RESEARCH
MILK
AND
MOLASSES ENEMAS: CLEARING THINGS UP
Authors: Kimberley Wallaker, BSN, RN, CEN, Ezio Fortuna, RN, EMT-P, CEN, Stuart Bradin, DO, Michelle Macy, MD, MS, Michelle Hassan, BSN, RN, CEN, CPEN, and Rachel Stanley, MD, MHSA, Ann Arbor, MI Introduction: We aimed to describe current nursing practice and clarify the safest and most effective dose of milk and molasses enemas used to relieve constipation in pediatric patients presenting to a suburban pediatric emergency department. Methods: We surveyed emergency nurses about current practice in administration of milk and molasses enemas. In addition, we identified consecutive patients aged 2 to 17 years with a discharge diagnosis of constipation or abdominal pain between 2009 and 2012. Stable patients were included from the emergency department, in the absence of chronic medical conditions. For each patient, we recorded demographic characteristics, chief complaint, nursing administration technique, stool output, patient tolerance, side effects, amount of enema given, and patient disposition.
onstipation is commonly treated in the pediatric emergency department with milk and molasses enemas. Milk and molasses enemas are hyperosmotic, causing water to be drawn into the intestines, promoting stool evacuation. 1 In addition, there is therapeutic effect
C
Kimberley Wallaker is Registered Nurse, Children's Emergency Services, University of Michigan Health System, Ann Arbor, MI. Ezio Fortuna is Registered Nurse, Children's Emergency Services, University of Michigan Health System, Ann Arbor, MI. Stuart Bradin is Attending Physician, Children's Emergency Services, University of Michigan Health System, Ann Arbor, MI. Michelle Macy is Attending Physician, University of Michigan Health System, Ann Arbor, MI. Michelle Hassan is Registered Nurse, University of Michigan Health System, Ann Arbor, MI. Rachel Stanley is Attending Physician, Children's Emergency Services, University of Michigan Health System, Ann Arbor, MI. For correspondence, write: Kimberley Wallaker, BSN, RN, CEN, University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.08.012
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Results: We identified 500 patients with abdominal pain or
constipation, 87 of whom were later excluded. Milk and molasses enemas were found to be effective at relieving constipation in our population, with a success rate averaging 88% in patients given 5 to 6 mL/kg with an institutional guideline maximum of 135 mL. The success rate was found to vary with age, along with the amount of enema given. Discussion: Our nursing survey showed that varying practice exists regarding technique and dosing of milk and molasses enemas. Historical chart review showed that milk and molasses enemas in our emergency department were safe and effective with minimal side effects. Key words: Constipation; Encopresis; Enema; Milk; Molasses;
Pediatric
found in the reaction of sugar combining with milk, creating gases and promoting peristalsis, leading to properties of irritation to the intestinal lining, as well as softening of stool. 1 At times, milk and molasses enemas have been shown to have harmful effects similar to those seen with other enemas, such as rectal perforation and allergic reactions. Unlike other enemas, milk and molasses enemas have also been associated with cardiopulmonary compromise. 1 However, the association between milk and molasses enemas and cardiopulmonary compromise was only identified in a single-site case series, in which all patients had serious underlying medical conditions. 1 There are still many hospitals, including ours, that use milk and molasses enemas for children with constipation, therefore showing the need for further research to evaluate the safety of this treatment and develop a standardized dosing protocol in stable patients without severe underlying conditions. Milk and molasses enemas should be avoided in patients with allergies to either milk or molasses, and care should be taken in administration to patients with serious underlying medical conditions because serious side effects have been reported. 1 It is recommended that these enemas only be administered in the ED setting to allow for close monitoring. 2 Few standards exist for preparation and administration of milk and molasses enemas, and current guidelines suggest varying amounts of milk and molasses for administration. 2–4
WWW.JENONLINE.ORG
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RESEARCH/Wallaker et al
Our study was initiated with 2 aims in mind. The first aim was to describe milk and molasses enema administration techniques among pediatric emergency nurses. The second aim was to identify a safe and effective dose for milk and molasses enemas that would also produce the greatest effect with the fewest adverse events and side effects.
