中医药疗法对小儿急性非细菌性腹泻病的系统评价及随机对照试验
|
摘要
腹泻病(diarrhoea disease)是5岁以下儿童生长发育障碍、营养不良和死亡的主要原因。腹泻的发生与小儿时期生理病理特点及感染、饮食、免疫等因素有关。尽管“腹泻病诊断治疗指南”的推广降低了小儿腹泻病的死亡率,但其仍是常见病及5岁以下小儿死亡的主要原因之一。因此,临床需要简、便、效、廉的治疗方案。中医药治疗小儿腹泻病历史悠久,疗效确切,有一定的特点和优势。为客观评价中医药疗法的疗效,分析临床研究中的问题及对策,本论文在循证医学原则指导下,借鉴其方法和思路,做了相关研究。
一、文献研究
1.研究目的：综述中医及现代医学对小儿腹泻病的认识及循证医学的方法应用于中医药疗法治疗小儿腹泻病的必然性和可行性
2.研究结果：
(1)中医学认为泄泻是由于脾胃功能失调,引起大便稀薄或如水样,便次增多的疾病。病因以外感时邪、内伤饮食和脾胃虚弱多见,其病位在脾胃,景岳对其病理机制作出了精辟论述：“泄泻之本,无不由于脾胃,盖胃为水谷之海,而脾主运化,使脾健胃和,则水谷腐熟,而化气化血,以行营卫,若饮食失节,起居不时,以致脾胃受伤,则水反为湿,谷反为滞,精华之气,不能输化,乃致合污下降,而泻利作矣。”(《景岳全书·泄泻》)李中梓在总结前人经验的基础上,对泄泻的治法,作了进一步的概括,提出淡渗、升提、清凉、疏利、甘缓、酸收、燥脾、温肾、固涩等九法,对泄泻治疗学的丰富和发展有着重要的临床价值。
中医学治疗腹泻病方法多样,内有中药辨证论治,外有针灸、推拿、穴位贴敷及其他外治法,取得良好临床疗效。中医药治疗儿童腹泻灵活多变,副作用小,应用前景非常广泛。
(2)现代医学对小儿腹泻病的认识
现代医学认为腹泻的发生与小儿时期特点及感染、饮食、免疫等因素有关。其的病理机制可归纳为以下四种：渗透性腹泻、分泌性腹泻、渗出性腹泻、肠动力紊乱性腹泻。但目前有关其病因、发病机理、病理生理等方面仍未完全清楚。
肠道微生态可能在小儿腹泻病的发生中具有重要意义。儿童肠道微生态平衡紊乱主要表现：一方面以双歧杆菌为主的益生菌数量明显减少,各菌群之间正常比例严重失调；另一方面肠道正常菌的转移和一些机会菌(主要是过路菌)大量的生长繁殖引起疾病。当肠道菌群的种类、数量和比例发生异常变化,偏离正常的生理组合,转变为病理性组合状态,即出现菌群失调,引起许多疾病。儿科的急慢性腹泻均可能与肠道菌群失调密切相关。
(3)循证医学的方法应用于中医药疗法治疗小儿腹泻病的必然性和可行性
论证了循证医学方法系统评价中医药疗效的必要性在于循证医学所倡导的系统评价所具备的方法学特性适合中医学发展规律的要求,且中医药的疗效亟待借鉴新的研究方法进行客观评价；其可行性在于有数量充足的中医药临床试验可供系统评价,已有进行相关实践的范例。
3.研究结论
(1)中医药治疗小儿泄泻方法多样,简验便廉,有非常丰富的古代及现代文献支撑。(2)现代经验报道多,临床研究少。临床随机对照实验研究更少,且临床研究设计不合理,在随机化、盲法、对照选择、病例的纳入与排除标准、结局指标的选定方面存在较多问题,报告的有关临床疗效重复性或经不起反复实践的考验。
二、小儿急性非细菌性腹泻病临床治疗效应的系统评价
1.研究目的：对化湿法对小儿急性非细菌性腹泻病的治疗效应及思密达对小儿非细菌性腹泻病的治疗效应做出系统评价,从而为以思密达为对照,化湿法联合推拿手法对小儿腹泻病治疗效应的临床研究提供循证医学依据。
2.研究方法：收集文献并对其进行质量评价和资料提取,采用Cochrane协作网提供的RevMan 4.2.10软件进行Meta分析。
3.研究结果：
(1)关于化湿法为治则的中草药治疗小儿急性非细菌性腹泻病的系统评价共纳入28篇文献,通过Meta分析发现：在以临床疗效为评价指标做优劣性分析时,所纳入的27篇文献中认为化湿中医治法对小儿腹泻病的效应优于思密达的有16篇,另11篇则持否定意见。在以止泻时间为评价指标,所纳入5篇文献中认为化湿中医治法对小儿腹泻病的效应优于思密达的有3篇,另2篇则持否定意见。总之,以化湿法为治疗原则的中草药对小儿急性非细菌性腹泻病具有确切疗效。
(2)本研究共纳入中医文献28篇,诸位医家对小儿泄泻病因病机的认识基本一致,认为小儿“脾常不足”,在此基础上复感风、寒、湿邪,致脾胃受伤,水反为湿,谷反为滞,合污而致泄泻,“脾虚湿困”为其发病主要原因。治疗法则以运脾化湿为治疗大法,或兼清热,或兼疏风,或兼消滞,或兼收敛。28篇纳入文献均有列出中药复方主要药物组成,处方用药中健运脾胃、化湿类药物种类最广,使用频率最高,依次为茯苓(18次,占64.29%),白术(10次,占35.71%),苍术(8次,占28.57%)藿香(8次,占28.57%),健脾药尚有党参或太子参(共7次),山药(4次),黄芪(3次),炒扁豆(2次)；其它利水渗湿药物有车前子(5次),泽泻(3次),法半夏(3次),猪苓(2次)；同时使用苍术和茯苓的文献有8篇,占28.75%。其次使用较广泛的药物是调理气机药物,此类药有6种,其中陈皮应用频率最高,共出现6次,占21.43%；厚朴(3次,占10.71%),木香(2次,占7.14%),砂仁、香附、枳壳各1次。收敛药物有5种,焦山楂4次,石榴皮、诃子各3次,番石榴叶、赤石脂各2次。消食导滞药物使用也较多,有炒谷麦芽(5次)、鸡内金(4次)、神曲(3次)、五谷虫(1次)。笔者认为出现这样的用药规律与小儿泄泻的病因病机是相吻合的。
(3)思密达用于治疗小儿腹泻病临床疗效确切,但与中药复方相比哪种治疗方法具有优势,文献报道结果多有不同。在以临床疗效为评价指标进行优劣性分析时,11篇独立文献报告系统评价分析结果表明,与中医非药物治疗和空白对照相比较,提示思密达确有治疗小儿腹泻病的效应；而60篇独立文献结果表明,与中西药或空白对照相比较,思密达口服治疗小儿腹泻病无明显优势；在以止泻时间为评价指标进行分析时,6篇独立文献报告系统评价分析结果表明：与中医非药物治疗和空白对照相比较,思密达口服可显著性缩短小儿腹泻时间；22篇独立文献结果表明,与中西药或空白对照相比较,思密达口服缩短小儿腹泻时间无明显优势。所纳入的文献均具有发表性偏倚。总之,以临床疗效及止泻时间做为效应评价指标,思密达可作为中药、西药新药治疗小儿腹泻病临床疗效评价的阳性对照药物。
(4)存在问题
临床研究在方法学上的欠缺严重影响了研究质量,存在的主要问题有：①临床对照试验未能较好遵守随机、对照的原则；②样本量的确定不够严谨；③统计方法应用欠规范；④疗效评价、诊断标准及中医症候诊断标准尚未统一；⑤对随访及不良反应的观察不够重视。
三、小儿急性非细菌性腹泻病的临床及实验研究
1.研究目的：对中医治疗小儿泄泻进行随机对照临床研究,从临床证候表现及微生态调节的角度着眼,客观规范地评价运脾化湿为主法治疗小儿急性非细菌感染性腹泻病的疗效。
2.研究方法：(1)临床研究采用前瞻性、多中心的随机对照临床研究方法,研究的目标人群为6个月～3岁急性非细菌性腹泻病患儿,采用中心随机化分配系统分为中药组、中药+推拿组、思密达组,分配比例为1：1：1,观察临床症状并检测治疗前后肠道微生态的变化,随访、观察不良反应事件及合并用药情况,进行安全性评价。(2)实验研究采用实时荧光定量PCR(FQ-PCR)技术检测腹泻患儿治疗前后粪便双歧杆菌、乳酸杆菌及大肠杆菌含量。
3.研究结果：
(1)治疗后中药组、中药复方+推拿组的总有效率优于思密达组,三者进行比较具有显著性差异。中药组、中药复方+推拿组、思密达组止泻时间分别为(2.78±1.54)天、(2.36±1.25)天、(2.90±1.73)天。仅从具体数值上分析,中药复方+推拿组的止泻时间最短,其次是中药组,思密达组止泻时间最长,但统计学分析三种治疗措施的止泻时间无显著性差异。(2)本论文检测了26例急性非细菌性腹泻患儿的粪便标本中双歧杆菌、乳酸杆菌和肠杆菌的含量,结果发现：仅从数值上看,治疗后三组腹泻患儿粪便标本中的双歧杆菌、乳酸杆菌及大肠杆菌含量数值较治疗前增加,与治疗前相比,无显著相关性；研究进一步分析了主要临床症状(大便次数、大便性状及大便症状积分)与双歧杆菌、乳酸杆菌和肠杆菌含量的相关性,结果发现：大便次数、大便稀烂程度及大便症状积分与大肠杆菌、乳酸杆菌、双歧杆菌之间无显著相关关系。
4.结论
(1)从优劣性分析,治疗后中药组、中药+推拿组总有效率优于思密达对照组,但统计学分析三种治疗措施的止泻时间无显著性差异。
(2)治疗后三组腹泻患儿粪便中双歧杆菌、乳酸杆菌、大肠杆菌的数量较治疗前增加,但与治疗前相比,无显著相关性；大便次数、大便性状及大便症状积分与双歧杆菌、乳酸杆菌、大肠杆菌之间无显著相关关系。
5.分析与展望
在严格的实验设计情况下,未能得出具有统计学意义的结论,笔者分析如下：
由于时间限制、临床试验过程中受患儿及其家长的依从性的影响以及患儿家长对临床试验知情同意书的不理解、不配合,导致目前入组病例数距离预计值有很大差距,样本量不足是导致目前研究未能得出有效统计学意义的可能原因。
基于此,笔者认为目前研究结果并不能说明中医药治疗小儿急性非细菌性腹泻患儿的临床疗效不确切,且无法得出腹泻患儿主要临床症状与双歧杆菌、乳酸杆菌及大肠杆菌含量无相关关系的结论；同样,不能推论中药复方、推拿手法、思密达的干预与双歧杆菌、乳酸杆菌及大肠杆菌含量变化无相关关系。通过扩大样本量,或可得出中药复方、推拿疗法改善大便性状、减少大便次数的可能作用途经是通过调节微生态平衡,恢复肠道微生态环境。
本次研究中中医证型分布以湿热证较多,笔者推测这可能与岭南地域气候特点有关,但尚不能得出小儿急性腹泻病湿热证占主导地位的结论,仍有待于扩大样本量及研究区域的进一步研究。
由于样本量不足,影响了结果的说服力。我们对中医药治疗小儿急性非细菌感染性腹泻病的作用机制研究进行了有益的探索,因病例数不足,得出的数据仅供参考,这也是本次研究的遗憾之处。在总结了前期的经验基础上,我们将继续进行该项研究,以期得到客观和科学的结论,为中医药治疗小儿急性非细菌性腹泻提供可靠的临床证据。
Diarrhea disease is the major cause for maldevelopment, malnutrition and death of children under 5 years old. The development of diarrhea disease is closely associated with physical and pathological features of children, infection, improper diet, and their low immune ability. Although the popularization of Diagnostic and Therapeutic Guide for Diarrhea Disease decreased the mortality of infantile diarrhea, such disease was still one of the main reasons leading to death of children under 5 years old. Therefore, a simple, convenient, effective and inexpensive therapeutic regimen was required in clinical. Traditional Chinese medicine cherished long history and effectiveness in treating infantile diarrhea disease, besides its characteristics and advantages. In order to make an objective evaluation on TCM therapeutic effect and analyze problems and strategies in clinical studies, we conducted a relevant research in these fields at the guide of evidence-based medicine, adopting its methods and thoughts.
