Department of paediatric general surgery

Women’s and children’s directorate

Guideline

Bowel washouts: via the rectum – in children

1 Scope
Children’s services and special care baby unit (SCBU)/ neonatal intensive care
unit (NICU).

2 Purpose
 To standardise and improve patient care.
 To inform nursing and medical staff.
 To provide a tool for teaching.

3 Introduction
Bowel washouts and/ or laxatives can be used to empty or clean the bowel.
Whilst the use of laxatives may be seen as a simpler, less intrusive/
embarrassing method, it is essential that the underlying problem is
considered; laxatives can be contraindicated in some conditions (eg if the
child has a mechanical obstruction - stimulating peristalsis with laxatives can
cause pain +/- perforation.)

A rectal washout involves using 0.9 % sodium chloride to washout the

rectum/bowel via a rectal catheter. Rectal bowel washouts may be included
as part of a child’s care for a number of reasons:

 To deflate and clear the bowel of faeces in children with

Hirschsprung’s disease.
 To prepare the bowel for surgery/ investigation.
 As part of a treatment programme for constipation.
 To decompress the bowel and deflate the abdomen by removing gas
 To relieve low intestinal obstruction due to meconium
plug/meconium ileus in the neonate.

Hospital policies and guidelines pertaining to consent, record keeping,

relevant infection control policies, privacy and dignity and disposal of
equipment should be cross referenced with this guideline.

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Bowel washout via rectum in children

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Department of paediatric general surgery

Women’s and children’s directorate

4 Assessment of need and patient

Rectal bowel washout is an invasive procedure. Where undertaken, a clear
rationale for its use should be documented.

Prior to a rectal bowel washout being performed, the patient should be

assessed and documentation pertaining to the following recorded:

 Vomiting – frequency, colour, amount, bile stained

 Abdominal distension – tight or shiny abdomen? Degree of
distension?
 Bowel action – time since last bowel action – consistency, +/- blood

5 Who can perform a rectal bowel

washout?
A first level registered children’s nurse or member of medical staff who can
demonstrate understanding, knowledge and practical competence.

As per the NMC code of professional conduct, a nurse must ensure knowledge
and skills are kept up to date, obtain help and supervision from a competent
practitioner if an aspect of practice is beyond your level of competence and
deliver care based on current evidence and best practice.

6 Prepare the patient

 Consideration must be given to the psychological effects of rectal
procedures in children. These procedures can be regarded as intrusive/
form of assault.
 Rectal bowel washout can be a particularly distressing procedure as
the position which an older child will be placed in will obstructs his/ her
view of what the nurse is doing.
 Explain procedure to child and parents/ carer to allay fears and help
the child/ parents/ carer cope with the procedure.
 Liaise with/ refer to play specialist where appropriate to aid child’s
understanding/ provide distraction therapy
 Gain verbal consent and document that this was gained.

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Department of paediatric general surgery

Women’s and children’s directorate

7 Prepare the equipment

Having the equipment prepared ensures that the procedure can be performed
efficiently.

Equipment Rationale
Two nurses/ equivalent (in some areas one nurse and Two persons are required to
one nursery nurse may perform the rectal washout and, perform a rectal washout.
where parents are being taught, one of the persons
may be a parent).

Dressing trolley To use as a work surface

Bowl of hot tap water
Suitable bed/ cot/ babytherm.
Cots used should have cot sides which lower
completely. Cots/ beds should preferably be height
adjustable.
Neonates should preferably be placed on a babytherm.
Inco sheets
Two towels
0.9% sodium chloride (Sodium Chloride) – warmed
To warm the sodium chloride.
To lay the patient on and to
comply with lifting and handling
recommendations
The child will be exposed and
thus get a reduced body
temperature.
To protect the bed linen
One towel to protect the
patient’s dignity, the other to dry
the patient with after the
procedure has been completed
Water should never be used in
children to void the risk of water
intoxication.

Warming the sodium chloride

helps to prevent the bowel from
having spasms during the
procedure and also helps
prevent a decrease in the
child’s body temperature
Rectal catheter/ Ryles nasogastric (NG) tube of To administer and evacuate the
appropriate Fr for the child. Sodium Chloride through.
As a guide: Rectal catheters/ Ryles NG
10 Fr Premature infant tubes have large gauge eyelet
10 -12 Fr Newborn to allow easier evacuation of
14- 16 Fr Up to 8-12 weeks of age the faeces.
24 Fr 5 kg +

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Department of paediatric general surgery

Women’s and children’s directorate

Bolus feeding set To attach to the rectal catheter/

Ryles NG tube to administer
the Sodium Chloride through
Non sterile gloves and aprons for each assistant To protect uniform and prevent
cross infection
Soap/flannel For cleaning the patient at the
end of the procedure
Yellow bin bag For disposal of equipment at
the end of the procedure
Vomit bowls To collect the output
Scales To weigh the output
KY jelly To lubricate the rectal catheter
pre insertion

8 Prepare the environment

Having the environment prepared ensures that the procedure can be
performed without interruption.