administration device used; amount typically administered; and perception of the patient’s tolerance, using a pain scale from 0 to 10 based on the nurse’s perception of patient behavior after the enema. Survey data were reviewed by research staff only. CHART REVIEW
Methods DESIGN
Our study consisted of 2 parts. Part 1 was an anonymous online survey completed by nurses after each enema administered to pediatric patients. Part 2 consisted of a retrospective chart review on a cohort of children who received enemas for the treatment of constipation in a tertiary-care pediatric emergency department. Data were extracted from the existing medical record, and there was no further contact with or interventions performed on study participants. Approval was received from the University of Michigan Institutional Review Board for exempt status. SETTING
The University of Michigan Children’s Emergency Department is a suburban, tertiary-care referral center with more than 20,000 pediatric ED visits in 2012. SURVEY SAMPLE
Approximately 20 pediatric nurses, with varying levels of expertise, were invited to participate in the recurrent survey regarding enema administration. Inclusion criteria were current employment status as a registered nurse in Children’s Emergency Services and administration of a milk and molasses enema between September 2010 and May 2012. A link was sent to registered nurses who were currently employed in Children’s Emergency Services through their work E-mail addresses that directed them to complete a brief 10-question anonymous online survey— after administration of each enema—during the 21-month period from September 2010 to May 2012. SURVEY ADMINISTRATION
Survey data were collected by use of an anonymous online survey distributed by a hyperlink included in a group Email to all pediatric emergency nursing staff on a quarterly basis. Once the nurse accessed the hyperlink, questions were asked regarding the nurse’s professional background and experience with administering enemas. No personal identifiers were collected in this survey. Surveys were completed by staff members each time they administered an enema to different patients aged between 2 and 17 years. Information was obtained about the enema
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JOURNAL OF EMERGENCY NURSING
A retrospective chart review was performed for patients aged 2 to 17 years who visited the University of Michigan Children’s Emergency Services from January 2009 to April 2012 and who were documented to have a discharge diagnosis of constipation or abdominal pain to determine whether a milk and molasses enema was administered. Patients were excluded if they had a chronic medical condition such as seizure disorder, chronic lung disease with respiratory compromise, congenital heart disease, immune compromise, or previous rectal surgery. Children who were critically ill on arrival to the emergency department or hemodynamically unstable were excluded as well. Data collected from eligible patient records included patient demographic characteristics and the following key variables: patient age, sex, chief complaint, weight, total volume of enema administered, stool output (none, small, moderate, or large), side effects, adverse events, and patient disposition. Patient age was categorized into 3 groups: 2 to 9 years, 10 to 15 years, and 16 to 17 years. The enema amount (in milliliters per kilogram) was calculated and categorized into the following groups: 1 to 4 mL/kg, 5 to 6 mL/kg, and 7 mL/kg or greater. The main outcome of interest was enema success rate based on nurse documentation of at least moderate stool and minimal side effects (including abdominal pain, vomiting, and need for admission). STATISTICAL METHODS
Descriptive statistics were calculated for nursing surveys completed and chart review data. A 2-proportion Z test was used for differences between categorical enema amount and enema success rates. All analyses were conducted with Microsoft Excel 2010 (Microsoft, Redmond, WA), and P b .10 was considered statistically significant. We separated the groups analyzed into the following groups, taking into consideration the sample size for each group: 1 to 4 mL/kg, 5 to 6 mL/kg, and 7 mL/kg or greater. The survey results were downloaded and descriptive statistics calculated. INTERVENTION
A standard guideline, available from within our institution, was used as a reference for enema administration within our study. 3 Enemas used during the study consisted of a 1:1 solution of whole milk and molasses administered either through an enema bag, enema bottle, or flexible tubing with
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TABLE 1
Clinical data of nursing experience and methods for administering milk and molasses enemas Nursing survey item
n (%)
Nursing experience b1 y 3 (3.2) 1-5 y 43 (46.2) 6-10 y 18 (19.4) 11-15 y 12 (12.9) ≥ 16 y 17 (18.3) Method of enema instillation Flexible catheter and catheter-tip syringe 35 (38.9) Enema bag 30 (33.3) Enema bottle 25 (27.8) Patient tolerance according to nurse using pain scale a 0-3 52 (55.9) 4-7 37 (39.8) 8-10 4 (4.3) a Patient tolerance is the nurse’s impression of the patients’ pain and response to the enema using a numeric pain scale from 0 to 10.