1. Literature researches
1.1 Object:
Writer summary TCM and modern medicine recognition on infantile diarrhea, elaborate necessity and feasibility of evidence-based medicine methodology application in Chinese medicine treatment for infantile diarrhea.
1.2 Results:
(1)TCM believed diarrhea was a disease with the symptoms of loose stool or watery stool and frequent defecation caused by functional disorder of spleen and stomach. In TCM theory, the causes of diarrhea are exogenous pathogenic evil, importer diet, or deficiency of both spleen and stomach more often, and the diseased part locates at spleen and stomach. ZHANG Jing-yue, a famous doctor of Ming dynasty, explored the pathogenesis of diarrhea:"The fundamental cause for diarrhea is the dysfunction of spleen and stomach. Stomach is the sea of water and cereals and spleen is in charge of transportation and transformation. If the functions of spleen and stomach are normal, intake cereals will be digested well and transformed into essence-qi and blood, supplementing Ying qi and Wei qi; while if the functions of spleen and stomach are damaged by improper diets or irregular daily life, water will be turn into pathogenic dampness, cereals will be transformed into stagnation, and essence qi will not be transformed and transported, leading to diarrhea together with filthy things." (JingYue QuanShu). LI Zhong-zhi, a famous doctor of Ming dynasty, made a fully summarization about the treatments of diarrhea on the experiences of his predecessors:"there are nine kinds of major therapeutic methods for diarrhea, which are inducing urine with mild taste medicines, lifting, cooling, dispersing, relaxing with sweet taste medicines, astringing with sour taste medicines, drying spleen, warming kidney and consolidating", manifesting important clinical values for the development of diarrhea therapeutics.
There were many kinds of effective therapeutic methods for diarrhea in TCM, including internal medicine, such as treatment based on syndrome differentiation, and external medicine, such as acupuncture, moxibustion, massage, acupoints-application and others. Boosting of agility and few side-effects, TCM has a broad feature for the treatment of infantile diarrhea.
(2)Modern medicine considered the development of infantile diarrhea was associated with the features of infant and the factors of infection, diet, immune function. The pathological mechanism of this disease could be summarized into the following four types:osmotic diarrhea, secretory diarrhea, exudative diarrhea and motility disturbance diarrhea. However, now the relative etiological factor, pathological mechanism, pathophysiology were not yet fully understood.
Intestinal microecology may have an important significance on the development of infantile diarrhea. The disorder of intestinal microecology balance of infants mainly manifested as the following:one is the serious imbalance of normal proportion of each microbial population due to decreased number of probiotics mainly as Bacillus bifidus; the other is the diseases resulted from normal enteric flora transfer and mass multiplication and growth of some opportunists (mainly as transient flora). Once abnormal changes of kinds, number, and proportion of intestinal flora occurred, they would deviated from normal physiological composition and thansformed into pathologic composition, thus alteration of intestinal flora occurred and in turn resulted in many diseases. Pediatric acute and chronic diarrhea might be both closely associated with alteration of intestinal flora.
(3) The necessity of systemic evaluation of Chinese medicine efficacy with Evidence-based medicine methodology is that the methodology characteristics of systemic evaluation advocated by evidence-based medicine was suited to the requirements of the development law of Traditional Chinese Medicine, and there was an urgent need to perform objective evaluation of Chinese medicine efficacy by new research methods for reference; and its feasibility lies on a sufficient number of clinical trials on Chinese medicine were available for the systemic evaluation and there has been some of examples for performing relevant practice.
1.3 Problems
In the literature of today, there were more experience reports but few clinical studies. And randomized control clinical trials were more less and had unreasonable design and many problems in term of randomization, blind design, selection of control group, inclusion and exclusion criteria of subjects and selection of end point, also whose relative clinical effects were poorly reproduced or could not bear the test of practice again.
2. Evidence-based Medicine Research
2.1 Object:
Writer performed a systemic review of the effect of Eliminating Dampness on clinical efficacy and its antidiarrheal time in infantile acute nonbacterial diarrhea treatment, effect of Dioctahedral smectite on clinical efficacy and its antidiarrheal time in infantile nonbacterial diarrhea treatment. So as to provide the basis on Evidence-based medicine of dioctahedral smectite as control, treatment effect of Chinese Herbal used Eliminating Dampness compound massage for diarrhea in children.
2.2 Methods:
Writer collected documents,evaluated the quality of the literature and extracted data. On the time, writer used software RevMan 4.2.10 provided by Cochrane Collaboration to do Meta-analysis.
2.3 Results:
(1)Total 28 literatures were included in the systemic evaluation of Chinese herbal medicine belonging to Therapeutic Principle of Eliminating Dampness in treatment of infantile acute nonbacterial diarrhea, and by the meta-analysis of which we found that:①In the superiority-inferiority assessment with clinical efficacy as evaluation indexes conducted in 27 literatures, results of 16 literatures revealed the efficacy of Chinese Medicine according to Eliminating Dampness for infantile diarrhea treatment was superior to Dioctahedral smectite, while the results of the other 11 literatures denied this opinion.②In 5 literatures used antidiarrheal time as the evaluation index, results of 3 literatures revealed the efficacy of Chinese Medicine according to Eliminating Dampness for infantile diarrhea treatment was superior to Dioctahedral smectite, while the results of the other 2 literatures was opposite to this. Although all literature had report bias, in general, these literatures had little bias. In short, Chinese herbal medicine belonging to Therapeutic Principle of Eliminating Dampness possessed the exact curative effect in infantile acute nonbacterial diarrhea treatment.
(2) A preliminary analysis of therapeutic method and the rules for Chinese medicine application in the 28 literatures included in the study. The therapeutic principle mainly was Activating Spleen and Removing Dampness, which was combined with the therapeutic method of Clearing Heat, Eliminate stasis, Dispelling Wind, or Astringe. For herbs prescription and application, the medicine type most widely and frequently used is herbs with the function invigorating spleen and stomach, dissipating dampness, which were in turn Poria (18 times,64.29%), Atractylodes macrocephala Koidz (10 times,35.71%), Atractylodes Polysaccharides (8 times,28.57%), Agastache rugosa (8 times, 28.57%); and other herbs with the function of invigorating spleen included Codonopsis lanceolata or Radix pseudostell (total 7 times), Chinese Yam (4 times), Astragalus (3 times), parched hyacinth bean (2 times); other herbs with the function of removing dampness by promoting diuresis included plantain seed (5 times), Alisma orientale Juzepcz (3 times), prepared Pinellia tuber (3 times), Polyporus (2 times); and simultaneous application of Poria and Polyporus appeared in 8 articles, according to 28.57% of total. The medicine type followed above in term of application extent was Regulating Qi Activity, which included 6 herbs, among them, tangerine peel is most frequently used for 6 times (21.34%), followed by Magnolia officinalis (3 times,10.71%), Radix Aucklandiae (2 times,7.14%), and one time of villous amomum fruit, Cyperus rotundus L., and bitter orange. Five herbs with Astringe function were used, including charred Fructus Crataegi (4 times),3 times of Pomegranate Rind and myrobalan,2 times of guava leaf and halloysitum rubrum. Also the drugs for Remove Stagnated Food and Promote Digestion were used more often, such as roasted byne (5 times), endothelium corneum gigeriae galli (4 times), medicated leaven (3 times), oriental latrine fly larvina (1 time). We concluded that the rule of herbs application revealed in this study was consisted with the etiology and pathogenesis of infantile diarrhea.
(3) Dioctahedral smectite appeared exact clinical efficacy in infantile diarrhea treatment, but there were different results in literatures in term of which therapy was superior when compared with Chinese Herbal Compound. In the superiority-inferiority assessment with clinical efficacy as evaluation indexes, the results of systemic evaluation of 11 independent literatures showed the effects of oral Dioctahedral smectite was significantly different when compared with non-drug therapy in Chinese medicine and blank control group, which indicated exact effect of Dioctahedral smectite in infantile diarrhea treatment; however, the results of 60 independent literatures revealed there was no significant difference for clinical efficacy of oral Dioctahedral smectite in infantile diarrhea compared with Western and Chinese medicine or blank control group, and the clinical effect of Dioctahedral smectite in infantile diarrhea treatment was not obviously different to management of Chinese medicine and Western medicine, and had no any treatment advantages; In analysis used antidiarrheal time as the evaluation index, results of systemic evaluation of 6 independent literatures revealed that oral Dioctahedral smectite could significantly decrease the duration of infantile diarrhea compared with non-drug therapy in Chinese medicine and blank control group, which indicated exact effect of reducing duration of infantile diarrhea of Dioctahedral smectite; and the results of 22 independent literatures showed there was no significant difference for decrease of infantile diarrhea duration of oral Dioctahedral smectite compared with Western and Chinese medicine or blank control group, and the decrease of infantile diarrhea-duration of Dioctahedral smectite was not obviously different to management of Chinese medicine and Western medicine, and had no any treatment advantages. All literatures included in the analysis had publication bias. On the whole, when clinical efficacy and antidiarrheal time was used as evaluative index, Dioctahedral smectite could be served as the positive control drug in clinical efficacy evaluation of new Chinese medicine and Western medicine in infantile diarrhea treatment.
2.4 Problems
The methodology limitation of clinical studies resulted in a serious effect on the quality of studies, in which the present problems mainly included: (1)Principles of randomization and control were not well kept in clinical control trials; (2) Determination of sample size was not rigorous enough; (3) Lack of standardized statistical methods; (4) Standards of clinical evaluation and diagnosis as well as the diagnostic criteria of TCM Syndromes were not unified; (5)Observation of follow-up and adverse effects were not be attended enough.
