VOLUME 8 NUMBER 2 2003 ISSN: 0965-0288 Effective

Bulletin on the effectiveness Health Care of health service interventions forfor decisiondecision makersmakers Treating nocturnal This bulletin summarises in children the research evidence on the effects of ■ Nocturnal enuresis in involvement. Currently, interventions for the children (bedwetting) there is insufficient treatment of nocturnal affects many families. evidence to support the use enuresis in children Although it has a high rate of any particular of spontaneous remission, intervention. bedwetting may bring social ■ The use of alarms has been and emotional stigma, shown to reduce night-time and inconvenience to both bedwetting both during the child and their family. treatment and after ■ A variety of interventions treatment stops. Before are used to treat nocturnal embarking on alarm enuresis. These include treatment, families need to alarms, drugs such as be made aware of both the , simple time and the high level of behavioural methods such parental involvement as star charts, as well as necessary to attain success. more complex multi-faceted ■ Drug therapy such as interventions. desmopressin reduces the ■ Much of the available number of wet nights per research evaluating the week compared with effects of interventions is of , but only for as long poor quality and there are as the drug is used. Drugs few direct comparisons could be used to reduce between different types of bedwetting for a specific intervention. purpose, such as nights away from home. Children ■ Simple behavioural and their families need to interventions are widely be warned about possible used as standard first-line side effects of some of the treatment, but they require drugs. a high level of parental

CENTRE FOR REVIEWS AND DISSEMINATION A. Background Box 1 Interventions used to treat nocturnal enuresis Behavioural interventions Nocturnal enuresis (bedwetting) is ■ the involuntary loss of at Lifting: involves taking the child to the toilet during the night usually night, in the absence of physical before the time that bedwetting is expected, without necessarily , at an age when a child could waking the child. reasonably be expected to be dry (by ■ Waking: involves waking the child to allow them to get up and consensus, at a developmental age of urinate. five years).1,2 Although bedwetting has a high rate of spontaneous ■ Reward systems (e.g. star charts): the child might receive a star for remission, it may bring social and every dry night, and a reward after a preset number of stars have emotional stigma, stress and been earned. inconvenience to both the child with ■ enuresis and their family.3 Children Retention control training: attempting to increase the functional who wet the bed may experience bladder capacity by delaying for extended periods of time parental disapproval, sibling teasing during the day. and repeated treatment failure which ■ Stop-start training: teaching children to interrupt their stream of urine 4,5 may lower self esteem. in order to strengthen their pelvic floor muscles

Prevalence and causes ■ Dry bed training: can include enuresis alarms, waking routines, Nocturnal enuresis affects many positive practice, cleanliness training, bladder training, and rewards. families. Estimating the prevalence is Enuresis alarms difficult, however, because there are ■ variations in methods of diagnosis Enuresis alarms: wake the child in the night at the onset of wetting. and in definitions.6,7 In the UK, the When a child begins to urinate, a sensor (either a bed pad or one most recent estimates suggest that worn inside pyjamas) is moistened, and the alarm is triggered. the prevalence of frequent ■ Over-learning: may be initiated after successful alarm treatment bedwetting (more than once a week) (e.g. achievement of 14 consecutive dry nights). Extra drinks are is higher in boys and shows a steady given at bed-time to cause additional stress to the detrusor muscles in 8-10 decline with age. Around one in the bladder. Alarm treatment is then continued until 14 consecutive six of five-year-olds regularly wet the dry nights are once again achieved. bed compared to around one in twenty 11-year-olds.8-10 Pharmacological interventions ■ The causes of primary nocturnal Drugs: include desmopressin and, less commonly, tricyclic drugs such enuresis, where a child has never as , and . been dry at night, are unclear. such as desmopressin, simple to become dry,23 consensus is that a Genetic,2,11-13 physiological14,15 and behavioural methods such as star thorough assessment should be psychological16-19 factors, as well as charts and more complex undertaken including a general delay in maturation of the behavioural methods including dry physical examination, urinalysis and mechanism for bladder control,20,21 bed training. Other less common investigation of attitudes.8 In keeping have been suggested. Other factors interventions include psychotherapy, with the objectives of the National which may contribute to bedwetting surgery, fluid deprivation and Service Framework for Children, any include: , apnoea complementary therapies. Box 1 intervention should be centred on and upper airway obstructive describes the most commonly used the needs of the child.27 Although it symptoms22 and diet or mild behavioural, alarm and is yet to be subjected to rigorous drinks with diuretic effects (e.g. 8 pharmacological interventions. evaluation, the ‘three systems cola). 24 Treatment for children who wet the approach’ is advocated as a way to bed is often carried out by health understand, assess and select professionals in general practice. appropriate treatment for nocturnal B. Management Bedwetting may be discovered when enuresis. of enuresis a child is seen for a complaint other The Enuresis Resource and than enuresis. Having established Information Centre (ERIC) has A wide variety of interventions are that the child is at an age where one produced guidelines on minimum used to treat nocturnal enuresis. could reasonably expect a dry bed standards of practice in the These include enuresis alarms, drugs (i.e. at least five years old) and wants treatment of enuresis to assist

