What is the proper procedure for administering an enema to a 2-year-old child?

Enema Administration in a 2-Year-Old Child

Use only normal saline enema at 10 mL/kg in a 2-year-old child; sodium phosphate enemas are absolutely contraindicated at this age due to life-threatening risks of severe hyperphosphatemia, hypocalcemia, hypernatremia, and death. 1, 2

Critical Safety Warning

Never use sodium phosphate (Fleet) enemas in children under 2 years of age. 1, 3, 4

• Sodium phosphate enemas cause severe electrolyte disturbances including hyperphosphatemia, hypocalcemia, hypernatremia, and acute kidney injury in young children 2, 3, 5
• Multiple case reports document life-threatening toxicity and death in infants and toddlers, even those without underlying renal or bowel dysfunction 3, 5, 6, 4
• The risk is particularly high in children with developmental delay, bowel dysfunction, or renal abnormalities, but serious complications occur even in previously healthy children 3, 6, 4

Recommended Enema Type and Dosage

Administer normal saline enema at 10 mL/kg body weight. 1

• This is the only safe enema formulation for a 2-year-old child 1
• Calculate the exact volume based on the child's weight (e.g., for a 12 kg child, use 120 mL of normal saline) 1
• Combine with 24 hours of clear liquids if being used for bowel preparation 1

Preparation and Equipment

Gather all necessary equipment before beginning the procedure:

• Normal saline solution (0.9% sodium chloride) warmed to body temperature 1
• Appropriate-sized soft catheter or enema tip (small pediatric size)
• Water-soluble lubricant
• Waterproof pad or towels
• Gloves
• Container for expelled fluid

Step-by-Step Administration Procedure

Position the child:

• Place the child in left lateral (side-lying) position with knees flexed toward chest 7
• Alternative position: supine with hips and knees flexed
• Ensure the child is on a waterproof pad

Prepare the equipment:

• Warm normal saline to body temperature (cold fluid causes cramping)
• Lubricate the catheter tip generously with water-soluble lubricant
• Have the calculated volume (10 mL/kg) ready in appropriate syringe or enema bag 1

Insert the catheter:

• Gently insert the lubricated catheter tip 2-3 cm (approximately 1 inch) into the rectum
• Never force insertion; if resistance is met, stop and reassess
• Angle the catheter slightly toward the umbilicus

Administer the solution:

• Instill the normal saline slowly and gently over 5-10 minutes 1
• If the child experiences cramping or discomfort, pause administration temporarily
• Monitor for behavioral changes indicating significant discomfort 1

Retention and expulsion:

• Encourage retention of the enema for 5-15 minutes if possible
• Young children may not be able to retain the fluid for long periods
• Allow the child to expel the enema naturally into a diaper or toilet

Critical Monitoring During and After Administration

Monitor hydration status closely: 8

• Assess capillary refill time, skin turgor, mucous membranes, and mental status every 1-2 hours 8
• Measure baseline body weight before administration 8
• Watch for signs of dehydration: weight loss >3-5% indicates mild dehydration, 6-9% moderate, ≥10% severe 8

Watch for complications:

• Behavioral changes, lethargy, or altered mental status 1, 8
• Persistent vomiting or inability to tolerate oral fluids 8
• Signs of severe dehydration or shock 8

When to Escalate Care Immediately

Initiate emergency intervention if any of the following occur: 8

• Severe dehydration (≥10% fluid deficit) with shock or near-shock 8
• Altered mental status or lethargy 8
• Persistent vomiting or inability to tolerate oral fluids 8
• Any signs of tetany or seizures (suggesting severe electrolyte disturbance) 4

Common Pitfalls to Avoid

Do not use any phosphate-containing enema products - this cannot be overemphasized, as the consequences are potentially fatal 1, 2, 3, 5

Do not insert the catheter too deeply - insertion beyond 2-3 cm risks rectal perforation in young children 7

Do not administer the solution too rapidly - rapid administration causes severe cramping and may result in immediate expulsion before therapeutic effect 1

Do not ignore signs of dehydration - young children dehydrate rapidly, and progression to severe dehydration constitutes a medical emergency 8

Alternative Approaches to Consider

If enema administration is being considered for constipation management, oral PEG-3350 (polyethylene glycol) is generally preferred as first-line therapy in children over 6 months of age, with response rates exceeding 90% 2, 8

For bowel preparation purposes, PEG-3350 at 1.5 g/kg/day for 4 days is the preferred method, sometimes combined with a normal saline enema if necessary 2, 8