Simple behavioural interventions for nocturnal enuresis in children

Hassan F, El-Makawi SM, Raafat Amn O, Bastawy N, Saad S, M.Hussein S, Mahmoud D, Mohamed Abdelhamid ElKhashab K. Vitamin D and vitamin B12 profiles in children with primary nocturnal enuresis, an analytical cross-sectional study

PURPOSE

To outline the prevalence of vitamin D and vitamin B12 deficiencies in enuretic children.

METHODS

An analytical descriptive study was conducted on enuretic children who were followed up at the outpatient clinic for nocturnal enuresis at the Children's Hospital, Cairo University. Sociodemographic and clinical data were recorded. The levels of vitamin D and vitamin B12 were assessed and correlated with the severity of enuresis.

RESULTS

Two hundred and eighty-eight children were enrolled. Insufficiency of Vitamin D predominated (n = 139; 48.3%). Vitamin D deficiency was present in 31.3%, n = 90 and it was normal in 20.5%, n = 59). Vitamin B12 deficiency was observed in 25% of the studied children, n = 72). The one-sample Wilcoxon signed-rank test was significant for both vitamins (P value =0.001). Vitamin D showed a stronger inverse correlation with the number of enuresis episodes per day than vitamin B12 (-0.680 vs. -0.219 respectively). A cut-off of 13.7 ng/ml for vitamin D was detected, below which the child was predicted to have failed dry nights. Using multivariate logistic regression, higher vitamin D levels and behavioural treatment coexistence were significant protective factors for the absence of dry nights.

CONCLUSION

Low levels of vitamin D and B12 were detected in children with primary nocturnal enuresis, which could be considered a burden on the clinical severity of enuresis.

Assessment of readability and quality of patient education materials specific to nocturnal enuresis

BACKGROUND

Bedwetting, or nocturnal enuresis (NE), is a common childhood disease. Families increasingly turn to free online resources for health education in order to navigate treatment options.

OBJECTIVE

We aim to determine the readability and quality of online health information that families may encounter when searching for information on pediatric NE.

STUDY DESIGN

The search term 'bedwetting' was queried in commonly used search engines. Included articles were further categorized as institutional/reference, commercial, non-profit/charitable, or personal. An online readability platform calculated 3 commonly used readability assessments as well as a consensus score. Quality was assessed by two independent pediatric urologists using a validated DISCERN instrument. Differences in readability were further assessed by article category type.

RESULTS

36 websites were reviewed, 3 did not include treatment options and were not included in quality assessment. 55.6% of the articles were categorized as institutional/reference, 27.8% as non-profit/charitable, 11.1% as personal, and 5.6% as commercial. The average, standard deviation, and range of readability level were as follows: overall consensus score = 9.56 ± 2.09, FK Grade Level Formula score = 9.38 ± 2.17 (range 5.8-14.1), SMOG Index score = 8.89 ± 1.79 (range 6.4-12.9), and the GF Index score = 11.86 ± 2.34 (range 8.4-16.9). The overall consensus score, 9.56, correlates to a 9th-grade reading level. 16 articles were considered to be of 'good' quality, 12 of 'fair' quality, and 5 of 'poor' quality; according to the DISCERN scoring. There was no statistically significant difference in readability scores across website categories. Two articles included the outdated treatment option of intranasal DDAVP.

DISCUSSION

These findings are concordant with the increasing body of literature demonstrating that patient education materials are too difficult to read. Pediatric urologists should be aware of the readability and quality of available online content for common clinical presentations. They can ensure that institutional articles online are useful to patients by participating in the development and design of these materials.

CONCLUSION

We demonstrated that online articles that families encounter via a search engine query for bedwetting are written at a higher level than recommended and the majority are of 'fair' quality. There is much room for improvement for institutions to provide high quality, readable content that supports the needs of families seeking information on NE.

Limited caffeine consumption as first-line treatment in managing primary monosymptomatic enuresis in children: how effective is it? A randomised clinical trial

OBJECTIVE

Evidence about the negative caffeine effect on enuresis in children remains understudied or poorly understood. The study aimed to investigate the effect of caffeine restriction on the improvement and severity of primary monosymptomatic nocturnal enuresis (PMNE).

