learning, and three (7.7%) had a reputation of healing and possessed a book of homemade remedies.

Mean age of non-specialists was 50.4 years old, 55.5 years old for knowledgeable, and 57.9 years old for specialists. The mean age of specialists was significantly higher than the mean age of non-specialists (p = 0.031). Similar results were obtained in a previous study where specialists were significantly older than the two other groups [1]. This indicates that people with higher knowledge in Polynesian medicine tend to be the eldest.

Overview of health disorders reported for children

A total of 69 health disorders belonging to 17 different health categories (as defined by the International Classification of Diseases 11th) were reported (Table 2). The most represented health category was digestive system (12 cited disorders, 17.6%) followed by skin disorders (10, 14.7%), respiratory system (8, 11.8%), infectious diseases (8, 11.8%), injury, poisoning, and other consequences of external causes (7, 10.3%), and genitourinary system (7, 10.3%). In terms of number of citations by participants, respiratory system ranked first (86 citations, 19.6%), followed by digestive system (76 cit., 17.3%), mental, behavioral or neurodevelopmental disorders (61, 13.9%), skin disorders (46 cit., 10.5%), and injury, poisoning, and other consequences of external causes (43 cit., 9.8%).

Table 2 Children illnesses and their disease categories reported during the survey by the 86 participants from the five islands in the Society archipelago

Of the 69 health disorders reported, a group of behavioral symptoms called “ira” and described by participants as infants and children presenting restlessness, irritability, and jerk ranked first in terms of citations (60 participants, 69.8%). Sinusitis ranked second (35, 40.7%), followed by ranula (salivary cyst) (25, 29.1%), teething (24, 27.9%), cough (23, 26.7%), fracture (18, 20.9%), fever (17, 19.8%), and vaginal and urethral discharge (15, 17.4%).

While some disorders could be clearly identified thanks to their Tahitian and/or French names (e.g., cough =“hota”, fever = “fiva”, filariasis = “māriri”, sinusitis = “nanu”), others disorders could not be identified precisely. Indeed, some disorders were named based on the body part affected (e.g., lower abdomen = “tia”, teeth = “niho”, umbilic = “pito”), their causative agents (e.g., to be penetrated by the cold = “puta to'eto'e”), their main symptoms (e.g., discharge or presence of pus = “tui”, yellow body = “ira re’are’a”), and their foreign names (e.g., “rūmati” = rheumatism, “covid” = COVID-19). This specificity of Polynesian diseases classification was already described in others islands such as the Samoan islands and the Society Islands [15, 16].

Another set of disorders called “he’a” was difficult to translate in biomedical terms. “He’a” could be categorized into two main health categories: skin disorders and disorders of the genitourinary system (e.g., menstrual bleeding disorders, urinary tract infection, vaginal or urethral discharge). It was defined by participants as something bad/impure inside the body that needs to be expelled. Naturally, these impurities are expelled either by the skin, or by the vaginal or urethral way, and thus, symptoms are skin disorders, leucorrhea, urinary tract infection, or menstrual disorders. The he’a category was reported to be transmitted from mother to child. When women give birth and are not previously treated by a rā’au he’a (remedy for he’a), they transmit diseases through their vagina which induce health disorders on the skin of the babies. Later, the children can also develop vaginal (for females) or urethral (for males) diseases if not treated. To prevent or treat this set of disorders, Polynesian people reported using remedies that clean the body or expel internal impurities, so we classified them as detoxifying agents. The he’a category was already described as an important type of diseases in the Society Islands as it is one of the three categories of diseases (along with ira and fati) being predisposing factors for other diseases. It was defined by French scientists as an “humoral illness” following the medical concepts developed by Hippocrates [16, 17]. The he’a category is called “epa” in the Marquesas islands [2]. In Tongan islands, the “kahi” category is reported to be caused by an internal blockage and encompasses various genitourinary disorders similar to those described in the he’a category [18].

