The Appropriateness of Glycerin Enema in Pediatric Patients Visiting the Emergency Department
Round 1
Reviewer 1 Report
In this paper the Authors analyze the efficacy of of Glycerin Enema in Pediatric Patients Visiting the Emergency Department Using the Leech Score. It is a debated and interesting topic about a common condition in HD patients. A comprehensive and extensive literature review of the NCBI database PubMed was also carried out. The article was well conducted and it is interesting in its fields. It is a well-structured paper, written in good English and the References are up dated.
Minor issues:
In the “discussion” section I suggest to better analyze the diagnostic process of constipated patients. In fact, a proper diagnostic process should combine, in addition to clinical and instrumental values, several clinical/physiatric parameters such as puborectalis muscle function, perineal defense reflex, agonist and antagonist muscle synergies, and last but not least, postural examination (lumbar lordosis) and respiratory function.. Therefore the following papers should be considered:
“Clinical and instrumental parameters in patients with constipation and incontinence: their potential implications in the functional aspects of these disorders.Brusciano L, Limongelli P, del Genio G, Rossetti G, Sansone S, Healey A, Maffettone V, Napolitano V, Pizza F, Tolone S, del Genio A. Int J Colorectal Dis. 2009 Aug;24(8):961-7. doi: 10.1007/s00384-009-0678-2. Epub 2009 Mar 7..”
“An imaginary cuboid: chest, abdomen, vertebral column and perineum, different parts of the same whole in the harmonic functioning of the pelvic floor.Brusciano L, Gambardella C, Tolone S, Del Genio G, Terracciano G, Gualtieri G, Schiano di Visconte M, Docimo L. Tech Coloproctol. 2019 May 7. doi: 10.1007/s10151-019-01996-x.”
Author Response
Thank you very much for your good evaluation of our research. As recommended, the contents of the diagnosis process for constipation patients have been added as follows.
“To diagnose constipation, not only clinically, but also various tools such as abdominal anal examination, clinical physiatric assessment, and instrumental evaluation can be used. It is a disease that is easily encountered but has a variety of diagnostic approaches.24,25”
Reviewer 2 Report
This is an important topic. Enemas are a commonly used therapy for children presenting to emergency departments with constipation or abdominal pain, but little literature exists to guide clinical decisions or the selection of a solution.
This study attempts to show that a big proportion of enemas are performed in PEDs inappropriately. Patient care could be impacted by this research by acknowledging that glycerin enema was inappropriately prescribed and by identifying factors that influence the prescription of glycerin enema in the pediatric emergency department (PED).
By the authors’ description of aims, this research could be the subject of an audit of clinical practices and the identification of factors contributing to the inappropriate use of enemas would be a meaningful basis of modification of clinical practices.
There are several shortcomings regarding this research.
The authors indicate factors affecting proper enema administration but fail to recognize, comment and offer explanations for the factors leading to enema administration when it is not indicated and this is the main issue to be discussed, since their data suggest that for nearly each case of appropriate administration they recorded a case of inappropriate administration (446/552). Most relevant studies suggest that treating physicians determine that enema therapy is indicated according to usual clinical practice or local/institutional guidelines.
Title “….Using the Leech Score” can be omitted- it is the criterion used to judge the appropriateness
Page 3 and table 1: “inadequate / adequate” appears instead of inappropriate
Author Response
- The authors indicate factors affecting proper enema administration but fail to recognize, comment and offer explanations for the factors leading to enema administration when it is not indicated and this is the main issue to be discussed, since their data suggest that for nearly each case of appropriate administration they recorded a case of inappropriate administration (446/552). Most relevant studies suggest that treating physicians determine that enema therapy is indicated according to usual clinical practice or local/institutional guidelines.
 Thank you for the detailed review. As the reviewers pointed out, this study failed to identify the factors that influence inappropriate enema. However, unlike what the researchers predicted, there was no difference according to the level of the treating physicians, so the current diagnosis and treatment of fecal impaction depend only on the experience of each physician without the precise diagnosis criteria and guidelines or the established policies of each institution. Therefore, we have added the limitations of the findings of this study to the discussion, and we believe that further prospective studies are needed to overcome them.
“Apart from symptoms, nonspecific abdominal pain and acute gastroenteritis were more common diagnoses in inappropriate enema. Non-specific abdominal pain is a diagnosis that leads to abdominal pain that is less likely to be an organic cause32. Acute gastroenteritis refers to symptoms of diarrhea or vomiting33. It is interpreted that, regardless of diagnosis, enema was often performed to improve symptoms (abdominal pain, vomiting, etc.). Enema was a commonly used treatment for children who visited the emergency room for gastrointestinal symptoms. However, the decision-making for the enema depends on the doctor's experience and hospital policy, rather than the exact diagnostic decision-making. Therefore, it is necessary to diagnose fecal impaction and conduct disimpaction through appropriate diagnostic pathway.”
“Finally, in this study, we failed to find any factors affecting the inadequate enema., However, the study was a retrospective study, and there were limitations that were evaluated using one diagnostic tool using Leech score. In the future, a prospective registry and study is needed to apply an accurate diagnosis and treatment pathway using the diagnostic criteria of fecal impaction.”
- Title “….Using the Leech Score” can be omitted- it is the criterion used to judge the appropriateness
 Thank you for the detailed review. We have deleted it as advised by the reviewer.
- Page 3 and table 1: “inadequate / adequate” appears instead of inappropriate
 Thank you for the detailed review. We have corrected the point you pointed out.
Round 2
Reviewer 2 Report
The authors addressed the recommendations
