76: Glycerin Enemas and Suppositories in Premature Infants: A Systematic Review and Meta-Analysis

Premature infants often receive glycerin enemas or suppositories to facilitate meconium evacuation and transition to enteral feeding. The evidence to support this practice remains unclear. To establish the level of evidence regarding the use of glycerin enemas and suppositories in premature infants. We conducted a systematic search of Medline, Embase, the Cochrane Library, and trial registries for randomized controlled trials that assessed the effects of using glycerin enemas and suppositories in premature infants. All records were reviewed independently and in duplicate. Abstracted data were meta-analyzed in Review Manager using a random effects model. We identified 185 premature infants treated prophylactically with glycerin enemas (n=81, one trial) or suppositories (n=104, two trials). Infants were less than 32 weeks gestation and had no congenital malformations. In all three trials, administration of glycerin enemas or suppositories started within the first two days of life and was stopped on or before day 15. This treatment strategy was associated with earlier initiation of stooling in one trial (2 vs 4 days, P=0.02) and a trend towards earlier meconium evacuation in another (6.5 vs 9 days, P=0.11). One other trial did not report stooling outcomes. Meta-analysis indicated that the use of glycerin enemas or suppositories had no statistically significant effect on time to full enteral feeds (0.7 days faster with treatment, P=0.49). There were no reports of rectal bleeding or perforation but there was a trend towards increased risk of necrotizing enterocolitis with glycerin enemas or suppositories (risk ratio=2.72, P=0.13). All three trials were limited by small sample sizes and the possibility of selective reporting. One study used a sham procedure to maintain blinding while the other two were open studies with no blinding. At least three other trials are underway. Daily administration of glycerin enemas or suppositories does not appear to expedite transition to full enteral feeding in premature infants less than 32 weeks gestation. Meta-analyzed data suggest that treatment may be associated with increased risk of necrotizing enterocolitis. These conclusions may change as more results become available. Careful monitoring of ongoing trials is required.