Introduction
The primary duty of nurses is to provide quality clinical care to patients, which, in addition to specialized knowledge and practical skills, requires the ability to assess, manage, and address ethical conflicts, as nursing is a profession closely related to ethical issues (Yuguero et al., 2019). Nurses frequently face ethical challenges due to their decisions regarding the health and lives of individuals. Nurses should adhere to ethical principles to ensure patients' safety and protect their rights, as ethics are an integral part of the concept of care (Sadat Hosseini et al., 2023). 
The Florence Nightingale Pledge, recognized as the first ethical code for the nursing profession, encompasses important guidelines for nurses. Phrases such as "I will endeavor to maintain and elevate the standard of my profession and will work with loyalty to assist the physician in his work and devote myself to the welfare of those committed to my care. I will abstain from whatever is deleterious and mischievous. I will not knowingly administer any harmful drug," helped clarify the purpose and function of nursing at the time of introducing this covenant and defined new professional values for nursing. Since then, nursing has been increasingly recognized as a profession with its own values and unique principles (Rosenkoetter & Milstead, 2010). With the advancement of scientific and technological knowledge in the field of health, there was a need to develop specific ethical codes for nursing to help resolve the ethical dilemmas faced by nurses. These codes are recognized as tools for describing the responsibilities and common values unique to the nursing profession, guiding nurses in their activities and decision-making, as well as outlining how they disseminate health information to the public. Contemporary ethical principles in medicine are categorized into four types: Autonomy, beneficence, non-maleficence, and justice (Turkmen & Savaser, 2015).
The principle of autonomy asserts that individuals should have the freedom to make health-related decisions based on their own values, beliefs, and expectations without external pressure. Grounded in self-determination, it aims to uphold human dignity by requiring nurses to respect each person's values and choices. A key aspect of autonomy in healthcare is informed consent, which allows individuals to exercise their rights when they possess accurate information about their health situation. Additionally, the principles of truthfulness and honesty underpin informed consent, placing the onus on healthcare professionals to ensure patients are well-informed and understand their treatment options, including the right to refuse care. This principle also emphasizes the importance of maintaining patient privacy during treatment interactions (Cobanoglu, 2009). 
The principle of beneficence emphasizes the duty to benefit patients, guiding nurses to prioritize actions that promote patient welfare while minimizing harm (Jonsen et al., 2022). 
The principle of non-maleficence involves preventing harm to others, emphasizing the need to avoid actions that could result in injury. It comprises three interconnected elements: Non-maleficence, preventing damage, and eliminating harm (Jonsen et al., 2022). 
The principle of justice emphasizes the fair treatment of all individuals, underscoring the importance of equitable resource distribution, particularly when making treatment decisions (Cobanoglu, 2009; Rosenkoetter & Milstead, 2010).
In the field of medical ethics, discussions related to bioethics often emphasize the primacy of adults, while the application of these principles to children frequently encounters challenges (American Academy of Pediatrics [AAP], 2007). Because children are unable to advocate for their own rights and face a variety of health issues along with differences in various stages of growth and development, the unique circumstances of each child often lead to dilemmas and ethical conflicts regarding their treatment and care (Schulz et al., 2023). Therefore, pediatric nursing stands at the intersection of complex ethical considerations, where the well-being of children is paramount, yet often complicated by issues of consent, confidentiality, and the rights of guardians (Carnevale, 2012; Dickey et al., 2002).
The unique developmental stages of children necessitate a nuanced understanding of their ability to provide informed consent, while simultaneously upholding the confidentiality that is essential to establishing trust in the nurse-patient relationship (Self et al., 2017). Furthermore, the overarching goal of promoting child welfare often requires navigating the expectations and desires of parents or guardians, which can sometimes oppose the best interests of the child (Watts et al., 2014). Ethical dilemmas arise when there is a conflict of values, either between individuals or within a single individual, regarding which available options should be selected. Consequently, it is essential for nurses to effectively address these challenges and make informed decisions, which necessitates an understanding of basic principles, regulations, and other pertinent information, along with a dedication to ongoing skill enhancement in their nursing practice (Jonsen et al., 2022). 
By examining existing literature and real-world scenarios, we aim to equip pediatric nurses with the knowledge and ethical frameworks necessary to make informed decisions in their practice, ultimately fostering a safe and supportive environment for their young patients. Thus, this narrative review aims to navigate the ethical dilemmas in pediatric nursing by examining the interplay between consent, confidentiality, and child welfare, thereby providing a foundation for developing tailored ethical frameworks that address these interconnected dimensions.

