Guidelines for the treatment of constipation in children Constipation is one of the most common gastrointestinal dysfunctions in childhood, starting in the neonatal period and persisting into adulthood in about one-third of children. In some of these children, treatment with dietary fiber and laxatives is not effective, resulting in a chronic, persistent clinical course. In recent years, the creation of neurogastroenterology and gastrointestinal dynamics, as well as the increased awareness of the bio-psycho-social model of functional gastrointestinal disorders, have not only further revealed the pathogenesis of functional constipation, but also opened up new horizons for clinical diagnosis and treatment. Based on these new concepts, the psychological behavioral and biofeedback treatments currently being carried out in the clinic have achieved remarkable therapeutic effects. Children’s functional constipation psychological behavioral treatment 1, functional constipation psychological behavioral treatment of the theoretical basis According to the modern biological a psychological a social medical model, functional gastrointestinal disease pathophysiological mechanism involves gastrointestinal power abnormality, gastrointestinal hypersensitivity, brain and intestinal axis interaction function abnormality and mental psychological abnormality. The brain-gut axis refers to the bidirectional pathway of the central nervous system and the enteric nervous system in regulating the intestinal function. Extrinsic stimuli and intrinsic information are connected to the higher centers through neural connections, affecting gastrointestinal sensation, dynamics, and endocrinology; and vice versa, visceral activities also act on central sensation, emotion, and behavior, i.e., brain-gut and gut-brain interactions. These modulations are accomplished through a variety of brain-gut peptides and regulatory factors such as vasoactive intestinal peptide and 5-hydroxytryptamine. Animal models have shown that psychobehavioral influences on visceral sensation and/or dynamics occur at different levels in the rat gastrointestinal tract smooth muscle, spinal cord dorsal horn, cerebral cortex and hippocampus. Psychobehavioral factors and defecation function Psychobehavioral factors and constipation are causally related to each other, and various psychobehavioral factors can affect gastrointestinal function. In children with special behavioral manifestations (female ding ding autism and obesity, the incidence of constipation is higher, the incidence of behavioral abnormalities in children with functional constipation is 3-4 times higher than that of ordinary children, the frequency of fecal incontinence is related to illegal and aggressive behavior. Mental status, such as short-term anxiety and stress, also affects bowel habits. Zhou Huiqing et al. on the urban primary and secondary school students functional constipation risk factors of the national multi-center survey results show that in more than 50,000 research subjects functional constipation accounted for 25.92%, insomnia, fatigue, mood anxiety and irritability, such as 9 factors for the most likely risk factors. A Sri Lankan study concluded that stressful events such as separation from close friends, failure in exams, intimidation, parental unemployment, frequent corporal punishment and living in a war-affected area were associated with a high prevalence of constipation. Artificial fecal control can lead to defecation dysfunction Fecal control behaviors, often triggered instinctively by avoiding painful defecation, are one of the main causes of poor bowel function in children. Studies have shown that 97% of children with constipation have fecal control behaviors, in which the child maintains an upright position and forcefully contracts the gluteal and pelvic floor muscles until the stimulus to defecate disappears, resulting in rectal adaptation, which makes feces harder in the rectum and more difficult to pass, thus creating a vicious cycle that eventually leads to chronic rectal dilatation. Consciously or subconsciously ignoring the defecation stimulus can also change or reduce the brain’s feedback on the sensation of rectal stimulation, resulting in rectal hypercompliance, a lack of urge to defecate even when full, and constipation caused by failure to start the defecation program in time.Klauser et al. randomly arranged healthy volunteers to have a normal defecation or to intentionally inhibit defecation, and the results of a 2-week observation showed that intentional inhibition of defecation resulted in a decrease in the Klauser et al. showed that intentionally inhibiting defecation could reduce the frequency of defecation, decrease the amount of defecation, and prolong the transmission time of feces in the whole colon and recto-biliary colon, suggesting that constipation can be “learned”. Inadequate toilet behavior training causes constipation in children, domestic research shows that 42.1% of children with constipation is due to the lack of defecation training or training is not standardized. A study in Turkey reported that the main risk factors for childhood constipation were consistently not toileting at school (OR=5.9) and problems with bowel control after 2 years of age (08=3.1). 3 .Psychobehavioral treatment strategies for functional constipation A minority of patients with functional constipation have co-morbidities with psychological disorders and persistent symptoms. For those with obvious psychological factors, a complete psychotherapy program should be developed by a psychiatrist, and appropriate medications should be chosen as adjunctive treatment. The intervention of psychological behavioral problems in most patients with mild symptoms and insignificant psychological stressors includes education, defecation training, biofeedback therapy, etc. 4. Psychological Behavioral Education for Functional Constipation Education should firstly establish a therapeutic doctor-patient relationship as the basis for correcting disease behaviors, identifying with the concerns of the affected children and their parents about the disease and the painful mental experience, helping to reduce anxiety, enhancing confidence, cooperating with the treatment, and Reinforce healthy behaviors. The content of education includes, explaining the pathophysiological mechanisms of constipation and the purpose, measures and necessity of long-term treatment. Xu Hui et al. randomly divided school-age children into a general treatment group and a health education group according to the inclusion and exclusion criteria of Rome III. In addition to medication, behavioral interventions and biofeedback, the health education group strengthened the KAP (Knowledge-Attitude-Practice) model of health education, which included explaining the pathophysiological mechanisms of constipation, guiding the various therapeutic measures, encouraging parents and children, and providing education every 2 weeks. and the affected children to have a conversation of more than 15 min every 2 weeks for a total of 8 times, and the results showed that the medication adherence and behavioral adherence in the health education group were significantly higher than that in the general treatment group, and the symptom scores were significantly lower. 