Colon Irrigation in Infants

Introduction:

The colon initiates the movement of stools (the left-out solid waste after digestion of food) by enabling them to move along its walls and helps to get rid of the waste and toxins from the body. It also helps grow good bacteria in the gut called the microbiome. These microbiomes help to fight against infections and shield the body from colon cancer. Colon irrigation or colon cleansing is usually done before the colonoscopy (colon or large intestine examination using a colonoscope).

Why Is Colon Irrigation Done?

Colon irrigation is done to clean the colon and prevent stool stagnation. It is usually done in the following cases:

• Hirschsprung Disease: It is an intestinal disorder characterized by improper development of intestinal nerves before birth, leading to a partial loss of certain nerve cells in the colon. This causes colon inflammation called colitis, which could hinder stool movement and cause increased bacterial growth. There can be abdominal cramping and intermittent pain. Hence, colon irrigation is done to enable the passage of stools.

• Meconium Plug Disease: The baby’s first stool is called meconium. Meconium is a dark green material that comes out as stool during or shortly after birth. When this meconium is thick and black, it causes colon obstruction and difficulty for the newborn to pass stools. The part of the small intestine above the blockage gets enlarged and results in swelling. This condition is common in preterm babies.

• Meconium Ileus: In meconium ileus, thickened meconium obstructs the distal part of the ileum (end portion of the small intestine); hence, colon irrigation is needed in these infants to relieve the obstruction.

• To manage constipation.

• The colon is lined by a substance called mucus which acts as a lubricant for the feces to pass through. Before a colonoscopy or colonic manometry (tests to assess the strength of the colon’s movements), catheter placement, and bowel surgery procedures, colon irrigation is required to remove the feces and mucus to obtain a clear picture.

What Is Used for Colon Irrigation?

The colon can be cleansed using:

• Laxatives.

• Enema (a procedure to remove the contents of the rectum using liquid or gas).

• Supplements.

• Herbal teas.

• Colon irrigation or colon hydrotherapy (done at the doctor’s office).

What Are the Parameters to Be Noted Before Colon Irrigation?

The following factors have to be noted in cases of bowel obstruction.

Physical Factors: These include:

• Vomiting: The frequency, color (if it contains bile or blood), and the amount of the vomiting has to be noted.

• Abdominal Extension: The abdomen has to be examined and noted if it is tight, shiny, soft, or firm, checked for the presence of visible bowel loops and veins, and the degree of abdominal extension.

• The Action of the Bowel: The time, frequency, color, amount, presence or absence of blood, and consistency must be observed.

• Nasogastric Aspirate: It is the process of introducing a nasogastric tube into the stomach and draining its contents. The aspirate’s color and the amount should be made a note of. The appearance of green vomitus is an indicator of bowel obstruction as it denotes the presence of bile.

Medical Factors: These have to be evaluated by the surgeons, such as the length and size of the tube to be inserted and the amount of sodium chloride solution to be used.

What Is Required for Colon Irrigation?

The following supplies are required for colon irrigation;

• Nelaton catheter (a thin tube put inside the rectum to remove the fluids). The appropriate size and length of the catheter have to be selected based on the weight of the baby, as shown below:

The above values are just a guide and can differ in certain babies.

• Water-based lubricant.

• Sterile gloves.

• Incontinence sheet (small, impermeable multi-layered sheet with a good absorbing capacity to prevent the bed from getting soiled).

• 60 millilitrer catheter tip syringe.

• 0.9 % sodium chloride solution. This has to be warmed before use but not in a microwave oven. A cold solution can cause babies, especially premature babies, to cool down quickly.

What Is the Procedure for Colon Irrigation?

Colon irrigation is carried out in the following ways:

• The procedure is explained in detail before informed consent is obtained from the parents.

• All the essential parameters have to be recorded.

• The operating staff should wash their hands thoroughly and use sterile gloves.

• The assistant can use play therapy or other techniques to distract the child.

• The infant is positioned on its back with the knees bent towards the chest as in the frog position. Older kids can be turned on the left side.

• The appropriate size and length of the catheter are chosen.

• A 0.9 % sodium chloride solution is warmed by placing it in a basin containing warm water.

• The catheter tip syringe needs to be lubricated.

• The warm sodium chloride solution is drawn into the syringe, and the incontinence sheet is placed under the anus.

• The catheter is then inserted slowly into the rectum to a predetermined length based on the infant’s size and weight. The catheter should not be moved forcefully if there is any resistance. After injecting half the volume, the child’s tolerance level is noted.

• The syringe is removed, and the fluid is allowed to flow back freely.

• The rest of the sodium chloride solution is administered similarly until a clear fluid returns. If the fluid is not clear or turbid, a surgeon should be consulted.

• The catheter is removed after the procedure and the child is cleaned and dried.

• The amount of return is then measured based on its contents, such as color, consistency, volume, and smell.

• The saline should be allowed to flow back freely and should not be aspirated. The amount of saline injected must be the same when it flows out along with the stool. If the returned amount of solution is more or not equal to the amount injected, the catheter is reinserted, and the syringe is drawn back gently and held for a while to relieve any gas if present. The amount of saline should not exceed 250 ml or 20 ml/kg.

What Are the Risks Associated With Colon Irrigation?

The risks include

• Perforations in the Rectum:The rectum is the end portion of the large intestine through which solid waste exits the body. Insertion of the tube along the rectum can cause a few tissues to tear in the area, especially when the child is nervous and tightens up or if the insertion is done wrong. This can be painful and pave the way for infections in the future.

• Infection: If the equipment used is not sterile, it can cause infections in the child as their immune system is weak and can capture infections quickly.

• Electrolyte Imbalance and Dehydration: During the removal of fluids, the salt content gets reduced, which causes an electrolyte imbalance leading to dehydration.

What Are the Complications of Colon Irrigation Procedure?

The complications include

• Risk of saline reabsorption.

• Abdominal discomfort.

• Nausea and vomiting.

• Bowel perforation.

• Loose stools after the procedure.

• Difficulty in inserting the catheter.

• Discomfort and lack of cooperation by the child.

• Increased wash-out rate can cause electrolyte imbalance.

What Are the Other Methods of Colon Irrigation?

• Peristeen: It is a system to clean the colon and is advised in kids over three years of age with long-term constipation. It consists of a water bag, a unit to regulate air and water, a pump to activate the water, a balloon, and a balloon-attached pre-rectal catheter. Peristeen can be used only after careful medical examination and assessment of the contraindications. The stomal therapist (usually a registered nurse who will assist the patient before and after the stomal surgery, that is, surgery involving the formation of a stoma or surgically created a pathway for the passage of waste) instructs the parents or the caretaker on how to use the system. This enables younger children to understand and be educated about self-care and older kids to carry out the procedure themselves. The system is customized based on each child’s requirements. The amount of water and the frequency of washout is set by the stomal therapist based on the child’s needs. The system can be used by the kids in the toilet. The washouts reach as high as the splenic flexure (bend where the transverse and descending colon meet in the upper abdomen), which causes complete bowel emptying.

• Increased Washout in a Newborn: If the abdomen is not decompressed fully, newborns will require increased volumes of washout. This can be evaluated by the healthcare surgical team based on the child’s needs.

Conclusion:

Colon irrigation is recommended only in infants and kids under certain conditions. It is usually not a painful procedure, but mild discomfort may be experienced by the child. After careful evaluation, skilled experts can perform the colon irrigation procedure efficiently.