# Intranasal Midazolam Prior to Enema for Management of Constipation in the Pediatric Emergency Department

## TL;DR

This study examines whether giving midazolam to children before an enema improves bowel movement success in treating constipation in the emergency department.

## Contribution

The study is the first to evaluate intranasal midazolam's effect on enema success in pediatric constipation management.

## Key findings

- Intranasal midazolam did not significantly improve overall bowel movement success rates.
- Preschool-aged children showed a small improvement in success rates with midazolam.
- Midazolam was linked to longer emergency department stays and higher admission rates.

## Abstract

Introduction: Constipation is a common complaint in the pediatric emergency department (PED). Management often includes an enema administered in the PED, especially for children with significant discomfort or those who have failed outpatient therapy with oral bowel motility agents. Enema administration can be anxiety-provoking and may cause children to further withhold stool. Midazolam, a rapid-acting benzodiazepine, is sometimes given prior to an enema for anxiolysis. This study evaluated the effect of intranasal midazolam on the success rate of bowel movement after an enema for the management of constipation in the pediatric emergency department (PED).

Methods: Retrospective cohort study at a single, academic, quaternary-care hospital. Patients 2 to 10 years of age receiving at least one enema for management of constipation from May 1, 2016, through April 30, 2021, were included. Exclusion criteria include neurodevelopmental disorders, prior abdominal surgeries, or administration of any non-intranasal midazolam anxiolytic agents. The primary outcome was the success of bowel movement in the emergency department (ED). Secondary outcomes included ED length-of-stay (LOS), enema-to-discharge time, number of enemas administered, and admission rates.

Results: Intranasal midazolam was administered in 214 (27%) out of 795 encounters. There was no difference in rates of successful bowel movements between the midazolam and no-midazolam groups (83.6% vs. 84.2%, respectively). When stratified by age in multivariate regression analysis, the rate of bowel movement success was higher in preschool-aged children receiving midazolam (ARR 1.09; CI 1.01-1.18, p=0.032). Midazolam was associated with longer ED LOS (271 min vs. 235 min, p=0.004), longer enema-to-discharge time (121 min vs. 93 min, p < 0.001), more frequent administration of multiple enemas (14% vs. 7%, p=0.021), and higher admission rates (7% vs. 2%, p=0.002).

Conclusions: Intranasal midazolam prior to enema administration was not associated with an overall higher rate of successful bowel movement in the PED. Pre-school-aged children showed a small improvement in bowel movement success with midazolam. Midazolam administration was associated with worse secondary outcomes, but there are likely other confounding factors such as severity of illness. Intranasal midazolam may provide benefits to preschool-aged children, but a prospective study is needed to confirm this finding.