Constipation is one of the most common symptoms in pediatric outpatient clinics, accounting for about 10%-25% of pediatric gastroenterology clinics, 90% of which are functional constipation (FC) with no clear etiology. Although it is easy to treat in the early stage of the disease, it is easy to be neglected by the family because of the mild symptoms, and often it is not seen until a long time after the onset of the disease, which makes the treatment very difficult, and severe constipation is often combined with abdominal distension, abdominal pain and abdominal masses, and even fecal incontinence, which seriously affects the growth and development and physical and mental health of the child. With the rapid development of modern molecular biology, imaging and biophysics, people have conducted in-depth research on the etiology and clinical treatment of childhood constipation, and have made great progress, and more and more etiologies and mechanisms have been elucidated, such as congenital megacolon and its homologous diseases, intestinal nerve dysplasia, sphincter loss retardation, etc. On this basis, the accurate treatment for the etiology has been gradually reflected; at the same time At the same time, on the basis of the research on adult constipation, pediatric researchers in China, combined with the specific situation of childhood constipation development in China, have also conducted in-depth discussions on the standardized diagnosis and treatment protocol of functional constipation in children, and at a meeting of the Chinese Pediatric Surgery Branch of the Chinese Medical Association held in Xi’an in October 2010, the Chinese Pediatric Surgery and Anorectal Surgery Group formally proposed a standardized diagnosis and treatment protocol for the treatment of functional constipation in children in China. standardized diagnosis and treatment process for the treatment of functional constipation in children in China, which laid the foundation for future multicenter collaboration nationwide and marked the era of standardization in the study of childhood constipation in China [13]. Although we have made some progress in the diagnosis and treatment of childhood constipation, we clearly realize that there are still some unsolvable problems in the study of childhood constipation, for example, the subjects of our current research are mostly older children, whose conditions are basically similar to those of adults, and we have borrowed too much from the research model of adult constipation in the diagnosis and treatment, while the diagnosis and treatment of purely pediatric constipation, i.e. The treatment of infantile constipation is not applicable, as infantile constipation is not the same as that of older children to some extent, both in terms of pathogenesis, pathological basis and clinical treatment ideas are very different, but this point has not actually attracted extensive attention of scholars, we will elaborate on some of the problems in the treatment of infantile constipation, as well as the similarities and differences with older children’s constipation, with a view to formulating We would like to make a modest contribution to the future development of the diagnosis and treatment of constipation in infants and young children, and to share with our colleagues. Prevalence of constipation in infants and young children The reports on the prevalence of constipation in children are very rare, and in the only few reports, most of them are limited to older children and school-age children; in foreign countries Issenmann et al. reported the prevalence of 16% in 22-month-old children, and Bellman reported the prevalence of 2.3% in boys and 0.7% in girls in 7-year-olds. In China, Zhang Shucheng et al. conducted a large-scale survey of 19,286 school-age children in 19 urban areas in 5 northern cities, including Beijing, Tianjin, Shenyang, Jilin, and Harbin, and found that the prevalence of constipation in children in northern cities was 4.73%; the sex ratio was 1.1:1. However, the prevalence of constipation in infants and toddlers has not been reported systematically due to the number of cases and regional bias, but preliminary findings suggest that the prevalence of constipation in infants and toddlers is much higher than that in school-age children, and the specific prevalence needs to be confirmed by a large sample of data. It is evident that constipation in infants and young children is a common condition in infants and young children and should be given great attention by medical practitioners. Diagnostic criteria for infantile constipation The most significant difference between infants and older children is that infants have poorly developed language skills and cannot actively describe their own feelings, so they can only analyze them with the observation and description of their caregivers, so they can no longer rely on the subjective symptoms of the affected children in terms of diagnosis. As early as 1993, Loening-Baucke et al. noted this feature and were the first [18] to propose criteria for constipation in young children: frequency of defecation <3 times/week; painful defecation with crying; or stool storage even though the frequency of defecation is 3 times/week. However, since this criterion was summarized by Loening-Baucke in his long-term clinical practice, was applied only within the scope of his work and was not widely disseminated, and was mostly based on clinical symptoms, it was characterized by varying degrees of subjectivity and lack of universal uniformity, which made it difficult to make horizontal comparisons with the results of other research centers. In order to solve the above problems, in September 1997, the Working Group on Diagnostic Criteria for Functional Gastrointestinal Disorders (FGIDs) of the International Society for Functional Gastrointestinal Disorders in Children met in Rome and established for the first time a classification for children (Class G) in the Rome Criteria system, establishing functional constipation in children The