2 EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children VOLUME 8 NUMBER 2 2003 managers and practitioners in the Report series.28 Further details of In addition, strict inclusion/exclusion planning, execution and evaluation review methods are available in the criteria were imposed in many of the of enuresis services.25 ERIC also has Appendix. trials. Consequently, the children details of over 600 enuresis clinics in Although over 100 RCTs have been involved are not necessarily 26 the UK. Some clinics are based in identified across the Cochrane representative of the wider hospitals and others in health reviews, there are few direct population of those who wet the centres (often run by school nurses) comparisons between different types bed, either in the community or in Most but not all clinics are open to of intervention. The difficulty in institutions. clients without the need for a comparing interventions is professional referral. exacerbated by the lack of uniformity in outcome measures and D. Effects of the failure of some studies to C. Nature of the adequately assess baseline levels of interventions bedwetting. Many of the included D1. Behavioural interventions evidence RCTs have methodological problems other than alarms Simple such as small sample sizes and high This issue of Effective Health Care behavioural interventions are widely rates of attrition (drop-outs), leading summarises the research evidence used as standard first-line treatment. to low statistical power and potential from randomised controlled trials Twelve RCTs were included in a bias. In addition, many are poorly (RCTs) on the effects of interventions Cochrane review assessing the reported. For example, many trial for the treatment of nocturnal effects of simple behavioural authors give insufficient detail about enuresis in children. The bulletin is interventions.29 None of the RCTs the method of randomisation or based upon a series of systematic were of good methodological quality. inadequately report follow-up data. reviews that have been carried out The review found that star charts, A number of the included RCTs by the Cochrane Incontinence whether with or without lifting or have recruited children by Group, and are available via the waking, were associated with fewer advertising in the media, or from Cochrane Library. The Cochrane wet nights and lower failure rates enuresis clinics. Participating reviews are all based on a previous while on treatment, and longer-term families may have been especially systematic review originally success after treatment. However, motivated to tackle the bedwetting. published in 1997 as part of the CRD each finding was based on a single

Outcome: Number cured (achieving 14 consecutive dry nights)

Study alarm control RR (fixed) Weight RR (fixed) or sub-category n/N n/N 95% CI % 95% CI

01 alarm vs control Werry 1965 6/21 1/27 6.50 7.71 [1.00, 59.25] Sloop 1973 11/21 1/21 7.43 11.00 [1.56, 77.76] Sacks 1974 51/64 2/9 26.07 3.59 [1.05, 12.25] Jehu 1977 18/19 0/20 3.63 38.85 [2.50, 602.54] Bollard 1981a 12/15 0/15 3.72 25.00 [1.61, 387.35] Bollard 1981b 16/20 2/20 14.87 8.00 [2.11, 30.34] Wagner 1982 10/12 1/12 7.43 10.00 [1.51, 66.43] Lynch 1984 7/18 0/18 3.72 15.00 [0.92, 244.51] Bennett 1985 4/9 0/9 3.72 9.00 [0.55, 146.11] Wagner 1985 8/13 1/13 7.43 8.00 [1.16, 55.20] Houts 1986 9/12 0/11 3.86 17.54 [1.14, 269.84] Moffatt 1987 42/61 1/55 7.82 37.87 [5.39, 266.00] Ronen 1992 12/19 0/18 3.81 23.75 [1.51, 373.78] Subtotal (95% CI) 304 248 100.00 12.55 [7.32, 21.53] Total events: 206 (alarm), 9 (control) Test for heterogeneity: Chi2 = 7.40, df = 12 (P = 0.83), I2 = 0% Test for overall effect: Z = 9.20 (P < 0.00001)