DESIGN

Randomised clinical trial.

SETTING

Two referral hospitals in Tehran, Iran, from 2021 to 2023.

PATIENTS

Five hundred and thirty-four PMNE children aged 6-15 years (each group 267).

INTERVENTIONS

Amount of caffeine consumption was recorded by the feed frequency questionnaire and was estimated by Nutrition 4 software. Caffeine consumption per day in the intervention group was <30 mg, and in the control group, 80-110 mg. All children were asked to return 1 month later to check the recorded data. The ordinal logistic regression analysis was used to assay the effects of caffeine restriction on PMNE by relative risk (RR) at a 95% CI.

MAIN OUTCOME MEASURES

The effect of limited caffeine consumption on the improvement and severity of PMNE.

RESULTS

The mean age of the intervention and control groups was 10.9±2.3 and 10.5±2.5 years, respectively. The mean number of bed-wetting before caffeine restriction in the intervention and control group was 3.5 (SD 1.7) times/week and 3.4 (SD 1.9) times/week (p=0.91) and 1 month after intervention were 2.3 (SD 1.8) times/week and 3.2 (SD 1.9) times/week, respectively (p=0.001). Caffeine restriction significantly reduced the severity of enuresis in the intervention group. Fifty-four children (20.2%) improved (dry at night) in caffeine restriction and 18 children (6.7%) in the control group with RR 0.615 at 95% CI 0.521 to 0.726, p=0.001. The caffeine restriction significantly reduced the enuresis in children with a number-needed-to-treat benefit 7.417. It means you must treat 7.417 PMNE children with caffeine limitation to improve one child with enuresis (become dry).

CONCLUSION

Caffeine restriction can be helpful in reducing PMNE or its severity. Constructive limitation of caffeine is suggested as one of the first-line treatments in the management of PMNE.

TRIAL REGISTRATION NUMBER

IRCT20180401039167N3.

The efficacy of standard urotherapy in the treatment of nocturnal enuresis in children: A systematic review

INTRODUCTION

Standard urotherapy in children with nocturnal enuresis (NE) is first-line treatment according to the current International Children's Continence Society (ICCS) guidelines. ICCS defines standard urotherapy as information and demystification, instruction in how to resolve lower urinary tract dysfunction, lifestyle advice, registration of symptoms and voiding habits, and support and encouragement. These interventions often are time consuming and some aspects of urotherapy, such as fluid restrictions, can be a frustrating process for a child, which emphasizes the importance of clarifying their relevance. The purpose of this review is to perform a systematic search in literature to evaluate the use of standard urotherapy in the treatment of children with primary NE (PNE).

STUDY DESIGN

A systematic literature search was conducted in MEDLINE, Embase, and CENTRAL based on the key concepts of standard urotherapy and NE. We identified 2,476 studies. After a systematic selection process using the Covidence tool, 39 studies were included. The quality of the studies was assessed by the QualSyst Checklist. Our protocol adheres to the PRISMA statement and was registered in PROSPERO database (CRD42020185611).

RESULTS

Most of the 39 included studies scored low in quality. All studies combined several urotherapy interventions and studied different study populations. Twenty-two randomized controlled trials (RCTs) were included, which reported 0-92% of children being dry after urotherapy treatment. Three RCTs, all individualizing and optimizing drinking and voiding during the day and practicing optimal toilet posture, scored higher in quality based on the QualSyst score, and reported few children experiencing complete resolution of NE (5-33%). Eight studies compared the efficacy of urotherapy to a control group, however, conflicting results were found.

DISCUSSION

This systematic review presents available literature in the field of standard urotherapy in the treatment of children with PNE. One possible explanation for low efficacy rates of urotherapy in NE is the large heterogeneity of the study populations and interventions. Additionally, the intervention period and the intensity of intervention can have an impact on the outcome.

CONCLUSION

The number of clinical studies on standard urotherapy in children with NE is limited and many of them are of poor quality. High quality research in a well-defined NE population is needed to establish the role of standard urotherapy in first-line treatment of children with NE or as an add-on to other first line treatments. We conclude that at present there is insufficient evidence for recommending standard urotherapy to children with PNE as a first line treatment modality.

Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: an umbrella review

Top-tier evidence on the safety/tolerability of 80 medications in children/adolescents with mental disorders has recently been reviewed in this jour-nal. To guide clinical practice, such data must be combined with evidence on efficacy and acceptability. Besides medications, psychosocial inter-ventions and brain stimulation techniques are treatment options for children/adolescents with mental disorders. For this umbrella review, we systematically searched network meta-analyses (NMAs) and meta-analyses (MAs) of randomized controlled trials (RCTs) evaluating 48 medications, 20 psychosocial interventions, and four brain stimulation techniques in children/adolescents with 52 different mental disorders or groups of mental disorders, reporting on 20 different efficacy/acceptability outcomes. Co-primary outcomes were disease-specific symptom reduction and all-cause discontinuation ("acceptability"). We included 14 NMAs and 90 MAs, reporting on 15 mental disorders or groups of mental disorders. Overall, 21 medications outperformed placebo regarding the co-primary outcomes, and three psychosocial interventions did so (while seven outperformed waiting list/no treatment). Based on the meta-analytic evidence, the most convincing efficacy profile emerged for amphetamines, methylphenidate and, to a smaller extent, behavioral therapy in attention-deficit/hyperactivity disorder; aripiprazole, risperidone and several psychosocial interventions in autism; risperidone and behavioral interventions in disruptive behavior disorders; several antipsychotics in schizophrenia spectrum disorders; fluoxetine, the combination of fluoxetine and cognitive behavioral therapy (CBT), and interpersonal therapy in depression; aripiprazole in mania; fluoxetine and group CBT in anxiety disorders; fluoxetine/selective serotonin reuptake inhibitors, CBT, and behavioral therapy with exposure and response prevention in obsessive-compulsive disorder; CBT in post-traumatic stress disorder; imipramine and alarm behavioral intervention in enuresis; behavioral therapy in encopresis; and family therapy in anorexia nervosa. Results from this umbrella review of interventions for mental disorders in children/adolescents provide evidence-based information for clinical decision making.

Low compliance contribute to insufficient Desmopressin response of primary monosymptomatic nocturnal enuresis and the role of voiding school

AIMS

To evaluate the impact of compliance on the therapeutic effects of Desmopressin, as well as the importance of establishing the voiding school for low-compliance children in primary monosymptomatic enuresis treatment.

METHODS

Eighty-nine patients with primary monosymptomatic enuresis treated with Desmopressin were observed during the 2017-2020 at University Children's Hospital Belgrade, Serbia. The average patients age was 7.7 ± 2.4 years; 65 (73%) were boys and 24 (27%) % were girls. After the 3 months of Desmopressin treatment, the effect of therapy was evaluated according to the compliance. After the treatment, low-compliance patients and their parents were suggested to visit a voiding school.

RESULTS

A significant decrease in the median enuresis frequency was noticed during the Desmopressin treatment (25.0 (20.0-26.0) vs 10.0 (2.0-17.0) per month, before vs after treatment, respectively) (p < 0.001). Patients with low compliance had a poorer response to Desmopressin (p < 0.001). An median enuresis reduction in the good compliance group was 92.3% (86.7 -95%), while in the low compliance group was 28.6% (16.7-43.3%). After attending voiding school, there was a significant increase in compliance (p < 0.001), associated with an median percent decrease in enuresis of 84.0% (75.0-95.5%) (p < 0.001).

CONCLUSION

Compliance considerably influences the beneficial effects of Desmopressin. Patients with poor therapeutic effects should be evaluated for compliance and introduced to voiding school.