internationalized criteria (G4b), i.e. Rome II criteria, marked the era of standardization in the study of functional constipation in children. After the introduction of the Rome II criteria, the research on childhood constipation entered a climax. However, in the process of practical application, scholars found that the criteria were not perfect, and in fact many key issues of constipation were not reflected, such as the content of soiled stool and fecal retention, which might lead to a significant proportion of patients missing the diagnosis, thus its practicality and validity were severely challenged. In order to address the above issues, the American Digestive Disease Week (DDW-2006) was held at the Los Angeles International Convention Center from May 20 to 25, 2006, where a panel of functional gastroenterology experts revised the Rome II criteria for functional constipation in children, released the newly revised Rome III criteria, established 2 pediatric classifications (G and H), and clearly proposed the neonatal/infantile constipation The diagnostic criteria for neonatal/infant constipation (G7) are: (1) 2 or fewer bowel movements per week; (2) at least 1 episode of incontinence per week after a controlled bowel movement; (3) history of stool retention; (4) history of painful and strenuous bowel movements; (5) large fecal masses in the rectum; and (6) large enough feces to block the toilet. The diagnosis is made in young children from newborn to 4 years of age, with at least 2 of the following symptoms present for up to 1 month. The establishment of the Rome III criteria made up for the shortcomings of Rome II and marked the growing maturity of research on childhood constipation, which once again set off a worldwide craze for research on childhood constipation. In general, in the treatment of constipation in older children, the nature of constipation should be distinguished first, i.e., whether the constipation is organic or functional, and then children with functional constipation should be examined specifically for constipation and typed, emphasizing the importance of objective examination and clinical typing; however, constipation in infants and children is different. The screening of organic lesions, i.e., the examination of the initiating factors causing constipation, is sufficient to confirm the presence of organic changes, while the requirements for special examination and clinical typing of constipation are relatively diluted, which is not to say that special examination and typing are not important for infantile constipation; in fact, this is a helpless choice, because most of the special examinations, such as fecal imaging, anorectal manometry, rectal mucosal However, due to the developmental characteristics of infants and young children, the patient's compliance is very poor, and they cannot understand the doctor's intention or cooperate with the doctor's instructions, so even if the examination is performed, the results are inaccurate; therefore, the importance of objective examination should not be overemphasized in infants and young children, as long as organic diseases can be excluded, which is also the core aspect of the diagnosis of constipation in infants and young children. The core aspect. In infants and young children, there are many causes of constipation, including intestinal diseases, systemic diseases and neurological lesions. Although the exact mechanism is not well understood, it is clear that certain diseases can often cause constipation (see Table 1). In the neonatal and infantile periods, a significant proportion of infantile constipation is due to congenital anatomical abnormalities, the most common anatomical abnormality being congenital anorectal malformations, including perineal fistulas and common cloacal malformations, and many children with postoperative anorectal malformations have constipation, especially those with low-level malformations, and nearly 30% of patients have overflow incontinence secondary to too much constipation. Other abnormalities of bowel development include anal stenosis, anterior anus, congenital megacolon, small left colon syndrome, fecal intestinal obstruction and fecal tethering (usually associated with megacolon), which predispose children to constipation after surgery even after postnatal repair; presacral masses (called Currarino's triad if associated with anal stenosis and sacral malformation) can be early Other anomalies such as rectal duplication, rectal prolapse, rectal stenosis, small bowel tumors (von Recklinghausen neurofibroma) and abdominal tumors may obstruct the colon or rectum and cause constipation. The causes of neurogenic constipation include spina bifida, spondylolisthesis, and traumatic paraplegia, among others. Constipation in these patients may be the result of primary colonic weakness due to damage to the nerves innervating the colon, or it may be the result of functional constipation itself. In addition, another more important cause of constipation is functional abnormalities related to ganglion cells, such as congenital megacolon, enteric neuronal dysplasia and other neural crest abnormalities, including pheochromocytoma, MEN2B and South American hookworm disease, among other causes that may cause obstruction. Finally, abdominal wall muscle development abnormalities such as P-B syndrome may also lead to constipation due to the inability to generate the abdominal pressure needed for the defecation process and the difficulty of fecal elimination. In addition to these developmental factors, constipation in infants and young children can also be secondary to their own disorders. Since infants and young children do not leave their mothers for long, they are not affected by many diseases caused by external environmental factors, among which the ones directly related to constipation are perianal diseases, such as anal fissures, perianal infections, and perianal abscesses; perianal diseases are the most common conditions in infancy and early childhood, and constipation often occurs as a