Hematochezia associated with the use of hypertonic sodium polystyrene sulfonate enemas in premature infants

The onset of hematochezia with the use of sodium polystyrene sulfonate enemas in an index case prompted us to review our experience with the use of such enemas in neonates. Sodium polystyrene sulfonate enemas were used in 20 of 2317 patients. Of these 20 patients, four (20%) had evidence of hematochezia temporally related to the use of the enemas. No episodes of such bleeding occurred in infants who were older than 29 weeks of gestation or larger than 1250 gm birth weight. In one case an autopsy performed within 2 days of the enemas showed extensive vascular congestion within the mucosa and submucosa with focal areas of hemorrhage. Approximately 20% sorbitol (1098 mOsm/L) was the vehicle for suspension of the sodium polystyrene sulfonate. On the basis of evidence regarding similar morbidities in adults, we are concerned that the hyperosmolar suspending agent, sorbitol, may be the cause of such pathologic conditions in the colon of susceptible infants.