Regarding the set of disorders called “ira,” it was mainly defined as a group of behavioral disorders including restlessness, irritability, to wake with a start, and convulsion. It was also frequently associated with blue spots on the skin, medically known as Mongolian blue spots. While most of the participants (51, 85%) employed the term “ira” only, a few others added a modifier to precise the type of “ira” treated. For example, “ira 'īriti” was cited by six participants and could be defined as an “ira” with spasms and convulsions. “Ira manu” was cited by five participants and could be defined as an “ira” with children presenting a face or doing movements similar to birds. “Ira re’are’a” was cited by one participant and could be defined as an “ira” with jaundice. “Ira to'eto'e” was cited by one participant and could be defined as an “ira” with cold sweat. Less frequently, the term “ira” was also combined with terms used to define specific disorders such as “nanu” for sinusitis, “niho” for teething and “pito” for umbilic cord care. In these few cases (i.e., ira nanu, ira niho, ira tūpito), no changes in the meaning of the original disorders were noted. The ira category is widely known throughout Polynesia (especially, in the Cook, French Polynesian, Tongan, and Samoan islands), and it is also called “ila” in some places (e.g., Samoan and Tongan islands) [15, 19]. In these islands, ira (or ila) refers to childhood diseases and can also be defined as a mark on the skin such as a mole or a freckle [20]. In the Society Islands, Lemaître reported 20 varieties of ira, of which 6 were detailed (i.e., ira 'īriti, ira 'ōfera, ira to'eto'e, ira vāhi, ira vau, and ira moe) [21]. This author defined ira as productive of nervous disorders. In the same area, Grépin and Grépin noted that fever, spasms, and nervous symptoms are the main characteristics of ira [17]. They also mentioned the blue spots on the skin from the lumbar region as being part of the ira category. In the Samoan and Tongan islands, the definition of ira/ila seems to have slightly different meanings. In Tonga, it was reported that “ila” refers to red patches (similar to burns) on the skin of children [19]. In Samoa, it was defined as a childhood diarrhea by some authors [20]. Overall, ira represents one of the most important categories of childhood diseases in the area, and thus, Polynesian people have developed a rich pharmacopeia to prevent and treat it.

Further details on the he’a and ira categories as well as on other ailments are provided in the sections below.

Overview of Polynesian medical practices for children

Overall, the Polynesian medical practices used for children included biologically based practices (reported by 86 participants, 100%), and manipulative practices (i.e., massage [39 participants, 45.3%], blowing into the mouth [8 participants, 9.3%], pushing on the gingiva [4 participants, 4.7%], and cutting the gingiva [3 participants, 3.5%]). Among the biologically based practices, herbal ingredients rank first in terms of citations (731 UR, 93%), followed by the use of animal ingredients (24 UR, 3.0%), a Polynesian cosmetic product called monoi (23 UR, 2.9%), and other products (i.e., mint alcohol [2 UR], saccharose [2 UR], seawater [2 UR], salt [1 UR.], starch [1 UR], and vinegar [1 UR]). The total number of UR is 787.

A total of 469 remedies were reported to be used for children, of which 347 were unique remedies (meaning that these remedies had different ingredients, different uses, and different part of plants used if the ingredients were similar). Up to 17 ingredients were mixed in the remedies. Of the 347 unique remedies, mono-ingredient remedies were the most represented (145 remedies, 224 UR), followed by two-ingredient remedies (97 remedies, 125 UR), four-ingredient remedies (38 remedies, 44 UR), three-ingredient remedies (36 remedies, 45 UR), and remedies with five and more ingredients (31 remedies, 31 UR). The mean number of remedies cited by participants was 5.4 remedies.

Regarding the number of remedies reported by category of diseases, the set of disorders called “ira” presented the highest number of cited remedies (50 remedies, 95 UR), followed by sinusitis (30 remedies, 39 UR), ranula (salivary cyst) (17 remedies, 27 UR), cough (15 remedies, 25 UR), fracture (14 remedies, 21 UR), otitis (13 remedies, 15 UR), and lower abdominal disorders (13 remedies, 13 UR).