02 delayed alarm vs control Lynch 1984 1/18 0/18 33.33 3.00 [0.13, 69.09] Wagner 1985 7/13 1/13 66.67 7.00 [1.00, 49.16] Subtotal (95% CI) 31 31 100.00 5.67 [1.11, 28.99] Total events: 8 (alarm), 1 (control) Test for heterogeneity: Chi2 = 0.20, df = 1 (P = 0.65), I2 = 0% Test for overall effect: Z = 2.08 (P = 0.04)

03 unsupervised alarm vs control Bollard 1981a 9/15 0/15 100.00 19.00 [1.20, 299.63]

0.001 0.01 0.1 1 10 100 1000 favours control favours alarm

Figure 1 Comparison: alarm vs control – number cured during treatment

2003 VOLUME 8 NUMBER 2 EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children 3 Outcome: Numbers remaining cured (achieving 14 dry nights and not relapsing)

Study Treatment Control RR (fixed) Weight RR (fixed) or sub-category n/N n/N 95% CI % 95% CI

01 alarm vs control Sloop 1973 7/21 1/21 33.33 7.00 [0.94, 52.04] Bollard 1981a 8/15 0/15 16.67 17.00 [1.07, 270.41] Bollard 1981b 10/20 0/20 16.67 21.00 [1.31, 335.74] Wagner 1982 5/12 0/12 16.67 11.00 [0.67, 179.29] Wagner 1985 6/13 0/13 16.67 13.00 [0.81, 209.42] Subtotal (95% CI) 81 81 100.00 12.67 [4.06, 39.52] Total events: 36 (Treatment), 1 (Control) Test for heterogeneity: Chi2 = 0.52, df = 4 (P = 0.97), I2 = 0% Test for overall effect: Z = 4.37 (P < 0.0001)

02 delayed alarm vs control Wagner 1985 2/13 0/13 100.00 5.00 [0.26, 95.02]

03 unsupervised alarm vs control Bollard 1981a 4/15 0/15 100.00 9.00 [0.53, 153.79]

0.001 0.01 0.1 1 10 100 1000 favours control favours alarm

Figure 2 Comparison: alarm vs control – numbers remaining cured after treatment

small trial. Of the two trials likely to find statistically significant variety of simple behavioural addressing retention control training, differences, even where some interventions including star charts, one was too small to provide difference may exist, and often only rewards, wakening, lifting and stop- meaningful information, and the one small trial compared alarms with start training (pelvic floor muscle other had a very high (80%) drop- another method. In these training).31 Most of the trials out rate. Another small trial showed circumstances, no conclusions can comparing behavioural interventions that there might be some benefits be drawn. with alarms tended to favour alarms. associated with cognitive therapy Do alarms work? The review’s main In one small trial, alarms were found compared with star charts, but these findings were that alarm treatment to be better than stop-start training findings will need to be confirmed in was more effective during treatment in terms of wet nights per week both larger trials. than control interventions (see during and after treatment. There A feature of the included RCTs was Figure 1). In terms of success rates were no statistically significant high dropout or non-adherence once treatment was completed (see differences between alarms and rates. Families reported that waking Figure 2), about half the children methods such as lifting, wakening or the child at night was disruptive remained dry after using alarms, rewards in four other small trials, and stressful, suggesting that some compared with almost none of those although all trials favoured alarms in of these simple behavioural who received no treatment or respect of a reduction in the mean interventions are not suitable for all. waiting list control. number of wet nights. There was not enough evidence to conclude Which type of alarm is best? A number of RCTs have assessed the Most whether supplementing alarm effects of complex behavioural of the alarms evaluated were of the treatment with behavioural treatment programmes such as dry type that woke the child interventions improved the bed training. In the 1997 systematic immediately by means of a bell or effectiveness of the alarm. review undertaken by CRD,28 buzzer. Insufficient evidence was Are alarms better than drugs? complex behavioural treatment found to draw conclusions about the The programmes such as dry bed relative effectiveness of different Cochrane review included 18 RCTs training were not found to be more types of alarm. There was some that involved comparisons between effective than alarm treatment. An limited evidence that an immediate alarms and drugs either alone or in 31 update is nearing completion and alarm was better than a delayed combination. Limited evidence will be available as a Cochrane alarm, and that one which woke the suggested that alarms were better review later this year.30 child rather than the parents had than drug treatment. Although desmopressin appeared to have a D2. Alarms better results. Children were Fifty-three RCTs were more immediate effect, alarms were included in a Cochrane review reported to prefer a body-worn alarm to a bed pad and alarm. more effective by the end of a assessing the effects of alarm course of treatment (RR 0.71, 95% CI Are alarms better than other interventions for nocturnal 0.50 to 0.99) and after treatment 31 behavioural interventions? enuresis. The methodological The stopped (RR 0.27, 95% CI 0.11 to quality of many of the RCTs was Cochrane review included eight 0.69). Alarms were also found to be poor. Many were too small to be RCTs comparing alarms with a better than tricyclics both during

