Meconium Evacuation for Facilitating Feed Tolerance in Preterm Neonates: A Systematic Review and Meta-Analysis

Abstract

Background: A delayed passage of meconium is considered as a risk factor for feed intolerance in preterm neonates. Objectives: The aim of this study was to review the effects of different therapeutic agents for meconium evacuation on feed tolerance in preterm neonates. Methods: A systematic review of randomised controlled trials (RCTs) of different therapeutic agents for meconium evacuation in preterm neonates (gestation <32 weeks and/or birth weight <1,500 g) using the Cochrane systematic review methodology was undertaken. Databases including Google Scholar were searched in January 2016. The primary outcome was the time to reach full feeds (TFF; ≥120 ml/kg feeds with stoppage of parenteral nutrition >24 h). Secondary outcomes included necrotising enterocolitis (NEC), weight at discharge and adverse effects. The results were summarised as per the GRADE guidelines. Results: Six RCTs (2 each of glycerine suppository and enema, 1 normal saline enema and 1 oral osmotic contrast agent; n = 442) with a low or unclear risk of bias were included. The pooled estimate (random effects model) showed no reduction in TFF [mean difference (MD) -0.03, 95% CI -2.47, 2.41, p = 0.98; level of evidence: low]. No differences in NEC [risk ratio (RR) 1.71, 95% CI 0.63, 4.65, p = 0.30; level of evidence: low] and weight at discharge (MD -0.08, 95% CI -0.30, 0.15, p = 0.50; level of evidence: low) were found. The trial assessing oral osmotic contrast agents reported a trend towards a higher incidence of NEC ≥ stage II. There were no other adverse effects. Conclusion: Limited low-quality evidence indicates that prophylactic glycerine suppository, small volume glycerine/normal saline enema or oral osmotic contrast agents to evacuate meconium did not reduce TFF in preterm neonates. Large, well-designed trials are essential to study this clinically significant issue.

A critical analysis of risk factors for necrotizing enterocolitis

“…In a meta-analysis of 6 studies using different forms of meconium evacuation strategies, there was no effect on NEC (RR 1.71, 95% CI 0.63–4.65, 6 studies, 442 infants) but there was a trend towards increasing risk with oral gastrographin administration (RR 2.61, 95% CI 0.88–7.74, 1 study, 96 infants). 62 A review of only glycerin laxative enemas or suppositories showed no effect on NEC (RR 2.75, 95% CI 0.58–13.1, 2 studies 96 infants), although the point estimate suggested a greater probability of harm than benefit in the risk of NEC with use of glycerin. 63…”

Oral N - Acetyl Cysteine for Meconium Ileus of Preterm Infants

“…As a result of definition problems and lack of standard approaches to MIPI, there are not enough clinical trails addresses to reach early full enteral feedings in very low-birth weight infants with MIPI (17). There are only six trials in a recent metaanalysis and all have the small sample size and some of them heterogenic (17).…”

“…As a result of definition problems and lack of standard approaches to MIPI, there are not enough clinical trails addresses to reach early full enteral feedings in very low-birth weight infants with MIPI (17). There are only six trials in a recent metaanalysis and all have the small sample size and some of them heterogenic (17). As a result of these limitations this recent systematic review suggested that the use of a glycerine suppository, small-volume enema with glycerine or normal saline, or the administration of an oral osmotic agent, such as gastrografin, to evacuate the meconium did not reduce the time to reach full enteral feeds in very low birth weight neonates (17).…”

“…There are only six trials in a recent metaanalysis and all have the small sample size and some of them heterogenic (17). As a result of these limitations this recent systematic review suggested that the use of a glycerine suppository, small-volume enema with glycerine or normal saline, or the administration of an oral osmotic agent, such as gastrografin, to evacuate the meconium did not reduce the time to reach full enteral feeds in very low birth weight neonates (17). However, we observed a difference by rectal and oral NAC administration especially on reaching earlier full enteral feeding when compared to saline enema in infants with MIPI.…”

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“…His daily abdominal X-ray indicated significantly expanding intestinal gas, and we diagnosed him with meconium-related ileus. Intragastric administration of 3 mL/kg 5-fold-diluted amidotrizoic acid succeeded in triggering mass excretion of feces, as described in previous studies (31)(32)(33)(34)(35). Subsequently, abdominal distention improved, and enteral feeding was resumed.…”