 Move child to appropriate treatment area (eg treatment room)

wherever possible to ensure the child’s bed area is protected as an
area of ‘safety’ away from clinical procedures and to help prevent
interruption.
 Ensure good lighting in environment where the procedure will take
place.
 Ensure the environment will maintain the child’s privacy.
 Ensure the room used is warm (use a babytherm for neonates) as
the child will be exposed and so at risk of their body temperature
dropping.

9 Perform the rectal bowel washout

Action Rationale
Wash hands and put on disposable gown and gloves Protection of clothing and
prevention of cross infection.
Check expiry dates on equipment and that packaging is To prevent complications,
intact. minimize the risk of introducing
infection, maintain patient
safety.
Decide which assistant will (i) insert the rectal catheter
(‘nurse A’) and (ii) administer and evacuate the sodium
chloride (‘nurse B’)

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Department of paediatric general surgery

Women’s and children’s directorate

Position all equipment ready for use: The nurse inserting the catheter
Place bowl of hot water onto trolley. needs easy access to the
Place bottles/ bags of Sodium Chloride into the bowl of catheters and KY jelly. The
hot water. other assistant needs access to
Ensure all equipment is within easy reach of the relevant the warmed 0.9% Sodium
nurse/ assistant. Chloride and vomit bowls.
Child’s lower clothing garments should be removed and To prevent soiling of child’s
a dry towel placed over the patient. clothing and to aid in keeping
the child warm.

Place a number of disposable pads under the patient. Protection of bed linen, maintain
patient’s comfort and dignity. By
placing a number of pads under
the patient initially, the wet one’s
can be removed and a dry one
is immediately available
underneath.

Position the patient: Maintain patients comfort whilst

In infants, position as is most comfortable for the child. increasing the ease of the
This is usually on their back (supine) but any position procedure.
can be adopted.
In older children, position the patient laying on their left
side with knees bent up to the abdomen.

Nurse ‘A’ should locate the anus then apply some KY To lubricate the catheter
jelly to the tip of the rectal catheter and then gently insert
the catheter into the rectum until all the ‘eyes’ on the If all the eyes are not inside the
catheter are inside the anus. anus the sodium chloride will
not run up into the bowel but
instead, will run straight out onto
the bed.
Nurse ‘B’ primes the giving set then connects the giving
set to the end of the catheter with the clamp on.

Nurse ‘B’ then pours approximately 20 mls of the warm

Sodium Chloride into the syringe (10mls in pre-term
neonates), then, holding the syringe up at shoulder
height, releases the clamp to allow the Sodium Chloride
to run into the patient via gravity.
Once all the sodium chloride has run in, nurse ‘B’ should
invert the syringe downwards below the level of the bed/
cot and allow the faeces stained output to run into the
vomit bowl.
Nurse A should leave the rectal tube in the rectum.

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Women’s and children’s directorate

Nurse ‘B’ repeats running in the sodium chloride (use 20 To completely clear the faeces.
ml each time in a newborn, 50 mls in an older child and
up to 100mls in a teenager) and allowing it to run out
again until the output runs clear (this may take a total of
200 mlsplus in a newborn and up to 2 litres in an older Removing the rectal catheter
child). Nurse ‘A’ should keep the rectal catheter in place each time can cause irritation to
throughout. the bowel wall.

Once the output is running clear, nurse ‘B’ should hold

the syringe over a vomit bowl whilst Nurse ‘A’ slowly
withdraws the catheter 2-4 cm. Once there is no free
running fluid, Nurse ‘A’ should remove the catheter a
further 2-4cms and pause again whilst any remaining
fluid is removed. Continue until the entire catheter has
been removed.

In an older patient it is useful to ask the child to sit on the

toilet/ commode and try to evacuate any stool/ sodium
chloride that may still be in the bowel.

Always weigh the output and document In infants (especially premature

infants) there is a risk of
reabsorption of sodium chloride.
In the case of retention of the
sodium chloride, contact the
surgical team; consider
checking the child’s electrolytes.
Clean the patient and dry the area

Dispose of equipment as per hospital policy

Document the time of the procedure, total volume of

Sodium Chloride used and total volume of output.
Where applicable, also document the reduction in
abdominal distension.