3. Clinical and experimental study of infantile acute nonbacterial diarrhea
3.1 Object:
A randomized control clinical study of Chinese medicine in infantile diarrhea treatment was conducted to evaluate objectively and standardized the effect of main therapeutic method of Activating Spleen and Dissipating Dampness on infantile acute nonbacterial infectious diarrhea in terms of clinical syndrome appearance and microecological regulation. 3.2 Methods:
(1) the clinical study was designed as a prospective, multi-center, randomized, control trial in target population of 6-month to 3-year-old infants with acute nonbacterial diarrhea, who were allocated into Chinese medicine group, Chinese medicine+massage group, Dioctahedral smectite group in proportion of 1:1:1 with Central randomization system. Clinical symptoms observation and detection of intestinal microecology change between pre/post-treatment, follow-up, observation of adverse effect events and drug combination were performed, also treatment safety was evaluated.
(2) Real-time Fluorescent Quantitative PCR Technique (FQ-PCR) technique used to perform the detection of Bacillus bifidus, lactobacillus, and Escherichia Coli. 3.3 Results:
(1) Post-treatment total effective rates of Chinese medicine, Chinese Herbal Compound massage treatment were superior to Dioctahedral smectite, and there were significant differences when compared these three treatments. The antidiarrheal time of Chinese medicine, Chinese Herbal Compound+massage and Dioctahedral smectite was 2.78±1.54 days,2.36±1.25 days and 2.90±1.73 days, respectively. By analysis only on specific number, although Chinese Herbal Compound massage therapy had the shortest antidiarrheal time, followed by Chinese medicine and Dioctahedral smectite therapy had the longest one, there was no significant difference between the antidiarrheal times of three treatments revealed by statistics analysis.
(2) Content of Bacillus bifidus, lactobacillus, and Escherichia Coli in stool specimens were detected in 26 infants with acute nonbacterial diarrhea, and the results showed no significant correlations were revealed between content of Bacillus bifidus, lactobacillus, and Escherichia Coli in post-treatment stool specimens of infants in the three groups and that in pre-treatment stool specimens;further analysis of correlation of main clinical symptoms (stool frequency, character of stool, and score of stool symptoms) and the content of Bacillus bifidus, lactobacillus, and Escherichia Coli indicated there was no significant relation between stool frequency, loose degree of stool as well as score of stool symptoms and the content of Bacillus bifidus, lactobacillus, and Escherichia Coli.
3.4 Conlusion:
(1)Post-treatment total effective rates of Chinese medicine, Chinese Herbal Compound massage treatment were superior to Dioctahedral smectite in superiority-inferiority assessment. However, there was no significant difference between the three treatments in term of antidiarrheal time.
(2) The results showed no significant correlations were revealed between content of Bacillus bifidus, lactobacillus, and Escherichia Coli in post-treatment stool specimens of infants in the three groups and that in pre-treatment stool specimens; and there was no significant relation between stool frequency, loose degree of stool as well as score of stool symptoms and the content of Bacillus bifidus, lactobacillus, and Escherichia Coli.
3.5 Analysis of result and Prospecting
The reasons for failure to effectively confirm the efficacy of Chinese medicine therapy in infantile diarrhea treatment in case of strict design of experimental study were consider as following:
Limitation of time, effect of compliance of infants and their parents during study as well as lack of understanding of informed content and noncompliance of infants and their parents resulted the present number of patients enrolled in the study was far from the planned sample size, and thus the inadequate sample size might the reason for that no statistical significance was revealed in present study.
In view of this, we believed that results of our study could not indicate uncertain clinical efficacy of Chinese medicine in infantile acute nonbacterial diarrhea treatment, and could not come to a conclusion of no correlation between the main clinical symptoms of infants with diarrhea and contents of Bacillus bifidus, lactobacillus, and Escherichia Coli; the same, we also could not infer that interventions of Chinese herbal compound, massage manipulation, and Dioctahedral smectite were not associated with content changes of Bacillus bifidus, lactobacillus, and Escherichia Coli.
The force of results could be affected due to the lack of sample size. In present, the study on action mechanism of Traditional Chinese Medicine in the treatment of infantile acute nonbacterial infectious diarrhea was still in exploratory stage, and the data obtained in our study could only be use for conference due to the lack of patient's number, which also was the regret of our study. Based the experience summary of preliminary study, we will continue to conduct the clinical trial in order to obtain objective and scientific conclusions, thus to provide reliable clinical evidences for the Chinese medicine treatment of acute nonbacterial diarrhea in infants.
一、文献研究
1.研究目的：综述中医及现代医学对小儿腹泻病的认识及循证医学的方法应用于中医药疗法治疗小儿腹泻病的必然性和可行性
2.研究结果：
(1)中医学认为泄泻是由于脾胃功能失调,引起大便稀薄或如水样,便次增多的疾病。病因以外感时邪、内伤饮食和脾胃虚弱多见,其病位在脾胃,景岳对其病理机制作出了精辟论述：“泄泻之本,无不由于脾胃,盖胃为水谷之海,而脾主运化,使脾健胃和,则水谷腐熟,而化气化血,以行营卫,若饮食失节,起居不时,以致脾胃受伤,则水反为湿,谷反为滞,精华之气,不能输化,乃致合污下降,而泻利作矣。”(《景岳全书·泄泻》)李中梓在总结前人经验的基础上,对泄泻的治法,作了进一步的概括,提出淡渗、升提、清凉、疏利、甘缓、酸收、燥脾、温肾、固涩等九法,对泄泻治疗学的丰富和发展有着重要的临床价值。
中医学治疗腹泻病方法多样,内有中药辨证论治,外有针灸、推拿、穴位贴敷及其他外治法,取得良好临床疗效。中医药治疗儿童腹泻灵活多变,副作用小,应用前景非常广泛。
(2)现代医学对小儿腹泻病的认识
现代医学认为腹泻的发生与小儿时期特点及感染、饮食、免疫等因素有关。其的病理机制可归纳为以下四种：渗透性腹泻、分泌性腹泻、渗出性腹泻、肠动力紊乱性腹泻。但目前有关其病因、发病机理、病理生理等方面仍未完全清楚。
肠道微生态可能在小儿腹泻病的发生中具有重要意义。儿童肠道微生态平衡紊乱主要表现：一方面以双歧杆菌为主的益生菌数量明显减少,各菌群之间正常比例严重失调；另一方面肠道正常菌的转移和一些机会菌(主要是过路菌)大量的生长繁殖引起疾病。当肠道菌群的种类、数量和比例发生异常变化,偏离正常的生理组合,转变为病理性组合状态,即出现菌群失调,引起许多疾病。儿科的急慢性腹泻均可能与肠道菌群失调密切相关。
(3)循证医学的方法应用于中医药疗法治疗小儿腹泻病的必然性和可行性
论证了循证医学方法系统评价中医药疗效的必要性在于循证医学所倡导的系统评价所具备的方法学特性适合中医学发展规律的要求,且中医药的疗效亟待借鉴新的研究方法进行客观评价；其可行性在于有数量充足的中医药临床试验可供系统评价,已有进行相关实践的范例。
3.研究结论
(1)中医药治疗小儿泄泻方法多样,简验便廉,有非常丰富的古代及现代文献支撑。(2)现代经验报道多,临床研究少。临床随机对照实验研究更少,且临床研究设计不合理,在随机化、盲法、对照选择、病例的纳入与排除标准、结局指标的选定方面存在较多问题,报告的有关临床疗效重复性或经不起反复实践的考验。
二、小儿急性非细菌性腹泻病临床治疗效应的系统评价
1.研究目的：对化湿法对小儿急性非细菌性腹泻病的治疗效应及思密达对小儿非细菌性腹泻病的治疗效应做出系统评价,从而为以思密达为对照,化湿法联合推拿手法对小儿腹泻病治疗效应的临床研究提供循证医学依据。
2.研究方法：收集文献并对其进行质量评价和资料提取,采用Cochrane协作网提供的RevMan 4.2.10软件进行Meta分析。
3.研究结果：
(1)关于化湿法为治则的中草药治疗小儿急性非细菌性腹泻病的系统评价共纳入28篇文献,通过Meta分析发现：在以临床疗效为评价指标做优劣性分析时,所纳入的27篇文献中认为化湿中医治法对小儿腹泻病的效应优于思密达的有16篇,另11篇则持否定意见。在以止泻时间为评价指标,所纳入5篇文献中认为化湿中医治法对小儿腹泻病的效应优于思密达的有3篇,另2篇则持否定意见。总之,以化湿法为治疗原则的中草药对小儿急性非细菌性腹泻病具有确切疗效。
(2)本研究共纳入中医文献28篇,诸位医家对小儿泄泻病因病机的认识基本一致,认为小儿“脾常不足”,在此基础上复感风、寒、湿邪,致脾胃受伤,水反为湿,谷反为滞,合污而致泄泻,“脾虚湿困”为其发病主要原因。治疗法则以运脾化湿为治疗大法,或兼清热,或兼疏风,或兼消滞,或兼收敛。28篇纳入文献均有列出中药复方主要药物组成,处方用药中健运脾胃、化湿类药物种类最广,使用频率最高,依次为茯苓(18次,占64.29%),白术(10次,占35.71%),苍术(8次,占28.57%)藿香(8次,占28.57%),健脾药尚有党参或太子参(共7次),山药(4次),黄芪(3次),炒扁豆(2次)；其它利水渗湿药物有车前子(5次),泽泻(3次),法半夏(3次),猪苓(2次)；同时使用苍术和茯苓的文献有8篇,占28.75%。其次使用较广泛的药物是调理气机药物,此类药有6种,其中陈皮应用频率最高,共出现6次,占21.43%；厚朴(3次,占10.71%),木香(2次,占7.14%),砂仁、香附、枳壳各1次。收敛药物有5种,焦山楂4次,石榴皮、诃子各3次,番石榴叶、赤石脂各2次。消食导滞药物使用也较多,有炒谷麦芽(5次)、鸡内金(4次)、神曲(3次)、五谷虫(1次)。笔者认为出现这样的用药规律与小儿泄泻的病因病机是相吻合的。
(3)思密达用于治疗小儿腹泻病临床疗效确切,但与中药复方相比哪种治疗方法具有优势,文献报道结果多有不同。在以临床疗效为评价指标进行优劣性分析时,11篇独立文献报告系统评价分析结果表明,与中医非药物治疗和空白对照相比较,提示思密达确有治疗小儿腹泻病的效应；而60篇独立文献结果表明,与中西药或空白对照相比较,思密达口服治疗小儿腹泻病无明显优势；在以止泻时间为评价指标进行分析时,6篇独立文献报告系统评价分析结果表明：与中医非药物治疗和空白对照相比较,思密达口服可显著性缩短小儿腹泻时间；22篇独立文献结果表明,与中西药或空白对照相比较,思密达口服缩短小儿腹泻时间无明显优势。所纳入的文献均具有发表性偏倚。总之,以临床疗效及止泻时间做为效应评价指标,思密达可作为中药、西药新药治疗小儿腹泻病临床疗效评价的阳性对照药物。
(4)存在问题
临床研究在方法学上的欠缺严重影响了研究质量,存在的主要问题有：①临床对照试验未能较好遵守随机、对照的原则；②样本量的确定不够严谨；③统计方法应用欠规范；④疗效评价、诊断标准及中医症候诊断标准尚未统一；⑤对随访及不良反应的观察不够重视。
三、小儿急性非细菌性腹泻病的临床及实验研究
1.研究目的：对中医治疗小儿泄泻进行随机对照临床研究,从临床证候表现及微生态调节的角度着眼,客观规范地评价运脾化湿为主法治疗小儿急性非细菌感染性腹泻病的疗效。
2.研究方法：(1)临床研究采用前瞻性、多中心的随机对照临床研究方法,研究的目标人群为6个月～3岁急性非细菌性腹泻病患儿,采用中心随机化分配系统分为中药组、中药+推拿组、思密达组,分配比例为1：1：1,观察临床症状并检测治疗前后肠道微生态的变化,随访、观察不良反应事件及合并用药情况,进行安全性评价。(2)实验研究采用实时荧光定量PCR(FQ-PCR)技术检测腹泻患儿治疗前后粪便双歧杆菌、乳酸杆菌及大肠杆菌含量。
3.研究结果：
(1)治疗后中药组、中药复方+推拿组的总有效率优于思密达组,三者进行比较具有显著性差异。中药组、中药复方+推拿组、思密达组止泻时间分别为(2.78±1.54)天、(2.36±1.25)天、(2.90±1.73)天。仅从具体数值上分析,中药复方+推拿组的止泻时间最短,其次是中药组,思密达组止泻时间最长,但统计学分析三种治疗措施的止泻时间无显著性差异。(2)本论文检测了26例急性非细菌性腹泻患儿的粪便标本中双歧杆菌、乳酸杆菌和肠杆菌的含量,结果发现：仅从数值上看,治疗后三组腹泻患儿粪便标本中的双歧杆菌、乳酸杆菌及大肠杆菌含量数值较治疗前增加,与治疗前相比,无显著相关性；研究进一步分析了主要临床症状(大便次数、大便性状及大便症状积分)与双歧杆菌、乳酸杆菌和肠杆菌含量的相关性,结果发现：大便次数、大便稀烂程度及大便症状积分与大肠杆菌、乳酸杆菌、双歧杆菌之间无显著相关关系。
