Pediatric tuina combined with glycerin enema in the management of pediatric intussusception: an observational study

Abstract

Objective

To investigate the clinical efficacy and safety of pediatric tuina combined with glycerin enema for pediatric intussusception, in order to reduce unnecessary invasive procedures, enhance the safety of intussusception reduction, and conserve medical resources.

Methods

This was an observational study of routine clinical practice with a non-randomized, single-arm design. A total of 128 children diagnosed with intussusception in Zigong Maternal and Child Health Care Hospital from September 2024 to November 2025 were enrolled as the research subjects, including 58 males and 70 females. All children had an onset time of less than 48 h, and color Doppler ultrasound indicated intussusception accompanied by at least one related clinical symptom (abdominal pain, vomiting, paroxysmal crying, etc.). All children received pediatric tuina combined with glycerin enema via anal administration as the first-line treatment in accordance with the standardized diagnosis and treatment protocol formulated by our hospital. For children with failed reduction after combined treatment, ultrasound-guided hydrostatic enema reduction was further performed; laparoscopic surgery was adopted for those who failed hydrostatic enema reduction. This was a single-arm observational study with no control group.

Results

Of the 128 enrolled children, 1 was excluded due to complicated lymph node invagination. Among 127 children who received the initial combined therapy, successful reduction was achieved in 102 cases, with a success rate of 80.3%. Of the 25 failed cases, 23 achieved successful reduction via ultrasound-guided hydrostatic enema (success rate 88.4%), and the remaining 3 underwent successful laparoscopic reduction. Multivariate analysis identified intussusception type, length ≥ 3 cm, and age as independent risk factors for treatment failure, with the predictive model showing good performance (AUC = 0.797). No severe complications were observed during follow-up.

Conclusion

Pediatric tuina combined with glycerin enema is feasible and safe for selected children with intussusception. This regimen is easy to perform without additional specialized equipment, helps reduce unnecessary primary enema intervention and avoid overtreatment, and may assist in distinguishing transient from fixed intussusception. Even in cases of failed initial reduction, it may provide favorable conditions for subsequent procedures. As a conservative adjuvant therapy in selected patients, this combined modality shows good clinical application potential and deserves further validation in future large-sample, multicenter controlled studies.

Introduction

Intussusception is a common acute abdominal condition in infants and young children, characterized by acute onset and rapid progression of the disease [1]. Except for a small number of cases that can be spontaneously reduced, most cases require timely intervention; otherwise, it is likely to lead to intestinal ischemia and necrosis, and even be life-threatening. At present, clinical treatments are mainly divided into non-surgical and surgical methods. Non-surgical treatment is dominated by image-guided enema reduction, with common approaches including B-ultrasound-guided hydrostatic enema reduction and X-ray-guided air enema reduction. Laparoscopic intussusception reduction is the primary surgical treatment modality [2].

Glycerol enema is mainly composed of glycerol and sorbitol, and is commonly used to relieve constipation and promote intestinal peristalsis [3]. As an adjuvant therapy in the reduction treatment of pediatric intussusception, glycerol enema can optimize the therapeutic effect. Administration of one tube of glycerol enema prior to intussusception enema can effectively shorten the enema operation time, stabilize the enema pressure, and prevent fecal blockage of the catheter, thereby reducing the risk of intestinal wall necrosis and perforation and improving treatment safety [4, 5]. In addition, glycerol enema may contribute to the diagnosis of intussusception in children without the typical clinical triad [6].

Pediatric tuina is an external therapy guided by traditional Chinese medicine (TCM) theory. Based on the physiological and pathological characteristics of children, it exerts therapeutic effects primarily by applying precise stimulation to the meridians and specific acupoints, regulating qi and blood circulation in the superficial meridians, and thus preventing and treating diseases [7].

As an important branch of TCM pediatrics, this therapy is widely used in the prevention and treatment of pediatric intestinal diseases, and has a favorable curative effect especially on common gastrointestinal disorders such as infantile diarrhea, intestinal obstruction, and indigestion. Its advantages include safe operation, minimal pain, absence of adverse drug reactions, and high acceptability among children and their guardians [8–10].

Two meta-analyses comprising a total of 2005 patients [11, 12] demonstrated that pediatric tuina was well accepted by children and significantly improved fecal characteristics, including increased defecation frequency.

Although pediatric tuina and glycerin enema have been separately reported in the treatment of intussusception [6, 8, 13], the combined application of these two modalities for pediatric intussusception has not been previously reported.

Since our hospital applied the combined therapy of pediatric tuina and glycerol enema via anal administration for the treatment of pediatric intussusception, satisfactory outcomes have been achieved while ensuring the safety of children. Herein, we report the results of this study.

Subjects and methods

Study subjects

This study was approved by the Ethics Committee of Zigong Maternal and Child Health Hospital (Ethics Approval No.: 2024–13) and conducted in strict compliance with the requirements of the Declaration of Helsinki. Clinical trial number: not applicable. This study was an observational, single-arm investigation conducted within routine clinical practice, with a non-randomized design. A formal sample size calculation was not performed a priori, as this was an exploratory study designed to evaluate the feasibility of a combined tuina and glycerin enema strategy for pediatric intussusception. Accordingly, this work does not fall within the scope of mandatory clinical trial registration as required by the International Committee of Medical Journal Editors (ICMJE).

All procedures in this study adhered to the hospital's standardized diagnosis and treatment protocols, and the entire research process was comprehensively documented to ensure data traceability. Patients were enrolled consecutively during the study period. The recruitment flow diagram is shown in Fig. 1. Prior to the initiation of treatment, the treatment process was fully explained to the parents/guardians of all children, who provided informed consent and signed the informed consent form.

Fig. 1.

tudy flow of the patients diagnosed with intussusception. A total of 136 children with suspected intussusception were evaluated for eligibility. Eight patients were excluded because they were diagnosed with asymptomatic small bowel intussusception, leaving 128 consecutive patients who were enrolled and included in the final analysis

A total of 136 children with suspected intussusception diagnosed by color Doppler ultrasound were initially assessed. Among them, 8 children were excluded due to asymptomatic small bowel intussusception. Finally, we enrolled 128 eligible children (58 males, 70 females) at our institution between September 2024 and November 2025, all of whom presented with at least one clinical symptom (abdominal pain, vomiting, paroxysmal crying, abdominal mass, etc.). The time of symptom onset was confirmed with the parents, and all children had a symptom duration of less than 48 h. All patients were managed in accordance with our hospital’s standardized diagnostic and therapeutic protocol for intussusception (Fig. 2).