Herbal ingredients

A total of 67 plant species (representing 731 UR) belonging to 40 botanical families were identified (Table 3). The ten most frequently cited plant species were Cocos nucifera (47 participants citing the plants, 57 UR [including different citations by the same participant]), Gardenia taitensis (40 participants, 56 UR), Annona muricata (33 participants, 35 UR), Hibiscus rosa-sinensis “Carnation” (33 participants, 36 UR), Saccharum officinarum (33 participants, 52 UR), Citrus x aurantiifolia (30 participants, 40 UR), Curcuma longa (29 participants, 35 UR), Cordyline fruticosa (25 participants, 27 UR), Microsorum grossum (24 participants, 27 UR), and Spondias dulcis (23 participants, 28 UR). Among these plants, two (Citrus x aurantiifolia, Saccharum officinarum) can be considered as excipients as they were mainly used in combinations with other plants. Indeed, remedies including Citrus x aurantiifolia or Saccharum officinarum were multi-ingredients remedies in 97.5 and 96% of the cases, respectively. Citrus x aurantiifolia, which is a modern introduction and so a newly incorporated ingredients in Polynesian TM, may be considered as vitamin C provider and flavor enhancer, while Saccharum officinarum can be considered as a sweetener. Although Cocos nucifera was also employed as an excipient in most of the remedies, nine out of 43 remedies (17.3%) consisted of Cocos nucifera only, suggesting the role of this plant as a bioactive ingredient. Pétard already reported that coconut oil, coconut water, and sugarcane juice are mainly used as excipients [4]. This author also mentioned coconut oil as a bioactive ingredient, especially for its purgative property. Regarding lime juice, the same author reported similar findings and confirmed it is mainly used in combination with other plants. However, its role as an excipient is not clearly mentioned.

Table 3 Ethnobotanical data of the 67 plant species recorded from the 86 participants in the five islands from the Society archipelago

Of the reported 40 botanical families, Lamiaceae ranked first (7 species), Malvaceae ranked second (4 species), and Euphorbiaceae, Moraceae, Poaceae, Rubiaceae, and Zingiberaceae ranked third (3 species each). Coleus and Hibiscus were the most represented genera (3 species each), followed by Allium, Citrus, Cyperus, and Ficus (2 species each).

The most common used plant organs were leaf (39 species), followed by leafbud (15 species), fruit (14 species), flower (8 species), whole plant (8 species), and bark (7 species). In terms of citations, leaf ranked first again (266 UR), followed by fruit (163 UR), leafbud (58 UR), stem (54 UR), rhizome (44 UR), and whole plant (39 UR). The importance of leaves and fruits in the Polynesian pharmacopeia can be partly explained by their ease of access and also by the fact that it lends itself perfectly to the method of preparation expressing the juice of the plant by pressure.

The most common methods of preparation reported were, respectively: to crush and press the plant(s) in a cloth to get the juice (52 species), to boil the plant(s) in water (37 species), to crush the plant(s) and let it/them ferment for a few days (12 species), to heat the plant(s) (7 species), to use the plant(s) without any preparation (6 species). In terms of citations, crushing and pressing the plant(s) in a cloth to get the juice ranked first (441 UR), boiling the plant(s) in water ranked second (231 UR), crushing the plant(s) and let it/them ferment for a few days ranked third (15 UR), cooking the plant(s) ranked fourth (14 UR), and using the plant(s) without any preparations ranked fifth (13 UR). Previous studies already reported the importance of crushing the plant and getting the juice by expression in the Polynesian pharmacopeia [2, 4, 5, 14]. This practice is strongly associated with the widespread use of tools (i.e., mortar and pestle) in Polynesian cuisine (Fig. 2). Here, these utensils are employed to crush the plants. Regarding the expression of juice, it can be realized with homemade fiber cloths made either from Cyperus javanicus stems or from coconut fluff [14]. Nowadays, these homemade fiber cloths have been mainly replaced by a commercialized cotton cloth.

Fig. 2

Main methods of preparation used in Polynesian traditional medicine as reported by the 86 participants from the five islands in the Society archipelago. A Mortar and pestle used to crush the ingredients; B Cotton cloth used to express the juice from the crushed ingredients; and C Method of assembling herbal ingredients before putting them in boiling water for decoction

The most common methods of administration mentioned were oral (48 species), local application (34 species), bath (28 species), bath and oral (12 species), and bath and massage (10 species). In terms of citations, oral administration ranked first (370 UR), followed by bath (121 UR), local application (86 UR), bath and massage (23 UR), and bath and oral (20 UR). Although oral administration and massage are largely described in the Polynesian literature [1, 2, 5], taking a bath was not so common in adults. Therefore, we can hypothesize that this method of administration is mainly used for babies and children.