secondary change of perianal diseases. Constipation often appears as a secondary change of perianal diseases, manifested as obvious anal pain during defecation, and the pain can reflexively cause defecation to stop, forming a fear of defecation, and the child refuses to defecate or consciously holds the stool, which stays in the colon for too long and becomes drier and aggravates constipation. Although there are no exact figures, we found that the actual proportion is definitely not less than 60% in the actual clinical work, therefore, in the work of infants and children with constipation, clinicians should pay close attention to the anorectal examination to avoid missing the diagnosis. In addition, systemic metabolic status, including neonatal sepsis, hypothyroidism, maternal diabetes causing small left colon syndrome, hypothyroidism and renal tubular acidosis, systemic neurological damage such as multiple tuberous sclerosis syndrome and systemic diseases including collagen vascular disease, inflammatory bowel disease and cystic fibrosis may cause abnormal bowel function. Postoperative neurovascular changes may also cause delayed intestinal transit function and increased fecal elimination burden, leading to constipation. Medications are also a common cause of constipation, such as opiates, anticholinergics, antidepressants, and antihistamines. Of the many factors that cause constipation in infants and young children, many are physiological in nature. The first and foremost is the dietary factor, infants and young children are in a special period of dietary conversion and rapid growth and development, "spleen is often insufficient", "spleen is weak and easy to hurt" physiopathological characteristics are particularly prominent, constipation is mostly related to improper diet feeding. Modern children are often overfed, stagnant and dysfunctional, or because of excessive milk and not easy to digest, or because of adding supplementary food too quickly, parents one-sided pursuit of high nutrition, or because of the child's partial food and picky eating fatty, sweet and thick taste or arbitrary snacking, all of which cause the spleen and stomach overload, poor transportation, stagnation of the gastrointestinal, long and heat, resulting in heat accumulation in the stomach and intestines. Constipation in infants is often manifested as a lack of bowel movement, and the child will not ask for bowel movement for 3-5 days or even longer, and parents urge him to defecate but it is difficult to discharge the stool, which is a manifestation of delayed large intestine conduction. Premature milk feeding in young infants or lack of proper amount of dietary fiber in the diet of older children can cause constipation; food allergy is also one of the common causes of constipation in infants and young children; secondly, neuropsychological factors such as timidity, fear, etc. can also cause constipation. Physiological factors are the most common cause of constipation in infants and young children, and the majority of constipation in infants and young children is physiological, which is reported to account for about 95% of constipation in children, so we should attach great importance to the role of physiological factors in constipation in infants and young children. Infant constipation treatment considerations The overall principle of infant constipation treatment is early detection and early treatment, to remove the cause, as far as possible using non-invasive, non-toxic, recoverable non-invasive means. Unlike constipation in older children, older children emphasize objective examination, typing according to the examination, and taking graded and individualized treatment plans on the basis of typing; while in infants and young children, the main emphasis is on differential diagnosis, symptom-based diagnosis, downplaying examination and typing, and not emphasizing graded treatment, with basic treatment and Chinese medicine conditioning as the main focus, appropriately supplemented by measures such as bowel cleansing and anal dilation to prevent secondary damage as much as possible. The following are some notes on the treatment of constipation in infants and young children: 1. Still emphasize the importance of basic treatment The treatment of constipation in children has always been a concern for pediatricians, and the guidelines for the standardized treatment of functional constipation in children proposed by the Chinese Pediatric Surgery and Anorectal Surgery Group in 2010 have detailed discussions on the background, ideas and basis of constipation in children and the triage of diagnosis and treatment. The guidelines emphasize the importance of basic treatment, including: increasing dietary fiber content, increasing water intake to enhance colon stimulation, defecation habit training, using the correct method of defecation, developing good defecation patterns, and the appropriate application of synbiotics, probiotics, and laxative medications; in infant and child constipation, the importance of basic treatment remains the top priority and cannot be overemphasized as an option. Basic treatment is of great importance in the treatment of constipation in children, but in the past, basic treatment was often included in the category of "general" treatment, and clinicians often ignored it, and all the items of basic treatment are relatively trivial, which must take more time to explain and explain, so it is often simplified during clinical consultation, resulting in very poor treatment results. [8] In fact, after simple basic treatment, a significant proportion of patients with constipation will relieve or even disappear on their own, eliminating the need for cumbersome examination and even treatment, which is simple, convenient, and economical; on the contrary, if basic treatment is neglected, it may lead to patients' slow response to various treatment measures and poor treatment outcome, resulting in half the effort. Even if the examination and evaluation are repeated in the future, it is impossible to