a catheter-tip syringe—with the tip of the enema delivery device advanced no further than the suggested 4 inches, depending on patient age, to avoid perforation. 5 Wong’s Nursing Care of Infants and Children recommends an enema insertion length of 2.5 cm for patients weighing 5 to 10 kg, 5 cm for those weighing 11 to 30 kg, 7 cm for those weighing 31 to 50 kg, and 10 cm for those weighing greater than 50 kg. 5 Milk and molasses enemas were avoided in children aged younger than 2 years. 1 Enemas were ordered at the discretion of the treating physician. The typical enema volume administered was 6 mL/kg with the institutional guideline in place at the time of the study, advising no more than 135 mL in a single osmotic enema administration. 2,3
Results NURSING SURVEY
Twenty nurses submitted 94 responses to our online survey after administering a milk and molasses enema, which represents nearly half of the 200 enemas performed from September 2010 to May 2012. Survey results showed variable techniques of enema administration based on the use of our institutional guideline and written physician orders received (Table 1). Of those surveyed, 38.9% administered enemas using a flexible
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catheter and catheter-tip syringe, 33.3% used an enema bag, and 27.8% used an enema bottle, showing varying practices among staff, who also had varying levels of experience (Table 1). CHART REVIEW
Of 500 visits during which an enema was administered or constipation was the discharge diagnosis, 87 were excluded. Eighteen visits were excluded because no stool results were charted, and 17 visits were excluded because no volume was charted for the enema administered, although an enema was in fact given. No weight was charted for 27 patients, and 11 visits were excluded because patients received an enema other than a milk and molasses enema. Fourteen visits were removed because patients were aged younger than 2 years. Table 2 provides a summary of the patient demographic characteristics, weight, and chief complaint for those patients who received a milk and molasses enema and were included in the study. Milk and molasses enemas were generally effective across the different age groups. Stool output was achieved in greater than 80% of enema administrations when given in amounts of at least 4 mL/kg (Figure 1). The recommended guideline within our facility of 6 mL/kg had an effectiveness of 88% in the 106 patients who received this amount. Patients aged younger than 10 years received a higher volume per kilogram of milk and molasses enema than older patients (4.5 mL/kg vs 3 mL/kg). Patients aged between 10 and 15 years of age received an average of at least 3 mL/kg with an 80% success rate, and patients aged older than 15 years received on average less than 3 mL/kg with an 83% success rate (Figures 1 and 2). The results showed that an enema amount of 5 to 6 mL/ kg produced greater stool output compared with no dose and/or smaller doses (1-4 mL/kg) (P = .056). Dosing of 5 to 6 mL/kg resulted in greater stool output compared with smaller doses (P = .037). The results could not show whether a 5- to 6-mL/kg enema dose was more effective or less effective than larger doses of 7 mL/kg or greater (P = .619). Of the 500 patients who received enemas, 26 were admitted. Two patients were admitted for reasons not directly related to their diagnosis of constipation or abdominal pain, such as port replacement or admitting diagnosis of pneumonia. As for the remaining admissions, it cannot be determined with the data available whether admission was related to enema administration. Twentyfour patients were admitted for varying diagnoses related to gastrointestinal complaints, including upper gastrointestinal bleed (1 patient), urinary obstruction (1 patient), constipation (3 patients), requirement for further
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TABLE 2
Demographic characteristics and presenting chief complaint of patients given milk and molasses enemas. Sex Male Female Chief complaint Abdominal pain Chest/back pain Constipation/change in stool Vomiting Dysuria Other Age b 10 y 10-15 y N 15 y Weight b 22 kg 22-50 kg N 50 kg Not documented
n (%)
268 (53.6) 232 (46.4) 349 (69.8) 11 (2.2) 72 (14.4) 38 (7.6) 5 (1) 25 (5.0) 282 (56.4) 141 (28.2) 77 (15.4) 187 (37.4) 185 (37) 101 (20.2) 27 (5.4)
FIGURE 1 Percent success rate of milk and molasses enema by dose.
7.00
Milliliters Per Kilogram
Patient characteristic
6.00 5.00 4.00 3.00 2.00 1.00 0.00
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years Male
Female
medications (2 patients), serial abdominal examinations (10 patients), vomiting (2 patients), dehydration (2 patients), appendicitis (1 patient), bowel obstruction (1 patient), and syncope (1 patient), that cannot be directly correlated to the enema administration.
Discussion
Our study provided evidence of a wide spectrum of nursing practices in relation to enema administration; however, even with variable administration techniques, our chart review showed milk and molasses enemas to be safe and effective with minimal adverse effects. Several adverse effects were examined for in charting, on the basis of previous adverse effects seen in studies involving milk and molasses enemas, including allergic reactions, perforation, severe bleeding, and shock. None of these reactions were noted while our study was being conducted. Small amounts of blood were noted in 9 patients’ stool samples. Bleeding was not significant enough to require
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JOURNAL OF EMERGENCY NURSING
FIGURE 2 Average dose of milk and molasses administered (in milliliters per kilogram) by patient age.
