With the popularization of digestive endoscopy technology in children, the application of colonoscopy in children is becoming more and more widely. Intestinal preparation, as the basis for colonoscopy, directly affects the diagnosis and treatment results of colonoscopy. Compared with adults, children's important organ functions are incomplete, and their cognition, communication and tolerance are weak. There are also great differences in the structure of children's digestive tract at different ages.

At present, there is no evidence-based guideline for intestinal preparation related to children's digestive endoscopy. Therefore, based on the clinical practice of our country, formulating evidence-based guideline for intestinal preparation in children that meets international standards is of great significance to guiding the intestinal preparation of children in our country.

This guide combines multidisciplinary experts to use the evaluation of recommendation hierarchical evaluation, formulate and evaluate the system, follow the international guidelines report specifications, and formulate intestinal preparation guidelines related to the diagnosis and treatment of children with digestive endoscopy in my country, in order to provide guidance and decision-making basis for pediatricians.

With the popularization of digestive endoscopy technology in children, colonoscopy, small intestine and capsule endoscopy are becoming more and more widely used in childhood diseases, and the quality of intestinal preparation directly affects the diagnosis and treatment results of digestive endoscopy.

Chinese children's digestive endoscopy doctors have been referring to adult guidelines and foreign children's guidelines for intestinal preparation for many years. However, in fact, due to the large differences in the anatomic structure of the digestive tract of children of different ages, the imperfect development of various important organs, the cognition, communication, and tolerance are different from those of adults, and the level of domestic and foreign drug applications and endoscopic technology development, it is urgent to formulate intestinal preparation guidelines related to the diagnosis and treatment of digestive endoscopy in Chinese children.

Currently, the latest reference standard for intestinal preparation for children abroad is the guide to gastroenterology of children developed by the European Society of Gastroenterology and the European Association for Pediatric Gastroenterology, Hepatology and Nutrition in 2017.

The latest domestic reference standard was released by the Pediatric Collaboration Group of the Chinese Medical Association's Gastroenterology Endoscopy Branch in 2018.

These two guidelines only briefly mention the methods of intestinal preparation and do not give detailed recommendations. In clinical work, what pediatric endoscopists need more are standards involving dietary restrictions, education, laxative selection, dosage and timing, auxiliary drugs and special circumstances in children of different age groups.

The Pediatric Collaborative Group of the Chinese Medical Association's Gastroenterology Endoscopy Branch and the Pediatric Digestive Endoscopy Professional Committee of the Chinese Medical Association's Endoscopy Branch.

This guide aims to guide and promote children's digestive endoscopy doctors to carry out children's intestinal preparation in a more standardized and scientific manner, thereby improving the quality of children's digestive endoscopy's intestinal preparation in all aspects and maximizing the benefits of children.

one,

Guidelines Development Process

1. Guidelines for formulating

This guide was jointly initiated by the Pediatric Collaborative Group of the Chinese Medical Association's Gastroenterology Endoscopy Branch and the Pediatric Digestive Endoscopy Professional Committee of the Chinese Medical Association's Endoscopy Branch. It is supported by the methodology and evidence provided by the Evidence-Based Medicine Center of Lanzhou University, China Center.

This guide will be launched on April 15, 2020, and the finalization will be October 7, 2020.

The method and process for formulating this guide is mainly based on the specific requirements of the report entries issued by the World Health Organization in 2014 and published by the Chinese Medical Association in 2016, and is formulated and reported in accordance with the specific requirements of the report entries of the guideline research and evaluation tools and health care practice guides.

2 Guidelines for the establishment of working groups

This guide has established a working group for the development of guidelines including multidisciplinary experts such as pediatrics, internal medicine, surgery and evidence-based medicine, which are mainly divided into steering committees, secretaries, evidence evaluation groups, consensus groups and external audit groups. All working group members have filled out statements of interest, and there is no direct economic conflict of interest with this guide.

3 Guide to Registration

This guide has deconstructed the 10 clinical issues that were finally included in the International Practice Guidelines Principles.

Search based on the specific problems of deconstruction:

Search for evidence of research types such as dle, thechranelibrary, ebase, episteonikos, China Biomedical Literature Database, Wanfang Database and China National Knowledge Infrastructure Database, mainly including systematic review, ta analysis, reticular ta analysis, randomized controlled trials, cohort studies, case control studies, case series, case reports and epidemiological investigations;

Search for official websites of Yimaitong, esge, the American Society of Gastroenterology and the American Society of Colon and Rectal Surgeons, and include relevant guidelines for the field of digestive endoscopic intestinal preparation;

Supplementary searches for some other websites such as Google Scholar, and traces back to the literature reference list. The search time for all types is to build the library until September 1, 2020. The search method is to combine specific topic words for each clinical problem with free words, and the publication language is limited to Chinese and English.

After completing the literature search, two members of the evidence evaluation group will screen the literature independently in the order of the title, abstract and the full text. Literatures that meet the specific clinical problems will be included. After completing the screening, the two will check it. If there are any differences, it will be determined through joint discussion or consultation with third parties.

7 Evaluation and Grading of Evidence

The evidence group used the systematic evaluation risk of bias assessment tool scale to evaluate the included systematic evaluation, ta analysis and network ta analysis.

Methodological quality evaluation of the corresponding types of original research was performed using the chrane risk of bias assessment tool, the quality evaluation tool for diagnostic accuracy research, the Newcastle-Ottawa scale and the Canadian Institute of Health Economics scale.

