Continuing Education Module 19: Child Health

Administration of rectal suppositories in children

It is important to take steps to limit distress and discomfort during the administering of rectal suppositories in children, writes Naomi Bartley

Table 1 Administration of rectal suppositories

Indications for administration Potential complications Contraindications • Deliver medication • Anxiety, embarrassment • Paralytic Ileus • Oral route contraindicated (nil orally, • Local trauma or discomfort • Colonic obstruction nausea or vomiting) • Specific adverse effects of individual • Chronic constipation • Alternative to an injection (for a very ill medication • Post-operative gastro-intestinal or child) • Risk of bleeding (children with bleeding gynaecological surgery • Empty the bowel prior to surgery or disorders) • Caution: children with acute endoscopic examination exacerbation of inflammatory • Local treatment of haemorrhoids or anal bowel disease, diarrhoea, rectal pruritus trauma, active rectal bleeding or • Treatment of constipation (after any condition predisposing to rectal alternatives of diet or oral laxatives) injury or abscess • Suspicion of abuse

Consider and discuss child and parental preferences

The administration of rectal medication is frequently performed tinal mucosa or have systemic effects. They dissolve at body in children’s nursing and is often viewed as a basic skill. However, temperature4 and are absorbed via the intestinal blood sup- it may hold potential risks.1 Children may view this procedure as ply. Absorption may be unreliable if a stool is present in the distressing and embarrassing and appropriate knowledge and rectum and/or if medication is passed along with a stool after skills are essential in order to ensure safe and effective care. administration.5 Nursing priorities include individual child assessment, medica- Common medications administered via this route are anal- tion knowledge, safe medication practices and the promotion of gesics, sedatives and anti-emetics.6 Suppositories are generally optimum comfort for the child. indicated for use in infants and young children. Adopting an evidence-based approach to this procedure pro- Administration motes safe practice while creating a more positive experience for It is important to limit distress during the administration of a the child. This article presents a structured approach to admin- suppository as some children may find the procedure uncomfort- istering rectal suppositories to children, which aims to minimise able or embarrassing. Each child should be individually assessed distress, and ensure correct administration and optimal efficacy to determine their suitability for the procedure. Meanwhile, of the medication. explaining the process fully to both the child and parent will Rectal suppositories improve co-operation and trust. A suppository is a solid bullet-shaped preparation,2 which is If possible, encourage the child to empty their bowels prior inserted into the rectum. It is administered when the oral route to the administration of the suppository. This will avoid the is not acceptable or when a local effect on the bowel is required medication being expelled prior to its absorption3 and it will (see Table 1). also improve the efficacy of the medication. Older children There are two types of suppositories:3 may be able to self-administer their medication with some • A stimulant suppository – stimulates bowel activity, softens stool supervision. (for example, glycerine, sodium bicarbonate) Insertion technique • A retention suppository – delivers medication (for example, Debate exists in relation to the insertion technique of paracetamol). suppositories.7 Inserting the blunt end first has been advocated in Suppositories may exert a local effect on the gastrointes- order to improve retention.8 However, manufacturer’s instructions

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Child Health-June(RecSupp).indd 1 22/05/2012 10:55:54 Clinical Focus 2012

Table 2

Insertion of rectal suppositories

Before the procedure • Gather all necessary equipment including: medication; child’s chart; prescription sheet; disposable incontinence sheet; tissues; bedpan; toilet or commode (if appropriate); gloves and apron; water-based lubrication gel; bravery certificates or stickers (if available) • Explain the procedure to the child and family • Encourage the child to empty their bowels • Ensure a bedpan, toilet, commode or call bell is easily accessible • Ensure medication has been stored as per manufacturer’s instructions (certain suppositories should be refrigerated) • Remove all wrapping from suppository and ensure the medication is intact • To ensure accurate medication dosage – do not cut suppositories9 • Place an incontinence pad underneath the buttocks (to prevent soiling of linen and distress to the child)

Administering the suppository • Ensure privacy for the child, covering them with a blanket to maintain dignity and prevent embarrassment • Wash your hands, put on a disposable apron and gloves to reduce the potential transfer of micro-organisms • Lie the child on their left side with their knees bent and drawn up towards the abdomen. This position allows gravity to assist with the passage of the medication3 • Ask the child to take slow deep breaths to relax the anal sphincter • Visualise the peri-anal area, assess for abnormalities • Lubricate the apex of the suppository with lubricating gel • Insert the suppository apex first into the child’s rectum, just past the internal sphincter9 • Gently hold the buttocks for five to 10 minutes, if possible to reduce pressure on the anal sphincter and also risk of expelling medication9 • Clean away any lubricating jelly to prevent anal irritation and ensure comfort • Administer all medications safely as per local nursing policies10

After the procedure • Encourage the child to retain the medication for 20 minutes or as long as possible to enhance medication absorption3 • Dispose of equipment appropriately and wash your hands • Reassure and praise the child, and ensure they are comfortable • Record the medication administration as per local policy, monitor effectiveness of the medication • If stool or medication is expelled immediately post-administration, report to medical staff and document within the nursing notes

usually advise that suppositories should be inserted apex first. of medicine. In Fundamental aspects of children’s and young people’s nursing procedures (Glasper A, Aylott M, Prudhoe G. Eds). Quay Books, 2007: 123-80 As there is little evidence to support this change in practice, 3. Dougherty L, Lister S. Manual of clinical nursing procedures, 7th Edn, Blackwell suppositories should be administered in accordance with the Science, Oxford; 2008 manufacturer’s instructions. 4. Higgins D. Administering a suppository. Nursing Times. 2007; 103(10): 26-7 5. Algren CL, Arnow D. Pediatric variations of nursing interventions. In Wongs’ Administration of suppositories is an invasive experience for nursing care of infants and children, (Hockenberry MJ, Wilson D. Eds.), Mosby Elsevier: any child. Table 2 presents a standardised approach to admin- Missouri; 2007; 8th edn: 1083-139 6. Bindler RC, Ball JW. Clinical skills manual for pediatric nursing, 4th Edn., Pearson istering rectal suppositories to children so as to create minimal Prentice Hall, New Jersey; 2008 distress. 7. Bradshaw A, Price L. Rectal suppository insertion: the reliability of the evidence as a basis for nursing practice, J Clinical Nursing. 2005; 16(1): 98-103 Naomi Bartley is a clinical placement co-ordinator in Our Lady’s Children’s 8. Abd-El-Maeboud K, El-Nagger T, El-Hawi E, Mahound S, Abd-El-Hay S. Rectal Hospital, Crumlin in Dublin suppository: commonsense and mode of insertion, The Lancet 1991; 338(8770): 798- References 800 1. Ford L, Maddox C, Moore E, Sales R. The safe management of medicines for children. 9. Barron C, Hollywood E. Drug administration. In Clinical Skills in Children’s Nursing In Practices in Children’s Nursing: Guidelines for Community and Hospital (Trigg E, (Coyne I, Neill F, Timmins F, Eds.), Oxford University Press, Oxford; 2010: 147-81 Mohammed TA, Eds). Edinburgh; Churchill Livingstone, 2010; 3rd edn: 45-74 10. An Bord Altranais. Guidance to nurses and midwives on medication management, 2. Barrett G, Fletcher T, Russell T. Fundamental aspects to safe administration An Bord Altranais: Dublin; 2003

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