Boxer Underwear Incorporating Textile Moisture Sensor to Prevent Nocturnal Enuresis

Around 15% of children still wet their bed after five years old. Although bedwetting alarms have proven to be effective to achieve nighttime dryness, they are cumbersome so children could be reluctant to use them. Therefore, the moisture sensor and wire were made unobtrusive by seamlessly integrated them into fully textile underwear by using conductive yarns. Consequently, the alarm acceptability should be enhanced by improving children’s comfort. Three conductive textile metallic yarns, made of silver or stainless steel, were considered to fabricate the urine leakage sensor. Silver-plated-nylon yarn, which showed the highest electrical conductivity, outperformed the stainless-steel yarns regarding its ability to detect urine leakage as well as its detection speed. Furthermore, it was proven to withstand multiple urine soakings and the following machine-washings, even at high temperature (60 °C). However, the electrical current, necessary to detect the leakage, tends to corrode the silver. Therefore, the detection circuit was adapted. Eventually, the designed leakage sensor was seamlessly integrated into a child’s trunk underwear, into which a miniaturized alarm can be plugged. The resulting textile underwear aims at replacing the rigid alarm system currently available, hence improving the quality of life of enuretic children and help them achieving nighttime dryness.

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) affects up to 20% of five-year-olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs.

OBJECTIVES

To assess the effects of enuresis alarms for treating enuresis in children.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles.

SELECTION CRITERIA

We included randomised or quasi-randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data.

MAIN RESULTS

We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) -2.68, 95% confidence interval (CI) -4.59 to -0.78; 4 trials, 127 children; low-quality evidence). Low-quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post-treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low-quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD -0.96, 95% CI -2.32 to 0.41; 1 trial, 47 children; very low-quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low-quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post-treatment. Compared with control alarms, code-word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate-quality evidence) but there is probably little to no difference in the number of children remaining dry post-treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate-quality evidence). Very low-quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry-bed training, and star chart plus rewards) (MD -0.81, 95% CI -2.01 to 0.38; low-quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low-quality evidence) and may slightly increase the number of children remaining dry post-treatment (RR 1.39, 95% CI 0.81 to 2.41; low-quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD -0.64, 95% CI -1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low-quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post-treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate-quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post-treatment, because the quality of evidence is very low. Due to very low-quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD -0.88, 95% CI -0.38 to -1.38; 2 trials, 156 children; low-quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low-quality evidence) and the number of children remaining dry post-treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low-quality evidence) compared with desmopressin alone. Alarm plus dry-bed training may increase the number of children achieving a complete response compared to dry-bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low-quality evidence). It is unclear if there is any difference in the number of children remaining dry post-treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low-quality evidence). Due to very low-quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code-word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate-quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate-quality evidence). Very low-quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments.

AUTHORS' CONCLUSIONS

Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately-powered trials with robust randomisation are still needed to determine the full effect of alarm therapy.

Intelligent autonomous treatment of bedwetting using non-invasive wearable advanced mechatronics systems and MEMS sensors : Intelligent autonomous bladder monitoring to treat NE

Post-void alarm systems to monitor bedwetting in nocturnal enuresis (NE) have been deemed unsatisfactory. The aim of this study is to develop a safe, comfortable and non-invasive pre-void wearable alarm and associated technologies using advanced mechatronics. Each stage of development includes patient and public involvement and engagement (PPI). The early stages of the development involved children with and without NE (and parents) who were tested at a hospital under the supervision of physicians, radiologists, psychologists, and nurses. The readings of the wearable device were simultaneously compared with B-mode images and measurements, acquired from a conventional ultrasound device, and were found to correlate highly. The results showed that determining imminent voiding need is viable using non-invasive sensors. Following on from "proof of concept," a bespoke advanced mechatronics device has been developed. The device houses custom electronics, an ultrasound system, intelligent software, a user-friendly smartphone application, bedside alarm box, and a dedicated undergarment, along with a self-adhesive gel pad-designed to keep the MEMS sensors aligned with the abdomen. Testing of the device with phantoms and volunteers has been successful in determining bladder volume and associated voiding need. Five miniaturised, and therefore more ergonomic, versions of the device are being developed, with an enabled connection to the cloud platform for location independent control and monitoring. Thereafter, the enhanced device will be tested with children with NE at their homes for 14 weeks, to gain feedback relating to wearability and data collection involving the cloud platform. Graphical Abstract Design of the MyPAD advanced mechatronics system.