say whether the basic treatment is faulty or the patient is really insensitive to the treatment measures, thus indirectly affecting the therapeutic effect. It can be seen that the "basic treatment" in the treatment of children's constipation is very important, not only has a "therapeutic" effect, but also can prevent constipation and recurrence, clinicians in the actual work should be persistent implementation, persistent, I believe the treatment effect will be evident to all. 2. Appropriate application of bowel cleansing and anal dilatation treatment through bowel cleansing and other measures to keep the intestinal tract empty, on the basis of which to take basic treatment, drug therapy and other follow-up treatment. Emptying the intestine is a prerequisite for all treatments, especially for those patients with long-term constipation and large fecal stones formation, which should actually be classified as basic treatment; if the intestine is not emptied, then even the most effective treatment measures will not work, because the long-term dry stool leads to serious intestinal canal dilatation, fecal accumulation, and even huge fecal stones formation, and the intestinal flora environment is seriously dysfunctional, whether the colon, the Even if various therapeutic measures are applied externally to regulate it, it is only a drop in the bucket compared to the huge malignant stimulation in the intestine, which cannot awaken the potential physiological functions, so emptying the intestine is crucial for the treatment of constipation. Moreover, bowel management and especially bowel lavage as part of basic treatment is not only important in laying the foundation for subsequent treatment, but in fact, bowel lavage itself is a good therapeutic measure; in older children, the effectiveness of bowel lavage has been repeatedly emphasized and confirmed, and in infants and children, the role of bowel lavage should not be neglected and should be selectively applied, as it plays a crucial role in the treatment of constipation, both as an It is an effective treatment and a starting point for other therapeutic measures. In clinical practice, anal dilation is usually used after surgery for various anal malformations, to prevent scar formation, or in the treatment of organic diseases such as internal sphincter failure, but in fact we have found that in infantile constipation, the role of anal dilation in some cases should not be underestimated. In infants and children, this type of constipation is mainly caused by fear of defecation secondary to perianal disorders and spasm of the perianal muscles, which should theoretically belong to the type of spastic outlet obstruction, but this cannot be concluded due to the lack of objective examination evidence; clinically, the main manifestations are fear of defecation, refusal to defecate, retraction of the external anal opening, and pronounced spasm of the sphincter after finger palpation. Pathophysiologically, it may be due to various perianal disorders that cause inflammation, edema, hypertrophy, or scar formation in the puborectal muscle or external sphincter, resulting in failure to relax in the defecation state and, on the contrary, spastic contraction, which leads to difficulty in defecation and dry and hard stools. For these patients, anal dilation is a non-invasive, easy and effective treatment, so in clinical treatment, doctors can selectively use it, but remember to master the indications, if applied blindly, but may aggravate the fear of defecation of the child, aggravating constipation. Western medicine generally believes that constipation in infants and young children is caused by abnormal gastrointestinal hormones, dysbiosis of intestinal flora or abnormal coordination of perianal muscles, and some problems cannot be relieved by simple exogenous interventions, so sometimes the treatment is awkward, while traditional Chinese medicine has unique advantages in the treatment of constipation, so in clinical practice we should pay attention to the combination of Chinese and Western medicine in constipation. Therefore, we should pay attention to the application of the combination of Chinese and Western medicine in constipation. According to Chinese medicine, the large intestine conduction function is the continuation of the stomach's function of circulation and lowering, and depends on the spleen's transportation and transformation. The development of intestinal wall and the strength of intestinal peristaltic function also depend on the spleen and stomach to transport the water and grain essence, and if the spleen is not healthy, the intestinal power is insufficient. In order to get quick results, parents often use laxatives such as phenolphthalein tablets (fruit guide tablets), rhubarb, senna, aloe vera, cassia, etc. These methods are effective for a while, but long-term use will cause the child's intestinal peristaltic function to fail to recover and even form dependence. Children are "infantile yin and yang" and have a weak spleen and stomach, so laxatives may also deplete the qi and injure the fluid, causing spleen deficiency and aggravating constipation, so we should be cautious with laxative drugs and focus on restoring the transport function of the spleen and stomach, such as Wenzhang and Hovenia pills. Of course, heat and qi stagnation are also common abnormalities that cause constipation, so attention should be paid to identify and deal with them in the clinical treatment. In conclusion, the prevalence of constipation in infants and young children is high, and the pathophysiology, clinical diagnosis and treatment strategies are very different from those of constipation in older children, with more emphasis on clinical diagnosis and exclusion of organic diseases, and less emphasis on graded treatment, diluted examination and typing in treatment, with basic treatment and Chinese medicine as the mainstay, supplemented by measures such as bowel cleansing and anal dilation as appropriate to prevent secondary damage as much as possible.