What are the guidelines for using enemas in pediatric patients?

Enema Use in Pediatric Patients

Age-Specific Recommendations

For infants with normal or frequent bowel movements, a normal saline enema at 10 mL/kg is sufficient when combined with 24 hours of clear liquids for bowel preparation. 1

Critical Safety Considerations by Age

• Sodium phosphate (NaP) enemas should NEVER be used in children younger than 2 years of age due to life-threatening risks of hyperphosphatemia, hypernatremia, hypocalcemia, and severe dehydration 2, 3, 4

• Between ages 2-5 years, NaP enemas should only be used with extreme caution and are generally contraindicated in this age group 2, 3, 4

• The Israeli Society of Pediatric Gastroenterology and Nutrition recommends NaP should not be used in children younger than 12 years 1

Absolute Contraindications for Sodium Phosphate Enemas

NaP enemas must be avoided in children with: 1

• Any type of kidney disease or renal insufficiency
• Bowel dysfunction (including Hirschsprung's disease, anorectal malformations)
• Medications affecting renal function
• Significant comorbidities (liver disease, hypertension, hypoparathyroidism, diabetes, heart disease)

Preferred Enema Types by Clinical Scenario

For Bowel Preparation (Colonoscopy)

Infants: Normal saline enema (10 mL/kg) combined with 24 hours of clear liquids 1

Older children: Can use enemas as part of bowel preparation, but oral PEG-3350 (1.5 g/kg/day for 4 days) is preferred, sometimes combined with an enema 1

For Constipation/Fecal Impaction

Glycerin enemas are appropriate for children aged 2-8 years presenting with vomiting, irritability, and prolonged time since last defecation 5

High-dose oral PEG (1.5 g/kg/day for 6 days) is equally effective as enemas for rectal fecal impaction treatment, with success rates of 68% for PEG versus 80% for enemas (not statistically different) 6

Important Clinical Pitfalls

Mucosal Injury Risk

NaP-containing preparations cause superficial mucosal abnormalities that can mimic early inflammatory bowel disease in 3.3-24.5% of patients, with 10-fold greater mucosal inflammation compared to PEG 1. This is particularly problematic when evaluating for inflammatory bowel disease.

Hydration Maintenance

Adequate hydration during any bowel preparation is critical in children, especially when using enemas or oral preparations 1

When NOT to Use Enemas

• Do not use enemas for lung abscesses coexisting with empyema - this refers to avoiding surgical drainage, not bowel-related enemas 7, 8
• Avoid routine use in children with underlying renal or bowel dysfunction 2, 3

Practical Algorithm for Enema Selection

1. Age < 2 years: Only normal saline enema (10 mL/kg); NEVER sodium phosphate 1, 2, 3

2. Age 2-12 years with constipation: Prefer oral PEG over enemas when possible; if enema needed, use glycerin 5, 6

3. Age > 12 years: Can consider NaP enemas ONLY if no renal/bowel dysfunction or other contraindications 1

4. Bowel preparation for procedures: Normal saline for infants; consider PEG-based regimens for older children 1

Monitoring Requirements

When enemas are administered, monitor for: 2, 3

• Electrolyte disturbances (calcium, phosphate, potassium)
• Signs of dehydration
• Neurological symptoms (tetany, apathy)
• Behavioral changes indicating discomfort