observation for any patients within the study. It cannot be determined whether bleeding may be due to the passage of hard stool or hemorrhoids, as a result of constipation or enema administration—exhibiting the importance of rectal examination before enema administration. 6 Similar to prior studies, our study showed that vomiting and abdominal pain were 2 side effects commonly seen after administration of milk and molasses enemas. Of note, when we examined presenting chief complaints, 69.8% of patients presented with abdominal pain and 7.6% with vomiting before enema administration (Table 2). The percentage of patients with abdominal pain or vomiting decreased significantly after enema administration (Figure 3). Therefore it cannot be determined whether these symptoms were direct results
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Wallaker et al/RESEARCH
of the enema administration or symptoms experienced with a diagnosis of constipation. Enema amounts and results were shown to vary with different patient age groups. On average, patients aged younger than 10 years received 4.5 mL/kg, patients aged 10 to 15 years received 3 mL/kg, and patients aged older than 15 years received less than 3 mL/kg. For larger dosing amounts (N 7 mL/kg), the sample size was small in comparison to the other groups (only 30 patients received N 7 mL/kg). Developmental level has an impact on patient tolerance of enema administration as well, which may impact enema effectiveness. Recommendations suggest retention of the enema for approximately 2 minutes before defecation, which may be difficult in patients in early stages of toilet training; however, longer retention leads to increased stimulation. 5 No association was noted between sex and enema results. As evidenced by our nursing survey, there is varying clinical practice among nurses in relation to administration of milk and molasses enemas (Table 1). Other than the nursing survey results, information was not collected on each patient related to device used with enema administration or height of the enema catheter-tip insertion. Several barriers exist that may impact nurses’ ability to adhere to clinical practice guidelines. 7 Communication, awareness of current practice guidelines, feelings toward current practice, training, and staff workload can all have a great impact on nursing technique, which may affect the success rate within our study. 7 Technology can also play a major role in compliance. When our study was being conducted, written orders were still being used. Currently, computer orders are in place, which may allow for increased clarity in enema orders such as dosing and allow for a maximum dose recommendation to increase compliance.
Limitations
Varying methods of enema administration including technique, enema amount, patient retention of enema fluid, and experience of staff administering the enema are all limitations. Variability may be caused by several factors, including few models of evidence-based research available explaining the standard protocol for administration of milk and molasses enemas, stressing the need for a standard protocol to be developed to aid in compliance. More information is needed to examine whether enema amount or teaching of administration technique improves patient outcome and reduces side effects with enema administration. At the beginning of our study, guidelines indicated a maximum enema dose of 6 mL/kg, with a total dose no
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10.0
5.0
5.0 4.0
0.25
Age 2-5
0.7
0.0 0.2
0.1
Age 6-10
Abdominal Pain
Vomiting
Age 11-18 Admitted
FIGURE 3 Percentage of patients with side effects after enema.
greater than 135 mL. 2,3 A maximum dose of 135 mL was a great limitation to our study because any patient weighing greater than 22 kg is expected to receive less than the recommended 6 mL/kg according to hyperosmotic enema guidelines within our facility when our study was conducted.
Implications for Emergency Nurses
Although our research shows a success rate of at least 80% in patients receiving variable enema doses, further data are needed to examine other variables including administration technique, patient enema retention, and incremental dosing of enemas with alternate maximum dosages involving practices seen at other institutions. At the time of our study, our institutional guideline suggested a milk and molasses enema of no more than 135 mL for safe administration. Further studies are needed to determine whether patients receiving greater than 135 mL as a maximum dose have similar success rates and no harmful side effects.
Conclusions
In this single-center study, milk and molasses enemas were safe and effective for treating constipation in patients ranging in age from 2 to 17 years without chronic medical conditions. Even though various methods were used to administer these enemas, the outcomes have shown enemas to be effective, exhibiting minimal side effects with an optimal success rate in patients receiving 6 mL/kg of enema with an institutionally suggested maximum of 135 mL in place when this study was conducted.
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Acknowledgments
REFERENCES
4. Hansen S, Whitehill J, Goto C, Quintero C, Darling B, Davis J. Safety and efficacy of milk and molasses enemas compared with sodium phosphate enemas for the treatment of constipation in a pediatric emergency department. Pediatr Emerg Care. 2011;27: 1118-20.
1. Walker M, Warner B, Brilli R, Jacobs B. Cardiopulmonary compromise associated with milk and molasses enema use in children. J Pediatr Gastroenterol Nutr. 2003;36:144-8.
5. Brown TL. Pediatric variations of nursing interventions. In: Hockenberry MJ, Wilson D, eds. Wong’s Nursing Care of Infants and Children. 9th ed. St Louis, MO: Mosby; 2011:998-1051.
2. Baker S, Liptak G, Colletti R. Constipation in infants and children: evaluation and treatment. J Pediatr Gastroenterol Nutr. 1999;29:612-26.
6. Pirie J. Management of constipation in the emergency department. Clin Pediatr Emerg Med. 2010;11:182-8.
3. Felt B, Brown P, Coran A, Kochhar P, Opipari-Arrigan L, Marcus S, et al. Functional constipation and soiling in children. http://cme.med. umich.edu/pdf/guideline/peds03.pdf. Accessed April 20, 2010.
7. Abrahamson K, Fox R, Doebbeling B. Facilitators and barriers to clinical practice guideline use among nurses. Am J Nurs. 2012;112: 26-35.
We thank Liz Lind for assistance with statistical analysis and Rachel Sledge for volunteering to participate in our initial data collection.