4.结论
(1)从优劣性分析,治疗后中药组、中药+推拿组总有效率优于思密达对照组,但统计学分析三种治疗措施的止泻时间无显著性差异。
(2)治疗后三组腹泻患儿粪便中双歧杆菌、乳酸杆菌、大肠杆菌的数量较治疗前增加,但与治疗前相比,无显著相关性；大便次数、大便性状及大便症状积分与双歧杆菌、乳酸杆菌、大肠杆菌之间无显著相关关系。
5.分析与展望
在严格的实验设计情况下,未能得出具有统计学意义的结论,笔者分析如下：
由于时间限制、临床试验过程中受患儿及其家长的依从性的影响以及患儿家长对临床试验知情同意书的不理解、不配合,导致目前入组病例数距离预计值有很大差距,样本量不足是导致目前研究未能得出有效统计学意义的可能原因。
基于此,笔者认为目前研究结果并不能说明中医药治疗小儿急性非细菌性腹泻患儿的临床疗效不确切,且无法得出腹泻患儿主要临床症状与双歧杆菌、乳酸杆菌及大肠杆菌含量无相关关系的结论；同样,不能推论中药复方、推拿手法、思密达的干预与双歧杆菌、乳酸杆菌及大肠杆菌含量变化无相关关系。通过扩大样本量,或可得出中药复方、推拿疗法改善大便性状、减少大便次数的可能作用途经是通过调节微生态平衡,恢复肠道微生态环境。
本次研究中中医证型分布以湿热证较多,笔者推测这可能与岭南地域气候特点有关,但尚不能得出小儿急性腹泻病湿热证占主导地位的结论,仍有待于扩大样本量及研究区域的进一步研究。
由于样本量不足,影响了结果的说服力。我们对中医药治疗小儿急性非细菌感染性腹泻病的作用机制研究进行了有益的探索,因病例数不足,得出的数据仅供参考,这也是本次研究的遗憾之处。在总结了前期的经验基础上,我们将继续进行该项研究,以期得到客观和科学的结论,为中医药治疗小儿急性非细菌性腹泻提供可靠的临床证据。
Diarrhea disease is the major cause for maldevelopment, malnutrition and death of children under 5 years old. The development of diarrhea disease is closely associated with physical and pathological features of children, infection, improper diet, and their low immune ability. Although the popularization of Diagnostic and Therapeutic Guide for Diarrhea Disease decreased the mortality of infantile diarrhea, such disease was still one of the main reasons leading to death of children under 5 years old. Therefore, a simple, convenient, effective and inexpensive therapeutic regimen was required in clinical. Traditional Chinese medicine cherished long history and effectiveness in treating infantile diarrhea disease, besides its characteristics and advantages. In order to make an objective evaluation on TCM therapeutic effect and analyze problems and strategies in clinical studies, we conducted a relevant research in these fields at the guide of evidence-based medicine, adopting its methods and thoughts.
1. Literature researches
1.1 Object:
Writer summary TCM and modern medicine recognition on infantile diarrhea, elaborate necessity and feasibility of evidence-based medicine methodology application in Chinese medicine treatment for infantile diarrhea.
1.2 Results:
(1)TCM believed diarrhea was a disease with the symptoms of loose stool or watery stool and frequent defecation caused by functional disorder of spleen and stomach. In TCM theory, the causes of diarrhea are exogenous pathogenic evil, importer diet, or deficiency of both spleen and stomach more often, and the diseased part locates at spleen and stomach. ZHANG Jing-yue, a famous doctor of Ming dynasty, explored the pathogenesis of diarrhea:"The fundamental cause for diarrhea is the dysfunction of spleen and stomach. Stomach is the sea of water and cereals and spleen is in charge of transportation and transformation. If the functions of spleen and stomach are normal, intake cereals will be digested well and transformed into essence-qi and blood, supplementing Ying qi and Wei qi; while if the functions of spleen and stomach are damaged by improper diets or irregular daily life, water will be turn into pathogenic dampness, cereals will be transformed into stagnation, and essence qi will not be transformed and transported, leading to diarrhea together with filthy things." (JingYue QuanShu). LI Zhong-zhi, a famous doctor of Ming dynasty, made a fully summarization about the treatments of diarrhea on the experiences of his predecessors:"there are nine kinds of major therapeutic methods for diarrhea, which are inducing urine with mild taste medicines, lifting, cooling, dispersing, relaxing with sweet taste medicines, astringing with sour taste medicines, drying spleen, warming kidney and consolidating", manifesting important clinical values for the development of diarrhea therapeutics.
There were many kinds of effective therapeutic methods for diarrhea in TCM, including internal medicine, such as treatment based on syndrome differentiation, and external medicine, such as acupuncture, moxibustion, massage, acupoints-application and others. Boosting of agility and few side-effects, TCM has a broad feature for the treatment of infantile diarrhea.
(2)Modern medicine considered the development of infantile diarrhea was associated with the features of infant and the factors of infection, diet, immune function. The pathological mechanism of this disease could be summarized into the following four types:osmotic diarrhea, secretory diarrhea, exudative diarrhea and motility disturbance diarrhea. However, now the relative etiological factor, pathological mechanism, pathophysiology were not yet fully understood.
Intestinal microecology may have an important significance on the development of infantile diarrhea. The disorder of intestinal microecology balance of infants mainly manifested as the following:one is the serious imbalance of normal proportion of each microbial population due to decreased number of probiotics mainly as Bacillus bifidus; the other is the diseases resulted from normal enteric flora transfer and mass multiplication and growth of some opportunists (mainly as transient flora). Once abnormal changes of kinds, number, and proportion of intestinal flora occurred, they would deviated from normal physiological composition and thansformed into pathologic composition, thus alteration of intestinal flora occurred and in turn resulted in many diseases. Pediatric acute and chronic diarrhea might be both closely associated with alteration of intestinal flora.
(3) The necessity of systemic evaluation of Chinese medicine efficacy with Evidence-based medicine methodology is that the methodology characteristics of systemic evaluation advocated by evidence-based medicine was suited to the requirements of the development law of Traditional Chinese Medicine, and there was an urgent need to perform objective evaluation of Chinese medicine efficacy by new research methods for reference; and its feasibility lies on a sufficient number of clinical trials on Chinese medicine were available for the systemic evaluation and there has been some of examples for performing relevant practice.
1.3 Problems
In the literature of today, there were more experience reports but few clinical studies. And randomized control clinical trials were more less and had unreasonable design and many problems in term of randomization, blind design, selection of control group, inclusion and exclusion criteria of subjects and selection of end point, also whose relative clinical effects were poorly reproduced or could not bear the test of practice again.
2. Evidence-based Medicine Research
2.1 Object:
Writer performed a systemic review of the effect of Eliminating Dampness on clinical efficacy and its antidiarrheal time in infantile acute nonbacterial diarrhea treatment, effect of Dioctahedral smectite on clinical efficacy and its antidiarrheal time in infantile nonbacterial diarrhea treatment. So as to provide the basis on Evidence-based medicine of dioctahedral smectite as control, treatment effect of Chinese Herbal used Eliminating Dampness compound massage for diarrhea in children.
2.2 Methods:
Writer collected documents,evaluated the quality of the literature and extracted data. On the time, writer used software RevMan 4.2.10 provided by Cochrane Collaboration to do Meta-analysis.
2.3 Results:
(1)Total 28 literatures were included in the systemic evaluation of Chinese herbal medicine belonging to Therapeutic Principle of Eliminating Dampness in treatment of infantile acute nonbacterial diarrhea, and by the meta-analysis of which we found that:①In the superiority-inferiority assessment with clinical efficacy as evaluation indexes conducted in 27 literatures, results of 16 literatures revealed the efficacy of Chinese Medicine according to Eliminating Dampness for infantile diarrhea treatment was superior to Dioctahedral smectite, while the results of the other 11 literatures denied this opinion.②In 5 literatures used antidiarrheal time as the evaluation index, results of 3 literatures revealed the efficacy of Chinese Medicine according to Eliminating Dampness for infantile diarrhea treatment was superior to Dioctahedral smectite, while the results of the other 2 literatures was opposite to this. Although all literature had report bias, in general, these literatures had little bias. In short, Chinese herbal medicine belonging to Therapeutic Principle of Eliminating Dampness possessed the exact curative effect in infantile acute nonbacterial diarrhea treatment.
