Specific Care Questions Milk with Molasses Enema

In an otherwise healthy child with constipation what is the harm of administering a milk with molasses enema?

Report by:

Y.R. Chan, EBP Medical Director & Jacqueline Bartlett, EBP Program Manager

Search checked by:

Y.R. Chan, EBP Medical Director 

Reviewed by:

Charles Roberts, GI Section Chair & Beth Lyman, Nutrition Support Nurse

Institution:

Children's Mercy Hospitals and Clinics

Date submitted:

March 24, 2006

Last modified:

April 17, 2006

Date placed on CPG site:

September 22, 2006

Question in PICO format:
In an otherwise healthy child with constipation [patient] what is the harm [outcome] of administering a milk with molasses enema [intervention]?

Type of question:
Harm

Clinical scenario:
An otherwise healthy five year old is admitted to the hospital for chronic constipation. The resident team orders a M&M enema to be given. Nursing staff refuse to give the enema citing "evidence" that Milk with Molasses enemas can harm a child.

Search strategy: 
National Guidelines Clearninghouse (NGC.org), BestBets.org, MEDLINE and CINAHL databases were searched using "enema", "molasses", and "milk". (Dr. S. Simon is credited with this search strategy.)
Search outcome: 
NGC.org = 42; Bestbets.org = 0; PubMed = 1;
Forty-one guidelines found were irrelevant. One guideline (Baker, SS, et al, n.d., Constipation in infants and children: Evaluation and treatment) was discussed it did not comment specifically on M&M enemas.
One additional systematic review (Ramkumar, D, & Rao, SSC, 2005 Efficacy and safety of traditional medical therapies for chronic constipation: Systematic review) was discussed, it did not comment specifically on M&M enemas.
One chapter from Advances in Pediatrics (McClung, HJ, Potter, C, 2004, Rational use of laxatives in children) stated that the only enemas that were safe were mineral oil and normal saline. Despite the strong wording of this opinion the author did not reference any studies supporting this opinion. The remaining paper is shown in the table.
Relevant paper: 
Author, date and countryPatient group Study type (level of evidence) Outcomes Key results Study weaknesses 
Walker M, Warner BW, Brillli BR, and Jacobs BR, 2003, U.S.A.PICU admissions at Cincinnati Childern's Hospital between 1994 - 2000. 140 patients were identified, data from 43 admissions located. Five patients with adverse effects from an enema were identified.Retrospective review, IVElectrolyte abnormalitiesOne patient had mild hypolamia.Ninety seven patients were unaccounted for in this document.
   Transient bacteremiaTransient bacteremia was a possible cause of shock in the patients, although there were no documented patients with positive blood cultures. 
   Rectal perforationThere were no radiographic findings consistent with bowel perforation in the patients. 
   Cardiac arrhythmiaEKGs were not obtained following enema administration 
 Allergic reactionA reaction was not documented 
   Abdominal compartment syndromeThe absence of organ swelling, ascites, or a significant amount of stool does not seem to indicate this syndrome.  

Comment:

The case series reported on 5 cases at Cincinnati Children's PICU that had a poor outcome after receiving a milk with molasses enema. In the introduction to the study it was stated that there have been no other studies commenting on the potential harm of M&M enemas which confirms our search findings.

The major criticisms of this case series, as it pertains to CMH&C's environment, are:

  1. All the patients had multi-system problems and were in the ICU. The clinical question focused on "otherwise healthy children" therefore it does not reflect the patient population presenting in the Emergency Room or Inpatient units.
  2. The authors did not set out to compare M & M enemas to other types of enemas. They set out to describe untoward events that they attribute to the use of M & M enemas. Therefore, the reader cannot discern if this intervention is more or less safe than other types of enemas.
  3. Within the authors conclusions they were not able to establish a clear link between the M&M enema and the poor patient outcome.
  4. Theorized concerns of M&M enemas include electrolyte abnormalities, electrolyte abnormalities, transient bacteremia, rectal perforation, cardiac arrhythmia, allergic reaction, and abdominal compartment syndrome and in all five cases the cause of the poor outcome was not attributed to these possible causes. (One patient did have a documented potassium of 2.7 however the authors did not link this outcome to the patient's reaction.)

Clinical bottom line:
There is a paucity of good and relevant published evidence to suggest that milk with molasses enemas are inherently more harmful to otherwise healthy individuals compared to other forms of enemas. If a M&M enema is given the medical team needs to pay particular attention to whether the patient has a milk protein allergy.

Level of evidence:
IV; Case Review

Reference(s):
Walker M. Warner BW. Brilli RJ. Jacobs BR. Cardiopulmonary compromise associated with milk and molasses enema use in children. [Case Reports. Journal Article] Journal of Pediatric Gastroenterology & Nutrition. 36(1):144-8, 2003 Jan.


These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time.

It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.

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