4 EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children VOLUME 8 NUMBER 2 2003 Outcome: Number of wet nights per week during treatment

Study Desmopressin Placebo WMD (fixed) Weight WMD (fixed) or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

01 10 mcg vs placebo Aladjem 1982 15 1.52(2.15) 17 4.40(1.94) 62.07 -2.88 [-4.31, -1.45] Kjoller 1984 13 2.49(2.52) 12 3.84(2.13) 37.93 -1.35 [-3.17, 0.47] Subtotal (95% CI) 28 29 100.00 -2.30 [-3.42, -1.18] Test for heterogeneity: Chi2 = 1.68, df = 1 (P = 0.20), I2 = 40.4% Test for overall effect: Z = 4.01 (P < 0.0001) 02 20 mcg vs placebo Folwell 1997 31 3.24(2.51) 31 4.86(1.95) 4.29 -1.62 [-2.74, -0.50] Tuvemo 1978 18 1.60(1.82) 18 3.97(2.20) 3.09 -2.37 [-3.69, -1.05] Segni 1982 20 2.20(1.34) 20 4.20(1.79) 5.59 -2.00 [-2.98, -1.02] Post 1983 B 20 4.90(1.92) 20 5.80(1.14) 5.61 -0.90 [-1.88, 0.08] Kjoller 1984 12 2.45(1.84) 12 3.84(2.13) 2.12 -1.39 [-2.98, 0.20] Terho 1984 54 2.16(2.00) 54 4.02(1.83) 10.27 -1.86 [-2.58, -1.14] Janknegt 1990 22 3.40(2.50) 22 5.30(1.80) 3.24 -1.90 [-3.19, -0.61] Rushton 1995 49 3.96(2.37) 47 4.90(1.64) 8.14 -0.94 [-1.75, -0.13] Skoog 1997 33 4.00(1.15) 36 5.00(1.20) 17.46 -1.00 [-1.55, -0.45] Sener 1998 31 1.10(1.39) 25 5.10(2.00) 6.29 -4.00 [-4.92, -3.08] Schulman 2001a 44 4.00(1.33) 47 4.50(1.37) 17.45 -0.50 [-1.05, 0.05] Schulman 2001b 109 4.00(1.57) 38 5.00(1.54) 16.45 -1.00 [-1.57, -0.43] 03 40 mcg vs placebo Post 1983 A 52 3.90(2.34) 52 5.00(1.91) 17.27 -1.10 [-1.92, -0.28] Janknegt 1990 22 3.80(2.20) 22 5.30(1.80) 8.25 -1.50 [-2.69, -0.31] Martin 1993 22 2.16(2.25) 22 3.68(2.25) 6.58 -1.52 [-2.85, -0.19] Skoog 1997 33 3.50(1.44) 36 5.00(1.20) 29.47 -1.50 [-2.13, -0.87] Yap 1998 34 2.50(2.70) 34 4.50(2.10) 8.81 -2.00 [-3.15, -0.85] Schulman 2001a 48 3.50(1.73) 47 4.50(1.37) 29.62 -1.00 [-1.63, -0.37] Subtotal (95% CI) 211 213 100.00 -1.33 [-1.67, -0.99] Test for heterogeneity: Chi2 = 3.11, df = 5 (P = 0.68), I2 = 0% Test for overall effect: Z = 7.63 (P < 0.00001) 04 60 mcg vs placebo Skoog 1997 33 3.50(1.15) 36 5.00(1.20) 56.09 -1.50 [-2.05, -0.95] Schulman 2001a 48 3.00(1.73) 47 4.50(1.37) 43.91 -1.50 [-2.13, -0.87] Subtotal (95% CI) 81 83 100.00 -1.50 [-1.92, -1.08] Test for heterogeneity: Chi2 = 0.00, df = 1 (P = 1.00), I2 = 0% Test for overall effect: Z = 7.08 (P < 0.00001) 05 combined dose vs placebo Birkasova 1978 22 2.10(2.25) 22 5.50(2.20) 100.00 -3.40 [-4.71, -2.09]