(2) A preliminary analysis of therapeutic method and the rules for Chinese medicine application in the 28 literatures included in the study. The therapeutic principle mainly was Activating Spleen and Removing Dampness, which was combined with the therapeutic method of Clearing Heat, Eliminate stasis, Dispelling Wind, or Astringe. For herbs prescription and application, the medicine type most widely and frequently used is herbs with the function invigorating spleen and stomach, dissipating dampness, which were in turn Poria (18 times,64.29%), Atractylodes macrocephala Koidz (10 times,35.71%), Atractylodes Polysaccharides (8 times,28.57%), Agastache rugosa (8 times, 28.57%); and other herbs with the function of invigorating spleen included Codonopsis lanceolata or Radix pseudostell (total 7 times), Chinese Yam (4 times), Astragalus (3 times), parched hyacinth bean (2 times); other herbs with the function of removing dampness by promoting diuresis included plantain seed (5 times), Alisma orientale Juzepcz (3 times), prepared Pinellia tuber (3 times), Polyporus (2 times); and simultaneous application of Poria and Polyporus appeared in 8 articles, according to 28.57% of total. The medicine type followed above in term of application extent was Regulating Qi Activity, which included 6 herbs, among them, tangerine peel is most frequently used for 6 times (21.34%), followed by Magnolia officinalis (3 times,10.71%), Radix Aucklandiae (2 times,7.14%), and one time of villous amomum fruit, Cyperus rotundus L., and bitter orange. Five herbs with Astringe function were used, including charred Fructus Crataegi (4 times),3 times of Pomegranate Rind and myrobalan,2 times of guava leaf and halloysitum rubrum. Also the drugs for Remove Stagnated Food and Promote Digestion were used more often, such as roasted byne (5 times), endothelium corneum gigeriae galli (4 times), medicated leaven (3 times), oriental latrine fly larvina (1 time). We concluded that the rule of herbs application revealed in this study was consisted with the etiology and pathogenesis of infantile diarrhea.
(3) Dioctahedral smectite appeared exact clinical efficacy in infantile diarrhea treatment, but there were different results in literatures in term of which therapy was superior when compared with Chinese Herbal Compound. In the superiority-inferiority assessment with clinical efficacy as evaluation indexes, the results of systemic evaluation of 11 independent literatures showed the effects of oral Dioctahedral smectite was significantly different when compared with non-drug therapy in Chinese medicine and blank control group, which indicated exact effect of Dioctahedral smectite in infantile diarrhea treatment; however, the results of 60 independent literatures revealed there was no significant difference for clinical efficacy of oral Dioctahedral smectite in infantile diarrhea compared with Western and Chinese medicine or blank control group, and the clinical effect of Dioctahedral smectite in infantile diarrhea treatment was not obviously different to management of Chinese medicine and Western medicine, and had no any treatment advantages; In analysis used antidiarrheal time as the evaluation index, results of systemic evaluation of 6 independent literatures revealed that oral Dioctahedral smectite could significantly decrease the duration of infantile diarrhea compared with non-drug therapy in Chinese medicine and blank control group, which indicated exact effect of reducing duration of infantile diarrhea of Dioctahedral smectite; and the results of 22 independent literatures showed there was no significant difference for decrease of infantile diarrhea duration of oral Dioctahedral smectite compared with Western and Chinese medicine or blank control group, and the decrease of infantile diarrhea-duration of Dioctahedral smectite was not obviously different to management of Chinese medicine and Western medicine, and had no any treatment advantages. All literatures included in the analysis had publication bias. On the whole, when clinical efficacy and antidiarrheal time was used as evaluative index, Dioctahedral smectite could be served as the positive control drug in clinical efficacy evaluation of new Chinese medicine and Western medicine in infantile diarrhea treatment.
2.4 Problems
The methodology limitation of clinical studies resulted in a serious effect on the quality of studies, in which the present problems mainly included: (1)Principles of randomization and control were not well kept in clinical control trials; (2) Determination of sample size was not rigorous enough; (3) Lack of standardized statistical methods; (4) Standards of clinical evaluation and diagnosis as well as the diagnostic criteria of TCM Syndromes were not unified; (5)Observation of follow-up and adverse effects were not be attended enough.
3. Clinical and experimental study of infantile acute nonbacterial diarrhea
3.1 Object:
A randomized control clinical study of Chinese medicine in infantile diarrhea treatment was conducted to evaluate objectively and standardized the effect of main therapeutic method of Activating Spleen and Dissipating Dampness on infantile acute nonbacterial infectious diarrhea in terms of clinical syndrome appearance and microecological regulation. 3.2 Methods:
(1) the clinical study was designed as a prospective, multi-center, randomized, control trial in target population of 6-month to 3-year-old infants with acute nonbacterial diarrhea, who were allocated into Chinese medicine group, Chinese medicine+massage group, Dioctahedral smectite group in proportion of 1:1:1 with Central randomization system. Clinical symptoms observation and detection of intestinal microecology change between pre/post-treatment, follow-up, observation of adverse effect events and drug combination were performed, also treatment safety was evaluated.
(2) Real-time Fluorescent Quantitative PCR Technique (FQ-PCR) technique used to perform the detection of Bacillus bifidus, lactobacillus, and Escherichia Coli. 3.3 Results:
(1) Post-treatment total effective rates of Chinese medicine, Chinese Herbal Compound massage treatment were superior to Dioctahedral smectite, and there were significant differences when compared these three treatments. The antidiarrheal time of Chinese medicine, Chinese Herbal Compound+massage and Dioctahedral smectite was 2.78±1.54 days,2.36±1.25 days and 2.90±1.73 days, respectively. By analysis only on specific number, although Chinese Herbal Compound massage therapy had the shortest antidiarrheal time, followed by Chinese medicine and Dioctahedral smectite therapy had the longest one, there was no significant difference between the antidiarrheal times of three treatments revealed by statistics analysis.
(2) Content of Bacillus bifidus, lactobacillus, and Escherichia Coli in stool specimens were detected in 26 infants with acute nonbacterial diarrhea, and the results showed no significant correlations were revealed between content of Bacillus bifidus, lactobacillus, and Escherichia Coli in post-treatment stool specimens of infants in the three groups and that in pre-treatment stool specimens;further analysis of correlation of main clinical symptoms (stool frequency, character of stool, and score of stool symptoms) and the content of Bacillus bifidus, lactobacillus, and Escherichia Coli indicated there was no significant relation between stool frequency, loose degree of stool as well as score of stool symptoms and the content of Bacillus bifidus, lactobacillus, and Escherichia Coli.
3.4 Conlusion:
(1)Post-treatment total effective rates of Chinese medicine, Chinese Herbal Compound massage treatment were superior to Dioctahedral smectite in superiority-inferiority assessment. However, there was no significant difference between the three treatments in term of antidiarrheal time.
(2) The results showed no significant correlations were revealed between content of Bacillus bifidus, lactobacillus, and Escherichia Coli in post-treatment stool specimens of infants in the three groups and that in pre-treatment stool specimens; and there was no significant relation between stool frequency, loose degree of stool as well as score of stool symptoms and the content of Bacillus bifidus, lactobacillus, and Escherichia Coli.
3.5 Analysis of result and Prospecting
The reasons for failure to effectively confirm the efficacy of Chinese medicine therapy in infantile diarrhea treatment in case of strict design of experimental study were consider as following:
Limitation of time, effect of compliance of infants and their parents during study as well as lack of understanding of informed content and noncompliance of infants and their parents resulted the present number of patients enrolled in the study was far from the planned sample size, and thus the inadequate sample size might the reason for that no statistical significance was revealed in present study.
In view of this, we believed that results of our study could not indicate uncertain clinical efficacy of Chinese medicine in infantile acute nonbacterial diarrhea treatment, and could not come to a conclusion of no correlation between the main clinical symptoms of infants with diarrhea and contents of Bacillus bifidus, lactobacillus, and Escherichia Coli; the same, we also could not infer that interventions of Chinese herbal compound, massage manipulation, and Dioctahedral smectite were not associated with content changes of Bacillus bifidus, lactobacillus, and Escherichia Coli.
The force of results could be affected due to the lack of sample size. In present, the study on action mechanism of Traditional Chinese Medicine in the treatment of infantile acute nonbacterial infectious diarrhea was still in exploratory stage, and the data obtained in our study could only be use for conference due to the lack of patient's number, which also was the regret of our study. Based the experience summary of preliminary study, we will continue to conduct the clinical trial in order to obtain objective and scientific conclusions, thus to provide reliable clinical evidences for the Chinese medicine treatment of acute nonbacterial diarrhea in infants.
引文
[1]黎世明,刘华.黎炳南读各家泄泻论[M].北京：人民卫生出版社,2003：
[2]北京儿童医院.王鹏飞儿科临床经验集[M].北京：人民卫生出版社,1981：40
[3]史宇广,单书健.当代名医临证精华小儿腹泻专辑[M].北京：中医古籍出版社,1988：57,109
[4]马凤彬.何炎樂老中医治疗小儿腹泻经验[J].新中医,1997,29(8)：8-9
[5]罗云坚,儿科专病中医临床诊治[M].北京：人民卫生出版社,2000：219-220
[6]于天顺,宗相卿.中医药辨治幼儿腹泻136例[J].辽宁中医杂志,1994,21(12)：188
[7]王恩桂.腹泻宁加味治疗小儿泄泻疗效观察[J].中医杂志,1994,35(9)：548
[8]施贻杰.辨证分型治疗小儿秋季腹泻76例疗效观察[J].河北中医,1997,19(4)：18
[9]王树山,杨松等.双苓止泻口服液治疗小儿轮状病毒性肠炎的临床研究[J].中国中酉医结合杂志,1995,15(5)：284
[10]江育仁.脾健不在补贵在运.上海中医药杂志[J],2002(1)：4-7
[11]韩谨.藿香平泻汤治疗小儿秋冬季腹泻70例临床观察[J],北京中医,2003,22(8)：26-27
[12]张蔚.运脾止泻方治疗小儿秋季腹泻疗效观察[J],中国中医急症,2004,13(7)：437
[13]许华,曾繁冬等.苍苓散治疗婴幼儿轮状病毒肠炎临床研究.中药新药与临床药理[J],1997(3)：81-83
[14]何颖辉,罗晓健,钱星文等.藿香正气胶囊对菌群失调小鼠黏膜免疫的影响[J],中国中药杂志,2007,22：
[15]董建栋,淡渗利湿法治泄泻的药理学探讨[J].时珍国医国药2008(19)1：226-227
[16]朱秋双；赵玉珍；张明远等.白术芍药散抗腹泻药效实验研究[J].黑龙江医药科学,2007,1：
[17]周东辉.推拿治疗小儿腹泻316例[J].浙江中西医结合杂志2005,15(3)：191.
[18]焦平,丰艳君.推拿治疗伤食型婴幼儿泄泻370例的临床疗效观察[J].河北中医药学报,2005,20(3)：26-28
[19]周鲲.推拿治疗婴幼儿泄泻的临床研究[J].中华实用中西医杂志,2005,18(3)：368-369.
[20]陈志伟,王梅芳.辨证推拿治疗小儿腹泻34例临床观察[J].上海中医药杂志,2004,38(8)：39-40.
[21]张玉英.敷脐疗法治疗小儿腹泻26例[J].吉林中医药,2003,2(7)：25.
[22]刘小英,王金权.温脐止泻散贴脐治疗小儿腹泻56例[J].中医外治杂 志,2005,14(4)：25.