Conquering Bedwetting: Non-Pharmacologic Methods for Managing Nocturnal Enuresis

Bedwetting, also called nocturnal enuresis, is a common developmental problem in school-aged children. In a study by Van Tijen, Messer, & Namdar (1998), children ranked it as the third most stressful life event, after parental fighting and divorce. About 15% of affected children outgrow bedwetting on their own each year without medical intervention (Kiddoo, 2015), but inadequate knowledge and lack of support and guidance from family may lead to low self-esteem and mental distress in children dealing with this situation. Nonpharmacologic interventions like bedwetting alarms have a higher success rate (75%) and lower relapse rate (41%) than pharmacologic interventions (Monda & Husmann, 1995). This article discusses nonpharmacologic interventions for nocturnal enuresis: bedwetting alarms, motivational therapy, dietary modification, behavioral modification, and pelvic floor muscle training.

Nocturnal enuresis: an update on management

Topics for DTB review articles are selected by DTB's editorial board to provide concise overviews of medicines and other treatments to help patients get the best care. Articles include a summary of key points and a brief overview for patients. Articles may also have a series of multiple choice CME questions.

Conservative interventions for treating functional daytime urinary incontinence in children

BACKGROUND

In children, functional daytime urinary incontinence is the term used to describe any leakage of urine while awake that is not the result of a known underlying neurological or congenital anatomic cause (such as conditions or injuries that affect the nerves that control the bladder or problems with the way the urinary system is formed). It can result in practical difficulties for both the child and their family and can have detrimental effects on a child's well-being, education and social engagement.

OBJECTIVES

To assess the effects of conservative interventions for treating functional daytime urinary incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains studies identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 11 September 2018). We also searched Chinese language bibliographic databases: Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang. No language restrictions were imposed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised, multi-arm studies, cross-over studies and cluster-randomised studies that included children aged between 5 and 18 years with functional daytime urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened records and determined the eligibility of studies for inclusion according to predefined criteria. Where data from the study were not provided, we contacted the study authors to request further information. Two review authors assessed risk of bias and processed included study data as described in the Cochrane Handbook for Systematic Reviews of Interventions. Where meta-analysis was possible, we applied random-effects meta-analysis using the Mantel-Haenszel method for dichotomous outcomes.

MAIN RESULTS

The review included 27 RCTs involving 1803 children. Of these, six were multi-arm and one was also a cross-over study. Most studies were small, with numbers randomised ranging from 16 to 202. A total of 19 studies were at high risk of bias for at least one domain. Few studies reported data suitable for pooling due to heterogeneity in interventions, outcomes and measurements.Individual conservative interventions (lifestyle, behavioural or physical) versus no treatmentTranscutaneous electrical nerve stimulation (TENS) versus sham (placebo) TENS. More children receiving active TENS may achieve continence (risk ratio (RR) 4.89, 95% confidence interval (CI) 1.68 to 14.21; 3 studies; n = 93; low-certainty evidence).One individual conservative intervention versus another individual or combined conservative interventionPelvic floor muscle training (PFMT) with urotherapy versus urotherapy alone. We are uncertain whether more children receiving PFMT with urotherapy achieve continence (RR 2.36, 95% CI 0.65 to 8.53, 95% CI 25 to 100; 3 studies; n = 91; very low-certainty evidence).Voiding education with uroflowmetry feedback and urotherapy versus urotherapy alone. Slightly more children receiving voiding education with uroflow feedback and urotherapy may achieve continence (RR 1.13, 95% CI 0.87 to 1.45; 3 studies; n = 151; low-certainty evidence).Urotherapy with timer watch versus urotherapy alone. We are uncertain whether urotherapy plus timer watch increases the number of children achieving continence compared to urotherapy alone (RR 1.42, 95% CI 1.12 to 1.80; 1 study; n = 58; very low-certainty evidence).Combined conservative interventions versus other combined conservative interventionsTENS and standard urotherapy versus PFMT with electromyographic biofeedback and standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.11, 95% CI 0.73 to 1.68; 1 study; n = 78; very low-certainty evidence).PFMT with electromyography biofeedback and standard urotherapy versus PFMT without feedback but with standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.05, 95% CI 0.72 to 1.52; 1 study; n = 41; very low-certainty evidence).Individual conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)PFMT versus anticholinergics. We are uncertain whether more children receiving PFMT than anticholinergics achieve continence (RR 1.92, 95% CI 1.17 to 3.15; equivalent to an increase from 33 to 64 per 100 children; 2 studies; n = 86; very low-certainty evidence).TENS versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 0.81, 95% CI 0.05 to 12.50; 2 studies; n = 72; very low-certainty evidence).Combined conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)Voiding education with uroflowmetry feedback versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportion of children achieving continence (RR 1.02, 95% CI 0.58 to 1.78; 1 study; n = 64; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The review found little reliable evidence that can help affected children, their carers and the clinicians working with them to make evidence-based treatment decisions. In this scenario, the clinical experience of individual clinicians and the support of carers may be the most valuable resources. More well-designed research, with well-defined interventions and consistent outcome measurement, is needed.