The evaluation process is completed independently by two people. If there is any disagreement, they will discuss it together or consult a third party to resolve the issue.

Finally, the quality of evidence and strength of recommendations for each clinical problem were graded using the grade method.

8 Recommended opinions

Based on the summary table of existing domestic and foreign evidence provided by the evidence group, the expert group has initially formulated recommendations that are in line with my country's clinical diagnosis and treatment practices, considering the preferences and values ​​of Chinese patients, the cost and pros and cons of intervention measures.

Two rounds of recommendation opinions were conducted on September 15, 2020 and September 18, 2020, and a total of 26 expert revision opinions were collected. Based on the existing evidence, the expert group further improved the recommendation opinions based on the revision opinions, and finally reached a consensus on all recommended opinions.

9 Guide writing and external review

After reaching a consensus on the recommendations, the guideline development working group shall refer to the report specifications of the international guideline and complete the writing of the first draft of the guideline, and submit it to the experts of the foreign review team for review, modify and improve it based on their feedback, and finally form the final draft of the guideline.

10 Guide Updates

This guide plans to update recommendations in accordance with the international guidelines update methods and procedures within 3 to 5 years.

two,

Recommendations and basis

Clinical question 1: How should children provide health education when preparing for intestinal tract?

Recommended opinions: It is recommended to provide health education to the legal guardians of children’s parents through auxiliary methods such as phone calls, text messages and mobile applications. For children ≥7 years old, it is recommended to use cartoon pictures or videos to provide health education to the legal guardians of children and their parents.

Patients' cognition and understanding of the disease affect the quality of intestinal preparation, and the quality of intestinal preparation is positively correlated with the detection rate of intestinal diseases.

Studies have shown that compared with traditional nursing measures, implementing enhanced nursing measures for children and their parents, including patient education, can significantly improve the quality of intestinal preparation and hospitalization satisfaction, and can also alleviate the anxiety of patients and their families.

Health education before colonoscopy can significantly improve the quality of intestinal preparation in adult patients, while educational interventions including written materials, educational videos, telephone re-education before the examination, and face-to-face guidance from doctors can also effectively improve the quality of intestinal preparation.

In addition to the traditional oral and written patient education methods, the acceptance and usage rate of auxiliary methods such as telephone, text messages and mobile applications is increasing.

The systematic evaluation results show that using smartphone applications can improve the effectiveness of patient education and the quality of patients' intestinal preparation is better. Using health education methods that combine auxiliary methods such as phone calls, text messages and mobile applications with individualization can also significantly improve the quality and compliance of patients' intestinal preparation.

Among the many health education methods that improve the quality of intestinal preparation, educational interventions in video or image form are easily understood and accepted. Compared with traditional education, video education interventions can significantly improve the full rate of intestinal preparation.

Research shows that using educational methods such as cartoon folding pages, color pictures, comics or animation can effectively improve the patient's intestinal preparation bbps and good intestinal preparation levels.

In addition, considering the ability to understand and accept pictures and videos, it is recommended that children ≥7 years old provide health education guidance for children and their parents’ legal guardians at the same time; for children 7 years old, it is recommended that health education guidance only be provided to their parents’ legal guardians to ensure that each child and his family read and understand the relevant content of intestinal preparation.

Clinical question 2: How should children restrict their diet before preparing their intestinal tract?

Recommended opinions: It is recommended that children who undergo intestinal preparation adopt a low-residue and low-fiber diet or a liquid-clearing diet 1 day before self-scopic examination. Intestinal nutritional powder as evidence of a low-residue and low-fiber diet is not sufficient and should be determined according to the specific situation of the patient.

Currently, the dietary patterns commonly used by children and adults when preparing intestinal tract are mainly liquid diets and low-residue and low-fiber diets.

A liquid-clear diet generally refers to a transparent liquid diet, such as clear water, clear juice, stewed broth and colorless sports drinks, which are easy to absorb and do not easily leave residues in the intestines. A low-fiber and low-residue diet generally includes dairy products, rice and noodles, cooked vegetables and meat with less connective tissue, etc., but does not include foods such as beans, whole wheat foods and raw fruits and vegetables that are high in fiber or gas-producing foods.

In addition, to avoid affecting microscopic results, patients need to restrict or fast foods such as dragon fruit, kiwi fruit, etc. that have color and fruit seeds.

Existing studies show that there is no statistically different intestinal preparation rates after children aged 6 to 18 years old and after receiving a low-fiber diet and a clear liquid diet. This is also confirmed by systematic reviews for adults, but the adverse reaction symptoms such as nausea, vomiting and headache in patients after receiving a low-fiber diet are significantly reduced, which leads to better adherence and repetitive willingness to be performed.

Although adult evidence shows the advantages of a low residual and low fiber diet, children still lack relevant research evidence. Combined with the current situation where only exclusive breastfeeding is recommended for children 0 to 6 months old, it is recommended that children still retain a clear liquid diet.

Regarding the time of diet restriction, existing studies have shown that there is no statistical difference in the effect of intestinal preparation for children with 1 day or 2 day. There is no statistical difference in the quality of intestinal preparation for adults with 1 day or 2 day. However, patients who maintain a low-residual diet with 1 day have higher compliance and repetition desire. Therefore, it is recommended that children start diet preparation 1 day before microscopic examination.

Given that low-residue diets may cause nutritional deficiencies in patients, enteral nutrition powders as a high-energy low-residue low-fiber diet have been used in clinical practice.
Chapter completed!