Glycerin Enemas for VLBW Infants

Shim S-Y, Kim H-S, Kim D-H, et al. Induction of Early Meconium Evacuation Promotes Feeding Tolerance in Very Low Birth Weight Infants. Neonatology 2007;92:67–72. Article ; Article (PDF)

Methods: An observational study involving two subsequent periods was performed in inborn infants with birth weights of ≤1,500 g, before (control) and after (study) the induction of early meconium evacuation by routine glycerin enema. To evaluate feeding tolerance, we measured time to achieve full enteral feeding. Complications such as sepsis and necrotizing enterocolitis were compared.

Results. The study group achieved full enteral feeding significantly faster than the control group (hazard ratio (HR) = 2.9; 95% confidence interval (CI) = 1.8–4.8), and this effect was more definite in infants with a birth weight of ≤1,000 g (HR = 4.6; 95% CI = 1.9–11.1). The study group passed first meconium faster than the control group (median = 1.4 vs. 3.7 days; p<0.001). Sepsis was significantly reduced in the study group (7.7 vs. 27.8%; p = 0.02).

Conclusions. The induction of early meconium evacuation had a significantly positive effect on feeding tolerance and sepsis prevention in VLBWI.

Comments. Meconium obstruction of prematurity is a distinct clinical condition that occurs in very low birth weight infants, predisposing them to feeding intolerance, intestinal perforation and thereafter a prolonged hospitalization. Extreme premature infants have immature intestines characterized by weak peristalsis which results in a delayed passage of meconium. The concept of early evacuation of meconium may prevent intestinal obstruction and help these infants to accomplish full feeding in a shorter period of time. This study showed that early evacuation of meconium in VLBWI was effective in achieving full feeding early in their hospital course and less rate of sepsis which was most likely due to short duration of central lines in comparison to their controls. Finally meconium evacuation depends on volume and frequency of the enema. Small volume enemas do not accelerate meconium evacuation in VLBWI (J Pediatr Gastroenterol Nutr. 2007 Feb;44(2):270-3) and large and more frequent might have deleterious effect thus precaution is suggested. I agree with the authors that a prospective and randomized trial is needed to confirm their results before we change our practice. SAA

Glycerin suppositories are used occasionally in our unit with caution, we are usually concerned about NEC. I want to know the dose of glycerin enema and the frequency and the duration of use.

UserName: Dr FAWZYA AREF
Institution: maternityand children hospital- Jeddah KSA
email: fwzarif@yahoo.com

Looking at the methods of the paper by Shim et al (Neonatology 2007;92:67–72.), they compared their VLBWs before and after introduction of a protocol of only 1 ml/kg glycerin (1:4) and observed a significant difference in reaching full enteral feeds. The second paper mentioned in the discussion here however (Small volume enemas do not accelerate meconium evacuation in VLBWI (J Pediatr Gastroenterol Nutr. 2007 Feb;44(2):270-3) by Haiden et al)) describes a quite similar protocol using however a much higher volume than in the paper by Shim et al (10 ml/kg of glycerin 1:4) in a prospective randomized fashion and achieved only a trend towards earlier meconium evacuation and no changes in feeding tolerance. To me it is therefore questionable whether the observation by Shim et al in their population was really due to introduction of the enema protocol (using only 1 ml/kg) or if other factors played a role.

UserName: Andreas Repa
Institution: Department of Pediatrics and Adolescent Medicine Division of General Pediatrics and Neonatology Medical University of Vienna, Austria
email: andreas.repa@meduniwien.ac.at

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