Intussusception is a common abdominal emergency in children with significant morbidity.
Prompt diagnosis and management reduces associated risks and the need for surgical
intervention. Despite widespread agreement on the use of contrast enema as opposed
to surgery for initial management in most cases, debate persists on the appropriate
contrast medium, imaging modality, pharmacological adjuvant, and protocol for delayed
repeat enema, and on the best approach for surgical management for intussusception
in children. To assess the safety and effectiveness of non‐surgical and surgical approaches
in the management of intussusception in children. We searched the following electronic
databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8)
in the Cochrane Library; Ovid MEDLINE (1950 to September 2016); Ovid Embase (1974
to September 2016); Science Citation Index Expanded (via Web of Science) (1900 to
September 2016); and BIOSIS Previews (1969 to September 2016). We examined the reference
lists of all eligible trials to identify additional studies. To locate unpublished
studies, we contacted content experts, searched the World Health Organization International
Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (September 2016),
and explored proceedings from meetings of the British Association of Paedatric Surgeons
(BAPS), the American Soceity of Pediatric Surgery, and the World Congress of Pediatric
Surgery. We included all randomised controlled trials comparing contrast media, imaging
modalities, pharmacological adjuvants, protocols for delayed repeat enema, and/or
surgical approaches for the management of intussusception in children. We applied
no language, publication date, or publication status restrictions. Two review authors
independently conducted study selection and data extraction and assessed risk of bias
using a standardised form. We resolved disagreements by consensus with a third review
author when necessary. We reported dichotomous outcomes as risk ratios (RRs) with
95% confidence intervals (CIs). We analysed data on an intention‐to‐treat basis and
evaluated the overall quality of evidence supporting the outcomes by using GRADE criteria.
We included six randomised controlled trials (RCTs) with a total of 822 participants.
Two trials compared liquid enema reduction plus glucagon versus liquid enema alone.
One trial compared liquid enema plus dexamethasone versus liquid enema alone. Another
trial compared air enema plus dexamethasone versus air enema alone, and two trials
compared use of liquid enema versus air enema.
We identified three ongoing trials. We judged all included trials to be at risk of
bias owing to omissions in reported methods. We judged five of six trials as having
high risk of bias in at least one domain. Therefore, the quality of the evidence (GRADE)
for outcomes was low. Interventions and data presentation varied greatly across trials;
therefore meta‐analysis was not possible for most review outcomes. Enema plus glucagon
versus enema alone It is uncertain whether use of glucagon improves the rate of successful
reduction of intussusception when compared with enema alone (reported in two trials,
218 participants; RR 1.09, 95% CI 0.94 to 1.26; low quality of evidence ). No trials
in this comparison reported on the number of children with bowel perforation(s) nor
on the number of children with recurrent intussusception. Enema plus dexamethasone
versus enema alone Use of the adjunct, dexamethasone, may be beneficial in reducing
intussusception recurrence with liquid or air enema (two trials, 299 participants;
RR 0.14, 95% CI 0.03 to 0.60; low quality of evidence ). This equates to a number
needed to treat for an additional beneficial outcome of 13 (95% CI 8 to 37). It is
uncertain whether use of the adjunct, dexamethasone, improves the rate of successful
reduction of intussusception when compared with enema alone (reported in two trials,
356 participants; RR 1.01, 95% CI 0.92 to 1.10; low quality of evidence ). Air enema
versus liquid enema Air enema may be more successful than liquid enema for reducing
intussusception (two trials, 199 participants; RR 1.28, 95% CI 1.10 to 1.49; low
quality of evidence ). This equates to a number needed to treat for an additional
beneficial outcome of 6 (95% CI 4 to 19). No trials in this comparison reported on
the number of children with bowel perforation(s) or on the number of children with
recurrent intussusception nor any intraoperative complications, such as bowel perforation,
or other adverse effects. Only one trial reported postoperative complications, but
owing to the method of reporting used, a quantitative analysis was not possible. We
identified no studies that exclusively evaluated surgical interventions for management
of intussusception. This review identified a small number of trials that assessed
a variety of interventions. All included trials provided evidence of low quality and
were subject to serious concerns about imprecision, high risk of bias, or both. Air
enema may be superior to liquid enema for successfully reducing intussusception in
children; however, this finding is based on a few studies including small numbers
of participants. Dexamethasone as an adjuvant may be more effective in reducing intussusception
recurrence rates following air enema or liquid enema, but these results are also based
on a few studies of small numbers of participants. This review highlights several
points that need to be addressed in future studies, including reducing the risk of
bias and including relevant outcomes. Specifically, surgical trials are lacking, and
future research is needed to address this evidence gap. Management of intussusception
in children Review question How is intussusception best managed in children? Background
Intussusception is a medical emergency that occurs in children when a part of the
bowel 'telescopes' (folds) into another part of the bowel. This causes pain, vomiting,
and obstruction, preventing passage. If left untreated, the bowel can perforate, resulting
in passage of its contents into the abdominal cavity, causing further complications.
In rare cases, these events can cause death. Prompt diagnosis and management reduces
associated risks and the need for surgery. Once intussusception is diagnosed, most
doctors agree on the use of enema as initial treatment. This procedure involves introducing
a substance (air or liquid) into the bowel, via the rectum, with a particular pressure
that reduces the 'telescoped' bowel into its normal position. Debate persists on specifics
regarding what type of substance should be used for the enema, how the substance is
visualised during the process, whether extra medications should be given to enhance
treatment, and how one should deal with treatment failure, as well as the best approach
to surgical management of intussusception in children. Study characteristics Evidence
is current to September 2016. We identified six randomised studies, with a total of
822 participants, that explored the management of intussusception in children and
assessed different types of interventions. We also identified three ongoing trials.
Main results The main outcome was the number of children with a successfully reduced
intussusception. Furthermore, outcomes included the number of children returning with
a recurrent intussusception and evaluation of harms (adverse events) resulting from
the interventions. Evidence from two studies suggests that using air for the enema
to reduce intussusception is superior to using liquid for the enema. Evidence from
two studies also suggests that giving the child with intussusception a steroid medication,
such as dexamethasone, may reduce the recurrence of intussusception, irrespective
of whether liquid or air is used for the enema.
We identified only sparse information on intraoperative and postoperative complications
and on other adverse events. Quality of the evidence Of the six trials identified,
we considered all to be potentially biased owing to lack of detail in reporting of
how each study was undertaken. We found lack of consistency in how outcomes were defined
and measured. All included studies were subject to serious concerns of imprecision
based on few events, wide confidence intervals,or high risk of bias, Overall, we concluded
that the quality of evidence provided by these studies was low, and that the real
effects may differ significantly from those noted in these studies.
Further research is needed to help doctors better understand the most effective way
to manage intussusception in children.