06 dose titration vs placebo Rushton 1995 49 3.77(2.52) 47 4.90(1.82) 32.13 -1.13 [-2.01, -0.25] Schulman 2001b 99 3.20(1.69) 36 5.00(1.54) 67.87 -1.80 [-2.40, -1.20] Subtotal (95% CI) 148 83 100.00 -1.58 [-2.08, -1.09] Test for heterogeneity: Chi2 = 1.52, df = 1 (P = 0.22), I2 = 34.3% Test for overall effect: Z = 6.25 (P < 0.00001) -10 -5 0 5 10 favours desmopressin favours placebo

Figure 3 Comparison: Desmopressin vs placebo

(RR 0.73, 95% CI 0.61 to 0.88), and adherence or dropout was attributed that desmopressin (in a variety of after treatment stopped (RR 0.58, to the equipment being too difficult doses and forms) was better at 95% CI 0.36 to 0.94). Insufficient or complicated to use. A small reducing the number of wet nights reliable evidence was found to number of RCTs included in the per week during treatment support the practice of review involved alarms that compared to placebo (see Figure 3). supplementing alarm treatment with delivered electric shocks to the However, after treatment stopped, drug interventions. children’s skin. The use of these the limited evidence available Acceptability of alarms Most alarms was clearly unacceptable to suggested that this improvement alarms wake the child immediately parents and children, and they was not sustained. using a bell or buzzer but then sometimes caused side effects such Another Cochrane review of 54 require nightwear, and perhaps as skin burns and ulceration. RCTs found that treatment with bedding, to be changed. High D3. Drugs Three Cochrane reviews tricyclic or related drugs dropout rates in some of the trials have assessed the effects of drug (imipramine, amitriptyline, included in the Cochrane review therapy on nocturnal enuresis in , and suggest that there were problems children.32-34 One of these reviews desipramine but not mianserin) was with adherence, often reflecting the covers the less commonly used associated with a reduction of about unacceptability of the intervention. drugs and is currently being updated one wet night per week while on Potential difficulties, such as the and will be available later this year.34 treatment.33 For example, imipramine time needed to attain success and Forty-one RCTs were included in a was better at reducing the number the disruption to the family, need to Cochrane review assessing the of wet nights per week during be discussed before embarking on effects of desmopressin.32 The review treatment compared to placebo alarm treatment. In two trials, non- found that there was clear evidence (WMD -1.19, 95% CI -1.56 to -0.82).