Fig. 2.

Diagnosis and treatment flow chart of intussusception in our hospital

Diagnostic criteria

The diagnostic criteria for pediatric intussusception were referenced from the 6th edition of Pediatric Surgery [14].

Inclusion criteria

(1) Conforming to the diagnostic criteria for pediatric intussusception;(2) Aged under 14 years;(3) Presence of target sign on color Doppler ultrasound or confirmed intussusception on abdominal computed tomography (CT), with all children presenting at least one clinical symptom (abdominal pain, vomiting, paroxysmal crying, abdominal mass, etc.);(4) Duration of symptoms less than 48 h;(5) Informed consent obtained from the children’s guardians.

Exclusion criteria

(1) Manifestations of lethargy, dehydration, shock, peritonitis, intestinal perforation, hematochezia, passage of currant jelly-like stool, or positive findings of bloody or currant jelly-like stool on anal digital examination;(2) Children with symptom duration exceeding 48 h;(3) Identification of pathological predisposing factors (e.g., Meckel’s diverticulum, intestinal polyps, intestinal duplication, intestinal cysts, intestinal foreign bodies, intestinal tumors, etc.), intestinal ischemia, invagination of omentum/lymph nodes/appendix, or irreducible intussusception on color Doppler ultrasound or abdominal CT. (4) Asymptomatic small bowel intussusception.

Conservative treatment termination criteria

Conservative treatment should be discontinued promptly and converted to surgical intervention or enema reduction if any of the following criteria is met: (1) Worsening clinical manifestations, including severe abdominal pain, vomiting, abdominal distension, and rectal bleeding; development of peritonitis; unstable vital signs; or other abnormal physical signs; (2) No improvement or progression of the intussusception in terms of location and length; (3) Color Doppler ultrasound demonstrating rapid deterioration or disappearance of blood flow signals within the intussuscepted bowel; (4) Persistence of both the intussusception and related clinical symptoms 2 h after initiation of conservative treatment.

Methods

Pediatric tuina

All pediatric tuina procedures were performed by certified pediatric massage therapists with formal professional training and institutional credential documentation. To ensure procedural standardization and reduce operator variability, a uniform tuina protocol was strictly followed throughout the study. All therapists completed standardized training before enrollment, and the same tuina manipulation sequence, duration, and intensity were applied consistently for all patients. The pediatric tuina procedure was performed as follows:1.Separating Manipulation on Abdominal Yin-Yang (20 repetitions): Using the pulp of both thumbs, gently and slowly push from below the xiphoid process (superior to Zhongwan acupoint, CV12) along the costal arch margins to both sides with precise direction, repeating the maneuver 20 times.2.Clockwise Abdominal Kneading (3 min): Place the palm center on the abdomen, take the Shenque acupoint (CV8, umbilicus) as the center, and perform clockwise circular kneading with soft, penetrating force and uniform speed for 3 consecutive minutes.3.Point-Kneading Shenque (CV8), Tianshu (ST25), Zhongwan (CV12) and Guanyuan (CV4): Sequentially knead each acupoint with the pulp of the middle or thumb finger, gradually increasing the force from light to moderate until a local soreness and distension sensation is elicited. Each acupoint is kneaded for 30–60 s.4.Pinching Abdominal Corners: Pinch the abdominal corner areas on both sides below the umbilicus with the thumb and index/middle fingers, lift gently, hold briefly and then release. The pinching force should be mild to avoid excessive traction, repeating 3–5 times.5.Abdominal Shaking Manipulation (1–2 min): Place the palm centers on both sides of the abdomen, take the waist as the fulcrum, and perform coordinated left–right swinging and up-down jolting movements with both hands to drive the abdominal tissues to shake gently. The manipulation should be performed with soft and gentle force for 1–2 min.6.Separating and Straightening Intestinal Canal along the Body Surface Projection of Intussusception: First, identify the body surface projection position of the intussusception lesion. Using the finger pulp, perform gentle separating and straightening movements along the intestinal tract direction. The force should be soft and precise; excessive force is prohibited to avoid intestinal injury (Table 1, Fig. 3).

Table 1.

Key points of pediatric tuina manipulation

Operation Site	Acupoint/Manipulation Name	Key Manipulation Points
Abdomen	Separating Abdominal Yin-Yang	Thumb pushing: 20 repetitions (from below xiphoid process to both sides of costal arch), gentle and slow
	Shenque (CV8, Umbilicus)	Clockwise abdominal kneading: 3 min, palm adhering to abdomen, soft and penetrating force
	Tianshu (ST25), Zhongwan (CV12), Guanyuan (CV4)	Point-kneading: 30–60 s per acupoint, force gradually increasing from light to moderate, with local soreness and distension as appropriate
	Abdominal Corners; Abdominal Shaking	Pinching abdominal corners: 3–5 times (gentle lifting and pinching); Abdominal shaking: 1–2 min (bilateral palm swinging to drive abdominal tissue movement)
	Body Surface Projection Area of Intussusception	Separating and straightening intestinal canal: gentle straightening along intestinal direction to avoid injury

Fig. 3.