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MILK
AND
MOLASSES ENEMAS: CLEARING THINGS UP
Authors: Kimberley Wallaker, BSN, RN, CEN, Ezio Fortuna, RN, EMT-P, CEN, Stuart Bradin, DO, Michelle Macy, MD, MS, Michelle Hassan, BSN, RN, CEN, CPEN, and Rachel Stanley, MD, MHSA, Ann Arbor, MI Introduction: We aimed to describe current nursing practice and clarify the safest and most effective dose of milk and molasses enemas used to relieve constipation in pediatric patients presenting to a suburban pediatric emergency department. Methods: We surveyed emergency nurses about current practice in administration of milk and molasses enemas. In addition, we identified consecutive patients aged 2 to 17 years with a discharge diagnosis of constipation or abdominal pain between 2009 and 2012. Stable patients were included from the emergency department, in the absence of chronic medical conditions. For each patient, we recorded demographic characteristics, chief complaint, nursing administration technique, stool output, patient tolerance, side effects, amount of enema given, and patient disposition.
onstipation is commonly treated in the pediatric emergency department with milk and molasses enemas. Milk and molasses enemas are hyperosmotic, causing water to be drawn into the intestines, promoting stool evacuation. 1 In addition, there is therapeutic effect
C
Kimberley Wallaker is Registered Nurse, Children's Emergency Services, University of Michigan Health System, Ann Arbor, MI. Ezio Fortuna is Registered Nurse, Children's Emergency Services, University of Michigan Health System, Ann Arbor, MI. Stuart Bradin is Attending Physician, Children's Emergency Services, University of Michigan Health System, Ann Arbor, MI. Michelle Macy is Attending Physician, University of Michigan Health System, Ann Arbor, MI. Michelle Hassan is Registered Nurse, University of Michigan Health System, Ann Arbor, MI. Rachel Stanley is Attending Physician, Children's Emergency Services, University of Michigan Health System, Ann Arbor, MI. For correspondence, write: Kimberley Wallaker, BSN, RN, CEN, University of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.08.012
■
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Results: We identified 500 patients with abdominal pain or
constipation, 87 of whom were later excluded. Milk and molasses enemas were found to be effective at relieving constipation in our population, with a success rate averaging 88% in patients given 5 to 6 mL/kg with an institutional guideline maximum of 135 mL. The success rate was found to vary with age, along with the amount of enema given. Discussion: Our nursing survey showed that varying practice exists regarding technique and dosing of milk and molasses enemas. Historical chart review showed that milk and molasses enemas in our emergency department were safe and effective with minimal side effects. Key words: Constipation; Encopresis; Enema; Milk; Molasses;
Pediatric
found in the reaction of sugar combining with milk, creating gases and promoting peristalsis, leading to properties of irritation to the intestinal lining, as well as softening of stool. 1 At times, milk and molasses enemas have been shown to have harmful effects similar to those seen with other enemas, such as rectal perforation and allergic reactions. Unlike other enemas, milk and molasses enemas have also been associated with cardiopulmonary compromise. 1 However, the association between milk and molasses enemas and cardiopulmonary compromise was only identified in a single-site case series, in which all patients had serious underlying medical conditions. 1 There are still many hospitals, including ours, that use milk and molasses enemas for children with constipation, therefore showing the need for further research to evaluate the safety of this treatment and develop a standardized dosing protocol in stable patients without severe underlying conditions. Milk and molasses enemas should be avoided in patients with allergies to either milk or molasses, and care should be taken in administration to patients with serious underlying medical conditions because serious side effects have been reported. 1 It is recommended that these enemas only be administered in the ED setting to allow for close monitoring. 2 Few standards exist for preparation and administration of milk and molasses enemas, and current guidelines suggest varying amounts of milk and molasses for administration. 2–4
WWW.JENONLINE.ORG
1
RESEARCH/Wallaker et al
Our study was initiated with 2 aims in mind. The first aim was to describe milk and molasses enema administration techniques among pediatric emergency nurses. The second aim was to identify a safe and effective dose for milk and molasses enemas that would also produce the greatest effect with the fewest adverse events and side effects.