10 Problem solving tips

Problem Action to be taken
Child experiences spasm during the Ensure the Sodium Chloride being used has been
washout warmed sufficiently. If the Sodium Chloride is cold
spasms are more likely to occur.

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Bowel washout via rectum in children

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Department of paediatric general surgery
Women’s and children’s directorate
Sodium Chloride is bypassing the
catheter
The Sodium Chloride is not running
down the administration set
The Sodium Chloride has been
administered but has not run out
again since the syringe was inverted
The catheter keeps blocking
Cambridge University Hospitals NHS Foundation Trust
Bowel washout via rectum in children
Version 4; Approved February 2015
 Nurse ‘A’ should firstly attempt to insert the
catheter further (up to max of 10 cms in an
infant/30 cms in an older child).
 If the problem persists, attempt to insert a
larger gauge of rectal tube
 The catheter may be blocked. Remove, assess
and clear if necessary.
 If the problem still persists this may be due to
the severe degree of faecal impaction and very
hard stool. Ensure the Sodium Chloride is
warm to assist in breaking down the stool,
consider using enemas between washouts to
break down the stool. Where stools are very
hard and washouts fail, a manual evacuation
under GA may be required.
 This may be because the tip of the catheter is
against the bowel wall. Nurse ‘A’ should
remove the catheter slightly and reinsert to
reposition it.
 This may be because the catheter has become
blocked with faeces, remove and assess and
clear the tube if necessary.
 This may be because of a vacuum within the
administration set. Use the palm of your hand/
plunger from the syringe to cover the top of
the syringe and then remove again. This will
usually clear the vacuum.
 This may be because the catheter is against the
bowel wall. Nurse ‘A’ should rotate the tube/
slightly reposition it by inserting further/ removing
slightly.
 This may be because the catheter is blocked,
remove, assess and clear if necessary
 This may be because the volume administered
was insufficient, pour in further Sodium Chloride
and reassess. If the Sodium Chloride still does
not run out, contact the nurse specialist/ medical
or surgical team.
Attempt to use a larger gauge of catheter (rectal
catheter 24 Fr can often be used in a 5kg baby with
a normal anus)
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Department of paediatric general surgery

Women’s and children’s directorate

The measured volume of output is
less than that of the Sodium
Chloride administered
 Ascertain how much fluid may have bypassed
onto the sheets and therefore cannot be
measured accurately.
 If there is a significant difference in volumes
(ie over 20 mls in a neonate, 100 mls in a
baby, over 500 mls in an adolescent), re insert
a rectal catheter to clear the Sodium Chloride
solution
 Observe the child’s output into the nappy/
toilet over the next two hours as the Sodium
Chloride will usually spontaneously pass out.
 Inform the child’s medical/ surgical team if
concerns persist.

11 Monitoring compliance with and the

effectiveness of the guideline
Every child should receive care as per this guideline (unless otherwise
documented by the named consultant in the child’s medical notes).
Breaches of the guideline will be picked up and monitored by the incident
reporting system and discussed at the quarterly clinical governance meetings.

12 References
Bonnard A et al (2003) Definitive treatment for extended Hirschsprung’s
disease or total colonic form:- laparoscopic pull through technique. Pediatric
Endosurgery & Innovative Techniques 7(3) 255-260

Ghosh A, Griffiths D M (1998) Rectal biopsy in the investigation of

constipation. Archives of Diseases of the Child 79: 266-268

Johnson H (2005) Rectal Washout Clinical procedure. Great Ormond Street

Hospital For Children NHS Trust, London

Lim C, Dohle S (2005) Neonatal Bowel washout (Rectal) Clinical Guidelines.

Royal Children’s Hospital, Melbourne
http://www.rch.org.au/rchpg/index.cfm?doc_id=9220

Royal College of Nursing (2003) Digital rectal examination and the manual
removal of faeces: The role of the nurse. Third edition. London, RCN
Publishing Company

Royal College of Nursing (2003) Digital rectal examination: Guidance for

nurses working with children and young people. London, RCN Publishing
Company.

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Bowel washout via rectum in children

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Women’s and children’s directorate

Teitelbaum D H et al (2000) A decade of experience with the primary pull
through for Hirschsprung’s disease in the newborn period. Annals of Surgery
232(3) 372-380.

Equality and diversity statement

This document complies with the Cambridge University Hospitals NHS
Foundation Trust service equality and diversity statement.

Disclaimer
It is your responsibility to check against the electronic library that this
printed out copy is the most recent issue of this document.

Document management
Approval: Paediatric surgery- 12 February 2015
Owning department: Paediatric general surgery
Author(s): xxx
File name: 387160851.rtf
Supersedes: Version 3, March 2012
Version number: 4 Review date: February 2018
Local reference: Media ID: 3186

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