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Treating Nocturnal Enuresis in Children

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Treating Nocturnal Enuresis in Children 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 enuresis 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, stress 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 desmopressin, 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 placebo, 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 urine 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 disease, 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 urination 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 imipramine, amitriptyline and nortriptyline. 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: constipation, sleep 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 caffeine 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
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