Materials and Methods
This narrative review, conducted in 2024, systematically evaluated peer-reviewed articles addressing ethical challenges in pediatric nursing. The included studies comprised quantitative (descriptive, observational, and interventional) and qualitative designs, sourced from electronic databases: MEDLINE, PubMed, Embase, Web of Science (WoS), CINAHL, and Persian databases (Magiran and Scientific Information Database [SID]), supplemented by Google Scholar using the Tehran University of Medical Sciences’ digital library. No books or non-peer-reviewed sources were included in the analysis; books were reserved for the “background” and “discussion” sections only. A systematic search, without time restrictions, was conducted using the following keywords: “Pediatric nursing,” “ethical dilemmas,” “ethical challenges,” “beneficence,” “autonomy,” and “non-maleficence.” The inclusion criteria were as follows: articles written in English or Persian, peer-reviewed articles with keywords in the “title,” “abstract,” or “keywords,” and a focus on ethical challenges in pediatric/adolescent nursing. The exclusion criteria were studies on adult care ethics or non-article sources (e.g. books, theses). Two researchers independently screened titles and abstracts, followed by full-text review, removing duplicates and irrelevant studies. A secondary search of reference lists refined the selection, yielding 32 articles (Figure 1).

Quality of included articles was assessed using the scale for the assessment of narrative review articles (SANRA) checklist, focusing on methodological rigor, relevance, and clarity of findings (Baethge et al., 2019). Data analysis and synthesis followed a narrative synthesis approach (Popay et al., 2006) involving preliminary synthesis to identify recurring themes (e.g. decision-making, confidentiality), exploration of relationships between studies to understand ethical tensions, and synthesis of findings to address the study’s aim of balancing consent, confidentiality, and child welfare. Findings were organized thematically, with results presented in the subsequent section (Figure 1). 

Results
This narrative review identified ethical dilemmas in pediatric nursing, with a focus on the interplay between informed consent, confidentiality, and child welfare. The findings were organized into four key domains, aligned with the study’s aim and subsequent discussion: Dynamic participation of children, informed consent and assent, privacy and confidentiality, and balancing conflicting interests, as summarized in Table 1.


Each domain reflects specific ethical challenges faced by pediatric nurses globally, providing a foundation for exploring practical implications in pediatric care. 
Note: Table 1 presents selected examples from the 32 reviewed studies to illustrate key findings.
The narrative synthesis of the reviewed literature on ethical dilemmas in pediatric nursing revealed that these challenges are shaped by factors such as the child’s developmental stage, parental involvement, legal and ethical frameworks, and the dynamics of patient care. Ethical dilemmas were particularly pronounced in decision-making processes, including the dynamic participation of children, where pediatric nurses must navigate the delicate balance between advocating for the child’s best interests and respecting parental rights and wishes. This complexity is further heightened by the need for informed consent, especially when assessing a child’s capacity to provide assent, which introduces ethical ambiguities related to autonomy and parental authority (Hein et al., 2015; Spriggs, 2023).
One of the main challenges identified in this study is ethical numbness, which arises from the heavy workload and the focus on performing tasks quickly and efficiently. As a result, nurses may not be able to pay sufficient attention to ethical issues. This condition can lead to neglecting the needs of children and families (Choe et al., 2019; Varvani Farahani & Ozturk, 2024). Therefore, interprofessional collaboration plays an important role in addressing ethical dilemmas. The literature suggests that engaging with a multidisciplinary team can provide pediatric nurses with valuable support and diverse perspectives when confronted with ethical challenges (Lines et al., 2024). Collaborative approaches can enhance decision-making processes and ensure that the child’s welfare remains the primary focus (Tung et al., 2019).
Another prominent subtheme identified in the literature is the ethical and legal challenges surrounding end-of-life care. Pediatric nurses face the challenging task of facilitating discussions about transitioning from curative treatment to palliative care, which requires sensitivity to the emotional burdens experienced by families (Akard et al., 2019; Cole & Foito, 2019). The concept of “best interest” emerges as a critical consideration (Eekelaar, 2015), necessitating a nuanced understanding of the child’s medical, emotional, and cultural context to guide ethical decision-making in these sensitive situations (Ross, 2019).
Confidentiality also emerged as a key finding, highlighting the ethical tensions pediatric nurses face in maintaining the privacy of young patients while ensuring that parents are adequately informed (Eg & Jensen, 2023). The complexities of confidentiality are exacerbated by technological advancements, such as digital health records and social media, which introduce new challenges in safeguarding sensitive information (Keshta & Odeh, 2021). This finding highlights the importance of establishing clear policies and guidelines to support pediatric nurses in navigating these dilemmas and safeguarding the rights of both children and their families.