administration device used; amount typically administered; and perception of the patient’s tolerance, using a pain scale from 0 to 10 based on the nurse’s perception of patient behavior after the enema. Survey data were reviewed by research staff only. CHART REVIEW
Methods DESIGN
Our study consisted of 2 parts. Part 1 was an anonymous online survey completed by nurses after each enema administered to pediatric patients. Part 2 consisted of a retrospective chart review on a cohort of children who received enemas for the treatment of constipation in a tertiary-care pediatric emergency department. Data were extracted from the existing medical record, and there was no further contact with or interventions performed on study participants. Approval was received from the University of Michigan Institutional Review Board for exempt status. SETTING
The University of Michigan Children’s Emergency Department is a suburban, tertiary-care referral center with more than 20,000 pediatric ED visits in 2012. SURVEY SAMPLE
Approximately 20 pediatric nurses, with varying levels of expertise, were invited to participate in the recurrent survey regarding enema administration. Inclusion criteria were current employment status as a registered nurse in Children’s Emergency Services and administration of a milk and molasses enema between September 2010 and May 2012. A link was sent to registered nurses who were currently employed in Children’s Emergency Services through their work E-mail addresses that directed them to complete a brief 10-question anonymous online survey— after administration of each enema—during the 21-month period from September 2010 to May 2012. SURVEY ADMINISTRATION
Survey data were collected by use of an anonymous online survey distributed by a hyperlink included in a group Email to all pediatric emergency nursing staff on a quarterly basis. Once the nurse accessed the hyperlink, questions were asked regarding the nurse’s professional background and experience with administering enemas. No personal identifiers were collected in this survey. Surveys were completed by staff members each time they administered an enema to different patients aged between 2 and 17 years. Information was obtained about the enema
2
JOURNAL OF EMERGENCY NURSING
A retrospective chart review was performed for patients aged 2 to 17 years who visited the University of Michigan Children’s Emergency Services from January 2009 to April 2012 and who were documented to have a discharge diagnosis of constipation or abdominal pain to determine whether a milk and molasses enema was administered. Patients were excluded if they had a chronic medical condition such as seizure disorder, chronic lung disease with respiratory compromise, congenital heart disease, immune compromise, or previous rectal surgery. Children who were critically ill on arrival to the emergency department or hemodynamically unstable were excluded as well. Data collected from eligible patient records included patient demographic characteristics and the following key variables: patient age, sex, chief complaint, weight, total volume of enema administered, stool output (none, small, moderate, or large), side effects, adverse events, and patient disposition. Patient age was categorized into 3 groups: 2 to 9 years, 10 to 15 years, and 16 to 17 years. The enema amount (in milliliters per kilogram) was calculated and categorized into the following groups: 1 to 4 mL/kg, 5 to 6 mL/kg, and 7 mL/kg or greater. The main outcome of interest was enema success rate based on nurse documentation of at least moderate stool and minimal side effects (including abdominal pain, vomiting, and need for admission). STATISTICAL METHODS
Descriptive statistics were calculated for nursing surveys completed and chart review data. A 2-proportion Z test was used for differences between categorical enema amount and enema success rates. All analyses were conducted with Microsoft Excel 2010 (Microsoft, Redmond, WA), and P b .10 was considered statistically significant. We separated the groups analyzed into the following groups, taking into consideration the sample size for each group: 1 to 4 mL/kg, 5 to 6 mL/kg, and 7 mL/kg or greater. The survey results were downloaded and descriptive statistics calculated. INTERVENTION
A standard guideline, available from within our institution, was used as a reference for enema administration within our study. 3 Enemas used during the study consisted of a 1:1 solution of whole milk and molasses administered either through an enema bag, enema bottle, or flexible tubing with
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TABLE 1
Clinical data of nursing experience and methods for administering milk and molasses enemas Nursing survey item
n (%)
Nursing experience b1 y 3 (3.2) 1-5 y 43 (46.2) 6-10 y 18 (19.4) 11-15 y 12 (12.9) ≥ 16 y 17 (18.3) Method of enema instillation Flexible catheter and catheter-tip syringe 35 (38.9) Enema bag 30 (33.3) Enema bottle 25 (27.8) Patient tolerance according to nurse using pain scale a 0-3 52 (55.9) 4-7 37 (39.8) 8-10 4 (4.3) a Patient tolerance is the nurse’s impression of the patients’ pain and response to the enema using a numeric pain scale from 0 to 10.
