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RESEARCH
MILK
AND
MOLASSES ENEMAS: CLEARING
THINGS UP
Authors: Kimberley Wallaker, BSN, RN, CEN, Ezio Fortuna, RN, EMT-P, CEN, Stuart Bradin, DO,
Michelle Macy, MD, MS, Michelle Hassan, BSN, RN, CEN, CPEN, and Rachel Stanley, MD, MHSA, Ann Arbor, MI
Introduction: We aimed to describe current nursing practice
and clarify the safest and most effective dose of milk and
molasses enemas used to relieve constipation in pediatric
patients presenting to a suburban pediatric emergency
department.
Methods: We surveyed emergency nurses about current
practice in administration of milk and molasses enemas. In
addition, we identified consecutive patients aged 2 to 17 years
with a discharge diagnosis of constipation or abdominal pain
between 2009 and 2012. Stable patients were included from
the emergency department, in the absence of chronic medical
conditions. For each patient, we recorded demographic
characteristics, chief complaint, nursing administration technique, stool output, patient tolerance, side effects, amount of
enema given, and patient disposition.
onstipation is commonly treated in the pediatric
emergency department with milk and molasses
enemas. Milk and molasses enemas are hyperosmotic, causing water to be drawn into the intestines, promoting
stool evacuation. 1 In addition, there is therapeutic effect
C
Kimberley Wallaker is Registered Nurse, Children's Emergency Services,
University of Michigan Health System, Ann Arbor, MI.
Ezio Fortuna is Registered Nurse, Children's Emergency Services, University
of Michigan Health System, Ann Arbor, MI.
Stuart Bradin is Attending Physician, Children's Emergency Services,
University of Michigan Health System, Ann Arbor, MI.
Michelle Macy is Attending Physician, University of Michigan Health
System, Ann Arbor, MI.
Michelle Hassan is Registered Nurse, University of Michigan Health System,
Ann Arbor, MI.
Rachel Stanley is Attending Physician, Children's Emergency Services,
University of Michigan Health System, Ann Arbor, MI.
For correspondence, write: Kimberley Wallaker, BSN, RN, CEN, University
of Michigan Health System, 1540 E Hospital Dr, Ann Arbor, MI 48109;
E-mail: [email protected].
J Emerg Nurs ■.
0099-1767/$36.00
Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2013.08.012
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Results: We identified 500 patients with abdominal pain or
constipation, 87 of whom were later excluded. Milk and
molasses enemas were found to be effective at relieving
constipation in our population, with a success rate averaging
88% in patients given 5 to 6 mL/kg with an institutional
guideline maximum of 135 mL. The success rate was found to
vary with age, along with the amount of enema given.
Discussion: Our nursing survey showed that varying practice
exists regarding technique and dosing of milk and molasses
enemas. Historical chart review showed that milk and molasses
enemas in our emergency department were safe and effective
with minimal side effects.
Key words: Constipation; Encopresis; Enema; Milk; Molasses;
Pediatric
found in the reaction of sugar combining with milk, creating
gases and promoting peristalsis, leading to properties of
irritation to the intestinal lining, as well as softening of stool. 1
At times, milk and molasses enemas have been shown
to have harmful effects similar to those seen with other
enemas, such as rectal perforation and allergic reactions.
Unlike other enemas, milk and molasses enemas have also
been associated with cardiopulmonary compromise. 1
However, the association between milk and molasses
enemas and cardiopulmonary compromise was only
identified in a single-site case series, in which all patients
had serious underlying medical conditions. 1 There are still
many hospitals, including ours, that use milk and molasses
enemas for children with constipation, therefore showing
the need for further research to evaluate the safety of this
treatment and develop a standardized dosing protocol in
stable patients without severe underlying conditions.
Milk and molasses enemas should be avoided in patients
with allergies to either milk or molasses, and care should be
taken in administration to patients with serious underlying
medical conditions because serious side effects have been
reported. 1 It is recommended that these enemas only be
administered in the ED setting to allow for close monitoring. 2
Few standards exist for preparation and administration of
milk and molasses enemas, and current guidelines suggest
varying amounts of milk and molasses for administration. 2–4
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RESEARCH/Wallaker et al
Our study was initiated with 2 aims in mind. The first
aim was to describe milk and molasses enema administration techniques among pediatric emergency nurses. The
second aim was to identify a safe and effective dose for milk
and molasses enemas that would also produce the greatest
effect with the fewest adverse events and side effects.
administration device used; amount typically administered;
and perception of the patient’s tolerance, using a pain scale
from 0 to 10 based on the nurse’s perception of patient
behavior after the enema. Survey data were reviewed by
research staff only.