Intussusception Depth, Maximum Hydrostatic Enema Reduction Pressure and Lesion Location in Children with Intussusception. A Mean depth of intussusceptum: The mean length of intussuscepted intestinal canal was 2.67 cm; B Mean distribution of maximum hydrostatic enema reduction pressure: The mean maximum pressure was approximately 10.53 kPa; C Constituent ratio of intussusception lesion locations: The highest proportion was in the right upper periumbilical region (22%), followed by the right periumbilical region (16%) and left periumbilical region (14%);

Glycerin enema via anal administration

The child was placed in the left lateral decubitus position, and parents assisted in securing the child’s lower limbs and buttocks to fully expose the anal region. An appropriate dose of glycerin enema was administered according to the child’s age and weight. After removing the seal, a small amount of solution was extruded to lubricate the tip of the applicator. The catheter was gently inserted into the anus to a depth of approximately 2–3 cm, with strict attention to insertion depth given the relatively short anal canal in children. The solution was then slowly injected into the rectum by gentle compression of the bottle. Upon completion, the catheter was slowly removed, and the anus was briefly pressed with sterile gauze to prevent leakage. Parents were instructed to comfort the child and maintain retention of the solution for 5–10 min to ensure adequate lubrication of the intestinal wall, stimulation of intestinal peristalsis, and facilitation of defecation. Subsequently, the child was observed for 2 h, and a repeat abdominal color Doppler ultrasound was performed to evaluate the reduction status of the intussusception.

Glycerin enema was administered via the anal route. A structured adverse-event monitoring framework was applied, including real-time surveillance for anal mucosal irritation, abdominal cramping, vomiting, and rare intestinal perforation. Adverse events were graded as mild, moderate, or severe with corresponding standardized management. A 30-min post-administration observation period was performed to detect delayed reactions. No severe adverse events related to glycerin enema were observed.

Ultrasound-guided hydrostatic enema reduction

Before the operation, the related risks and precautions were fully informed to the family members, who provided informed consent and signed the consent form. The child was placed in the supine position on the ultrasound examination table; one family member fixed the child’s knees, and another fixed the upper limbs and trunk. A No. 16 Foley catheter was inserted through the anus, and 8–10 ml of normal saline was injected to inflate the water balloon for fixation. The initial perfusion pressure was set at 6 kPa. Under ultrasound monitoring, fluid filling in the intestinal lumen could be observed, and the typical target sign was visualized at the ileocecal region. The perfusion pressure was gradually adjusted according to the child’s response. When the pressure exceeded 10 kPa, the mode was switched to pulsed perfusion, with the pressure not exceeding the upper limit of 13.3 kPa throughout the procedure. Successful reduction was confirmed when dynamic ultrasound monitoring showed complete reduction of the intussuscepted intestinal segment and unobstructed inflow of fluid. During the operation, the child’s consciousness was closely monitored. The operation was stopped immediately if the intussuscepted intestinal segment showed no obvious loosening after 30 s of perfusion at a pressure > 12 kPa, or if the child presented with lethargy, frequent vomiting, aggravated abdominal distension, or other abnormal conditions.

Surgical treatment

For children who failed ultrasound-guided hydrostatic enema reduction, the subsequent surgical plan was formulated based on the disease assessment. Laparoscopic exploration and reduction under general anesthesia were preferred for children in stable general condition with mild abdominal distension. The child was placed in the supine position. After routine disinfection and draping, a 0.5 cm small incision was made 5 mm below the umbilicus, and a 5 mm Trocar was inserted to establish a CO₂ pneumoperitoneum with the pressure maintained at 8–10 mmHg. Under laparoscopic surveillance, a 5 mm Trocar was inserted into the left lower abdomen and right lower abdomen, respectively. The intussuscepted intestinal segment was mostly located in the right upper abdomen; intestinal forceps were used to clamp the distal and proximal intestinal tubes of the intussusceptum separately, with gentle manipulation to avoid violent tearing. After reduction, careful inspection was performed to evaluate the blood supply of the affected intestinal segment and check for associated malformations (e.g., diverticulum, neoplasm, intestinal duplication) within 150 cm of the proximal small intestine. If laparoscopic reduction failed after repeated attempts, the procedure was promptly converted to open surgery. The umbilical trocar incision was routinely extended to 2–3 cm in an arc shape, and the ileocecal region and intussuscepted intestinal segment were gently pulled out of the abdominal cavity; if the ileocecal region was fixed, the surrounding adhesions were first released before externalization. The intussuscepted intestinal segment was completely pulled out of the abdominal cavity for manual reduction, and intestinal resection and anastomosis or enterostomy were performed depending on the intestinal viability and pathological conditions.

Statistical analysis

Statistical analysis was performed using SPSS 26.0 software (IBM Corp., Armonk, NY, USA) and Python 3.9 with matplotlib, seaborn, and statsmodels packages. All tests were two-sided, and P < 0.05 was considered statistically significant.Continuous variables (e.g., age, onset duration) were expressed as mean ± standard deviation (xˉ ± s) and compared using independent-samples t-tests. Categorical variables (e.g., intussusception location, treatment outcome) were presented as frequencies and percentages [n (%)], and group comparisons were performed using the χ² test or Fisher’s exact test when the expected frequency was < 5.The therapeutic performance of tuina combined with glycerin enema was evaluated using sensitivity, positive predictive value (PPV), and overall accuracy. Specificity was not applicable due to the absence of a true negative population in this therapeutic cohort.Univariate binary logistic regression was used to screen potential factors associated with treatment failure (dependent variable: failure = 1, success = 0). Variables with P < 0.10 in univariate analysis were entered into the multivariate binary logistic regression model to identify independent risk factors. Multi-category variables (age group, intussusception type, and location) were transformed into dummy variables with the following reference groups: 1–3 years, small bowel intussusception, and right-sided location. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A forest plot was used to visualize the multivariate regression results. Model fit was assessed using Nagelkerke’s pseudo-R² and the likelihood ratio test.Receiver operating characteristic (ROC) curve analysis was performed to evaluate the discriminative ability of the prediction model, with an area under the curve (AUC) > 0.7 defined as good predictive performance. The 95% CI of the AUC was reported.A nomogram was established based on the multivariate logistic regression model to quantify individualized risk of treatment failure. Bootstrap calibration (100 resamples) was conducted to assess the agreement between predicted and observed probabilities, and a calibration curve was generated. Internal validation of the model was performed using the bootstrap method.