Discussion
Until around 1985, there was no distinction between ethical issues in pediatric and adult medical ethics, and the Beauchamp and Childress four-principle approach, including autonomy, beneficence, non-maleficence, and justice, was advocated for all groups. Following the Helsinki and Belmont Declarations, which recognized children as a distinct group and established ethical codes for research involving them, new discussions emerged regarding key issues in pediatric ethics, including informed consent, parental permission, and patient assent. The first draft of this document was prepared by William Bartholomew in the AAP Bioethics Committee in 1985, which has since evolved and become more formalized (Chowdhury et al., 2010). With the establishment of bioethics committees for children in hospitals and pediatric societies, specific issues in children have become more prominent. Children are considered vulnerable and dependent individuals in any society (Alahmad et al., 2020), so the ethical challenges that nursing faces in caring for children are more complex. In addition to the child, parents and caregivers play a significant role in the decision-making process (Quaye et al., 2019). In other words, vulnerability, dependence, lack of capacity, and the inability of children to make independent decisions make care even more challenging. Due to the assumptions raised in pediatric medical ethics and the responsibilities and challenges that follow, a distinct ethical space is created in contrast to discussions in adult medical ethics. Therefore, solving ethical dilemmas in pediatric clinical settings is not simply a matter of relying on the four principles of Beauchamp and Childress, and solutions to ethical conflicts in adult clinical settings should not be directly translated to pediatric ethical problems. Instead, it requires an understanding of the ethical challenges present in pediatric clinical settings and the subsequent elucidation of ethical solutions.
Pediatric nursing involves multifaceted decision-making that requires careful consideration of various factors, including the child’s developmental stage, parental wishes, and medical recommendations. A primary ethical dilemma arises when the medical team’s recommendations conflict with parents’ preferences, necessitating pediatric nurses to balance advocating for the child’s best interests with respecting parental rights (Roggero et al., 2024).
The key themes of ethical dilemmas in pediatric nursing identified in this review are discussed below.

Dynamic participation of children
The dynamic participation of children in healthcare decisions is increasingly recognized as a vital aspect of pediatric care. This concept emphasizes the importance of involving children in discussions regarding their health, treatment options, and care plans, tailored to their developmental stage and cognitive abilities (Lipstein et al., 2015; Olszewski & Goldkind, 2018). Engaging children in this way not only respects their autonomy but also empowers them to express their preferences and concerns. It enhances their understanding of their health conditions, potentially leading to improved treatment adherence and satisfaction with care. When children feel that their voices are heard, it fosters a therapeutic alliance between them and health care providers, which is essential for effective care delivery (Betzler, 2014). The dynamic participation of children also necessitates an age-appropriate approach to communication (Gottschalk & Borhan, 2023). Pediatric health care providers must be skilled in adapting their communication styles to suit the developmental level of each child (Bell & Condren, 2016). The ethical principle of autonomy necessitates that nurses respect a child’s evolving capacity for decision-making while simultaneously recognizing the authoritative role of parents (Parsapoor et al., 2014). This dual responsibility requires pediatric nurses to be skilled in assessing developmental stages and fostering an environment that encourages children to express their preferences and concerns regarding their care.