[23]唐学斌.桂椒散治疗婴幼儿夏季腹泻疗效观察[J].中国热带医学,2005,5(7)：1482-1478.[24]邹慧承.止泻敷贴灵敷脐治疗小儿腹泻的临床及实验研究[J]湖北中医杂志,2006,28(3)：19-20.
[25]周卫东.止泻膏敷脐治疗婴幼儿秋季腹泻96例[J].中国民间疗法,2004,12(4)：21-22.
[26]吴建荣,王荣茂.针灸加思密达治疗婴幼儿秋季腹泻54例[J]江苏中医药,2006,27(3)：49.
[27]董杨颖,陈飞燕.针刺治疗小儿腹泻91例[J].四川中医,2005,23(7)：109.
[28]于竹力.针灸治疗小儿腹泻32例[J].针灸临床杂志,2006,2(10)：19-20.
[29]沈玉鹏.肠灵液灌肠治疗小儿病毒性腹泻100例疗效观察[J]甘肃中医,2004,17(2)：19-20.
[30]刘飞霞.中药灌肠治疗婴幼儿腹泻88例[J].福建中医药,2004,35(3)：25-26.
[31]杨森,郭淑梅.中药灌肠治疗儿童秋季腹泻60例疗效观察[J]河北中
医,2005,27(9)：663-664.[32]陈利.中药浴足配贴脐治疗小儿慢性泄泻60例[J].四川中医2006,24(5)：87.[33]付建军,张常彩.中药外洗配合推拿治疗小儿泄泻的临床观察[J].基层医学论坛,2006,10(1)：43.[34]王晓燕,王丽萍.中药直肠滴注治疗小儿秋季腹泻疗效观察[J]现代中西医结合杂志,2005,14(21)：2803-2804.[35]雏荣东.穴位注射治疗婴幼儿秋季腹泻的对照观察[J].中国针灸,2004,24(5)：315-316.
[36]The World Health Organization,United Nations Children's Fund,WHO/UNICEF Joint Statement:Clinical Management of Acute Diarrhoea[C].The United Nations Children's Fund/World Health Organization,2004.
[37]Thapar N,Sanderson IR.Diarrhoea in children:an interface between developing and developed countries[J].Lancet,2004,363:641-653
[38]康白.微生态学原理[M].大连：大连出版社,1996：21.
[39]方鹤松.小儿腹泻病与肠道微生态的关系[J].中国实用儿科杂志,1996,11(4)：201-202.
[40]张琳,邱学,李素娥.婴幼儿轮状病毒肠炎肠道菌群的动态变化[J].中华儿科杂志,1994,32(5)：282-284.
[41]徐殿霞,李建秋,熊德鑫.腹泻儿童肠道菌群分析[J]中国微生态学杂志,1999,11(3)：163.
[42]侯晓华,张锦坤,代立人,等.慢性腹泻病人肠道菌群的研究[J].中华消化杂志,1990,10(1)：22-23.
[43]陈玉丽,傅冷西,庄则豪,等.慢性腹泻患者肠道菌群的分析[J].福建医科大学学报,1997,31(4)：421-423.
[44]李文建.肠道需氧优势菌群分离方法的建立及初步应用[J].中国微生态学杂志,1999,11(5)：315-316.]
[45]中华医学会儿科学会分会消化学组.儿童腹泻病诊断治疗原则的专家共识.中华儿科杂志,2009,47(8)：634-636
[46]Hahn, S, Kim Y, Garner P. Reduced osmolatity oral fehydration solution for treating dehydration due to diarrhea in children:systematic review[J]. BMJ,2001, 323(7304):81-85.
[47]Duggan C, Nurko S. "Feeding the gut":the scientific basis for continued enteral nutrition during acute diarrhea[J]. J Pediatr,1997,131(6):801-808
[48]Sandhu BK. European Society of Paediatric Gastroen-terology, Hepatology, and Nutrition Working Group on Acute Diarrhoea. Rationale for early feeding in childhood gastroenteritis [J]. J Pediatr Gastroenterol Nutr,2001,33(Suppl 2):S13-S16.
[49]Pang XL, Honma S,Nakata S, et 02. Human caliciviru-ses in acute gastroenteritis of young children in the community [J]. J Infect Dis,2000,181(Suppl 2):S288-S2914.
[50]World Health Organization,United Nations Children's Fund.WHO/UNICEF Joint Statement:Clinical Management of Acute Diarrhoea[R].The United Nations Children's Fund/World Health Organization,2004
[51]Sachdev I-IP, Mittal NK, Mittal SK, et al. A controlled trial on utility of oral zinc supplementation in acute dehydrating diarrhea in infants[J]. J Pediatr Gastroenterol Nutr, 1988,7(6):877-881.
[52]Szajewska H,Dziechciarz P,Mrukowicz J.Meta-analysis.Smectite in the treatment of acute infectious diarrhea in children[J].Aliment Pharmacol Ther,2006,23(2):217-227.
[53]董宗祁,方鹤松整理.中国腹泻病高峰会暨儿童腹泻国际研讨会会议纪要.临床儿科杂志,2004,22(6)：414-415
[54]方鹤松,小儿腹泻病药物治疗中的若干问题.临床儿科杂志,2001,19(3)：150-151
[55]Schwartz JC. Racecadotril:a new approach to the treatment of diarrhoea[J]. Int J Antimicrob Agents,2000,14(1):75-79.
[56]林果为,沈福民.现代临床流行病学[M].上海：复旦大学出版社第一版.2000：232～243
[57]Gordon Guyatt,Deborah Cook and Brian Haynes Evidence based medicine has come a long way.BMJ 2004;329:990-991
[58]胡立胜,周强.中医临床设计与SAS编程统计分析[M].北京：学苑出版社第一版,204：252～253
[59]李幼平,刘鸣.循证医学与中医药现代化[J].中国中医药信息杂志,1996,6(12)：14～16
[60]殷大奎.中国循证医学的回顾与展望[J].中国循证医学,2002,2(2)：77～78
[61]倪伟,李洁.试论循证医学与中医药研究[J].中国医药学报,2002,17(11)：644～645
[62]Glass GV.Primary,secondary,and meta-analysis of research.Educ Res,1976,5:3-8
[63]王建华.流行病学[M].第6版.北京：人民卫生出版社,2005：177-186.
[64]李幼平,刘鸣.循证医学与中医药现代化[J].中国中医药信息杂志,1996,6(12)：14～16
[65]Anonyymous Complentary medicine:time for critcal engagement[editorial].Lancet,2000:356:2023
[66]刘建平.循证医学与中医疗效评价.中医杂志,2007(48)1：27-28]
[67]贾文琴,杨克虎,田金徽等.Cochrane系统评价发表状况调查.中国循证医学杂志2009,9(6)：635～639
[68]Abramson J H. Meta-analysis:a review of p ros and cons[J]. Public Health Rev, 1991,18(1):1-47.
[69]Bailar J C,Mosteller F. Medical uses of statistics[M].2nd edition. Waltham Mass: N E J M Books,1992:422-427
[70]屈会起,张金钟,邱明才。循证医学的系统评价方法。中华医院管理杂志,2000,16(6)：334-336
[71]孙瑞元,宋青山主编.数学药理学新论[M].人民卫生出版社,2004：63—66
[72]Tang JinLing, Zhan SiYan, Edzard Ernst. Review of randomized trials of traditional Chinese medicine. BMJ,1999,319:160.
[73]Egger M, Smith GD, Schenider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ,1997,315:629-634.
[74]Salazar-Lindo E, Santisteban-Ponce J, Chea-Woe E, et al. Racecadotril in the treatment of acute watery diarrhea in children[J]. N Engl J Med,2000,343(7):463-467.
[75]Cezard JP, Duhamel JF, Meyer M, et al. Efficacy and tolerability of racecadotfil in acute diarrhea in children[J]. Gastroenterology,2001,120(4):799-805.
[76]舒敏,范娟,陈桂华等.儿童急性腹泻病治疗的循证评价.临床儿科杂志,2008,26(7)：627-632
[77]江育仁,张奇文主编.实用中医儿科学.上海：上海科技出版社,1995.131
[78]中华人民共和国卫生部药典委员会.中国药典,Ⅱ部[S].北京：化学工业出版 社,2000：127-127.
[79]徐友贵,王小明,黄驰,等.摘蕾除蘖对茅苍术产量的影响[J].中草药,1991,22(11)：517-517.
[80]青木俊二.苍术还有效成分β2桉叶醇及茅苍术醇对肠道平滑肌的作用[J]国外医学.中国中药分册,1991.13(2)：59
[81]谢露.苍术的药理研究.中医药研究,1992,(2)：59
[82]国家中医药管理局.中华本草.上海科技出版社,187-193；
[83]江苏新医学院.中药大辞典.上海人民出版社,1596-1600
[84]张明发,沈雅琴,朱自平,等.辛温(热)合归脾胃经中药药性研究(V)抗腹泻作用[J].中药药理与临床,1997,13(5)：2-5.
[85]张文芝.陈皮水煎液对离体唾液淀粉酶活性的影响[J].辽宁中医药杂志,1989,(4)：30.
[86]官福兰,王汝俊,王建华,等.陈皮及橙皮苷对离体肠管运动影响[J].时珍国医国药,2002,13(2)：65-67.
[87]国家药典委员会.中华人民共和国药典：Ⅰ部[M].北京：化学工业出版社,2005：22.
[88]Sun Cui-yu. The research progress of hawrhorn [J]. Primary Journal of Chinese Materia Medica,2001,15(5):53-54(In Chinese)
[89]Huang Xie-cai. Study of the original plants of Chinese drugs hawthorn[J]. GuanXi plants,1989,9(4):303-310(In Chinese
[90]黄珊珊,林原,刁云鹏等.焦山楂醇提取物对大鼠离体胃肠平滑肌条收缩性的影响.现代生物医学进展,2009,9(4)：612-614
[91]孙安达.各家论推拿手法治疗小儿腹泻[J].中国误诊学杂志,2001,1(10)：1551
[92]江浩,谭燕泉.推拿治疗小儿秋季腹泻186例疗效观察[J].山东中医杂志,2000,19(2)：92
[93]朱佩东.推拿治疗婴儿(湿热与寒湿型)腹泻32例临床疗效[J].按摩与导引,1999,15(1)：39
[94]俞大方.推拿学[M].上海：上海科学技术出版社,1997：16
[95]尹军霞,林德荣.肠道菌群与疾病.生物学通报,2004；39(3)：26-28
[96]金红芝,李堃宝.人肠道微生态系统的研究进展.自然杂志,2004；26(2)：88-91
[97]Nicholson,J.K.,E.Holmes,and I.D.Wilson,Gut microorganisms, mammalian metabolism and personalized health care.Nat Rev Microbiol,2005.3(5):p.431-8.
[98]Tamura,Z.,Nutriology of bifidobacteria.Bifidobacteria microflora,1983.3:p.3-16.