Results

Baseline characteristics of the study cohort

A total of 128 children with intussusception were included in this study (Table 2). The cohort comprised 58 males (45.31%) and 70 females (54.69%), with a median age of 15 months (range: 1–144 months). The majority of patients were aged 1–3 years (99 cases, 77.34%), followed by 0–1 year (15 cases, 11.72%), 3–6 years (13 cases, 10.16%), and 6–12 years (1 case, 0.78%). Common presenting symptoms included abdominal pain (88 cases, 68.75%), vomiting (94 cases, 73.44%), and paroxysmal crying (17 cases, 13.28%), with a mean symptom duration of 9.98 ± 8.05 h. Abdominal mass was detected in 12 cases (9.38%), all located in the umbilical right region. Regarding intussusception type, ileocolic intussusception was the most common (71 cases, 55.47%), followed by small bowel intussusception (51 cases, 38.94%) and colocolic intussusception (6 cases, 4.69%). The median length of the intussuscepted segment was 2.71 cm (range: 1.0–6.4 cm) (Fig. 4A). Intussusception was most frequently located in the umbilical right region (60 cases, 46.88%), followed by the umbilical left region (44 cases, 33.59%), umbilical inferior region (17 cases, 13.28%), and umbilical superior region (7 cases, 5.47%) (Fig. 4C).

Table 2.

Baseline characteristics of the included patients

Characteristics	All,n(%)	Umbilical right	Umbilical left	Umbilical superior	Umbilical inferior
	N = 128(100)	n (%) N = 60 (46.88)	n (%) N = 44 (33.59)	n (%) N = 7(5.47)	n (%) N = 17(13.28)
Sex
Male	58(45.31)	27 (45.00)	20 (45.45)	3 (42.86)	8 (47.06)
Female	70(54.68)	33 (55.00)	24 (54.55)	4 (57.14)	9 (52.94)
Age
0–1 year	15(11.72)	7 (11.47)	5 (11.36)	1 (14.29)	2 (11.76)
1–3 years	99(77.34)	46 (75.40)	34 (77.27)	5 (71.43)	14 (82.35)
3–6 years	13(10.16)	7 (11.47)	5 (11.36)	1 (14.29)	0 (0.00)
6–12 years	1(0.78)	1 (1.63)	0 (0.00)	0 (0.00)	0 (0.00)
Symptoms
Abdominal pain	88	41 (68.33)	30 (68.18)	5 (71.43)	12 (70.59)
Vomiting	94	44 (73.33)	32 (72.73)	5 (71.43)	13 (76.47)
Paroxysmal crying	17	8 (13.33)	6 (13.64)	1 (14.29)	2 (11.76)
Duration of symptoms(hour)	9.98 ± 8.05	9.87 ± 7.98	10.48 ± 8.67	9.11 ± 6.89	8.86 ± 6.62
Abdominal mass	12	12 (100.00)	0 (0.00)	0 (0.00)	0 (0.00)
Type of intussusception
Intussusception of the small bowel	51(38.94)	24 (40.00)	18 (40.91)	3 (42.86)	6 (35.29)
Ileocolic intussusception	71(55.47)	33 (55.00)	24 (54.55)	3 (42.86)	11 (64.71)
Colocolic intussusception	6(4.69)	5 (8.33)	0 (0.00)	1 (14.29)	0 (0.00)
Length of intussusception (cm)a	2.71 (1.0 ~ 6.4)	2.70(1.0 ~ 6.4)	2.714(1.3 ~ 4.0)	3.0(2.2 ~ 4.3)	2.63(1.5 ~ 3.6)

^aMedian (Min ~ Max)

Fig. 4.

Manipulation of Pediatric Tuina A. Abdominal tuina: Point-kneading at Shenque (CV8, umbilicus; B Separating and straightening the intestinal canal at the body surface projection area of the intussusceptum

Efficacy of pediatric tuina combined with glycerin enema via anal administration

All children were treated per our institutional protocol (Fig. 2). No patients presented with critical conditions, shock, hematochezia, or currant jelly-like stool at admission.

A total of 127 children received initial treatment with pediatric tuina combined with glycerin enema via anal administration. Complete resolution of abdominal pain and vomiting was achieved in 100 cases, with follow-up color Doppler ultrasound confirming no residual intussusception. Two additional cases showed partial symptom relief with reduced intussusception length on ultrasound; repeat application of the same combined therapy resulted in successful reduction, confirmed by follow-up ultrasound. The overall success rate of initial tuina and glycerin enema therapy was 80.3% (102/127).

As shown in Fig. 5 and Table 3 , the reduction success rate varied significantly by intussusception type: 96.07% for small bowel intussusception, 73.23% for ileocolic intussusception, and 16.66% for colocolic intussusception (P < 0.001). Success rates also differed significantly by age group (P = 0.175) and intussusception length (P < 0.001), with a higher success rate observed in cases with intussusception length < 3 cm (91.36%) compared to ≥ 3 cm (59.57%). No significant differences in success rates were found across symptom duration groups (P = 0.557) or intussusception location subgroups (all P > 0.05).

Fig. 5.

Success rates of pediatric tuina combined with glycerin enema for intussusception reduction stratified by clinical characteristics. A Success rate by intussusception type (***P < 0.001, **P < 0.01). B Success rate by age group (***P < 0.001, **P < 0.01, *P < 0.05). C Success rate by intussusception length (***P < 0.001). D Success rate by symptom duration (no significant difference between groups). E Success rate by intussusception location (no significant difference between groups). Error bars represent standard error of the mean (SEM)

Table 3.