Informed consent and assent
Informed consent and assent are critical components in pediatric decision-making, yet they often present ethical challenges due to the varying levels of understanding and capacity among children. Agreement or “consent” of a child for medical treatment or participation in research is not ethically the same as the agreement or consent of an adult (Spriggs, 2023). Informed and voluntary consent of an adult for undergoing treatment or participating in research is considered justifiable. However, when the patient or research participant is a child, the subject matter differs, as children have limited cognitive abilities and mental maturity, and they require someone to advocate for their interests (Morrow et al., 2015; Spriggs, 2023). Globally, parents are generally regarded as the most suitable decision-makers for their children, because they are assumed to care deeply for children and know them better than anyone else, thereby making the best decisions. However, parental consent is not considered “true” consent. Informed consent, as defined by medical literature, research ethics, law, philosophy, and psychology, requires competence in decision-making and includes three key elements: Disclosure, understanding, and voluntariness. For children, there is no agreement on how to apply or adapt these elements. In adults, the primary ethical value underlying informed consent is autonomy; however, for children, it is respect for persons, emphasizing the child’s welfare and interests (Spriggs, 2023; Varkey, 2021). Therefore, while in adults, decision-making and informed consent are based on the best personal interests, the principle of autonomy, which is a very important and emphasized principle in adults, does not seem to have a suitable and direct application for children and lacks direct applicability for them (Ke, 2023).
Basic assumptions regarding children and the responsibilities that follow create a different ethical space. Ethical assumptions about caring for children compared to adults are expressed as follows: the assumption of patient incompetence, the assumption of patient immaturity, the assumption of developed responsibility, the assumption of ethical need for support, and the assumption of parental authority over evolving values of the child. In contrast, assumptions related to adult care include the assumption of patient autonomy, the assumption of adult values and ownership, the assumption of full responsibility, the assumption of commitment to respect, the assumption of parental views on patient values, and the assumption of conflict between respect for autonomy and providing beneficence (Hester & Toby, 2012). These two comparisons, along with the presentation of different assumptions between children and adults, indicate that medical ethics in children have unique issues that differ from those in adults. In the field of caring for and treating children, the concept of consent (both parental and child) can be equally ambiguous and challenging for nurses (Reynolds et al., 2017). While Beauchamp and Childress accept that ethics in society reflects cultural, social, economic, and belief differences, they believe that a set of four principles can form the basis of a neutral approach to bioethical discussions, regardless of the context, which they consider as general laws that are not absolute and can be translated into different forms to resolve conflicts (Baines, 2008). From the perspective of medical ethics, the emphasis in all bioethical discussions is on the centrality of adults, while applying these principles in the realm of children sometimes faces challenges (Fallat et al., 2007). First of all, the physical and mental growth, cognitive capacities, and logical and reasoning skills of children differ at various developmental stages, so children lack the capacity for informed decision-making about their health and medical care like a fully mature adult. In essence, while beneficence dictates that parents or a legal guardian must act in the best interests of the child, assessing what a child’s interests are and determining the appropriate standard of interests makes the issue more complex. Another problem with the four-principle approach is that parental or guardian authority does not clearly follow the four principles (Bieber et al., 2020). Therefore, resolving ethical dilemmas in pediatric clinical settings requires more than the approach of Beauchamp and Childress (autonomy, beneficence, non-maleficence, justice), as it inadequately addresses the distinct complexities of pediatric care compared to adult clinical practice. These complexities, including children’s evolving autonomy and dependence on parental authority, demand a specialized ethical framework tailored to pediatric needs. This condition underscores the need for a new approach in pediatric medical ethics that reflects these unique challenges (Bieber et al., 2020).

