Management for intussusception in children

Steven Gluckman; Jonathan Karpelowsky; Angela C Webster; Richard G McGee

doi:10.1002/14651858.CD006476.pub3

Cochrane Database of Systematic Reviews

Tratamiento de la invaginación intestinal en niños

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DOI:

https://doi.org/10.1002/14651858.CD006476.pub3 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

01 junio 2017see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Colorrectal

Copyright:

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Steven Gluckman

University of Sydney, Sydney Adventist Hospital, Sydney, Australia
Jonathan Karpelowsky

Department of Paediatric Surgery, Children's Hospital at Westmead, Sydney, Australia
Angela C Webster

Sydney School of Public Health, The University of Sydney, Sydney, Australia
Richard G McGee

Correspondencia a: Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, Australia

[email protected]

Contributions of authors

SG: running searches, selecting studies, extracting data, analysing results, and writing the main review.

JK: drafting the protocol, identifying studies, and providing content area advice.

ACW: drafting the protocol and providing methodological advice.

RGM: drafting the protocol, running searches, selecting studies, extracting data, analysing results, and writing the main review.

Declarations of interest

Review authors have no conflicts of interest to declare.

Acknowledgements

Jooly Joseph and Madan Mohan Palliyil wrote an initial protocol for this review in 2007. We would like to thank Tanvir Kapoor for helping to draft the updated protocol. We would also like to thank the Cochrane Colorectal Cancer Review Group (Managing editor, Information specialist, editors and referees) for support and guidance provided.

Version history

Published

Title

Stage

Authors

Version

2017 Jun 01

Management for intussusception in children

Review

Steven Gluckman, Jonathan Karpelowsky, Angela C Webster, Richard G McGee

https://doi.org/10.1002/14651858.CD006476.pub3

2013 Oct 30

Surgical and non‐surgical management for intussusception in children

Protocol

Tanvir Kapoor, Richard G McGee, Jonathan Karpelowsky, Michael Su, Angela C Webster

https://doi.org/10.1002/14651858.CD006476.pub2

2007 Apr 18

Surgical and non‐surgical management for intussusception in children

Protocol

Tanvir Kapoor, Richard G McGee, Jonathan Karpelowsky, Michael Su, Angela C Webster

https://doi.org/10.1002/14651858.CD006476

Differences between protocol and review

In contrast to our published protocol, we decided to conduct the analysis using fixed‐effect meta‐analysis because it is more conservative in the presence of heterogeneity and small‐study effects. Although not specifically stipulated in the protocol, we saw both quasi‐RCTs and cluster RCTs as fit for inclusion in this review.

When data were missing, and intention‐to‐treat analysis was not possible, we planned to use available‐case or per‐protocol analysis.

Although we did not discuss these matters in the protocol, we used the GRADE approach and 'Summary of findings' tables to summarise our findings.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Child; Humans;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram for identification of randomised trials exploring management of intussusception in children.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 Enema plus glucagon versus enema alone, Outcome 1 Successfully reduced intussusception.

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Analysis 2.1

Comparison 2 Enema plus dexamethasone versus enema alone, Outcome 1 Successfully reduced intussusception.

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Analysis 2.2

Comparison 2 Enema plus dexamethasone versus enema alone, Outcome 2 Bowel perforation(s).

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Analysis 2.3

Comparison 2 Enema plus dexamethasone versus enema alone, Outcome 3 Recurrent intussusception.

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Analysis 2.4

Comparison 2 Enema plus dexamethasone versus enema alone, Outcome 4 Bowel resection.

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Analysis 3.1

Comparison 3 Air enema versus liquid enema, Outcome 1 Successfully reduced intussusception.