Outcomes of the included patients

Outcomes	All,n(%)	Tuina Combined with Glycerin Enema		P value	Ultrasound-guided Hydrostatic Enema		P value	Surgical Reduction		P value
	128(100)	Success	Failure		Success	Failure		Success	Failure
ALL Type of intussusception		102(80.31)	25(19.69)	< 0.001	23(88.46)	3(11.54)	< 0.001	3(100)	0(0.00)	< 0.001
Intussusception of the small bowel	51 (39.84)	49(96.07)	2(3.92)		2(100)	0		0(0.00)	0(0.00)
Ileocolic intussusception	71 (55.47)	52(74.29)	18(25.71)		16 (84.21)	3(15.78)		3 (100)	0(0.00)
Colocolic intussusception	6 (4.69)	1(16.66)	5(83.33)		5 (100)	0		0(0.00)	0(0.00)
Age				0.004			< 0.001			< 0.001
0–1 year	15 (11.72)	8(57.14)	6(42.86)		5(83.33)	1(16.67)		1(100.00)	0(0.00)
1–3 years	99 (77.34)	83(83.84)	16(16.16)		16(100.00)	0(0.00)		0(0.00)	0(0.00)
3–6 years	13 (10.16)	11(84.62)	2(15.38)		1(50.00)	1(50.00)		1(100.00)	0(0.00)
6–12 years	1 (0.78)	0(0.00)	1 (100.00)		0(0.00)	1(100.00)		1(100.00)	0(0.00)
Duration of symptoms(hour)				0.457			< 0.001			< 0.001
0–6 h	69 (53.91)	53(77.94)	15(22.06)		14(87.50)	2(12.50)		2(100.00)	0(0.00)
6–12 h	36 (28.13)	29(80.56)	7(19.44)		7(100.00)	0(0.00)		0(0.00)	0(0.00)
12 h-	23 (17.97)	20(86.96)	3(13.04)		2(66.67)	1(33.33)		1(100.00)	0(0.00)
Length of intussusception (cm)				< 0.001			< 0.001			< 0.001
< 3 cm	81 (63.28)	74(91.36)	7(8.64)		7(100.00)	0(0.00)		0(0.00)	0(0.00)
≥ 3 cm	47 (36.72)	28(60.87)	18(9.13)		16(84.21)	3(15.79)		3(100.00)	0(0.00)
Location of intussusception
Umbilical right superior	28 (21.88)	22 (81.48)	5 (18.52)	0.996	5 (83.33)	1 (16.67)	< 0.001	1 (100.00)	0 (0.00)	< 0.001
Umbilical right	21 (16.41)	17 (80.95)	4 (19.05)		4 (100.00)	0 (0.00)		0 (0.00)	0 (0.00)
Umbilical right inferior	11 (8.59)	9 (81.82)	2 (18.18)		2 (100.00)	0 (0.00)		0 (0.00)	0 (0.00)
Umbilical left superior	13 (10.16)	10 (76.92)	3 (23.08)		3 (100.00)	0 (0.00)		0 (0.00)	0 (0.00)
Umbilical left	18 (14.06)	14 (77.78)	4 (22.22)		3 (75.00)	1 (25.00)		1 (100.00)	0 (0.00)
Umbilical left inferior	13 (10.16)	10 (76.92)	3 (23.08)		2 (66.67)	1 (33.33)		1 (100.00)	0 (0.00)
Umbilical superior	7 (5.47)	6 (85.71)	1 (14.29)		1 (100.00)	0 (0.00)		0 (0.00)	0 (0.00)
Umbilical inferior	17 (13.28)	14 (82.35)	3 (17.65)		3 (100.00)	0 (0.00)		0 (0.00)	0 (0.00)
Total	128 (100.00)	102 (79.69)	25 (20.31)		23 (88.46)	3 (11.54)		3 (100.00)	0 (0.00)

P value: comparison of surgical success/failure rates among groups (Pearson’s χ²/Fisher’s exact test)

Ultrasound-guided hydrostatic enema reduction

Twenty-five children failed initial tuina and glycerin enema treatment, with persistent symptoms and no significant improvement in intussusception length on ultrasound. One additional case was diagnosed with intussusception complicated by lymph node invagination on ultrasound, deemed irreducible by tuina therapy; this patient directly underwent ultrasound-guided hydrostatic enema reduction, which failed, followed by successful laparoscopic reduction.

Among the 26 children who received ultrasound-guided hydrostatic enema reduction, 23 achieved successful reduction (88.46%), while 3 failed (11.54%). Enema pressure ranged from 8.6 kPa to 12.5 kPa (mean: 10.53 kPa) (Fig. 4B). All 3 failed cases were subsequently treated with laparoscopic surgery, with successful reduction achieved in all (Table 3B).

Laparoscopic surgery

Three children with failed ultrasound-guided hydrostatic enema reduction underwent laparoscopic intussusception reduction. In one patient, a submucosal hamartoma was identified at the intussusception site and confirmed by postoperative pathology. Operative time ranged from 60 to 130 min (mean: 85 min), and the mean length of hospital stay was 5.5 days. No intraoperative or postoperative complications were observed, and the overall technical success rate of surgical reduction was 100% (3/3). All children's intestinal function returned to normal, with no abnormalities in diet and defecation, and no relevant clinical symptoms such as abdominal pain or vomiting were observed."

Follow-up outcomes

Follow-up was conducted via hospital revisit and telephone contact for 3–6 months post-treatment, with recurrence confirmed by abdominal color Doppler ultrasound. No complications were observed in the 102 children with successful tuina and glycerin enema reduction. Among the 23 patients with successful hydrostatic enema reduction, 1 experienced recurrence 1 month later, which was successfully treated with a second hydrostatic enema; no further recurrence was reported during the 6-month follow-up period. No recurrence was observed in the 3 children who underwent surgical reduction (Table 2).

Predictive factors for treatment failure

Univariate binary logistic regression was performed to identify factors associated with failure of initial tuina and glycerin enema reduction (Table 3). Variables with P < 0.10 in univariate analysis were included in the multivariate model.

Multivariate analysis revealed that age group (0–1 year vs. 1–3 years: OR = 0.30, 95% CI: 0.11–0.82, P = 0.018; 6–12 years vs. 1–3 years: OR = 0.00, P < 0.001), intussusception length ≥ 3 cm (OR = 0.17, 95% CI: 0.08–0.37, P < 0.001), and intussusception type (ileocolic vs. small bowel: OR = 0.14, 95% CI: 0.05–0.38, P < 0.001; colocolic vs. small bowel: OR = 0.02, 95% CI: 0.00–0.09, P < 0.001) were independent risk factors for treatment failure (Table 4). Intussusception location, symptom duration, and gender showed no significant independent effects (all P > 0.05; Fig. 6A).

Table 4.

Univariate and multivariate logistic regression analyses of risk factors for treatment failure

Fig. 6.

