Journal of Pediatric Surgery xxx (2016) xxx–xxx

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

The role of dexamethasone in decreasing early recurrence of acute

intussusception in children: A retrospective study
Yigal Efrati, Baruch Klin, Eran Kozer, Ibrahim Abu-Kishk ⁎
Pediatric Division, Assaf Harofeh Medical Centre, Zerifin 70300, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

a r t i c l e i n f o a b s t r a c t

Article history: Background: Early recurrent intussusception (RI) is a concern after a successful pneumatic reduction. Steroids
Received 18 July 2016 have been suggested as a treatment that decreases early RI. The purpose of this study was to examine the role
Received in revised form 21 November 2016 of dexamethasone in decreasing early RI.
Accepted 26 December 2016 Methods: A retrospective review of 174 pediatric patients that underwent successful pneumatic reduction was
Available online xxxx
conducted. Two groups were identified: group 1 that received intravenous dexamethasone (0.5 mg/kg/dose)
on diagnosis or immediately after the reduction maneuver, and group 2 that were not given dexamethasone.
Key words:
Dexamethasone
Results: There were 113 boys and 61 girls ranging in age from 2 to 36 months. There were no statistical differences
Intussusception between the groups except for younger age in the dexamethasone group (P = 0.03). There was no significant dif-
Infants ference (p = 0.08) in the rate of early RI between the non-steroid group (5.4%, 4/74) and the steroid group 14%
Recurrence (14/100). Mean admission length was 30 h. The majority of RIs occurred in the first 8 h of admission.
Conclusions: We found that premedication of children with idiopathic intussusception with dexamethasone did
not decrease early RI.
Level of evidence: Level III retrospective comparative study.
© 2016 Elsevier Inc. All rights reserved.

1. Background It is postulated that focal lymphoid hyperplasia of the Payer paches

Intussusception is a common cause of bowel obstruction in infancy
and early childhood. Most cases of intussusception are idiopathic and
involve the terminal ileum invaginating through the ileocecal valve
into the colon.
Currently, the management of intussusception is pneumatic or hy-
drostatic reduction and surgical reduction is reserved for those cases
in which the above treatments fail or for those who present with
bowel necrosis or peritonitis [1,2].
Despite a growing body of literature supporting outpatient manage-
ment of patients with successful enema reduction, it is still common
practice to hospitalize patients for 24 to 48 h of observation [3,4]. This
recommendation is founded on concerns regarding recurrence and
post reduction complications [5].
The recurrence rate for non-surgical reduction is reported to be up to
20% [2–6]. A recent structured literature review and meta-analysis
found an overall recurrence rate of 12.7% [7]. A large survey found
that almost 50% of the instances of recurrent intussusception (RI) oc-
curred within the first week of non-operative reduction [8,9], which is
defined as early RI.
Abbreviations: RI, recurrent intussusception; ER, early recurrence.
⁎ Corresponding author. Tel.: +972 8 9779104; fax: +972 8 9779109.
E-mail addresses: yigale@asaf.health.gov.il (Y. Efrati), klin2@netvision.net.il (B. Klin),
erank@asaf.health.gov.il (E. Kozer), abukishki@gmail.com (I. Abu-Kishk).
in the terminal ileum may serve as a leading point for intestinal peristal-
sis, causing most intussusceptions, and that viral agents associated with
enteric infection may be the etiology of mesenteric lymphadenopathy in
intussusceptions [10,11].
There are very few reports and limited evidence that premedication
with steroids decreases episodes of recurrent intussusceptions (RIs) [12,13].
At our hospital, pneumatic reduction is the common treatment for
intussusceptions. Depending on the attending pediatric surgeon, dexa-
methasone is or is not administered. Our first clinical impression was
that the addition of dexamethasone to pneumatic reduction of intussus-
ception might have no influence on the incidence of early RI.
The current study aimed to assess the efficacy of dexamethasone in
preventing early recurrence (ER) of idiopathic intussusceptions among
pediatric patients.
2. Methods
A retrospective study of medical records was performed for all pedi-
atric patients (aged 1 week–18 years) admitted to Assaf Harofeh Medi-
cal Center for intussusception between January 1999 and September
2014. Patients were identified using the hospital computerized data-
base. This study was approved by the Institutional Review Board of
Assaf Harofeh Medical Center. All pediatric patients with idiopathic in-
tussusception were included in the study. Pediatric patients with

http://dx.doi.org/10.1016/j.jpedsurg.2016.12.020
0022-3468/© 2016 Elsevier Inc. All rights reserved.