Enuresis Management in the Primary Care Pediatrics Clinic

Enuresis is a frequent complaint not always volunteered by parents or patients. The pediatric clinician has to inquire about enuresis to break the secrecy surrounding this symptom that could be related to a more serious underlying renal, endocrine, or psychosocial disease. Determining the type of enuresis is crucial to offer optimal treatment. We present a review for the pediatric clinician to optimize their care of the child with monosymptomatic enuresis. [Pediatr Ann. 2018;47(10):e390-e395.].

Standard urotherapy as first-line intervention for daytime incontinence: a meta-analysis

According to the International Children's Continence Society (ICCS) guidelines for the treatment of daytime urinary incontinence (DUI) in children and adolescents, the first-line intervention for all types of DUI is standard urotherapy (SU). Despite this recommendation there is still no meta-analysis available on the effectiveness of SU. The aim of this study is to provide a meta-analytic evaluation of the intervention. This meta-analysis is based on Odds Ratios (OR) and consists of 26 patient samples out of 19 studies (N = 1609), collected from well-established medical databases. Remission rates after SU are compared to spontaneous remission rates, which are matched to the individual follow-up period. The meta-analysis shows that SU is an effective treatment of DUI. Compared to a spontaneous remission rate of 15.40% per year, urotherapy increases the probability to recover by a factor of 7.27 (6.57 if corrected for publication bias). After exclusion of three outlying samples this effect can be generalized for all types of SU and all patient populations. Moderator analyses cannot identify variables which significantly influence the variance of effect sizes. However, RCTs seem to be associated with lower effects, even when the control group is not considered for effect size calculation. Based on the present meta-analysis, SU is an effective intervention for treating DUI in children and adolescents. Of 100 patients in 1 year, approximately 56 patients (54 if corrected for publication bias) remit after being treated with SU, while only 15 out of 100 remit spontaneously. However, to further quantify the effect size of SU in comparison to spontaneous remission rates and other treatments, additional RCTs are still needed.

Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly?

Nocturnal enuresis is a common problem affecting school-aged children worldwide. Although it has significant impact on child's psychology, it is always under-recognized in India and considered as a condition which will outgrow with advancing age. Nocturnal enuresis classified as primary or secondary and monosymptomatic or nonmonosymptomatic. Factors that cause enuresis include genetic factors, bladder dysfunction, psychological factors, and inappropriate antidiuretic hormone secretion, leading to nocturnal polyuria. Diagnosis consists of detailed medical history, clinical examination, frequency-volume charts, and appropriate investigations. The frequency-volume chart or voiding diary helps in establishing diagnosis and tailoring therapy. The first step in treating nocturnal enuresis is to counsel the parents and the affected child about the condition and reassure them that it can be cured. One of the effective strategies to manage enuresis is alarm therapy, but currently, it is not easily available in India. Desmopressin has been used in the treatment of nocturnal enuresis for close to 50 years. It provides an effective and safe option for the management of nocturnal enuresis. This review covers the diagnosis and management of nocturnal enuresis and introduces the concept of “bedwetting clinics” in India, which should help clinicians in the thorough investigation of bedwetting cases.

