ObjectiveThis study aimed to explore the potential comparative effectiveness of various traditional Chinese medicine (TCM) decoctions plus conventional biomedical treatment (CBT) versus CBT alone in pediatric asthma using a Bayesian network meta-analysis (NMA).MethodsSeven databases were systematically searched for randomized controlled trials (RCTs) published up to 24 March 2025 that evaluated TCM decoctions in the treatment of pediatric asthma. The Bayesian NMA was conducted using R 4.4.1 and Stata 15.1. Risk of bias was assessed using the Cochrane tool (Review Manager 5.4.1), and interventions were tentatively ranked by surface under the cumulative ranking curve (SUCRA).ResultsA total of 21 RCTs involving 2,068 patients and 9 distinct TCM decoctions were included. The risk of bias was high or unclear in all studies included, with particular concerns regarding allocation concealment and blinding. Compared with CBT alone, Qing Qi Hua Tan Tang (QQHTT) + CBT significantly improved forced expiratory volume in one second (FEV1) (mean difference [MD] 1.20; 95% credible interval [CrI] [1.10, 1.40]). Ma Xing Shi Gan Tang (MXSGT) + CBT significantly increased peak expiratory flow (PEF) (MD 12.00; 95% CrI [8.00, 17.00]). According to SUCRA, QQHTT + CBT (SUCRA = 99.9%) and MXSGT + CBT (SUCRA = 97.1%) ranked highest for FEV1 and PEF.ConclusionSensitivity analyses confirmed the stability of the results regarding FVC and IgG, with Ma Xing Shi Gan Tang He Su Ting Wan (MXSGTHSTW) + CBT and Xiao Qing Long Tang (XQLT) + CBT which was ranked first in all analyses. For FEV1, the top-ranked interventions (QQHTT, Da Qing Long Tang [DQLT], MXSGTHSTW) remained in the top three across all analyses, with minor changes in ranking attributable to differences in inclusion criteria across studies. For PEF, the rankings in sensitivity analysis 1 were influenced by a reduction in the number of eligible treatments. For IgE, no decoction showed statistically significant differences, and the rankings were sensitive to the conditions of the analysis. Although QQHTT and MXSGT demonstrated statistical advantages in this NMA, serious methodological limitations exist in the included studies, particularly the lack of blinding and allocation concealment. Moreover, the inability to fully ensure the comparability of TCM decoctions means that these findings should be regarded as preliminary, hypothesis-generating and exploratory.Systematic Review Registrationidentifier CRD420251120217.