Please cite this article as: Efrati Y, et al, The role of dexamethasone in decreasing early recurrence of acute intussusception in children: A
retrospective study, J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.12.020
2 Y. Efrati et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx

known underlying intestinal pathology or patients who underwent sur-
gical intervention were excluded from the final analysis.
Data extracted from the charts included age, gender, presenting
symptoms and signs, and their duration prior to hospitalization. Success
rate and site of the intussusception was recorded.
Since this work was retrospective, there was no randomization in
the regimen of steroid administration. The final decision regarding ste-
roid administration was made by the attending surgeon who treated the
patient at admission.
All the participants underwent complete pneumatic reduction when
no signs of intestinal perforation or peritonitis were observed. The study
population was divided into two groups; group 1 received intravenous
dexamethasone (0.5 mg/kg/dose) on diagnosis or immediately after
the reduction maneuver, and group 2 received no steroids. All the par-
ticipants were followed 1–2 weeks later in the outpatient surgery clinic.
Early RI episodes were defined as those occurring within 1 week of suc-
cessful reduction. Patients with late recurrence were treated as for the
first intussusception event.
3. Data analysis
The studied population was described using categorical and contin-
uous variables. We performed two sets of analysis. Firstly, we compared
patients treated with corticosteroids with those who did not receive ste-
roids. Categorical variables of cases and controls were compared using
the chi square test or Fisher's exact test as appropriate. Continuous var-
iables of the two groups were compared using the Student t-test or the
Mann–Whitney Rank test as appropriate. A P value of less than 0.05
was considered significant. Statistical analysis was performed using
the Statistical Package for the Social Sciences statistical program PASW
Statistics 21th ed (SPSS, Inc., Chicago, IL).
4. Results
One hundred and seventy four patients were included in the final
analysis of the 15-year study period. There were 113 boys and 61 girls
(1.8:1 male: female ratio), who ranged in age from 2 to 36 months.
Table 1 summarizes the characteristics of the participants. The range
time of clinical symptoms was from 3 h to 14 h. Ileocolic intussusception
accounted for all of the participants, who underwent a diagnostic and
therapeutic air enema. Two groups of yes or no dexamethasone were
identified with no significant differences between them, except for
younger age in the dexamethasone group (P = 0.03). Except for statis-
tically, but not clinically, significant hyponatremia in the steroid group,
there were no statistical differences between the groups regarding lab-
oratory findings on admission (blood count, blood gases, and renal
function tests). Early RI was observed in four of 74 patients in the
non-steroid group and 14 of 100 in the steroid group, with a tendency
(but no statistical significance) toward recurrence when adding dexa-
methasone to pneumatic reduction (P = 0.08). Mean admission length
was 30 h (range 23–37 h). The majority of RI occurred in the first 8 h of
admission (55%), with no differences between the groups.
5. Discussion
Focal lymphoid hyperplasia in the terminal ileum may serve as a
leading point for the intestinal peristalsis, causing most intussuscep-
tions. Therefore, dexamethasone treatment for the intestinal lymphoid
hyperplasia has been advised as a treatment for idiopathic intussuscep-
tion in children in order to decrease the rate of recurrent intussuscep-
tions. In the current study, dexamethasone treatment was found
ineffective in decreasing the early recurrence rate of intussusceptions
after a successful pneumatic reduction.
In a prospective study of idiopathic intussusception patients who
had pneumatic reduction, Lin et al. [12] premedicated 122 patients
with intramuscular dexamethasone and 117 with placebo; 6 placebo
patients had early recurrent intussusception, but no early recurrence
occurred in steroid-treated patients. The present study failed to show
similar results despite defining the same period of early recurrence
and using the same dose of dexamethasone, but with a different method
of administration. Another study by Essa et al. [13] evaluated the role of
dexamethasone in decreasing early recurrent intussusception (defined
by the authors as a period of 72 h) by randomly assigning their patients
into two groups: group 1 (40 cases) received three doses of intramuscu-
lar dexamethasone, once before starting ultrasound guided saline re-
duction and every 8 h thereafter; group 2 (35 cases) did not receive
dexamethasone. The authors reported a higher incidence of early recur-
rent intussusception in the control group (14%) compared to the treated
group (2.5%). In contrast to prior studies, we did not demonstrate any
benefit in decreasing intussusception recurrence with dexamethasone.
While some of our methods differed from other studies, including dexa-
methasone administration, we do not believe that these differences can
explain the discrepant results.
One possible explanation for the lack of steroid efficacy in the pres-
ent study may be related to the known fact that intussusception in
young children is rarely associated with an obvious lead point [9]. It is
not known why some infants have a single episode of intussusception,
whereas other infants develop recurrent episodes, despite a similar clin-
ical presentation and the absence of a lead point. Although the incidence
of a lead point is more common in children with recurrence, most pa-
tients with lead points do not have a recurrence [9]. Furthermore, it is
reported that recurrent intussusception in children is more often

Table 1
Characteristics of the participants.