Balancing conflicting interests
Conflicts between the medical team’s recommendations and parents’ preferences are common ethical dilemmas in pediatric nursing that can significantly impact the decision-making process regarding a child’s care. When parents and health care providers have differing views on treatment options, it can create tension and uncertainty for both parties (Aarthun & Akerjordet, 2014). Pediatric nurses often find themselves in the challenging position of mediating these conflicts, requiring a delicate balance of advocating for the child’s best interests while also respecting the family’s wishes and needs. This situation requires strong communication skills, empathy, and a profound understanding of ethical principles (Azevêdo et al., 2017; Linney et al., 2019).
To effectively navigate conflicts between medical recommendations and parental preferences, pediatric nurses must engage in open and honest dialogue with families (Linney et al., 2019). This dialogue includes thoroughly explaining the rationale behind medical recommendations, discussing the potential risks and benefits of various treatment options, and actively listening to parents’ concerns and perspectives (Légaré et al., 2018). This situation, a dynamic process, can only be managed through a combination of logical and ethical decision-making that relies on the ability to think critically and develop ethical sensitivity. By fostering a collaborative approach, nurses can help facilitate mutual understanding and respect, ultimately leading to more informed and shared decision-making (Truglio-Londrigan & Slyer, 2018). Health care providers need to recognize that parents are often motivated by love and concern for their child’s well-being, and addressing their preferences with empathy can help build trust and rapport. This issue is more significant in the end-of-life children (Pfaff & Markaki, 2017; Younis et al., 2015). By addressing not only the physical symptoms but also the emotional and spiritual needs of patients and families, pediatric nurses can ensure that palliative care is tailored to the unique circumstances of each child and their family, ultimately promoting dignity and comfort during the final stages of life (Montgomery et al., 2017).
Moreover, addressing conflicts between medical recommendations and parental preferences may also involve exploring the underlying values and beliefs that shape parents’ decisions. Understanding the cultural, religious, or personal reasons behind a family’s preferences can provide valuable insights that inform the decision-making process (Pearson H et al., 2022). Pediatric nurses should strive to incorporate these values into the care plan whenever possible, working collaboratively with families to find solutions that respect both medical expertise and parental wishes. By prioritizing ethical considerations and engaging in respectful dialogue, pediatric nurses can help bridge the gap between medical recommendations and parental preferences, ultimately enhancing the quality of care provided to pediatric patients.

Privacy and confidentiality
From an ethical perspective, respecting autonomy, beneficence, and non-maleficence are important justifications for maintaining patient confidentiality. Respecting privacy and confidentiality is crucial for protecting the well-being of patients, establishing effective therapeutic relationships, and fostering trust within the health care community (Tegegne et al., 2022). Maintaining confidentiality creates an ethical right for individuals, and others are obligated to respect and protect this right. In health care settings, nurses play a significant role in addressing potential issues or challenges related to patient privacy and confidentiality by providing 24-hour care as primary caregivers. As they inevitably receive a lot of information about their patients, they are well-positioned to deliver quality and targeted health care (Piraino, 2012). This information often has private and sensitive aspects and must be carefully managed to prevent its disclosure to individuals outside the system (Brennan & McElvaney, 2020; Eg & Jensen, 2023). Unfortunately, privacy and confidentiality are repeatedly violated through various methods. For example, discussing a patient over the phone or in a public place with a colleague may jeopardize patient confidentiality (Blightman et al., 2014). Additionally, in multi-bed rooms, maintaining privacy and confidentiality during visits, examinations, and procedures is challenging. As a result (Kerr et al., 2014), the consequences of such breaches of privacy include patients feeling embarrassed that others may overhear their conversations or patients refraining from providing information about themselves (Noroozi et al., 2018).
Respecting privacy and maintaining confidentiality are top priorities for all healthcare professionals caring for hospitalized children and adolescents, and children have equal rights to privacy as adults (Ceylan & Çetinkaya, 2020). However, unfortunately, their right to privacy is often overlooked, especially when working with children and their parents, posing a more challenging and complex issue that can impact clinical actions. Typically, children and adolescents are accompanied by at least one of their parents when admitted to the hospital, which can increase the risk of sensitive information being overheard during examinations and procedures (Curtis & Northcott, 2017). Although guidelines for adolescent care recommend that the hospital environment should provide private and family-free time for visits and care for adolescents (15 to 24 years) with health care professionals (Sawyer et al., 2014), adolescents have reported that sometimes their health information is shared with their parents without their consent (Jensen & Eg, 2022). 
Some health care professionals may prefer counseling with parents present to ensure that they are involved in the treatment process and can support the child (Eg & Jensen, 2023). However, it is worth noting that this approach places less priority on the independence and autonomy of the child or adolescent patient (Sawyer et al., 2012). For example, one of the ethical dilemmas with children and adolescents is when communicating with them; a patient may intend to discuss sensitive issues with a nurse or physician, things they do not want their parents to know, such as alcohol consumption or sexual activity. Therefore, adolescents need to have the opportunity to speak privately with healthcare professionals, as these issues may be overlooked and have subsequent consequences (Adolphsen et al., 2016). 
It should be noted that hospitalization is a stressful experience for children and parents, and the violation of privacy and confidentiality is one of the stressful situations that children have remembered as their worst experience (Boztepe et al., 2017). Studies have shown that maintaining personal information and aspects of privacy, including psychological, social, and physical elements, is critically important for hospitalized adolescents. One of the main reasons adolescents are reluctant to receive medical care is concern about the confidentiality of their personal information (Ancker et al., 2018). Despite the emphasis on the duty to maintain confidentiality and its designation as a fundamental ethical obligation for healthcare professionals in ethical guidelines, research results indicate that these guidelines are often violated during the hospitalization of children (Sawyer et al., 2014). 
Healthcare professionals believe that absolute confidentiality cannot be guaranteed in caring for children. The National Health Association (NIH) guidelines state that parents (guardians) must be fully informed about the health conditions and relationships of their children up to the age of 18. Therefore, this regulation can create an ethical dilemma for healthcare professionals in maintaining confidentiality (Adolphsen et al., 2016). However, it is essential to note that parents have the primary ethical and legal responsibility for their children's health care (Ancker et al., 2018) and expect their children to be treated with dignity and respect during health care services, with upholding privacy being one of these ethical and legal responsibilities. On the other hand, it has been shown that children's awareness of their environment and privacy needs increases with age and cognitive development (Noghabi et al., 2019). Considering the child's age, growth, and cognitive status, parental presence may be necessary in some health care services. To promote independence and respect for the child's privacy, however, communication with parents should be limited in certain situations.
Studies on confidentiality in health care are limited, and research dedicated to studying confidentiality in pediatric healthcare settings is rare (Eg & Jensen, 2023). However, it seems that, besides the continuous presence of parents alongside their children, situations where confidentiality is violated are influenced by the physical environment, such as ward design, as well as the behavior and attitudes of staff. In a study, it was observed that nurses with higher levels of education who had received training on patient privacy and had read regulations related to the rights of pediatric patients were more concerned about patient privacy (McCarthy & Wyatt, 2014; (Ceylan & Çetinkaya, 2020). Therefore, nurses and other healthcare professionals need to strengthen their understanding of confidentiality issues and be mindful of how and where patient information is shared.