Multivariate logistic regression analysis and predictive performance of tuina combined with glycerin enema for intussusception reduction. A Forest plot of adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for independent risk factors associated with treatment failure. The red dashed vertical line indicates an OR of 1 (no effect). Reference groups: right-sided for intussusception location, small bowel for intussusception type, < 3 cm for intussusception length, 0–6 h for symptom duration, and 1–3 years for age group. B Receiver operating characteristic (ROC) curve for predicting successful reduction by initial tuina therapy. The area under the curve (AUC) was 0.797, indicating good predictive performance

Receiver operating characteristic (ROC) curve analysis demonstrated good predictive performance of the multivariate model for treatment failure, with an area under the curve (AUC) of 0.797 (Fig. 6B). The sensitivity of initial tuina and glycerin enema therapy for successful reduction was 79.69%, with a positive predictive value (PPV) of 100% and an overall accuracy of 79.69%. Specificity was not applicable in this therapeutic efficacy evaluation, as all patients were eventually cured.

Stratified subgroup analysis was performed to identify factors associated with the success rate of the initial combined therapy (Fig. 5). The reduction success rate varied significantly across different intussusception types (P < 0.001), with the highest rate observed in small bowel intussusception, followed by ileocolic intussusception, and the lowest in colocolic intussusception (Fig. 5A). Regarding age distribution, the success rate differed significantly among groups (P < 0.01), peaking in the 1–3 years subgroup (Fig. 5B). Additionally, the success rate was significantly higher in patients with an intussusception length of ≤ 3 cm compared to those with a length > 3 cm (P < 0.01) (Fig. 5C).

In contrast, no statistically significant differences in the treatment success rate were found among subgroups stratified by the duration of symptoms (0–6 h, 6–12 h, > 12 h; P = 0.457) (Fig. 5D) or by the abdominal location of the intussusception (umbilical right, left, superior, inferior; P > 0.05) (Fig. 5E).

Nomogram development and calibration

A nomogram was constructed to integrate the three independent predictors (age group, intussusception length ≥ 3 cm, and intussusception type) for individualized risk assessment of treatment failure (Fig. 7A). Each variable was assigned a point score based on its regression coefficient, and the total points were converted to a predicted probability of treatment failure, providing a clinically convenient tool for risk stratification before initiating the combined therapy.

Fig. 7.

Nomogram and calibration curve for predicting treatment failure of pediatric tuina combined with glycerin enema. A Nomogram incorporating intussusception type, length ≥ 3 cm, and age group to estimate the individualized probability of treatment failure. B Calibration curve (100 bootstrap resamples) showing good agreement between predicted and observed probabilities (mean absolute error = 0.032, n = 128)

Bootstrap calibration (100 resamples) was performed to evaluate the model’s predictive accuracy (Fig. 7B). The bias-corrected calibration curve closely followed the ideal 45° line, indicating good agreement between predicted and observed probabilities of treatment failure. The mean absolute error (MAE) was 0.032, confirming minimal bias and reliable calibration of the nomogram in this cohort of 128 children with intussusception.

Discussion

Intussusception is one of the most common acute abdominal emergencies in early childhood. Its typical clinical manifestations, including paroxysmal crying, abdominal pain, vomiting, abdominal mass, and currant jelly-like stool, as well as characteristic ultrasonic findings such as the target sign and sleeve sign, are well-recognized in clinical practice [15, 16]. According to clinicopathological characteristics, Grosfeld classified intussusception into four categories: common, special, anatomical, and other types. Among these, transient intussusception accounts for approximately 20% of cases, whereas fixed intussusception constitutes up to 80% [17].

Clinically, small bowel intussusception is mostly transient, and the majority of cases resolve spontaneously without specific intervention. A previous study conducted at Beijing Children’s Hospital reported that among 331 children with small bowel intussusception, 270 cases were transient, corresponding to a spontaneous reduction rate of 81.6% [18]. Furthermore, a report from West China Hospital indicated that short-segment (≤ 3.0 cm) small bowel intussusceptions had a significantly higher spontaneous reduction rate (96.29%) than other intussusception subtypes [19].

Spontaneous reduction of intussusception has been reported to occur in 17–38% of all cases [20–22]. Owing to substantial individual variability among children, the time window for spontaneous resolution of the intussuscepted segment varies widely. A study of 265 children with intussusception identified 59 cases of transient intussusception (22%), with a mean spontaneous reduction time of 23.69 ± 7.48 min [23]. Consistent with this, Kornecki et al. [20] and Kim [24] reported that most spontaneous reductions occurred within 6 h of symptom onset.

Based on clinical experience, experts have proposed standardized ultrasonic diagnostic criteria for transient small bowel intussusception:1. Intussusception depth < 3.5 cm; 2. Diameter < 2.5 cm; 3. No bowel wall edema or thickening at the intussusception site, with homogeneous echogenicity and a clear layered structure of the intestinal wall; 4. No pathological echoes (e.g., polyps, diverticula, cysts, foreign bodies) within the lumen of the intussuscepted bowel; 5. Preserved natural peristalsis of the intussusception segment and adjacent proximal/distal bowel loops; 6. Normal blood flow signals in the intestinal wall and mesentery at the intussusception site, with no evidence of ischemia or necrosis; 7. Absence of relevant clinical symptoms (abdominal pain, vomiting, paroxysmal irritability, bloody stools, abdominal mass).

In recent years, a growing number of clinical experts have advocated extending the dynamic observation period for children with mild intussusception to avoid unnecessary overtreatment such as enema reduction, emphasizing that not all cases require active intervention [25]. However, real-time continuous ultrasound monitoring to confirm spontaneous reduction is impractical in routine clinical settings, and clinician-led observation may therefore significantly extend the effective observation window.

However, some children may present with concomitant organic intestinal lesions, such as Meckel’s diverticulum or intestinal polyps, which require timely and targeted treatment. Delayed intervention may lead to progressive intestinal ischemia and necrosis, thereby seriously endangering the patient’s life.

Previous studies have demonstrated that multiple factors are closely associated with spontaneous reduction of small bowel intussusception, including duration of abdominal pain, fever, inflammatory markers, abdominal mass, currant jelly-like stool, external or drug stimulation, peritoneal effusion, mesenteric lymphadenopathy, and the width and length of the intussuscepted segment [26]. Among these, currant jelly-like or bloody stool represents an independent risk factor for failed spontaneous reduction and serves as a key indicator for clinical decision-making regarding surgical intervention. The presence of bloody stools suggests impaired intestinal perfusion, mucosal ischemia, or necrosis, which markedly reduce the likelihood of spontaneous reduction [5].