5, Functional constipation defecation training The necessity of defecation training Defecation training is a necessary measure to maintain the effect of laxative and establish normal defecation habits. Domestic Peng Yamei study 80 cases of child care institutions in 3-5 years old in line with the Rome II standard constipation children, intervention group of children in the routine application of laxative based on regular sitting stool 10-15 min training twice a day, 4 weeks after the intervention group of fecal characteristics Bristol classification, frequency of defecation and accompanied by the symptom score are significantly better than the control group, showing the effect of defecation habit training. Precautions for defecation training Before defecation training, firstly, fecal impaction should be removed and defecation pain should be eliminated, so as to prevent children from consciously and/or subconsciously controlling defecation due to pain and thus affecting the effect; secondly, instruction on methods and techniques should be given; lastly, long-term perseverance is necessary in order to restore the normal sensation of the rectum and to ensure the success of establishing a normal defecation habit. Methods and techniques of guidance ① infants and young children: parents should be instructed how to educate children to establish healthy defecation habits, that is, at the right time, using appropriate methods, such as the use of bright colors, the appearance of attracting children (the image of small animals) of the potty, after dinner training is more appropriate, not only the use of gastro-colonic reflexes, the parents of the mental and emotional relaxation, 1 time a day, and gradually form a habit, and can be used in a rewarding way to improve the effect. The effect. ② older children: guidance at the appropriate time (generally after dinner, to avoid mental stress due to time constraints) to choose the appropriate toilet, take the appropriate defecation posture, relax the legs and feet, knees slightly above the hips, deep breathing and holding the breath at the same time to push downward, repeated training, until the normal toileting. Biofeedback therapy for functional constipation in children 1. Pathophysiological basis of biofeedback therapy According to the function of colon transmission and anorectal function, functional constipation can be divided into two types: slow transmission type (STC) and outlet obstruction type (OOC). Studies on adults have shown that OOC accounts for about 40% of chronic constipation and is mainly due to poor coordination and synergy of the abdominal muscles, pelvic floor muscles and sphincter muscles during defecation. During normal defecation, when the intra-abdominal pressure and intra-rectal pressure increase, the puborectalis muscle and external anal sphincter relax, the anorectal angle becomes obtuse, and the feces are expelled. In contrast, in children with pelvic floor malcoordination, the pelvic floor muscles contract paradoxically during defecation, and the puborectalis and external anal sphincter do not appear to relax, i.e., the abdominal muscles and the pelvic floor muscles contradictory movements, so that the angle of the anorectal tube becomes sharp, resulting in the feces can’t be discharged from the old. Zhang Shucheng et al. studied 96 cases of constipated children aged 3-14 years old with defecography, which showed that functional OOC accounted for 60.4%, including puborectal muscle spasm syndrome, spasm of the external anal sphincter, pelvic floor spasm syndrome and so on. Recent studies have shown that biofeedback therapy has a definite effect on OOC. 2. Mechanism of biofeedback therapy Biofeedback therapy is essentially a psychological behavioral therapy. It uses instruments to record the biological information (electromyography, electroencephalogram, skin temperature, heart rate, blood pressure, etc.) related to psychophysiological processes that the human body is not aware of under normal circumstances and convert them into visual, auditory and other feedback signals, so that the patients can recognize their own physiological activities and consciously regulate and control their own abnormal physiological activities under the guidance of the teacher, which will cause neurological and humoral changes and feedbacks to the hypothalamus and the cerebral cortex through repeated trainings. Through repeated training, the hypothalamus and the cerebral cortex will produce neurological and humoral changes, forming a feedback pathway, controlling and correcting undesirable psychophysiological activities and establishing normal physiological activities. 3, functional constipation biofeedback treatment At present, children’s constipation biofeedback treatment is mainly local intestinal pressure and electromyography feedback treatment. Jiang Mifu et al. study included 47 cases of 4 ~ 12 years old in line with the Rome Ⅲ standard, anorectal manometry with pelvic floor muscle coordination disorders in constipated children, biofeedback treatment 2 times a week, each time 20-30 min, and in the home self-training morning and evening 15-20 min. treatment > 3 times the child, the rectal defecation pressure increased, the external anal sphincter electromyography value decreased. The total effective rate of relieving constipation was 88.9% after 3 months to 1 year of follow-up, which confirmed the therapeutic effect of biofeedback therapy in children with OOC constipation. Preparation before treatment should determine the indications for treatment, which must be consistent with the diagnosis of functional constipation OOC type; fully explain the whole process of treatment to the child before treatment, and strive to cooperate and remove the persistent stool. Therapeutic instrument biofeedback therapeutic instrument including treatment host, anal plug myoelectric receptors, body surface electrodes, electromyography sensors, pressure measurement catheter, biofeedback application software and computer. The computer screen can display the intrarectal pressure, simulated rectal systolic pressure during defecation and the electromyographic activity of puborectal muscle and external anal sphincter. Treatment: the child is placed in the left Nl~t” position, and the manometric catheter and anal pessary electrodes are incorporated into the anus as required; the child is allowed to simulate the defecation action, and the pressure and electromyography are observed. During the treatment the child can see the activity of the anorectal muscles during defecation through the video, and at the same time the child is taught to self-regulate according to the signals, to relax the pelvic floor muscles and external anal sphincter, and to feel the correct sensation of defecation with the rise of the rectal pressure and the fall of the anal canal pressure. The course of treatment was 30 min twice a week for 1 month; it was accompanied by offline training at home. Reinforcement of treatment every 3 months is recommended. Adjuvant therapy biofeedback therapy while increasing dietary fiber, supplementing water, increasing exercise, and developing the habit of regular defecation.