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Summary of findings for the main comparison. Enema plus glucagon versus enema alone

Enema plus glucagon versus enema alone summary of findings table
Patient or population: children with intussusception Setting: single centre, in‐patient setting Intervention: liquid enema plus glucagon Comparison: liquid enema alone
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)
	Risk with liquid enema alone	Risk with liquid enema plus glucagon
Successfully reduced intussusception	Study population		RR 1.09 (0.94 to 1.26)	218 (2 studies)	Low^a
	739 per 1000	805 per 1000 (694 to 931)
	Moderate
	649 per 1000	707 per 1000 (610 to 818)
Bowel perforation(s)	Outcome not reported in any studies
Recurrent intussusception (follow‐up: 6 months)	Outcome not reported in any studies
Bowel resection	Outcome not reported in any studies
Postoperative complication(s)	Outcome not reported in any studies
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI) CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to the estimate of effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aDowngraded two levels for serious concerns for high risk of selection, attrition, and performance bias

Summary of findings for the main comparison. Enema plus glucagon versus enema alone

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Summary of findings 2. Enema plus dexamethasone versus enema alone

Enema plus dexamethasone versus enema alone summary of findings table
Patient or population: children with intussusception Setting: single centre, in‐patient setting Intervention: enema plus dexamethasone Comparison: enema alone
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)
	Risk with enema alone	Risk with enema plus dexamethasone
Successfully reduced intussusception	Study population		RR 1.01 (0.92 to 1.10)	356 (2 studies)	Low^a
	157 per 1000	159 per 1000 (144 to 173)
	Moderate
	771 per 1000	779 per 1000 (710 to 849)
Bowel perforation(s)	Study population		RR 2.63 (0.11 to 62.66)	75 (1 study)	Low^b,c
	125 per 1000	329 per 1000 (14 to 1000)
	Moderate
	125 per 1000	48 per 1000 (3 to 995)
Recurrent intussusception (follow‐up: 6 months)	Study population		RR 0.14 (0.03 to 0.60)	299 (2 studies)	Low^a
	69 per 1000	10 per 1000 (2 to 42)
	Moderate
	370 per 1000	52 per 1000 (11 to 222)
Bowel resection	Study population		RR 0.88 (0.19 to 4.06)	75 (1 study)	Low^b,c
	86 per 1000	75 per 1000 (16 to 348)
	Moderate
	375 per 1000	330 per 1000 (71 to 1000)
Postoperative complication(s)	Outcome not reported in any studies
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI) CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to the estimate of effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aDowngraded two levels for serious concerns for high risk of attrition and performance bias ^bDowngraded one level for serious imprecision (95% CI is wide and includes null effect) ^cDowngraded one level for concerns for high risk of performance bias

Summary of findings 2. Enema plus dexamethasone versus enema alone

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Summary of findings 3. Air enema versus liquid enema

Air enema versus liquid enema summary of findings table
Patient or population: children with intussusception Setting: single centre, in‐hospital setting Intervention: air enema Comparison: liquid contrast enema
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)
	Risk with liquid contrast enema	Risk with air enema
Successfully reduced intussusception	Study population		RR 1.28 (1.10 to 1.49)	199 (2 studies)	Low^a
	677 per 1000	867 per 1000 (745 to 1000)
	Moderate
	712 per 1000	911 per 1000 (783 to 1000)
Bowel perforation(s)	Outcome not reported in any studies
Recurrence of intussusception (follow‐up: 6 months)	Outcome not reported in any studies
Bowel resection	Outcome not reported in any studies
Postoperative complication(s)	Outcome not reported in any studies
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI) CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to the estimate of effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aDowngraded two levels for serious concerns for high risk of selection, performance, and detection bias

Summary of findings 3. Air enema versus liquid enema

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Comparison 1. Enema plus glucagon versus enema alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Successfully reduced intussusception Show forest plot	2	218	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.94, 1.26]

Comparison 1. Enema plus glucagon versus enema alone

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Comparison 2. Enema plus dexamethasone versus enema alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Successfully reduced intussusception Show forest plot	2	356	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.92, 1.10]

2 Bowel perforation(s) Show forest plot	1	75	Risk Ratio (M‐H, Fixed, 95% CI)	2.63 [0.11, 62.66]

3 Recurrent intussusception Show forest plot	2	299	Risk Ratio (M‐H, Fixed, 95% CI)	0.14 [0.03, 0.60]

4 Bowel resection Show forest plot	1	75	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.19, 4.06]

Comparison 2. Enema plus dexamethasone versus enema alone

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Comparison 3. Air enema versus liquid enema

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Successfully reduced intussusception Show forest plot	2	199	Risk Ratio (M‐H, Fixed, 95% CI)	1.28 [1.10, 1.49]

Comparison 3. Air enema versus liquid enema

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Tratamiento de la invaginación intestinal en niños

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