Characteristics No steroids (n = 74) Steroid (n = 100) P value

Age (months) Mean 12.4 (10.4 ± 1.2) Mean 9.6 (6.7 ± 0.66) 0.03
Gender, male:female 47:27 66:34 0.7
Duration symptoms (h) Mean 8 (3–14) Mean 7.8 (4–12) 0.9
Restlessness 56 patients 65 patients 0.13
Lethargy 36 patients 43 patients 0.53
Diarrhea 10 patients 8 patients 0.31
Blood in stool 26 patients 24 patients 0.12
Current jelly 4 patients 10 patients 0.39
Recurrence 4 patients 14 patients 0.08

Laboratory value No steroids Mean (±SD) Steroids Mean (±SD) P value

WBC (normal range 5000–17,500) cells/mm3) 48 patients 13,212.16 (±3834.6) out of range - none 74 patients 13,087.5 (±4250.13) out of range - none 0.86
Hemoglobin (normal range 11.2–15 g/dL 48 patients 11.4 (±0.898) out of range - 18 patients 74 patients 11.6 (±0.834) out of range - 25 patients 0.28
Sodium (normal range 134–146 mmol/L) 45 patients 137.5 (±1.8) out of range - none 84 patients 136.2 (±2.5) out of range-7 patients 0.008
Potassium (normal range 3.5–6 mmol/L) 45 patients 4.3 (±0.43) out of range - none 82 patients 4.4 (±0.55)out of range-none 0.37
Urea (normal range 20–45 mg/dL) 37 patients 24.0 (±7.5) out of range - none 82 patients 22.6(±7.3) out of range - none 0.35
Bicarbonate (normal range 22–29 mEq/L) 18 patients 22.3 (±0.8) out of range - 8 patients 23 patients 22.9 (±1.2) out of range – 6 patients 0.24

Please cite this article as: Efrati Y, et al, The role of dexamethasone in decreasing early recurrence of acute intussusception in children: A
retrospective study, J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.12.020
 Y. Efrati et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx
managed successfully by non-operative reduction without complica-
tions and without a higher rate of surgical intervention compared
with children with a single episode [6].
The findings in the current study do not justify the routine use of ste-
roids in children with idiopathic intussusception. Steroids may have a
role in multiple recurrent intussusceptions only when lymphoid hyper-
plasia is involved. Only case reports have been published on the use of
steroids for children with multiple recurrences of intussusception, with-
out comparison to any control groups. In similar cases, the published
data reported different protocols of steroid treatment that may continue
for weeks [14,15].
The mean admission length in the current study was 30 h, with a
maximal recurrent rate within the first 8 h of hospitalization. Despite
studies recommending outpatient management or emergency room
observation for a few hours [16,17], this is not our policy. The low rate
of early recurrence and the good outcome of these patients raise the
question of motivation to use premedication to lower the recurrence
rate of intussusception.
In the current study, the steroid group was younger than the non-
steroid group. It could be argued that the difference in recurrence
rates was because of the significant differences in age distribution
between the two groups and not to the steroids. Gray et al., in a meta-
analysis study, examined age-related early recurrence. In post hoc
regression analysis, the estimated median age was not found to be
significant for overall, 24-h, or 48-h recurrence rates [7]. Furthermore,
a more recent work on 2295 patients revealed that early recurrence
occurs more frequently in patients older than 1 year. In this study, the
authors believed that a certain number of early recurrences in older
patients could be related to the fact that older patients have more
developed Peyer's patches [18]. However, in the current study, older
patients were in the non-steroid group with a relatively lower incidence
of early recurrence [4/74 (5%) vs 14/100 (14%)].
The limitations of this study include the relatively small number of
participants, the retrospective nature of the study, and potential
selection bias for patients who received dexamethasone premedication.
6. Conclusion
We found that premedication of children with idiopathic intussus-
ception with dexamethasone did not decrease early recurrent
intussusception.
Authors' contributions
YE, BK, and IA made substantial contributions to conception and de-
sign, YE, BK, NR and IA contributed to acquisition of data, EK contributed
to analysis and interpretation of data, YE, BK, EK, NR and IA were in-
volved in drafting the manuscript, and IA was responsible for revising
the article critically for important intellectual content. All the authors
have given final approval of the version to be published. All authors
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests. There are
no sources of funding or financial support.
Please cite this article as: Efrati Y, et al, The role of dexamethasone in decreasing early recurrence of acute intussusception in children: A
retrospective study, J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.12.020
3
Ethics approval and consent to participate
This study was approved by the Institutional Review Board of Assaf
Harofeh Medical Center. The need for consent to participate was waived
by the review board.
Consent for publication
Not applicable.
Availability of data and supporting materials
The datasets supporting the conclusions of this article are included
within the article and its additional files.
Funding
There are no sources of funding for this research.
Acknowledgement
Not applicable.
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