Although an abdominal mass is a classic clinical feature of intussusception, the intussuscepted mass in most transient cases is relatively small. Moreover, young children often cannot cooperate with physical examination due to severe irritability, making clinical detection unreliable. Therefore, further imaging evaluation, particularly ultrasound, is essential for accurate identification [27].

Ultrasonography is the preferred imaging modality for diagnosing intussusception, with a diagnostic accuracy exceeding 95% [28, 29]. As medical technology has advanced and ultrasonic diagnostic capabilities have improved, the positive detection rate of intussusception via ultrasound has continued to rise. However, many primary medical institutions in China face notable practical challenges, including a shortage of pediatric surgery specialists, limited access to air or hydrostatic enema reduction equipment, and unduly abbreviated observation periods.

These limitations frequently result in the misclassification of transient intussusception as fixed intussusception requiring urgent intervention, leading to the unnecessary emergency referral of children. Notably, many of these referred patients experience spontaneous reduction during transfer or subsequent follow-up ultrasound or enema attempts at tertiary hospitals. This scenario not only imposes substantial medical and transportation burdens on families but also elevates the risk of doctor-patient misunderstandings.

Thus, the accurate differentiation of intussusception subtypes and the scientific assessment of whether enema intervention is necessary hold profound clinical significance. Such precision is critical for minimizing pediatric patient discomfort, reducing the unnecessary utilization of medical resources, and fostering positive doctor-patient relationships [30].

Pediatric tuina, a characteristic non-invasive external therapy in traditional Chinese medicine, is widely used for various pediatric gastrointestinal disorders, including Infantile diarrhea, intestinal obstruction, and indigestion, with acceptable safety and favorable tolerability [7]. Although its potential adjunctive benefits in pediatric intestinal conditions have been recognized, high-quality evidence supporting tuina as a primary reduction modality for intussusception remains limited [6, 31, 32].

Intestinal preparation is a key factor influencing the success rate of enema reduction. Previous studies have demonstrated that residual large amounts of feces in the colon can be pushed toward the intussusceptum in the proximal colon during enema reduction, leading to unstable and unsustained intracolonic pressure. This instability impairs the effective reduction of the intussusceptum, prolonging enema duration and increasing the risk of reduction failure [33]. Additionally, children may exhibit defecatory responses during enema, and fecal matter can block or displace the catheter, further hindering the treatment process.

Therefore, when the patient’s condition allows, anal glycerin enema for children with intussusception can facilitate intestinal emptying, relax intestinal smooth muscle, and alleviate intestinal spasm. These effects not only help shorten the duration of subsequent enema reduction but also improve the overall reduction success rate [4]—which aligns with the rationale of our study, where glycerin enema was combined with pediatric tuina as the initial treatment to optimize intestinal conditions and enhance reduction efficacy. In our cohort of 128 children (none presenting with critical conditions, shock, hematochezia, or currant jelly-like stool at admission), 127 underwent initial treatment with this combined regimen, achieving an overall reduction success rate of 80.31% (102/127); notably, 2 of these cases required re-treatment with the same regimen to achieve complete reduction, as follow-up ultrasound initially showed residual intussusception with reduced intussuscepted segments.

Among the 128 children in our cohort, the vast majority presented to the hospital with typical symptoms of intussusception, including paroxysmal crying, abdominal pain, and vomiting, and all ultrasound examinations confirmed the characteristic target sign of intussusception—consistent with the classic clinical and imaging features of the disease described in previous literature.

Clinical practice has demonstrated that color Doppler ultrasound findings and the resolution of children’s primary symptoms following pediatric tuina combined with anal glycerin enema are important clinical indicators for judging the spontaneous reduction of intussusception. Notably, in some children in our study, re-examination color Doppler ultrasound performed 2 h after initial treatment still showed evidence of intussusception; however, compared with baseline, the volume of the intussuscepted segment was reduced or its position had shifted, and the initial clinical symptoms (e.g., paroxysmal irritability, abdominal pain, vomiting, abdominal mass) were completely relieved.

All such children achieved complete spontaneous reduction of intussusception on follow-up ultrasound the next day. Further analysis of our data (Fig. 5) showed that the reduction success rate of the combined regimen varied significantly by intussusception type (small bowel: 96.43%, ileocolic: 73.13%, colocolic: 16.67%; P < 0.001) and intussusception length (91.18% for < 3 cm vs. 59.70% for ≥ 3 cm; P < 0.001), while no significant differences were observed across symptom duration groups (P = 0.557) or intussusception location subgroups (all P > 0.05).

For children with incomplete symptom relief after initial treatment but stable general condition, with an observation period limited to 2 h, repeat administration of the combined therapy (pediatric tuina plus per rectal glycerin enema) may be considered at the attending clinician’s discretion. Strict adherence to the previously described criteria for discontinuing conservative treatment and proceeding to enema reduction or surgical intervention is required. Conversely, if symptoms show no significant improvement or even deteriorate after the first treatment, prompt air or hydrostatic enema reduction should be performed to avoid delaying care.

In our study, 23 of the 25 children who failed initial reduction with the tuina-glycerin enema combination achieved successful reduction using ultrasound-guided hydrostatic enema, yielding an overall success rate of 88.46% for this second-line intervention. The mean maximum enema pressure was 10.53 kPa, considerably higher than the 6 kPa threshold used for diagnostic enemas [34].

Even in fixed intussusception cases where complete reduction was not achieved with the combined regimen, the treatment still promoted partial release of the intussusceptum, relieved intraluminal pressure, reduced intestinal wall edema, and decreased the risk of intestinal ischemia and necrosis. Furthermore, the regimen provided effective intestinal cleansing, creating favorable conditions for subsequent air or hydrostatic enema reduction [4].

A critical safety consideration is that this combined approach is not recommended for children with currant jelly-like or bloody stools, as these features suggest established intestinal wall ischemia or necrosis [35, 36].

