Information about the use of Fleet enemas in children PSA #1: Both the adult and pediatric Fleet enemas that are sold OTC and are available to order in Epic contain phosphate. There is a misconception amongst many providers in the hospital that the pediatric Fleet is just saline and glycerin – this is not true PSA #2: Phosphate enemas can cause serious injury to patients with underlying renal disease, severe dehydration, and hyperphosphatemia. I know that all of you know this, but I have been asked to state it! PSA #3: There is essentially a black box warning from the FDA that states phosphate enemas should not be used in children under the age of 2. The reason listed is “risk of severe dehydration and serum electrolyte abnormalities leading to serious complications such as acute kidney injury, arrhythmias, and death” So in response to these issues, you will see a few changes in Epic: 1. There will be a hard stop for ordering a phosphate based Fleet enema in children <2 years of age. You simply will not be able to order this in the inpatient setting and you will be given a suggestion to consider something else. Pedia-Lax enemas are OK in this age group as they are simply glycerin 2. In patients over the age of 2, if the patient has a creatinine or phosphate level in the system and they are abnormal, a warning/best practice alert will pop up in Epic warning of using phosphate based enemas in this population and offering alternative selections. Unfortunately due to limitations in Epic, it will not raise an alert if no electrolytes are in the system. 3. The pharmacy will be working with the Epic team to make it more clear that adult and pediatric Fleet enemas contain phosphate by putting that into the product name as currently they just pop up as “adult Fleet enema” and “pediatric Fleet enema” and don’t indicate the presence of phosphate Other enema options to consider in children: Pedia Lax enemas (packaging says “liquid glycerin suppositories”), which contain 4 mL of liquid glycerin are easy and safe to use in infants and small children. These do not contain any phosphate so despite the label saying age 2+, we have safely used these in infants for years. This should be your first line agent if enema is needed in the younger age group Docusate enema (EnemeezÒ) contains 238 mg of docusate in a 5mL liquid vehicle. This also does not contain phosphate and can be helpful in older children but not infants Saline and glycerin (or soap) enemas – these can be mixed and administered using a variety of different methods including a Foley catheter, emptied Fleet enema container, etc. If you are considering this type of enema, please discuss with attending for further direction
Information about the use of Fleet enemas in children
Guideline · May 2020 · 2 min read
In brief
In brief
Clinical guidance on the appropriate use of sodium phosphate (Fleet) enemas in pediatric patients, including indications, dosing considerations, and safety precautions for constipation management and bowel preparation.
Written by the GCMD Library team from the guideline.
Fleet Enema Composition and Common Misconceptions
Both adult and pediatric over-the-counter Fleet enemas contain phosphate, contrary to widespread provider belief that pediatric formulations contain only saline and glycerin. This misconception has led to inappropriate use in vulnerable patient populations. All Fleet enema products available for ordering in Epic are phosphate-based preparations.
Safety Risks of Phosphate Enemas
Phosphate enemas pose serious risks in patients with renal disease, severe dehydration, or hyperphosphatemia, potentially causing acute kidney injury, electrolyte abnormalities, and cardiac arrhythmias. The FDA has issued a black box warning against use in children under 2 years due to risk of severe dehydration, electrolyte disturbances, and death. These complications can occur even with single-dose administration in high-risk populations.
Epic System Safety Modifications
A hard stop has been implemented preventing phosphate enema orders in children under 2 years, with system prompts suggesting safer alternatives like Pedia-Lax. For children over 2 years, best practice alerts will trigger if abnormal creatinine or phosphate levels are present in the system, though alerts cannot fire if no laboratory values are available. Product naming will be updated to clearly indicate phosphate content in all Fleet enema formulations.
Safe Alternative Enema Options
Pedia-Lax liquid glycerin suppositories (4 mL glycerin) are phosphate-free and recommended as first-line for infants and young children despite labeling for age 2 and above. Docusate enemas (Enemeez, 238 mg in 5 mL) provide a phosphate-free option for older children but are not appropriate for infants. Custom saline-glycerin or soap enemas can be prepared using Foley catheters or emptied Fleet containers, but require attending physician consultation for proper technique and volume guidance.
Statements in this guideline
Both adult and pediatric Fleet enemas sold over-the-counter and available to order in Epic contain phosphate.
Phosphate enemas can cause serious injury to patients with underlying renal disease, severe dehydration, and hyperphosphatemia.
The FDA states phosphate enemas should not be used in children under the age of 2 due to risk of severe dehydration and serum electrolyte abnormalities leading to serious complications such as acute kidney injury, arrhythmias, and death.
A hard stop will prevent ordering phosphate-based Fleet enemas in children under 2 years of age in the inpatient setting.
Pedia-Lax enemas are acceptable in children under 2 years of age as they contain only glycerin.
In patients over the age of 2, if the patient has an abnormal creatinine or phosphate level in the system, a warning will appear in Epic when ordering phosphate-based enemas.
Pedia-Lax enemas contain 4 mL of liquid glycerin, do not contain phosphate, and have been safely used in infants for years despite labeling indicating age 2 and above.
Pedia-Lax enemas should be the first-line agent if an enema is needed in the younger age group.
Docusate enema (Enemeez) contains 238 mg of docusate in a 5 mL liquid vehicle, does not contain phosphate, and can be helpful in older children but not infants.
If considering saline and glycerin or soap enemas, discuss with attending for further direction.