Colorectal Center specialists at Cincinnati Children's Hospital Medical Center provides information about enemas as part of the bowel management program. The following equipment is needed in order to administer an enema.
- Enema bag
- The determined enema (i.e. Fleet", Ped. Fleet", etc.)
- Catheter -- A catheter of 20-22 CH. Sometimes it is useful to use a Foley catheter (22 or 24 french) with a 30cc balloon
- Water soluble lubricant
There are different types of solutions to use for enemas: there are some ready solutions that can be bought in a drugstore or warm solutions that can be prepared at home based on water and salt.
The use of the solutions has to be indicated by the physician who is following your child.
The use of phosphate enemas (Fleet") is most convenient since it is already a prepared vial. However, pure saline enemas are often just as effective and some families find it easier and less expensive.
Occasionally, children will complain of cramping with the Fleet" enema but will have no complaints with the saline one. Children older than eight years of age or heavier than 65 pounds (30 kilograms) may receive one adult phosphate enema daily.
Children between three and eight of age or between 35 and 65 pounds (15 and 30 kilograms) may receive one pediatric phosphate enema a day. Children should never receive more than one phosphate enema a day because of the risk of phosphate intoxication. Children with impaired renal function should use Fleet" enemas with caution.
The phosphate enema administered on a regular basis should result in a bowel movement followed by a period of 24 hours of complete cleanliness.
If one enema is not enough to clean the colon (as demonstrated by an x-ray, plus the fact that the child keeps on soiling), then the child requires a more aggressive treatment, and a saline enema is added, in addition to the phosphate.
If the addition of the saline enema still results in inadequate results, then high colonic washings are indicated with a Foley catheter attached to the tip of the bottle of the Fleet" enema (see section on enemas using a Foley catheter).
Recipe for Normal Saline
The recipe for normal saline is 1000 ml of tap water with 1 ½ teaspoons of table salt. Do not change this recipe; doing so could be harmful.
Individualized Treatment
As mentioned previously, the Bowel Management program is an individual ongoing process and "no magic formula" exists to find out what is the right amount of enema solution necessary for your child. Therefore, a larger volume of saline solution is necessary in those children who have hypomotility as compared to those who have hypermotility and tend to empty their colon rapidly.
The "right" enema is the one that can empty a child's colon and can let him / her stay clean for the following 24 hours. This can be achieved only by trial and error and learning from previous lack of success.
The solution of the enema should be body temperature to decrease cramping.
Since the program is very personalized, the parents and children learn to look at the consistency and the amount of stool obtained after the enema to determine whether it was effective.
After a period of time, parents will know when the enema was not effective and when they need to repeat it with a saline solution. Suppositories very occasionally may be sufficient to stimulate a full bowel movement.
Administering the Enema
- Gather all your equipment.
- Position your child.
- Lubricate the catheter tip.
- Gently insert the catheter into the anus as high as possible. The catheter is flexible so parents can maneuver it into the colon.
If any resistance is met you may need to instill a small amount of fluid to dislodge some stool. Occasionally leakage occurred with this technique, resulting from kinking of the catheter.
- Attach the catheter to the enema bag.
- Instill the enema at this time, the higher the bag is held the faster the flow. Giving the enema should take about five to ten minutes, if there are cramps you should slow down the flow, by lowering the enema bag.
- Once the enema is instilled you may remove the catheter and hold the buttock cheeks together, trying to retain the fluid for at least five minutes if possible.
- After the retention time is up, you should now ask your child to sit on the toilet for about 30 to 45 minutes for optimal results.
Check the results of the enema, look into the toilet. If no stool or minimal stool, report these findings to your doctor. Your child may require a different or larger enema.
The Foley catheter is used as an alternative to the normal catheter and when the enema solution administered leaks.
The goal of this procedure is to use a balloon to act as a plug to avoid leaking during the enema process.
Administering the enema:
- Prepare the enema as previously described
- Lubricate a 20 to 24 F Foley catheter and gently introduce it through the anus
- Using a 20cc syringe fill it with warm water, attach the syringe to small port and instill 15cc of the water then pull back on the catheter.
If the balloon comes out, push the catheter back and instill the remaining 5 cc of water then pull back again. You may continue this process up to the full 30cc.
Remember, never to inflate the balloon in the anus or push the catheter in more than three inches. - While keeping tension on catheter, to avoid leaking, now proceed with the enema as before.
- When the enema is complete, clamp the end of the catheter, then detach bag, this will allow the solution to remain for optimal effect.
- When retention time is up, place your child on toilet and at this point you may deflate the balloon allowing the catheter to slip out, and continue as previously described.
To make sure you are administering the enema in the right way, the nurse or physician should administer the first enema with the parent present. This will clarify any questions the parent may have regarding the technique, positioning or amount of solution to be given.
For more information or to request an appointment, please contact the Colorectal Center at Cincinnati Children's.