Of the 469 reported remedies, 223 (47.5%) were administered for 3 days, 11 (2.3%) were advised to be taken until healing, 5 (1.1%) until the remedy is finished, 3 were administered for 7 days, 3 others were administered for 1 day, and 3 others were administered as much as the patient wanted. For 212 (45.2%) of the remedies, no duration of intake was reported. The 3-day rules of administration are one of the most remarkable specificity of Polynesian pharmacopeia [14, 22]. However, it does not seem to be limited to the French Polynesian islands as this practice was also described in the Cook Islands [20]. This could be explained by a link to the Christian doctrine of the Trinity, albeit it is difficult to ascertain this information [5].

Regarding their biogeographical origin, 28 (41.8%) plant species were introduced by Europeans and other population (Chinese, Japanese, Polynesians) after eighteenth century, 21 (31.3%) plant species were introduced in the islands by Polynesians (during their migration from the Western Pacific at the end of the first millennium), and 18 (26.9%) can be classified as indigenous. This is another specificity of the Polynesian pharmacopeia, most of the plants used are introduced species. Other publications already reported this information [1, 2, 5, 23].

Zootherapy

In this study, nine ingredients from animals were mentioned by the participants representing a total of 24 UR (Table 4). The most cited zootherapy ingredients was the soft tissue from the stone urchin (5 participants, 5 UR), followed by honeybee (4 participants, 6 UR), and venom from bees (3 participants, 3 UR). The most represented method of preparation was cooking the ingredients to get the oily phase (5 participants, 9 UR). The most represented method of administration was local application (12 participants, 10 UR). Sinusitis was the most reported health disorder treated by zootherapy ingredients (6 participants, 10 UR) followed by cough (4 participants, 4 UR) and otitis (3 participants, 3 UR).

Table 4 Zootherapy ingredients reported in the survey by the 86 participants from the five islands in the Society archipelago

As previously discussed [24], the use of animal species in medicine can raise concerns about illegal and unethical uses. In this study, none of the species cited by participants have been reported by the CITES (Convention on International Trade in Endangered Species of wild fauna and flora) or the IUCN (International Union for Conservation of Nature) as endangered or vulnerable species. Moreover, none of these species belong to the category A or B for protected species established by the Environment Department in French Polynesia. Also, stone urchin (Echinometra mathaei) has been described as a common and widely distributed species in the Indo-Pacific [25].

Other ingredients

Besides the use of plants and animals, other ingredients were employed by participants to prepare their remedies. Among them, monoi was the most cited ingredient (19 participants, 23 UR). In all cases, monoi was applied locally, including in massage (4 cases). Other mentioned ingredients included: mint alcohol (2 part. 2 UR), seawater (2 part., 2 UR), sugar alone (2 part., 2 UR), salt (1 part., 1 UR), starch (1 part., 1 UR), and white vinegar (1 part., 1 UR).

Monoi is a very popular cosmetic product in French Polynesia, and it is widely marketed throughout the world as an iconic Polynesian product. Monoi is made from coconut oil mixed with perfumed flowers or leaves, especially flowerbuds or open flowers from Gardenia taitensis. It is mainly employed for body and hair care [23]. Its use in medicine is less known, but it represents a significant part of the Polynesian pharmacopeia. In our study, monoi was reported for treating mainly otitis (7 participants) and fracture and sprain (6 participants). In most cases, monoi was cited to be prepared in mixture with other plant species and applied locally. Other studies already reported the use of monoi in medicine in French Polynesia for treating: otorrhea (ear discharge), fracture and sprain, furuncles and abscesses, and for backache and prick from rusted nails [4, 14, 26]. Of note, Pétard indicated that newborn babies in French Polynesia are regularly massaged with monoi from head to toe during their first months [4].

Other Polynesian medical practices

As mentioned in the overview of Polynesian medical practices section, manipulative practices were also reported by participants. This includes massage (39 participants), blowing into the mouth (8 participants), pushing on the gingiva (4 participants), and cutting the gingiva (3 participants). Massage therapy was mentioned as an adjuvant of a treatment. While we did not record the disorders treated by massage, we recorded them for the three other practices. Blowing into the mouth was reported to be used for sinusitis. It consists of exhaling air through the mouth of a child and by blocking his/her nose at the same time. It is said to help decongest the sinuses. Pushing the gingiva (defined as pushing hard on the gingiva with a finger) and cutting the gingiva were used to treat teething disorders and especially helped the teeth come out.