Further analysis of our data (Fig. 5) showed that the reduction success rate of the combined regimen varied significantly by intussusception type (96.07% for small bowel, 73.23% for ileocolic, 16.66% for colocolic; P < 0.001) and intussusception length (91.36% for < 3 cm vs. 59.57% for ≥ 3 cm; P < 0.001), while no significant differences were observed across symptom duration groups (P = 0.557) or intussusception location subgroups (all P > 0.05). Multivariate logistic regression analysis further confirmed these findings (Fig. 6A), identifying intussusception type (ileocolic vs. small bowel: OR = 0.14, 95% CI: 0.08–0.37, P < 0.001; colocolic vs. small bowel: OR = 0.02, 95% CI: 0.00–0.09, P < 0.001), intussusception length ≥ 3 cm (OR = 0.17, 95% CI: 0.08–0.37, P < 0.001), and age group (0–1 year vs. 1–3 years: OR = 0.30, 95% CI: 0.11–0.82, P = 0.018; 6–12 years vs. 1–3 years: OR = 0.00, P < 0.001) as independent risk factors for failure of the initial combined therapy. The multivariate model demonstrated favorable predictive performance for treatment failure, with an area under the ROC curve (AUC) of 0.797 (P < 0.001) (Fig. 6B), and the initial combined therapy exhibited a sensitivity of 79.69% and a positive predictive value of 100% for successful reduction.

A nomogram was constructed based on the multivariate logistic regression model to predict the risk of failure for the initial combined therapy (Fig. 7). The model incorporated three independent predictors: intussusception type, intussusception length ≥ 3 cm, and age group. The nomogram provides a visual tool for individualized risk assessment in clinical practice (Fig. 7).

In our experience, glycerin enema combined with pediatric tuina may facilitate spontaneous reduction of intussusception, facilitate the differentiation of transient from fixed subtypes, and provide effective intestinal preparation for subsequent enema reduction when necessary. This sequential, step-up strategy represents a feasible and safe conservative adjunct in selected hemodynamically stable patients. Our 3–6 month follow-up data further supported the safety and efficacy of this strategy: no complications were observed in the 102 children who achieved successful reduction with the initial combined therapy; among the 23 patients with successful hydrostatic enema reduction, only 1 case experienced recurrence 1 month later (successfully treated with a second hydrostatic enema, with no further recurrence); and no recurrence was reported in the 3 children who underwent laparoscopic surgery (1 of whom was diagnosed with submucosal hamartoma at the intussusception site via postoperative pathology). The 3 children who required laparoscopic surgery (all due to failed hydrostatic enema reduction) had an operative time ranging from 60 to 130 min (mean: 85 min) and a mean hospital stay of 5.5 days, with no intraoperative or postoperative complications observed.

It should be emphasized that while avoiding overtreatment, clinicians must maintain heightened vigilance against severe complications such as intestinal necrosis and perforation that may arise from delayed intervention. This requires not only familiarity with the clinical features of transient intussusception but also accurate differentiation from non-reducible subtypes, balancing both safety and effectiveness of treatment.

Against this background, our study suggests that when the patient’s condition permits, initial treatment with pediatric tuina combined with anal glycerin enema can safely extend the observation window and help avoid unnecessary enema intervention. Meanwhile, this approach allows timely identification of children with fixed intussusception who require active reduction—consistent with our data showing that 25 children (19.53%) failed the initial combined therapy and required further intervention (26 underwent hydrostatic enema, 3 required laparoscopic surgery). Furthermore, close short-term monitoring ensures no delay in definitive treatment, providing a safe, feasible, and novel option for the clinical management of pediatric intussusception.

Conclusion

Previous studies on intussusception have focused on optimizing reduction efficacy and preventing complications. However, conventional enema approaches carry risks of intestinal perforation and high medical costs, which may compromise treatment compliance, especially in recurrent cases [37, 38]. To address these clinical needs, we evaluated pediatric tuina combined with anal glycerin enema as an initial conservative strategy for selected children with intussusception.

This non-invasive, easily implemented regimen achieved an initial reduction success rate of 80.3%. Intussusception type, length ≥ 3 cm, and age were identified as independent risk factors for treatment failure, with the predictive model showing good performance (AUC = 0.797). The approach helps avoid unnecessary interventions, facilitates the differentiation between transient and fixed intussusception, and improves conditions for subsequent rescue procedures when needed. Short-term follow-up confirmed acceptable safety and low recurrence.

Limitations include a relatively small sample size, single-center design, selection bias, and lack of a control group. Only 3 cases underwent laparoscopic surgery in this study, which limits the statistical analysis and further interpretability of surgical outcomes. Causal conclusions should be interpreted cautiously due to the high spontaneous reduction rate of small bowel intussusception. Future large-sample, multicenter controlled studies are warranted to validate the efficacy, safety, and generalizability of this regimen.

In summary, pediatric tuina combined with anal glycerin enema represents a safe, feasible, and promising initial step-up strategy for clinically stable children with intussusception, balancing avoidance of overtreatment and timely intervention.

Abbreviations

PT

Pediatric tuina

GE

Glycerin enema

PI

Pediatric intussusception

USHE

Ultrasound-guided hydrostatic enema

Authors’ contributions

Conception and design: Xiaobin Huang、Min Liu. Collection and assembly of data: Jiqing Liu, Xiuling Wu, Shifen Huang, Bo Luo, Xi Zhang. Analysis and interpretation of the data: Jiqing Liu, Xiuling Wu, Shifen Huang. Drafting of the article: Xiaobin Huang； Critical revision of the article for important intellectual content: Bo Luo, Min Liu.

Funding

This research was funded by the 2024 Scientific Research Project of Zigong Municipal Health Commission (Grant No.: 24yb052).

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Zigong Maternal and Child Health Hospital (Ethics Approval No.: 2024–13) and conducted in strict compliance with the requirements of the Declaration of Helsinki. Written informed consent was obtained from the legal guardians of all children before enrollment and treatment.

Consent for publication

Written consent for publication of clinical data was obtained from all participants’ legal guardians.

Competing interests

The authors declare no competing interests.