Child welfare
Child welfare is a core aspect of pediatric nursing, focusing on meeting the physical, emotional, and social needs of children at every stage of their development (Schneiderman, 2006). Pediatric nurses encounter various challenges in ensuring the well-being of children, often needing to strike a balance between respecting the child's rights and the authority of their parents. These challenges are especially pronounced when medical decisions may not align with what parents believe is best for their children. 
Children have specific health and treatment needs due to their heightened vulnerability to physical, behavioral, and developmental challenges, as well as risks of neglect and maltreatment (Leslie et al., 2005). In examining various perspectives, pediatric medical ethics are based on a fundamental ethical concept: health care professionals and parents (guardians) are trustees of sick children. This means that health care professionals are ethically committed to supporting and promoting the welfare and interests and health-related desires of the child, which is limited by medical competence. However, the ethical concept of parents as trustees of the child has a broader scope, as it relates to both health-related and non-health-related interests of the child (Katz et al., 2016). From an ethical perspective, just as an adult human is dignified and respectable, children are also deserving of respect, honor, respect for personal matters, confidentiality, and upholding their rights. 
 In the field of pediatric ethics, four goals are considered for pediatric medicine: Disease and injury prevention, health promotion, and maintenance; relief from pain and suffering; care and comfort for those who are not treatable; and avoiding premature death and pursuing peaceful care, which should be effectively (good) provided at all stages (Mitchell & Guichon, 2019). That is, professional actions aimed at achieving these four goals must comply with health care standards to achieve a useful and desirable outcome, uphold human dignity, and align with the implementation of ethical principles and guidelines. This is the definition of pediatric professionalism. The AAP board considers professionalism in pediatric medicine to include several principles such as honesty and integrity, reliability and trustworthiness in responsibility, respect for others, confidentiality, compassion and empathy, increasing self-awareness and enhancing scientific competence, collaboration, responsibility for communication and support, and professional responsibility (Livingston et al., 2016). These principles form the basis of the professionalism and ethical principles of health care for children and their families, which should be continuous, patient-centered, comprehensive, and coordinated.
Therefore, considering the importance of childhood, their vulnerability, and the biological and psychological differences among age groups of children, the Convention on the Rights of the Child was developed in 1989 to promote the welfare and protection of children and was implemented in 1990 (Sandberg, 2015). Currently, 191 out of 193 United Nations member countries have joined this Convention and committed themselves to its implementation. According to this treaty, a child is defined as a person under the age of eighteen, unless the legal age of majority is set at an earlier age in the relevant countries (UNICEF, 2007).
The convention on the rights of the child is based on four principles. First, no child should suffer from discrimination. Second, when decisions are made regarding children, their best interests should be a top priority. Third, children have the right to life and should be allowed to grow. Fourth, children have the right to express their opinions freely, and this input should be considered in all matters concerning them (UNICEF, 2020). Therefore, based on these principles, efforts should be made to strongly demonstrate that children require more support and care from parents, officials, and individuals in relation to them and are classified as special groups in society. In the context of health care, investment in physical, spiritual, ethical, and mental dimensions can enhance health outcomes and quality of life, reflecting a broader commitment to ethical care on a global scale. This study was constrained by its reliance on English and Persian-language articles, potentially excluding relevant findings from other linguistic contexts. Additionally, the use of a narrative synthesis approach may introduce subjective interpretation of the reviewed literature.