[99]Huijsdens,X.W.,et al.,Detection of Helicobacter species DNA by quantitative PCR in the gastrointestinal tract of healthy individuals and of patients with inflammatory bowel disease.FEMS Immunol Med Microbiol,2004.41(1):p.79-84.
[100]Avgustin,G.,F.Wright,and H.J.Flint,Genetic diversity and phylogenetic relationships among strains of Prevotella(Bacteroides) ruminicola from the rumen.Int J Syst Bacteriol,1994.44(2):p.246-55.
[101]Brunser,O.,et al.,Effects of probiotic or prebiotic supplemented milk formulas on fecal microbiota composition of infants. Asia Pac J Clin Nutr,2006.15(3):p.368-76.
[102]徐殿霞,李建秋,熊德鑫1腹泻儿童肠道菌群分析[J]1中国微生态学杂志,1999,11(3)：163.
[103]方鹤松.小儿腹泻病与肠道微生态的关系[J].中国实用儿科杂志,1996,11(4)：201-202.
[104]张 琳,邱学 ,李素娥.婴幼儿轮状病毒肠炎肠道菌群的动态变化[J].中华儿科杂志,1994,32(5)：282-284.
[105]Huijdens XW,Linskens RK,Mark M,et al Quantification of bacteria adherent to gastrointestinal mucosa by real-time PCR[J].J Clin Microbiol,2002,40(12):4423-4427
[106]黄永坤,杨美芬,李海林《常见胃肠病患儿胃肠道菌群变化研究进展》实用儿科临床杂志,2007,22(4)：481-484
[107]Ozaki H, McLaughlin LW. The estimation of distances between specific backbone-labeled sites in DNA using fluorescence resonance energy transfer. Nucleic Acids Res,1992;20:5205
[108]Livak KJ, Flood SJ,Marmaro J. Oligonucleotides with fluorescent dyes at opposite ends provide a quenched probe system useful for detecting PCR product and nucleic acid hybridization. PCR Methods Appl,1995;4(6):357-362
[109]Morris T,Robertson B,Gallagher M. Rapid reverse transcription-PCR detection of hepatitis C virus RNA in serum by using the TaqMan fluorogenic detection system. J Clin Microbiol,1996;34(12):2933-2936
[110]Gelmini S, Orlando C, Sestini R, et al. Quantitative polymerase chain reaction-based homogeneous assay with fluorogenic probes to measure c-erbB-2 oncogene amplification.Clin Chem,1997;43(5):752-758
[111]Swan DC, Tucker RA, Holloway BP,et al. A sensitive, type-specific, fluorogenic probe assay for detection of human papillomavirus DNA. J Clin Microbiol, 1997;34(12):886-891
[112]Weinberger KM, Wiedenmann E, Bohm S, et al. Sensitive and accurate quantiataion of hepatitis B virus DNA using a kinetic fluorescence detection system (Taq Man PCR). J Virol Methods,2000;85(1-2):75-82
[113]沈永才,袁佩娜.16S rRNA荧光定量PCR法检测双歧杆菌[J].中国微生态杂 志,2001,13(2)：66-72
[114]Matsuki T,Watanabe K,Fujimoto J,et al Quantitative PCR with 16S Rrna-gene-targeted species-specific primers for analysis of human intestinal bifidobacteria[J].Appl Environ M icrobiol,2004,70(1):167-173
[115]楼金,陈洁.分子生物学技术在肠道正常菌群研究中的应用.国外医学儿科学分册2004；31(1)：1-4
[116]任平,夏天.脾虚腹泻患者肠道菌群的研究[J].中医杂志,1992,33(6)：33
[117]胡静,杨旭东.中药“神曲”对脾虚小鼠肠道菌群的调整及肠保护作用的研究[J].中国微生态学杂志,2004,16(4)：208
[118]陈海龙,吴成中,关凤林.大承气汤对MODS时肠道细菌微生态学影响的实验研究[J].中国微生态学杂志2007：2：132-134
[119]小桥恭一.中药有效成分与肠道细菌的关系[J].医学与哲学,1995,16(11)：598
[120]卢林,刘伦翠,海艳洁等.推拿联合微生态调节剂治疗肠易激综合征的临床研究.2008,11(5)：898-899
[121]胡随瑜,金益强.关于中医临床疗效评价的思考.中医中西医结合杂志,2005；25(1)：72
[2]北京儿童医院.王鹏飞儿科临床经验集[M].北京：人民卫生出版社,1981：40
[3]史宇广,单书健.当代名医临证精华小儿腹泻专辑[M].北京：中医古籍出版社,1988：57,109
[4]马凤彬.何炎樂老中医治疗小儿腹泻经验[J].新中医,1997,29(8)：8-9
[5]罗云坚,儿科专病中医临床诊治[M].北京：人民卫生出版社,2000：219-220
[6]于天顺,宗相卿.中医药辨治幼儿腹泻136例[J].辽宁中医杂志,1994,21(12)：188
[7]王恩桂.腹泻宁加味治疗小儿泄泻疗效观察[J].中医杂志,1994,35(9)：548
[8]施贻杰.辨证分型治疗小儿秋季腹泻76例疗效观察[J].河北中医,1997,19(4)：18
[9]王树山,杨松等.双苓止泻口服液治疗小儿轮状病毒性肠炎的临床研究[J].中国中酉医结合杂志,1995,15(5)：284
[10]江育仁.脾健不在补贵在运.上海中医药杂志[J],2002(1)：4-7
[11]韩谨.藿香平泻汤治疗小儿秋冬季腹泻70例临床观察[J],北京中医,2003,22(8)：26-27
[12]张蔚.运脾止泻方治疗小儿秋季腹泻疗效观察[J],中国中医急症,2004,13(7)：437
[13]许华,曾繁冬等.苍苓散治疗婴幼儿轮状病毒肠炎临床研究.中药新药与临床药理[J],1997(3)：81-83
[14]何颖辉,罗晓健,钱星文等.藿香正气胶囊对菌群失调小鼠黏膜免疫的影响[J],中国中药杂志,2007,22：
[15]董建栋,淡渗利湿法治泄泻的药理学探讨[J].时珍国医国药2008(19)1：226-227
[16]朱秋双；赵玉珍；张明远等.白术芍药散抗腹泻药效实验研究[J].黑龙江医药科学,2007,1：
[17]周东辉.推拿治疗小儿腹泻316例[J].浙江中西医结合杂志2005,15(3)：191.
[18]焦平,丰艳君.推拿治疗伤食型婴幼儿泄泻370例的临床疗效观察[J].河北中医药学报,2005,20(3)：26-28
[19]周鲲.推拿治疗婴幼儿泄泻的临床研究[J].中华实用中西医杂志,2005,18(3)：368-369.
[20]陈志伟,王梅芳.辨证推拿治疗小儿腹泻34例临床观察[J].上海中医药杂志,2004,38(8)：39-40.
[21]张玉英.敷脐疗法治疗小儿腹泻26例[J].吉林中医药,2003,2(7)：25.
[22]刘小英,王金权.温脐止泻散贴脐治疗小儿腹泻56例[J].中医外治杂 志,2005,14(4)：25.
[23]唐学斌.桂椒散治疗婴幼儿夏季腹泻疗效观察[J].中国热带医学,2005,5(7)：1482-1478.[24]邹慧承.止泻敷贴灵敷脐治疗小儿腹泻的临床及实验研究[J]湖北中医杂志,2006,28(3)：19-20.
[25]周卫东.止泻膏敷脐治疗婴幼儿秋季腹泻96例[J].中国民间疗法,2004,12(4)：21-22.
[26]吴建荣,王荣茂.针灸加思密达治疗婴幼儿秋季腹泻54例[J]江苏中医药,2006,27(3)：49.
[27]董杨颖,陈飞燕.针刺治疗小儿腹泻91例[J].四川中医,2005,23(7)：109.
[28]于竹力.针灸治疗小儿腹泻32例[J].针灸临床杂志,2006,2(10)：19-20.
[29]沈玉鹏.肠灵液灌肠治疗小儿病毒性腹泻100例疗效观察[J]甘肃中医,2004,17(2)：19-20.
[30]刘飞霞.中药灌肠治疗婴幼儿腹泻88例[J].福建中医药,2004,35(3)：25-26.
[31]杨森,郭淑梅.中药灌肠治疗儿童秋季腹泻60例疗效观察[J]河北中
医,2005,27(9)：663-664.[32]陈利.中药浴足配贴脐治疗小儿慢性泄泻60例[J].四川中医2006,24(5)：87.[33]付建军,张常彩.中药外洗配合推拿治疗小儿泄泻的临床观察[J].基层医学论坛,2006,10(1)：43.[34]王晓燕,王丽萍.中药直肠滴注治疗小儿秋季腹泻疗效观察[J]现代中西医结合杂志,2005,14(21)：2803-2804.[35]雏荣东.穴位注射治疗婴幼儿秋季腹泻的对照观察[J].中国针灸,2004,24(5)：315-316.
[36]The World Health Organization,United Nations Children's Fund,WHO/UNICEF Joint Statement:Clinical Management of Acute Diarrhoea[C].The United Nations Children's Fund/World Health Organization,2004.
[37]Thapar N,Sanderson IR.Diarrhoea in children:an interface between developing and developed countries[J].Lancet,2004,363:641-653
[38]康白.微生态学原理[M].大连：大连出版社,1996：21.
[39]方鹤松.小儿腹泻病与肠道微生态的关系[J].中国实用儿科杂志,1996,11(4)：201-202.
[40]张琳,邱学,李素娥.婴幼儿轮状病毒肠炎肠道菌群的动态变化[J].中华儿科杂志,1994,32(5)：282-284.
[41]徐殿霞,李建秋,熊德鑫.腹泻儿童肠道菌群分析[J]中国微生态学杂志,1999,11(3)：163.
[42]侯晓华,张锦坤,代立人,等.慢性腹泻病人肠道菌群的研究[J].中华消化杂志,1990,10(1)：22-23.
[43]陈玉丽,傅冷西,庄则豪,等.慢性腹泻患者肠道菌群的分析[J].福建医科大学学报,1997,31(4)：421-423.
[44]李文建.肠道需氧优势菌群分离方法的建立及初步应用[J].中国微生态学杂志,1999,11(5)：315-316.]
[45]中华医学会儿科学会分会消化学组.儿童腹泻病诊断治疗原则的专家共识.中华儿科杂志,2009,47(8)：634-636
[46]Hahn, S, Kim Y, Garner P. Reduced osmolatity oral fehydration solution for treating dehydration due to diarrhea in children:systematic review[J]. BMJ,2001, 323(7304):81-85.
[47]Duggan C, Nurko S. "Feeding the gut":the scientific basis for continued enteral nutrition during acute diarrhea[J]. J Pediatr,1997,131(6):801-808
[48]Sandhu BK. European Society of Paediatric Gastroen-terology, Hepatology, and Nutrition Working Group on Acute Diarrhoea. Rationale for early feeding in childhood gastroenteritis [J]. J Pediatr Gastroenterol Nutr,2001,33(Suppl 2):S13-S16.
[49]Pang XL, Honma S,Nakata S, et 02. Human caliciviru-ses in acute gastroenteritis of young children in the community [J]. J Infect Dis,2000,181(Suppl 2):S288-S2914.