2003 VOLUME 8 NUMBER 2 EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children 5 However, although about a fifth of ■ Simple behavioural interventions controlled trials which is described the children became dry while on are widely used as standard first under the Incontinence Group’s treatment (86/400 achieved 14 dry line treatment, but they require a details in The Cochrane Library. nights on imipramine compared to high level of parental The register contains trials identified 22/413 on placebo), this effect was involvement. Currently, there is from MEDLINE, CINAHL, the not sustained after treatment insufficient evidence to support Cochrane Central Register of stopped (6/192 on imipramine the use of any particular Controlled Trials (CENTRAL) and compared to 7/209 on placebo). intervention. handsearching of journals and Insufficient reliable evidence was ■ The use of an alarm intervention relevant conference proceedings. In found comparing desmopressin with has been shown to reduce night- addition, the cited references from tricyclics or other related drugs. time bedwetting in a majority of the included trials were searched. Likewise, there was a lack of reliable children both during treatment No language or other restrictions evidence comparing desmopressin or and after treatment stops. Over- were imposed on any of these tricyclics with simple and complex learning (giving children extra searches and non-English language behavioural interventions. fluids at bedtime after papers were translated where necessary. Acceptability of drugs The British successfully becoming dry using National Formulary (BNF) currently an alarm) may reduce the relapse Studies were assessed using the suggests that drug therapy is not rate. Before embarking on alarm methods of the Cochrane 36 usually appropriate for children treatment, families need to be Collaboration. All randomised or under seven years of age and is made aware of both the time and quasi-randomised trials of reserved for when alternative the high level of parental interventions for the treatment of measures have failed.35 Fluid involvement necessary to attain non-organic nocturnal enuresis in overload is potentially the most success. children were included (as defined serious complication with ■ Drug therapy such as by the trialists, usually up to age 16). desmopressin. It is associated with desmopressin reduces the Two reviewers screened the studies over-drinking at bedtime and its number of wet nights per week independently for eligibility. Where symptoms include headache, nausea, compared with placebo, but only the trials have been published in hyponatraemia, cerebral oedema and for as long as the drug is used. more than one publication, only the convulsions. Tricyclics have However, drugs could be used as primary source has been referenced. significant adverse effects, including a way to reduce the frequency of Two reviewers independently cardiotoxic and hepatotoxic effects wetting for a specific purpose assessed the quality of the eligible in overdose. Minor side effects such as nights away from home trials, and extracted data using a related to their anticholinergic (e.g. for holidays or staying with standard form. Primary outcomes of actions include postural friends). Children and their interest were: the number of wet hypotension, dry mouth, families need to be informed nights per week during treatment constipation, perspiration, about possible side effects of and at follow up; the number of tachycardia, nausea, lethargy and some of the drugs. children who were cured during . The BNF recommends that ■ Future research must be of higher treatment (defined as achieving 14 the possible side effects of the methodological quality, involve consecutive dry nights) or who various drugs should be considered comparisons between those relapsed at follow up; and any and that any prescription should not interventions used most adverse events. be continued for longer than three commonly in practice, be A fixed effect model was used to months without stopping for a full undertaken in appropriate calculate the pooled estimates and 35 re-assessment. settings and include follow-up the 95% confidence intervals.37 periods of longer duration. E. Implications Appendix on methods References The bulletin is based upon a series of ■ Much of the available research on systematic reviews that have been 1. World Health Organisation. the effects of interventions used carried out by the Cochrane Nonorganic enuresis. The ICD-10 to treat nocturnal enuresis in Incontinence Group. Full details of classification of mental and behavioural disorders: Clinical children is of poor quality and review methods are available on the there are few direct comparisons descriptions and diagnostic Cochrane Library. guidelines. Geneva: WHO, 1992. between different types of intervention. Relevant trials were identified from 2. American Psychiatric Association. the Group’s specialised register of Functional enuresis. Diagnostic and

