In an otherwise healthy child
with constipation what is the harm of administering a milk with
Y.R. Chan, EBP Medical Director & Jacqueline
Bartlett, EBP Program Manager
Search checked by:
Y.R. Chan, EBP Medical Director
Charles Roberts, GI Section Chair & Beth Lyman,
Nutrition Support Nurse
Children's Mercy Hospitals and Clinics
March 24, 2006
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
Type of question:
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
|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 country||Patient 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, IV||Electrolyte abnormalities||One patient had mild hypolamia.||Ninety seven patients were unaccounted for in this
| || || ||Transient bacteremia||Transient bacteremia was a possible cause of shock in the
patients, although there were no documented patients with
positive blood cultures.|| |
| || || ||Rectal perforation||There were no radiographic findings consistent with bowel
perforation in the patients.|| |
| || || ||Cardiac arrhythmia||EKGs were not obtained following enema administration|| |
| ||Allergic reaction||A reaction was not documented|| |
| || || ||Abdominal compartment syndrome||The absence of organ swelling, ascites, or a significant amount
of stool does not seem to indicate this syndrome. || |
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:
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.
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.
Within the authors conclusions they were not able to establish
a clear link between the M&M enema and the poor patient
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
Level of evidence:
IV; Case Review
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.