[50]World Health Organization,United Nations Children's Fund.WHO/UNICEF Joint Statement:Clinical Management of Acute Diarrhoea[R].The United Nations Children's Fund/World Health Organization,2004
[51]Sachdev I-IP, Mittal NK, Mittal SK, et al. A controlled trial on utility of oral zinc supplementation in acute dehydrating diarrhea in infants[J]. J Pediatr Gastroenterol Nutr, 1988,7(6):877-881.
[52]Szajewska H,Dziechciarz P,Mrukowicz J.Meta-analysis.Smectite in the treatment of acute infectious diarrhea in children[J].Aliment Pharmacol Ther,2006,23(2):217-227.
[53]董宗祁,方鹤松整理.中国腹泻病高峰会暨儿童腹泻国际研讨会会议纪要.临床儿科杂志,2004,22(6)：414-415
[54]方鹤松,小儿腹泻病药物治疗中的若干问题.临床儿科杂志,2001,19(3)：150-151
[55]Schwartz JC. Racecadotril:a new approach to the treatment of diarrhoea[J]. Int J Antimicrob Agents,2000,14(1):75-79.
[56]林果为,沈福民.现代临床流行病学[M].上海：复旦大学出版社第一版.2000：232～243
[57]Gordon Guyatt,Deborah Cook and Brian Haynes Evidence based medicine has come a long way.BMJ 2004;329:990-991
[58]胡立胜,周强.中医临床设计与SAS编程统计分析[M].北京：学苑出版社第一版,204：252～253
[59]李幼平,刘鸣.循证医学与中医药现代化[J].中国中医药信息杂志,1996,6(12)：14～16
[60]殷大奎.中国循证医学的回顾与展望[J].中国循证医学,2002,2(2)：77～78
[61]倪伟,李洁.试论循证医学与中医药研究[J].中国医药学报,2002,17(11)：644～645
[62]Glass GV.Primary,secondary,and meta-analysis of research.Educ Res,1976,5:3-8
[63]王建华.流行病学[M].第6版.北京：人民卫生出版社,2005：177-186.
[64]李幼平,刘鸣.循证医学与中医药现代化[J].中国中医药信息杂志,1996,6(12)：14～16
[65]Anonyymous Complentary medicine:time for critcal engagement[editorial].Lancet,2000:356:2023
[66]刘建平.循证医学与中医疗效评价.中医杂志,2007(48)1：27-28]
[67]贾文琴,杨克虎,田金徽等.Cochrane系统评价发表状况调查.中国循证医学杂志2009,9(6)：635～639
[68]Abramson J H. Meta-analysis:a review of p ros and cons[J]. Public Health Rev, 1991,18(1):1-47.
[69]Bailar J C,Mosteller F. Medical uses of statistics[M].2nd edition. Waltham Mass: N E J M Books,1992:422-427
[70]屈会起,张金钟,邱明才。循证医学的系统评价方法。中华医院管理杂志,2000,16(6)：334-336
[71]孙瑞元,宋青山主编.数学药理学新论[M].人民卫生出版社,2004：63—66
[72]Tang JinLing, Zhan SiYan, Edzard Ernst. Review of randomized trials of traditional Chinese medicine. BMJ,1999,319:160.
[73]Egger M, Smith GD, Schenider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ,1997,315:629-634.
[74]Salazar-Lindo E, Santisteban-Ponce J, Chea-Woe E, et al. Racecadotril in the treatment of acute watery diarrhea in children[J]. N Engl J Med,2000,343(7):463-467.
[75]Cezard JP, Duhamel JF, Meyer M, et al. Efficacy and tolerability of racecadotfil in acute diarrhea in children[J]. Gastroenterology,2001,120(4):799-805.
[76]舒敏,范娟,陈桂华等.儿童急性腹泻病治疗的循证评价.临床儿科杂志,2008,26(7)：627-632
[77]江育仁,张奇文主编.实用中医儿科学.上海：上海科技出版社,1995.131
[78]中华人民共和国卫生部药典委员会.中国药典,Ⅱ部[S].北京：化学工业出版 社,2000：127-127.
[79]徐友贵,王小明,黄驰,等.摘蕾除蘖对茅苍术产量的影响[J].中草药,1991,22(11)：517-517.
[80]青木俊二.苍术还有效成分β2桉叶醇及茅苍术醇对肠道平滑肌的作用[J]国外医学.中国中药分册,1991.13(2)：59
[81]谢露.苍术的药理研究.中医药研究,1992,(2)：59
[82]国家中医药管理局.中华本草.上海科技出版社,187-193；
[83]江苏新医学院.中药大辞典.上海人民出版社,1596-1600
[84]张明发,沈雅琴,朱自平,等.辛温(热)合归脾胃经中药药性研究(V)抗腹泻作用[J].中药药理与临床,1997,13(5)：2-5.
[85]张文芝.陈皮水煎液对离体唾液淀粉酶活性的影响[J].辽宁中医药杂志,1989,(4)：30.
[86]官福兰,王汝俊,王建华,等.陈皮及橙皮苷对离体肠管运动影响[J].时珍国医国药,2002,13(2)：65-67.
[87]国家药典委员会.中华人民共和国药典：Ⅰ部[M].北京：化学工业出版社,2005：22.
[88]Sun Cui-yu. The research progress of hawrhorn [J]. Primary Journal of Chinese Materia Medica,2001,15(5):53-54(In Chinese)
[89]Huang Xie-cai. Study of the original plants of Chinese drugs hawthorn[J]. GuanXi plants,1989,9(4):303-310(In Chinese
[90]黄珊珊,林原,刁云鹏等.焦山楂醇提取物对大鼠离体胃肠平滑肌条收缩性的影响.现代生物医学进展,2009,9(4)：612-614
[91]孙安达.各家论推拿手法治疗小儿腹泻[J].中国误诊学杂志,2001,1(10)：1551
[92]江浩,谭燕泉.推拿治疗小儿秋季腹泻186例疗效观察[J].山东中医杂志,2000,19(2)：92
[93]朱佩东.推拿治疗婴儿(湿热与寒湿型)腹泻32例临床疗效[J].按摩与导引,1999,15(1)：39
[94]俞大方.推拿学[M].上海：上海科学技术出版社,1997：16
[95]尹军霞,林德荣.肠道菌群与疾病.生物学通报,2004；39(3)：26-28
[96]金红芝,李堃宝.人肠道微生态系统的研究进展.自然杂志,2004；26(2)：88-91
[97]Nicholson,J.K.,E.Holmes,and I.D.Wilson,Gut microorganisms, mammalian metabolism and personalized health care.Nat Rev Microbiol,2005.3(5):p.431-8.
[98]Tamura,Z.,Nutriology of bifidobacteria.Bifidobacteria microflora,1983.3:p.3-16.
[99]Huijsdens,X.W.,et al.,Detection of Helicobacter species DNA by quantitative PCR in the gastrointestinal tract of healthy individuals and of patients with inflammatory bowel disease.FEMS Immunol Med Microbiol,2004.41(1):p.79-84.
[100]Avgustin,G.,F.Wright,and H.J.Flint,Genetic diversity and phylogenetic relationships among strains of Prevotella(Bacteroides) ruminicola from the rumen.Int J Syst Bacteriol,1994.44(2):p.246-55.
[101]Brunser,O.,et al.,Effects of probiotic or prebiotic supplemented milk formulas on fecal microbiota composition of infants. Asia Pac J Clin Nutr,2006.15(3):p.368-76.
[102]徐殿霞,李建秋,熊德鑫1腹泻儿童肠道菌群分析[J]1中国微生态学杂志,1999,11(3)：163.
[103]方鹤松.小儿腹泻病与肠道微生态的关系[J].中国实用儿科杂志,1996,11(4)：201-202.
[104]张 琳,邱学 ,李素娥.婴幼儿轮状病毒肠炎肠道菌群的动态变化[J].中华儿科杂志,1994,32(5)：282-284.
[105]Huijdens XW,Linskens RK,Mark M,et al Quantification of bacteria adherent to gastrointestinal mucosa by real-time PCR[J].J Clin Microbiol,2002,40(12):4423-4427
[106]黄永坤,杨美芬,李海林《常见胃肠病患儿胃肠道菌群变化研究进展》实用儿科临床杂志,2007,22(4)：481-484
[107]Ozaki H, McLaughlin LW. The estimation of distances between specific backbone-labeled sites in DNA using fluorescence resonance energy transfer. Nucleic Acids Res,1992;20:5205
[108]Livak KJ, Flood SJ,Marmaro J. Oligonucleotides with fluorescent dyes at opposite ends provide a quenched probe system useful for detecting PCR product and nucleic acid hybridization. PCR Methods Appl,1995;4(6):357-362
[109]Morris T,Robertson B,Gallagher M. Rapid reverse transcription-PCR detection of hepatitis C virus RNA in serum by using the TaqMan fluorogenic detection system. J Clin Microbiol,1996;34(12):2933-2936
[110]Gelmini S, Orlando C, Sestini R, et al. Quantitative polymerase chain reaction-based homogeneous assay with fluorogenic probes to measure c-erbB-2 oncogene amplification.Clin Chem,1997;43(5):752-758
[111]Swan DC, Tucker RA, Holloway BP,et al. A sensitive, type-specific, fluorogenic probe assay for detection of human papillomavirus DNA. J Clin Microbiol, 1997;34(12):886-891
[112]Weinberger KM, Wiedenmann E, Bohm S, et al. Sensitive and accurate quantiataion of hepatitis B virus DNA using a kinetic fluorescence detection system (Taq Man PCR). J Virol Methods,2000;85(1-2):75-82
[113]沈永才,袁佩娜.16S rRNA荧光定量PCR法检测双歧杆菌[J].中国微生态杂 志,2001,13(2)：66-72
[114]Matsuki T,Watanabe K,Fujimoto J,et al Quantitative PCR with 16S Rrna-gene-targeted species-specific primers for analysis of human intestinal bifidobacteria[J].Appl Environ M icrobiol,2004,70(1):167-173
[115]楼金,陈洁.分子生物学技术在肠道正常菌群研究中的应用.国外医学儿科学分册2004；31(1)：1-4
[116]任平,夏天.脾虚腹泻患者肠道菌群的研究[J].中医杂志,1992,33(6)：33
[117]胡静,杨旭东.中药“神曲”对脾虚小鼠肠道菌群的调整及肠保护作用的研究[J].中国微生态学杂志,2004,16(4)：208
[118]陈海龙,吴成中,关凤林.大承气汤对MODS时肠道细菌微生态学影响的实验研究[J].中国微生态学杂志2007：2：132-134
[119]小桥恭一.中药有效成分与肠道细菌的关系[J].医学与哲学,1995,16(11)：598
[120]卢林,刘伦翠,海艳洁等.推拿联合微生态调节剂治疗肠易激综合征的临床研究.2008,11(5)：898-899
[121]胡随瑜,金益强.关于中医临床疗效评价的思考.中医中西医结合杂志,2005；25(1)：72