Randomized controlled trial of prophylactic rectal stimulation and enemas on stooling patterns in extremely low birth weight infants

Abstract

OBJECTIVE:We hypothesized that rectal stimulation and small volume enemas would accelerate normalization of stooling patterns in extremely low birth weight infants. STUDY DESIGN: In a randomized controlled trial, infants with a gestational age p28 weeks received one of the following: twice daily rectal stimulation and/or enemas until two stools were passed daily, without enemas or stimulation, for three consecutive days. Intervention only occurred when symptoms, abdominal distension and no defecation, occurred in the previous 24 h. Enema administration occurred if abdominal distension persisted without defecation occurring after rectal stimulation. Multivariable linear regression was used to determine the contribution of a patent ductus arteriosus (PDA) on normalization of stooling patterns and feeding tolerance. RESULT: Rectal stimulation and/or small volume enemas did not accelerate the median (quartile range) time normalization of stooling patterns, 13 (11-20) days in control group and 16 (12-25.5) days in intervention group. A higher frequency of PDA occurred in the intervention than the non-intervention group. Infants with a persistent PDA had a longer duration of parenteral nutrition, worse feeding tolerance and more days to achieve normal stooling patterns. In multivariable regression analysis, a PDA, not repeated rectal stimulation and/or enemas, was significantly related to stooling and feeding tolerance. CONCLUSION: Twice daily administration of rectal stimulation and/or enemas did not normalize stooling patterns (fecal frequency). A PDA is an important determinant of acquisition of normal stooling patterns and feeding tolerance of very immature newborns.

Meconium Evacuation for Facilitating Feed Tolerance in Preterm Neonates: A Systematic Review and Meta-Analysis

“…Overall, 12% of neonates in the intervention group and 7% in the control group developed NEC. None of the individual studies showed any statistically significant increase in the risk of NEC in the intervention versus control arm, even though Haiden et al [29] and Saenz de Pipaón Marcos et al [28] noted an increased trend towards NEC in the intervention group. The former showed a statistically non-significant increase in NEC (21 vs. 8%) in the Gastrografin group, the latter showed a similar statistically non-significant increase in NEC (23 vs. 3%) in the intervention group.…”

“…Haiden et al [29] noted a trend towards reduced TFF in the oral Gastrografin group [median (range) 26 (9-109) vs. 19 (10-115) days, p = 0.15]. Saenz de Pipaón Marcos et al [28] found significantly increased TFF in the intervention versus control group [26 (21) vs. 15 (8) days, p = 0.005], but the regression analysis showed that patent ductus arteriosus rather than enema and rectal stimulation was significantly associated with an increased TFF. Results from the other studies [Haiden et al [25]: 26 (8-83) vs. 27 (5-75) days, p = 0.91; Mena et al [26]: 19.3 (8.2) vs. 20 (10.3) days; Khadr et al [24]: 7.4 (4.6-30.9) vs. 9 (4.4-13.3) days, p = 0.78, and Shinde et al [27]: 11.9 (3.1) vs. 11.3 (3.6) days] did not show any difference in TFF in the intervention versus control groups [24,25,26,27].…”

“…2). Four of the 6 studies had TFF as the primary outcome [24,26,27,29], and those by Haiden et al [25] and Saenz de Pipaón Marcos et al [28] had TFF as the secondary outcome. We used the method of Hozo et al [30] to derive the mean and standard deviation from the median and range reported in the original article.…”

“…The observational study by Shim et al [5] (n = 83) was excluded from the final analysis. Thus, a total of 6 studies (n = 442) assessing different interventions (glycerine suppository/enema, saline enema, oral osmotic contrast agent) for meconium evacuation were eligible for inclusion in the analysis [24,25,26,27,28,29]. The characteristics of these studies are shown in table 1.…”

“…Saenz de Pipaón Marcos et al [28] considered neonates born at ≤28 weeks of gestation that were randomised to either the intervention or control group. Intervention consisted of the following: twice daily enema (10 ml/kg saline) until the complete evacuation of meconium and rectal stimulation thereafter until two stools were passed daily without intervention for 3 days.…”