Conclusion
Pediatric nursing encompasses a unique set of ethical challenges that require a deep understanding of the balance between the rights of children and the authority held by their parents or guardians. The current frameworks for adult medical ethics often fall short in addressing the specific complexities inherent in pediatric care, underscoring the need for customized ethical guidelines that prioritize the well-being of children while also acknowledging the role of parents. This dual approach is crucial for pediatric nurses as they navigate the ethical dilemmas that arise, especially in decision-making situations that have a direct effect on the welfare of young patients. Moreover, strong communication skills and ethical awareness are essential for pediatric nurses in their daily practice. The insights gathered indicate that nurses should develop the ability to engage meaningfully with both children and their families, promoting open conversations that respect everyone’s viewpoints. By creating a trusting and respectful environment, pediatric nurses can more effectively advocate for the best interests of their young patients, while considering the rights and concerns of their parents. Ongoing education and collaboration across disciplines are vital for enhancing nurses’ skills in addressing ethical challenges, which in turn improves the quality of care provided to children. By fostering a culture of ethical awareness within pediatric nursing, not only are the rights of children protected, but the overall integrity of the healthcare system is also strengthened. Finally, the importance of establishing thorough ethical guidelines specifically for pediatric nursing cannot be emphasized enough. Given that children are naturally vulnerable and rely on adults for their care and decision-making, health care professionals must have access to a strong ethical framework that prioritizes the welfare of children while recognizing the authority of parents. By acknowledging the distinct ethical considerations in pediatric care and advocating for the development of specialized ethical standards, the nursing profession can reaffirm its commitment to delivering high-quality, ethical care to children. This commitment is vital for ensuring that the voices of young patients are acknowledged and valued within the health care system, ultimately creating a more just and compassionate atmosphere for everyone involved.
It is recommended to examine the implementation of ethical principles in childcare within specific cultures (e.g. Asian countries) as well as the practical application of ethical guidelines in various pediatric clinical settings to bridge the gap between theoretical frameworks and real-world practice.

Ethical Considerations
Compliance with ethical guidelines
No patient data was used in this study. The review process relied solely on publicly available, peer-reviewed literature. The authors maintained integrity in the synthesis and interpretation of findings, avoiding bias and ensuring transparency in reporting.

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

Authors' contributions
Conceptualization, study design, and writing the original draft: Maryam Modabber; Investigation and data collection: Maryam Modabber and Marzieh Maleki; Data analysis: Marzieh Maleki and Elham Salahi; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgements
The authors acknowledge the use of artificial intelligence tools, Grok 3 (standard version, non-BigBrain mode), developed by xAI, and ChatSnow version 4mini, between July 2024 and October 2024, during revision stages (in response to reviewer comments) of this manuscript. These tools were utilized to generate initial drafts of the Highlights and Plain Language Summary, as well as to assist with the final translation, summarization, and paraphrasing of the “Introduction” and “Discussion” sections. Subsequently, the authors reviewed and edited the content to ensure accuracy and alignment with the study's objectives.


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