The act of treating teething by cutting the gums with a lancet is an old medical tradition that was first scientifically developed by a French army surgeon, named Ambroise Paré, in 1575. This method was later used by English doctors, and so until the middle of the twentieth century [27]. Because English and French deeply influenced the Polynesian medicine, we can suggest that this practice of lancing gingiva might have been introduced by French and English medical doctors many decades ago. Although cutting gingiva might have been rooted in biomedical medicine, nowadays this practice is no more recommended by health professionals, especially as it can induce severe complications [28].

Other aspects of Polynesian medicine

During the survey, some participants provided additional information regarding the use of traditional medicine in general. Here, we give details regarding this information.

First of all, participants mentioned general rules of administration. For two participants, remedies have to be taken before 3 or 4 PM. Another participant also reported not giving a remedy in the afternoon. They think that the remedies might not be effective if this rule is not respected.

Secondly, three participants noted that plants or remedies already used should be discarded in specific places and not in the regular trash can. These places include homegardens (Fa’a’apu), flowerpots, and any locations where the plant can return to the earth.

Thirdly, food restrictions were also reported by participants. When the children is sick, meat, oil, and salt should be avoided (one participant). In the same way, another participant mentioned that chips, cheese, iced water, and iced juice are not recommended.

Dangerous practices reported by participants

One of the questions asked during the interviews focused on the dangerous traditional practices or treatments known by the participants. To this question, 45 participants (52.3%) mentioned the plant “metuapua'a” (Microsorum grossum), 11 participants (12.8%) answered the plant “ti'ati'amou'a” or “titi” (Davallia solida), 5 participants (5.8%) cited “tiare tahiti” (Gardenia taitensis), 3 participants mentioned “pātoa” (Rorippa sarmentosa), 3 participants expressed concerns about a dosage not respected, 2 participants mentioned the practice of blowing air into the children’s mouth, 2 participants cited avoiding combining conventional treatments and traditional treatments, 2 participants mentioned the plant “noni” (Morinda citrifolia), and 2 participants cited chili pepper (Capsicum frutescens). Finally, 23 participants did not answer this question. Regarding the plant “metuapua'a,” some participants provided details on the source of danger when using this plant. Of the 45 participants mentioning “metuapua'a,” 10 cited roots as being more dangerous, 7 participants mentioned the use of wrong dosage, 6 participants cited the oral administration, 6 participants mentioned avoiding combining this plant with conventional treatment, 6 participants reported that children are more prone to side effects than adults, 6 participants cited that the plant can induce death, and 4 participants mentioned that the plant should not be used at the same time than vaccinations.

The plant species called “metuapua'a” was already reported in other ethnobotanical studies as being widely used in French Polynesia: for fracture, shock, fall in the Marquesas islands [2], as a purgative and vermifuge in children [4], and as one of the most used fern species in Polynesian medicine and the Pacific [29]. In the book of Pétard, it was reported that this fern is mainly used as a purgative and vermifuge in children [4]. Besides its popularity, many reports of its toxic potential have been documented. From 1967 to 1970, various poisonings due to “metuapua'a” were reported in newborn babies and children [4]. In Moorea, different traditional healers mentioned Microsorum grossum as being poisonous [22, 30]. The medicinal potential of Microsorum species was attributed to the presence of phytoecdysteroids [31]. These compounds possess steroid-like effect and are recognized as safe [32, 33]. Therefore, the toxicity observed when using species from the genus Microsorum is still controversial. Some authors proposed that botanical confusion between different fern species may cause this toxicity [29]. This hypothesis is supported by different studies showing that the genus Microsorum is highly confusing from a taxonomic point of view [34, 35]. We can also state that other compounds present in the fern species could be responsible for its toxicity. Because most of the studies on Microsorum involved the use of leaves (fronds), roots that are less studied could contain such toxic compounds not already described. Also, phytochemical variation following temperature and seasonal variation, geographical location, or time of collect could also be involved. Of note, “metuapua'a” is also widely mentioned to be combined with other plant species especially “ti'ati'amou'a” [4]. In our survey, this plant species is also reported as the second most poisonous species. This suggest that compounds interactions between fern species could also be involved.

