Management for intussusception in children

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

doi:10.1002/14651858.CD006476.pub3

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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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