6 EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children VOLUME 8 NUMBER 2 2003 statistical manual of mental 15. Norgaard JP, Djurhuus JC. The 28. NHS Centre for Reviews and disorders. 3rd (revised) ed. pathophysiology of enuresis in Dissemination. A Systematic Review Washington: American Psychiatric children and young adults. Clin of the Effectiveness of Interventions Association, 1980. Pediatr (Phila) 1993;Spec No:5-9. for Managing Childhood Nocturnal Enuresis. CRD Report 11. York: 3. Fitzwater D, Macknin ML. 16. Rutter M, Yule W, Graham P. University of York, 1997. Risk/benefit ratio in enuresis Enuresis and behavioural deviance. therapy. Clin Pediatr (Phila) Some epidemiological 29. Glazener CMA, Evans JE. Simple 1992;31:308-10. considerations. In: Kolvin I, behavioural and physical MacKeith RC, Meadow SR. (eds) interventions for nocturnal 4. Warzak WJ. Psychosocial Bladder control and enuresis. enuresis in children. (Cochrane implications of nocturnal enuresis. 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The three adolescence. Br J Urol 1998;81: Update Software, 2003. systems: A conceptual way of 90-93. understanding nocturnal enuresis. 35. British Medical Association, Royal 11. Bakwin H. Enuresis in twins. Am J Scand J Urol Nephrol 2000;34: Pharmaceutical Society of Great Dis Child 1971;121:222-5. 270-277. Britain. British National Formulary. London: British Medical 12. Bakwin H. The genetics of enuresis. 25. Morgan R. Guidelines in the Association, Royal Pharmaceutical In: Kolvin I, MacKeith RC, Meadow minimum standards of practice in Society of Great Britain, 2003. SR. (eds) Bladder control and the treatment of enuresis. Bristol, enuresis. London: William UK: Enuresis Resource and 36. Clarke M, Oxman AD. Analysing Heinemann Medical Books, 1973. Information Centre, 1993. and presenting results. Cochrane Reviewers Handbook 4.1.4. 13. Eiberg H, Berendt I, Mohr J. 26. Enuresis Resource and Information The Cochrane Library, Issue 3. Assignment of dominant inherited Centre. 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2003 VOLUME 8 NUMBER 2 EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children 7 Acknowledgements ■ Adrian Grant, University of Aberdeen Effective Health Care would like to ■ Molly Haig, Enuresis Resource Effective acknowledge the helpful assistance and Information Centre Health Care of the following who commented on ■ Steve Holmes, Mendip PCT the text: ■ ■ Dee Kyle, Bradford South and This bulletin is based on Mark Baker, Yorkshire Cancer West PCT Network systematic reviews carried out by ■ ■ Colin Pollock, Regional Cathryn Glazener and Johnathan Richard Butler, East Leeds PCT Directorate of Public Health Evans of the Cochrane ■ Penny Dobson, Enuresis Resource (Yorkshire & Humber) Incontinence Group, with and Information Centre ■ June Rogers, Knowsley PCT ■ additional review work carried out Alison Evans, University of Leeds ■ Stephen Singleton, by Rachel Peto of the Centre for ■ Johnathan Evans, Nottingham Northumberland HA Reviews and Dissemination, City Hospital NHS Trust ■ Colin Waine, Sunderland HA University of York. ■ Cathryn Glazener, University of ■ Sheila Wallace, University of Aberdeen The bulletin was written and Aberdeen produced by staff at the Centre for Reviews and Dissemination, Effective Health Care Bulletins University of York. Vol. 3 5. Antimicrobial prophylaxis 5. Acute and chronic low in colorectal surgery back pain 1. Preventing and reducing 6. Deliberate self-harm 6. Informing, communicating the adverse effects of and sharing decisions with unintended teenage Vol. 5 people who have cancer The Effective Health Care bulletins are pregnancies 1. Getting evidence into Vol. 7 based on systematic review and 2. The prevention and practice synthesis of research on the clinical treatment of obesity 2. Dental restoration: what 1. Effectiveness of laxatives 3.Mental health promotion in effectiveness, cost-effectiveness and type of filling? in adults high risk groups 3. Management of 2. Acupuncture acceptability of health service 4. Compression therapy for gynaeological cancers 3. Homeopathy venous leg ulcers interventions. This is carried out 4. Complications of I 4. Interventions for the 5. Management of stable 5. Preventing the uptake of management of CFS/ME by a research team using established angina smoking in young people 5. Improving the recognition methodological guidelines, with 6. The management of 6. Drug treatment for and management of colorectal cancer advice from expert consultants for . in primary care Vol. 4 6. The prevention and each topic. Great care is taken Vol. 6 treatment of childhood to ensure that the work, and 1. Cholesterol and CHD: 1. Complications of obesity screening and treatment the conclusions reached, fairly diabetes II Vol. 8 2. Pre-school hearing, speech, 2. Promoting the initiation of and accurately summarise the language and vision breast feeding 1. Inhaler devices for the research findings. The University of screening 3. Psychosocial interventions treatment of asthma and 3. Management of lung York accepts no responsibility for any for schizophrenia COPD cancer 4. Management of upper consequent damage arising from the 4. Cardiac rehabilitation gastro-intestinal cancer use of Effective Health Care. Full text of previous bulletins available on our web site: www.york.ac.uk/inst/crd

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8 EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children VOLUME 8 NUMBER 2 2003