Types of health disorders and therapeutic management

Of the 69 health disorders cited, some had a high proportion of similar used plant species, thus showing cultural consensus among participants. This feature was identified thanks to the ICF index (Additional file 1: Table S1). The set of disorders called ira showed the highest ICF with 0.86 (158 UR, 23 used plant species), followed by tonsillitis and sore throat with an ICF of 0.8 (11 UR, 3 plant species), the set of disorders called he’a with an ICF of 0.78 (124 UR, 28 plant species), chickenpox with an ICF of 0.73 (12 UR, 4 plant species), vaginal and urethral discharge with an ICF of 0.7 (24 UR, 8 plant species), and ranula (salivary cyst) with an ICF of 0.68 (29 UR, 10 plant species). In terms of disease categories, mental, behavioral or neurodevelopmental disorders ranked first with an ICF of 0.86 (158 UR, 23 plant species), digestive system ranked second with an ICF of 0.76 (97 UR, 24 plant species), respiratory system ranked third with an ICF of 0.74 (125 UR, 33 plant species), genitourinary system ranked fourth (ex-aequo) with an ICF of 0.68 (48 UR, 16 plant species), and skin disorders ranked fourth (ex-aequo) with an ICF of 0.68 (77 UR, 25 plant species).

Among cited plant species, some were mostly dedicated to the treatment of specific disorders. This feature was identified thanks to the FL index (Additional file 2: Table S2). Annona muricata had a Fidelity Level (FL) of 100% for ira, Rosa sp. had a FL of 100% for sinusitis, Hibiscus rosa-sinensis “Carnation” had a FL of 87.9% for ira, Syzygium malaccense had a FL of 83.3% for he'a, and Curcuma longa had a FL of 82.8% for he'a. In terms of disease categories, Coleus scutellarioides had a FL of 100% for injury (sprain, fracture), Spondias dulcis had a FL of 78.3% for respiratory disorders (cough, tonsillitis, sore throat, asthma), and Ficus tinctoria had a FL of 71.4% for skin disorders (skin disorders related to he’a, eczema, furuncles, abscess, and other disorders with pus exudation).

In the following sections, we present in descending order of importance, the results obtained for each children disease cited by more than ten participants. In the section detailing each reported remedy, only data for remedies cited by three participants and more are presented.

An assessment of the efficacy and toxicity (based on a thorough bibliographic review) was performed for each most cited remedy. A summary of these evaluations can be found in Additional file 3: Table S3.

In Table 5, we detail the information on symptoms, causes, methods of diagnosis, and methods of prevention gathered from the participants to this survey for the most cited children illnesses.

Table 5 Description of the most cited children illnesses by the 86 participants in the five islands from the Society archipelagoIra

As stated above, the set of disorders called “ira” can be defined as a group of behavioral disorders including restlessness, irritability, to wake with a start, and convulsion. This definition was established based on information provided in our study and previous data on this topic.

A total of 50 unique remedies were cited for treating ira corresponding to 95 UR. Up to seven ingredients were combined in the remedies (see also Additional file 4: Table S4 for a detail on the number of ingredients present per remedy). Thirteen plant species belonging to 11 families were reported to be used to treat ira. The most cited plant species used for treating ira were Annona muricata [leaf] (33 UR), Hibiscus rosa-sinensis “Carnation” [flower or leaf] (29 UR), Gardenia taitensis [flowerbud or leaf] (28 UR), Saccharum officinarum [leaf, leafbud, or stem] (19 UR), and Microsorum grossum [leaf or rhizome] (11 UR).

The most cited remedy (21 participants, 33 UR) was composed of one ingredient: the leaves of Annona muricata. This preparation is boiled in water (20 participants, 95%) and mainly used (20 participants, 95%) for bathing the babies and children. In addition to the bath, five (23.8%) participants also added massages, five (23.8%) administered orally one or two teaspoons of the decoction, three applied the decoction locally on the fontanel, and two sprayed the decoction on the child’s face. Five participants reported using 30 leaves, four participants use 1 full hand of leaves, and two participants use about 12 to 15 leaves. Eight (38.1%) participants give the remedy for 3 days, and five (23.8%) parti