CHART REVIEW
Methods
DESIGN
Our study consisted of 2 parts. Part 1 was an anonymous
online survey completed by nurses after each enema
administered to pediatric patients. Part 2 consisted of a
retrospective chart review on a cohort of children who
received enemas for the treatment of constipation in a
tertiary-care pediatric emergency department. Data were
extracted from the existing medical record, and there was no
further contact with or interventions performed on study
participants. Approval was received from the University of
Michigan Institutional Review Board for exempt status.
SETTING
The University of Michigan Children’s Emergency Department is a suburban, tertiary-care referral center with
more than 20,000 pediatric ED visits in 2012.
SURVEY SAMPLE
Approximately 20 pediatric nurses, with varying levels of
expertise, were invited to participate in the recurrent survey
regarding enema administration. Inclusion criteria were
current employment status as a registered nurse in
Children’s Emergency Services and administration of a
milk and molasses enema between September 2010 and
May 2012. A link was sent to registered nurses who were
currently employed in Children’s Emergency Services
through their work E-mail addresses that directed them to
complete a brief 10-question anonymous online survey—
after administration of each enema—during the 21-month
period from September 2010 to May 2012.
SURVEY ADMINISTRATION
Survey data were collected by use of an anonymous online
survey distributed by a hyperlink included in a group Email to all pediatric emergency nursing staff on a quarterly
basis. Once the nurse accessed the hyperlink, questions
were asked regarding the nurse’s professional background
and experience with administering enemas. No personal
identifiers were collected in this survey. Surveys were
completed by staff members each time they administered
an enema to different patients aged between 2 and 17
years. Information was obtained about the enema
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A retrospective chart review was performed for patients aged
2 to 17 years who visited the University of Michigan
Children’s Emergency Services from January 2009 to April
2012 and who were documented to have a discharge
diagnosis of constipation or abdominal pain to determine
whether a milk and molasses enema was administered.
Patients were excluded if they had a chronic medical
condition such as seizure disorder, chronic lung disease with
respiratory compromise, congenital heart disease, immune
compromise, or previous rectal surgery. Children who were
critically ill on arrival to the emergency department or
hemodynamically unstable were excluded as well.
Data collected from eligible patient records included
patient demographic characteristics and the following key
variables: patient age, sex, chief complaint, weight, total
volume of enema administered, stool output (none, small,
moderate, or large), side effects, adverse events, and patient
disposition. Patient age was categorized into 3 groups: 2 to 9
years, 10 to 15 years, and 16 to 17 years. The enema amount
(in milliliters per kilogram) was calculated and categorized
into the following groups: 1 to 4 mL/kg, 5 to 6 mL/kg, and 7
mL/kg or greater. The main outcome of interest was enema
success rate based on nurse documentation of at least
moderate stool and minimal side effects (including abdominal pain, vomiting, and need for admission).
STATISTICAL METHODS
Descriptive statistics were calculated for nursing surveys
completed and chart review data. A 2-proportion Z test was
used for differences between categorical enema amount and
enema success rates. All analyses were conducted with
Microsoft Excel 2010 (Microsoft, Redmond, WA), and P b
.10 was considered statistically significant. We separated the
groups analyzed into the following groups, taking into
consideration the sample size for each group: 1 to 4 mL/kg,
5 to 6 mL/kg, and 7 mL/kg or greater. The survey results
were downloaded and descriptive statistics calculated.
INTERVENTION
A standard guideline, available from within our institution,
was used as a reference for enema administration within our
study. 3 Enemas used during the study consisted of a 1:1
solution of whole milk and molasses administered either
through an enema bag, enema bottle, or flexible tubing with
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TABLE 1
Clinical data of nursing experience and methods for
administering milk and molasses enemas
Nursing survey item
n (%)
Nursing experience
b1 y
3 (3.2)
1-5 y
43 (46.2)
6-10 y
18 (19.4)
11-15 y
12 (12.9)
≥ 16 y
17 (18.3)
Method of enema instillation
Flexible catheter and catheter-tip syringe
35 (38.9)
Enema bag
30 (33.3)
Enema bottle
25 (27.8)
Patient tolerance according to nurse using pain scale a
0-3
52 (55.9)
4-7
37 (39.8)
8-10
4 (4.3)
a
Patient tolerance is the nurse’s impression of the patients’ pain and response
to the enema using a numeric pain scale from 0 to 10.