a catheter-tip syringe—with the tip of the enema delivery device advanced no further than the suggested 4 inches, depending on patient age, to avoid perforation. 5 Wong’s Nursing Care of Infants and Children recommends an enema insertion length of 2.5 cm for patients weighing 5 to 10 kg, 5 cm for those weighing 11 to 30 kg, 7 cm for those weighing 31 to 50 kg, and 10 cm for those weighing greater than 50 kg. 5 Milk and molasses enemas were avoided in children aged younger than 2 years. 1 Enemas were ordered at the discretion of the treating physician. The typical enema volume administered was 6 mL/kg with the institutional guideline in place at the time of the study, advising no more than 135 mL in a single osmotic enema administration. 2,3
Results NURSING SURVEY
Twenty nurses submitted 94 responses to our online survey after administering a milk and molasses enema, which represents nearly half of the 200 enemas performed from September 2010 to May 2012. Survey results showed variable techniques of enema administration based on the use of our institutional guideline and written physician orders received (Table 1). Of those surveyed, 38.9% administered enemas using a flexible
■
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catheter and catheter-tip syringe, 33.3% used an enema bag, and 27.8% used an enema bottle, showing varying practices among staff, who also had varying levels of experience (Table 1). CHART REVIEW
Of 500 visits during which an enema was administered or constipation was the discharge diagnosis, 87 were excluded. Eighteen visits were excluded because no stool results were charted, and 17 visits were excluded because no volume was charted for the enema administered, although an enema was in fact given. No weight was charted for 27 patients, and 11 visits were excluded because patients received an enema other than a milk and molasses enema. Fourteen visits were removed because patients were aged younger than 2 years. Table 2 provides a summary of the patient demographic characteristics, weight, and chief complaint for those patients who received a milk and molasses enema and were included in the study. Milk and molasses enemas were generally effective across the different age groups. Stool output was achieved in greater than 80% of enema administrations when given in amounts of at least 4 mL/kg (Figure 1). The recommended guideline within our facility of 6 mL/kg had an effectiveness of 88% in the 106 patients who received this amount. Patients aged younger than 10 years received a higher volume per kilogram of milk and molasses enema than older patients (4.5 mL/kg vs 3 mL/kg). Patients aged between 10 and 15 years of age received an average of at least 3 mL/kg with an 80% success rate, and patients aged older than 15 years received on average less than 3 mL/kg with an 83% success rate (Figures 1 and 2). The results showed that an enema amount of 5 to 6 mL/ kg produced greater stool output compared with no dose and/or smaller doses (1-4 mL/kg) (P = .056). Dosing of 5 to 6 mL/kg resulted in greater stool output compared with smaller doses (P = .037). The results could not show whether a 5- to 6-mL/kg enema dose was more effective or less effective than larger doses of 7 mL/kg or greater (P = .619). Of the 500 patients who received enemas, 26 were admitted. Two patients were admitted for reasons not directly related to their diagnosis of constipation or abdominal pain, such as port replacement or admitting diagnosis of pneumonia. As for the remaining admissions, it cannot be determined with the data available whether admission was related to enema administration. Twentyfour patients were admitted for varying diagnoses related to gastrointestinal complaints, including upper gastrointestinal bleed (1 patient), urinary obstruction (1 patient), constipation (3 patients), requirement for further
WWW.JENONLINE.ORG
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RESEARCH/Wallaker et al
TABLE 2
Demographic characteristics and presenting chief complaint of patients given milk and molasses enemas. Sex Male Female Chief complaint Abdominal pain Chest/back pain Constipation/change in stool Vomiting Dysuria Other Age b 10 y 10-15 y N 15 y Weight b 22 kg 22-50 kg N 50 kg Not documented
n (%)
268 (53.6) 232 (46.4) 349 (69.8) 11 (2.2) 72 (14.4) 38 (7.6) 5 (1) 25 (5.0) 282 (56.4) 141 (28.2) 77 (15.4) 187 (37.4) 185 (37) 101 (20.2) 27 (5.4)
FIGURE 1 Percent success rate of milk and molasses enema by dose.
7.00
Milliliters Per Kilogram
Patient characteristic
6.00 5.00 4.00 3.00 2.00 1.00 0.00
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years Male
Female
medications (2 patients), serial abdominal examinations (10 patients), vomiting (2 patients), dehydration (2 patients), appendicitis (1 patient), bowel obstruction (1 patient), and syncope (1 patient), that cannot be directly correlated to the enema administration.
Discussion
Our study provided evidence of a wide spectrum of nursing practices in relation to enema administration; however, even with variable administration techniques, our chart review showed milk and molasses enemas to be safe and effective with minimal adverse effects. Several adverse effects were examined for in charting, on the basis of previous adverse effects seen in studies involving milk and molasses enemas, including allergic reactions, perforation, severe bleeding, and shock. None of these reactions were noted while our study was being conducted. Small amounts of blood were noted in 9 patients’ stool samples. Bleeding was not significant enough to require
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FIGURE 2 Average dose of milk and molasses administered (in milliliters per kilogram) by patient age.
