Glycerin Suppositories and Enemas in Premature Infants: A Meta-analysis

Abstract

BACKGROUND AND OBJECTIVES: Premature infants are often given glycerin suppositories or enemas to facilitate meconium evacuation and the transition to enteral feeds. We reviewed the best-available evidence for the use of glycerin suppositories and enemas in premature infants. METHODS: We searched MEDLINE, Embase, and Cochrane Central for randomized controlled trials (RCTs) of premature infants treated with glycerin suppositories or enemas through January 2022. Studies were screened and data extracted independently and in duplicate. We included RCTs of premature infants <32 weeks gestation and/or birth weight <1500 g who were treated with glycerin suppositories or enemas. Meta-analysis was performed using random effects and reported as relative risk or mean difference. RESULTS: We identified 6 single-center, RCTs of 389 premature infants treated with glycerin suppositories (n = 207) or enemas (n = 182). Mortality rates ranged from 0% to 17%, and the meta-analysis revealed no differences between treatment groups (P = .86). Active treatment was associated with earlier meconium evacuation (mean, 1.5 days; 95% confidence interval, 3.0 to 0.01; P = .05) but not a faster time to enteral feeds (mean, 0.5 days; P = .48). We identified 1 ongoing trial with a target recruitment of 220 premature infants. The quality of evidence was very low to moderate because of inadequate statistical power and other methodologic issues. CONCLUSIONS: The use of glycerin suppositories and enemas in premature infants is associated with earlier meconium evacuation, but the clinical significance of this finding is uncertain. Treatment has no definitive effects on mortality, necrotizing enterocolitis, or enteral feeds.

Interventions for Promoting Meconium Passage in Very Preterm Infants—A Survey of Current Practice at Tertiary Neonatal Centers in Germany

“…Although most NICUs using enemas reported doing so as a therapeutic intervention, the early initiation of enemas (median, on postnatal day 2) suggests that many NICUs did not wait for spontaneous meconium passage in preterm infants, which is known to be significantly delayed compared to term infants [ 1 ]. Saline, glycerin, mixtures thereof, and contrast agents were most commonly used as enema solutions, which is consistent with the literature [ 10 , 12 , 15 ]. In our survey, most NICUs used contrast agents as enema solutions only in refractory cases of perceived meconium obstruction.…”

“…In our survey, most NICUs used contrast agents as enema solutions only in refractory cases of perceived meconium obstruction. While older studies detected a nonsignificant trend toward an increased risk of NEC using glycerin enemas or suppositories [ 16 ], an updated meta-analysis did not confirm this finding [ 12 ]. In line with this, we also found no difference in NEC rates between NICUs using glycerol-containing enemas and suppositories or not.…”

“…A significant proportion of units used enemas and orally administered PEG early after birth as a prophylactic approach, presumably to shorten the time of meconium passage and full enteral feeds. The evidence for routinely promoting meconium passage via enemas or suppositories and orally administered contrast agents is low or, especially for PEG and maltodextrin, nonexistent [ 6 , 12 ]. Despite insufficient data, the use of the interventions mentioned above seems appropriate in anticipation of potential surgical interventions for severe meconium obstruction.…”

“…Although some of these interventions shortened the time to full enteral feeds [ 5 , 10 ], the overall evidence for routinely promoting meconium evacuation to facilitate feeding tolerance and accelerate meconium passage in preterm infants is limited [ 6 , 9 , 11 ]. In addition, conflicting data exist regarding the association of enemas and enteral administration of contrast agents with necrotizing enterocolitis (NEC) [ 5 , 8 , 12 ]. Thus, neonatologists’ approaches are quite variable and may include watchful waiting, early or late interventions (starting interventions routinely during the first postnatal days vs. only if no meconium is passed within a certain time after birth) or a use of interventions only in symptomatic infants, i.e., with feeding intolerance or abdominal distension.…”

Safety of different concentrations of glycerine enema for meconium evacuation in preterm infants: study protocol for a randomised controlled trial

“…Given the lack of data on the incidence of rectal bleeding, we will use the incidence rate of NEC to calculate the sample size. Drawing on data documented in previous research,8 12–14 the incidence of NEC in eligible infants was estimated to be around 7%. The non-inferiority margin is established at 0.07.…”