a catheter-tip syringe—with the tip of the enema delivery
device advanced no further than the suggested 4 inches,
depending on patient age, to avoid perforation. 5 Wong’s
Nursing Care of Infants and Children recommends an enema
insertion length of 2.5 cm for patients weighing 5 to 10 kg,
5 cm for those weighing 11 to 30 kg, 7 cm for those
weighing 31 to 50 kg, and 10 cm for those weighing greater
than 50 kg. 5
Milk and molasses enemas were avoided in children
aged younger than 2 years. 1 Enemas were ordered at the
discretion of the treating physician. The typical enema
volume administered was 6 mL/kg with the institutional
guideline in place at the time of the study, advising no more
than 135 mL in a single osmotic enema administration. 2,3
Results
NURSING SURVEY
Twenty nurses submitted 94 responses to our online
survey after administering a milk and molasses enema,
which represents nearly half of the 200 enemas performed
from September 2010 to May 2012. Survey results
showed variable techniques of enema administration
based on the use of our institutional guideline and
written physician orders received (Table 1). Of those
surveyed, 38.9% administered enemas using a flexible
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catheter and catheter-tip syringe, 33.3% used an enema
bag, and 27.8% used an enema bottle, showing varying
practices among staff, who also had varying levels of
experience (Table 1).
CHART REVIEW
Of 500 visits during which an enema was administered or
constipation was the discharge diagnosis, 87 were
excluded. Eighteen visits were excluded because no stool
results were charted, and 17 visits were excluded because
no volume was charted for the enema administered,
although an enema was in fact given. No weight was
charted for 27 patients, and 11 visits were excluded
because patients received an enema other than a milk and
molasses enema. Fourteen visits were removed because
patients were aged younger than 2 years. Table 2 provides
a summary of the patient demographic characteristics,
weight, and chief complaint for those patients who
received a milk and molasses enema and were included
in the study.
Milk and molasses enemas were generally effective
across the different age groups. Stool output was achieved in
greater than 80% of enema administrations when given in
amounts of at least 4 mL/kg (Figure 1). The recommended
guideline within our facility of 6 mL/kg had an effectiveness
of 88% in the 106 patients who received this amount.
Patients aged younger than 10 years received a higher
volume per kilogram of milk and molasses enema than older
patients (4.5 mL/kg vs 3 mL/kg). Patients aged between 10
and 15 years of age received an average of at least 3 mL/kg
with an 80% success rate, and patients aged older than 15
years received on average less than 3 mL/kg with an 83%
success rate (Figures 1 and 2).
The results showed that an enema amount of 5 to 6 mL/
kg produced greater stool output compared with no dose
and/or smaller doses (1-4 mL/kg) (P = .056). Dosing of 5 to 6
mL/kg resulted in greater stool output compared with smaller
doses (P = .037). The results could not show whether a 5- to
6-mL/kg enema dose was more effective or less effective than
larger doses of 7 mL/kg or greater (P = .619).
Of the 500 patients who received enemas, 26 were
admitted. Two patients were admitted for reasons not
directly related to their diagnosis of constipation or
abdominal pain, such as port replacement or admitting
diagnosis of pneumonia. As for the remaining admissions, it
cannot be determined with the data available whether
admission was related to enema administration. Twentyfour patients were admitted for varying diagnoses related
to gastrointestinal complaints, including upper gastrointestinal bleed (1 patient), urinary obstruction (1 patient),
constipation (3 patients), requirement for further
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TABLE 2
Demographic characteristics and presenting chief
complaint of patients given milk and molasses
enemas.
Sex
Male
Female
Chief complaint
Abdominal pain
Chest/back pain
Constipation/change in stool
Vomiting
Dysuria
Other
Age
b 10 y
10-15 y
N 15 y
Weight
b 22 kg
22-50 kg
N 50 kg
Not documented
n (%)
268 (53.6)
232 (46.4)
349 (69.8)
11 (2.2)
72 (14.4)
38 (7.6)
5 (1)
25 (5.0)
282 (56.4)
141 (28.2)
77 (15.4)
187 (37.4)
185 (37)
101 (20.2)
27 (5.4)
FIGURE 1
Percent success rate of milk and molasses enema by dose.
7.00
Milliliters Per Kilogram
Patient characteristic
6.00
5.00
4.00
3.00
2.00
1.00
0.00
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years
Male
Female
medications (2 patients), serial abdominal examinations (10
patients), vomiting (2 patients), dehydration (2 patients),
appendicitis (1 patient), bowel obstruction (1 patient), and
syncope (1 patient), that cannot be directly correlated to the
enema administration.
Discussion
Our study provided evidence of a wide spectrum of nursing
practices in relation to enema administration; however, even
with variable administration techniques, our chart review
showed milk and molasses enemas to be safe and effective
with minimal adverse effects. Several adverse effects were
examined for in charting, on the basis of previous adverse
effects seen in studies involving milk and molasses enemas,
including allergic reactions, perforation, severe bleeding,
and shock. None of these reactions were noted while our
study was being conducted.