observation for any patients within the study. It cannot be determined whether bleeding may be due to the passage of hard stool or hemorrhoids, as a result of constipation or enema administration—exhibiting the importance of rectal examination before enema administration. 6 Similar to prior studies, our study showed that vomiting and abdominal pain were 2 side effects commonly seen after administration of milk and molasses enemas. Of note, when we examined presenting chief complaints, 69.8% of patients presented with abdominal pain and 7.6% with vomiting before enema administration (Table 2). The percentage of patients with abdominal pain or vomiting decreased significantly after enema administration (Figure 3). Therefore it cannot be determined whether these symptoms were direct results
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of the enema administration or symptoms experienced with a diagnosis of constipation. Enema amounts and results were shown to vary with different patient age groups. On average, patients aged younger than 10 years received 4.5 mL/kg, patients aged 10 to 15 years received 3 mL/kg, and patients aged older than 15 years received less than 3 mL/kg. For larger dosing amounts (N 7 mL/kg), the sample size was small in comparison to the other groups (only 30 patients received N 7 mL/kg). Developmental level has an impact on patient tolerance of enema administration as well, which may impact enema effectiveness. Recommendations suggest retention of the enema for approximately 2 minutes before defecation, which may be difficult in patients in early stages of toilet training; however, longer retention leads to increased stimulation. 5 No association was noted between sex and enema results. As evidenced by our nursing survey, there is varying clinical practice among nurses in relation to administration of milk and molasses enemas (Table 1). Other than the nursing survey results, information was not collected on each patient related to device used with enema administration or height of the enema catheter-tip insertion. Several barriers exist that may impact nurses’ ability to adhere to clinical practice guidelines. 7 Communication, awareness of current practice guidelines, feelings toward current practice, training, and staff workload can all have a great impact on nursing technique, which may affect the success rate within our study. 7 Technology can also play a major role in compliance. When our study was being conducted, written orders were still being used. Currently, computer orders are in place, which may allow for increased clarity in enema orders such as dosing and allow for a maximum dose recommendation to increase compliance.
Limitations
Varying methods of enema administration including technique, enema amount, patient retention of enema fluid, and experience of staff administering the enema are all limitations. Variability may be caused by several factors, including few models of evidence-based research available explaining the standard protocol for administration of milk and molasses enemas, stressing the need for a standard protocol to be developed to aid in compliance. More information is needed to examine whether enema amount or teaching of administration technique improves patient outcome and reduces side effects with enema administration. At the beginning of our study, guidelines indicated a maximum enema dose of 6 mL/kg, with a total dose no
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10.0
5.0
5.0 4.0
0.25
Age 2-5
0.7
0.0 0.2
0.1
Age 6-10
Abdominal Pain
Vomiting
Age 11-18 Admitted
FIGURE 3 Percentage of patients with side effects after enema.
greater than 135 mL. 2,3 A maximum dose of 135 mL was a great limitation to our study because any patient weighing greater than 22 kg is expected to receive less than the recommended 6 mL/kg according to hyperosmotic enema guidelines within our facility when our study was conducted.
Implications for Emergency Nurses
Although our research shows a success rate of at least 80% in patients receiving variable enema doses, further data are needed to examine other variables including administration technique, patient enema retention, and incremental dosing of enemas with alternate maximum dosages involving practices seen at other institutions. At the time of our study, our institutional guideline suggested a milk and molasses enema of no more than 135 mL for safe administration. Further studies are needed to determine whether patients receiving greater than 135 mL as a maximum dose have similar success rates and no harmful side effects.
Conclusions
In this single-center study, milk and molasses enemas were safe and effective for treating constipation in patients ranging in age from 2 to 17 years without chronic medical conditions. Even though various methods were used to administer these enemas, the outcomes have shown enemas to be effective, exhibiting minimal side effects with an optimal success rate in patients receiving 6 mL/kg of enema with an institutionally suggested maximum of 135 mL in place when this study was conducted.
WWW.JENONLINE.ORG
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Acknowledgments
REFERENCES
4. Hansen S, Whitehill J, Goto C, Quintero C, Darling B, Davis J. Safety and efficacy of milk and molasses enemas compared with sodium phosphate enemas for the treatment of constipation in a pediatric emergency department. Pediatr Emerg Care. 2011;27: 1118-20.
1. Walker M, Warner B, Brilli R, Jacobs B. Cardiopulmonary compromise associated with milk and molasses enema use in children. J Pediatr Gastroenterol Nutr. 2003;36:144-8.
5. Brown TL. Pediatric variations of nursing interventions. In: Hockenberry MJ, Wilson D, eds. Wong’s Nursing Care of Infants and Children. 9th ed. St Louis, MO: Mosby; 2011:998-1051.
2. Baker S, Liptak G, Colletti R. Constipation in infants and children: evaluation and treatment. J Pediatr Gastroenterol Nutr. 1999;29:612-26.
6. Pirie J. Management of constipation in the emergency department. Clin Pediatr Emerg Med. 2010;11:182-8.
3. Felt B, Brown P, Coran A, Kochhar P, Opipari-Arrigan L, Marcus S, et al. Functional constipation and soiling in children. http://cme.med. umich.edu/pdf/guideline/peds03.pdf. Accessed April 20, 2010.
7. Abrahamson K, Fox R, Doebbeling B. Facilitators and barriers to clinical practice guideline use among nurses. Am J Nurs. 2012;112: 26-35.
We thank Liz Lind for assistance with statistical analysis and Rachel Sledge for volunteering to participate in our initial data collection.
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