Small amounts of blood were noted in 9 patients’ stool
samples. Bleeding was not significant enough to require
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JOURNAL OF EMERGENCY NURSING
FIGURE 2
Average dose of milk and molasses administered (in milliliters per kilogram) by
patient age.
observation for any patients within the study. It cannot be
determined whether bleeding may be due to the passage of
hard stool or hemorrhoids, as a result of constipation or
enema administration—exhibiting the importance of rectal
examination before enema administration. 6
Similar to prior studies, our study showed that
vomiting and abdominal pain were 2 side effects
commonly seen after administration of milk and molasses
enemas. Of note, when we examined presenting chief
complaints, 69.8% of patients presented with abdominal
pain and 7.6% with vomiting before enema administration (Table 2). The percentage of patients with abdominal
pain or vomiting decreased significantly after enema
administration (Figure 3). Therefore it cannot be
determined whether these symptoms were direct results
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Wallaker et al/RESEARCH
of the enema administration or symptoms experienced
with a diagnosis of constipation.
Enema amounts and results were shown to vary with
different patient age groups. On average, patients aged
younger than 10 years received 4.5 mL/kg, patients aged 10
to 15 years received 3 mL/kg, and patients aged older than
15 years received less than 3 mL/kg. For larger dosing
amounts (N 7 mL/kg), the sample size was small in
comparison to the other groups (only 30 patients received
N 7 mL/kg). Developmental level has an impact on patient
tolerance of enema administration as well, which may
impact enema effectiveness. Recommendations suggest
retention of the enema for approximately 2 minutes before
defecation, which may be difficult in patients in early stages
of toilet training; however, longer retention leads to
increased stimulation. 5 No association was noted between
sex and enema results.
As evidenced by our nursing survey, there is varying
clinical practice among nurses in relation to administration
of milk and molasses enemas (Table 1). Other than the
nursing survey results, information was not collected on
each patient related to device used with enema administration or height of the enema catheter-tip insertion.
Several barriers exist that may impact nurses’ ability to
adhere to clinical practice guidelines. 7 Communication,
awareness of current practice guidelines, feelings toward
current practice, training, and staff workload can all have a
great impact on nursing technique, which may affect the
success rate within our study. 7 Technology can also play a
major role in compliance. When our study was being
conducted, written orders were still being used. Currently,
computer orders are in place, which may allow for increased
clarity in enema orders such as dosing and allow for a
maximum dose recommendation to increase compliance.
Limitations
Varying methods of enema administration including technique, enema amount, patient retention of enema fluid, and
experience of staff administering the enema are all limitations.
Variability may be caused by several factors, including few
models of evidence-based research available explaining the
standard protocol for administration of milk and molasses
enemas, stressing the need for a standard protocol to be
developed to aid in compliance. More information is needed
to examine whether enema amount or teaching of administration technique improves patient outcome and reduces side
effects with enema administration.
At the beginning of our study, guidelines indicated a
maximum enema dose of 6 mL/kg, with a total dose no
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10.0
5.0
5.0
4.0
0.25
Age 2-5
0.7
0.0 0.2
0.1
Age 6-10
Abdominal Pain
Vomiting
Age 11-18
Admitted
FIGURE 3
Percentage of patients with side effects after enema.
greater than 135 mL. 2,3 A maximum dose of 135 mL was
a great limitation to our study because any patient
weighing greater than 22 kg is expected to receive less
than the recommended 6 mL/kg according to hyperosmotic enema guidelines within our facility when our
study was conducted.
Implications for Emergency Nurses
Although our research shows a success rate of at least 80% in
patients receiving variable enema doses, further data are
needed to examine other variables including administration
technique, patient enema retention, and incremental dosing
of enemas with alternate maximum dosages involving
practices seen at other institutions. At the time of our study,
our institutional guideline suggested a milk and molasses
enema of no more than 135 mL for safe administration.
Further studies are needed to determine whether patients
receiving greater than 135 mL as a maximum dose have
similar success rates and no harmful side effects.
Conclusions
In this single-center study, milk and molasses enemas were
safe and effective for treating constipation in patients
ranging in age from 2 to 17 years without chronic medical
conditions. Even though various methods were used to
administer these enemas, the outcomes have shown enemas
to be effective, exhibiting minimal side effects with an
optimal success rate in patients receiving 6 mL/kg of enema
with an institutionally suggested maximum of 135 mL in
place when this study was conducted.
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Acknowledgments
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We thank Liz Lind for assistance with statistical analysis and Rachel
Sledge for volunteering to participate in our initial data collection.
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