Examining the effectiveness of parental strategies to overcome bedwetting: an observational cohort study

OBJECTIVE

To examine whether a range of common strategies used by parents to overcome bedwetting in 7½-year-old children (including lifting, restricting drinks before bedtime, regular daytime toilet trips, rewards, showing displeasure and using protection pants) are effective in reducing the risk of bedwetting at 9½ years.

DESIGN

Prospective cohort study.

SETTING

General community.

PARTICIPANTS

The starting sample included 1258 children (66.7% boys and 33.2% girls) who were still bedwetting at 7½ years.

OUTCOME MEASURE

Risk of bedwetting at 9½ years.

RESULTS

Using propensity score-based methods, we found that two of the parental strategies used at 7½ years were associated with an increased risk of bedwetting at 9½ years, after adjusting the model for child and family variables and other parental strategies: lifting (risk difference=0.106 (95% CI 0.009 to 0.202), ie, there is a 10.6% (0.9% to 20.2%) increase in risk of bedwetting at 9½ years among children whose parents used lifting compared with children whose parents did not use this strategy) and restricting drinks before bedtime (0.123 (0.021 to 0.226)). The effect of using the other parental strategies was in either direction (an increase or decrease in the risk of bedwetting at 9½ years), for example, showing displeasure (-0.052 (-0.214 to 0.110)). When we re-analysed the data using multivariable regression analysis, the results were mostly consistent with the propensity score-based methods.

CONCLUSION

These findings provide evidence that common strategies used to overcome bedwetting in 7½-year-olds are not effective in reducing the risk of bedwetting at 9½ years. Parents should be encouraged to seek professional advice for their child's bedwetting rather than persisting with strategies that may be ineffective.

Nocturnal enuresis in children between laser acupuncture and medical treatment: a comparative study

Nocturnal enuresis (NE) is intermittent involuntary voiding during sleep in a child aged 5 years or more. The study was conducted to compare the effect of using laser acupuncture and medication for the treatment of children with nocturnal enuresis (NE) and evaluation of urodynamic parameter after treatment. A randomized study included 45 children ranged from 5 to 15 years presenting with NE. They were randomized into three equal groups-group A, managed with desmopressin acetate; group B, managed with laser acupuncture; and group C, managed with a combination of laser acupuncture and desmopressin-all groups received behavioral therapy. The children were evaluated before and after 3 months of the study to record the efficacy of therapy, side effects and bladder capacity, and 3 months of follow-up after cessation of treatment by bladder diary. A statistically significant higher cure rate was reported in group B patients (73.3 %), while in groups A and C, improvement was reported in 20.0 and 13.3 %, respectively (p value = 0.002). Laser acupuncture is noninvasive, painless tool, with no side effects and lower recurrence rate which can be considered as an alternative therapy for patients with NE.

Melatonin's Effect on the Efficacy of Desmopressin in the Treatment of Enuresis

PURPOSE

This study aims to evaluate and compare the efficacy of exogenous melatonin associated with desmopressin (dDAVP) and dietary recommendations.

METHODS

A total of 189 patients were enrolled from the Service of Pediatrics, Campus Bio-Medico University Hospital of Rome, from January 2013 to June 2015. Of the 189 original patients, 153 children, aged between 5 and 14 years (mean age, 8.7 years) were included in the study. After clinical evaluation and a 3-month period of observation without treatment, children were assigned to receive treatment in one of 3 groups: group 1, dDAVP at a dose of 120 mcg a day (Minirin); group 2, dDAVP at a dose of 120 mcg and dietary recommendations; or group 3, dDAVP at a dose of 120 mcg, dietary recommendations, and melatonin at a dose of 1 mg a day (Melamil plus). Each patient was treated for 3 months.

RESULTS

After the 3 months of therapy, a desiderable response was achieved in 30 of 51 patients (58.82%) treated with dDAVP, 35 of 53 patients (66.04%) treated with dDAVP and dietary recommendations, and 35 of 49 patients (71.43%) treated with dDAVP, dietary recommendations, and melatonin.

CONCLUSIONS

Although not statistically significant, the results show that the association between dDAVP treatment with dietary recommendations and melatonin could be considered a safe and effective treatment of NE. Considering that the statistically insignificant results might be due to the small sample size, the study will be continued to increase the number of subjects.

Enuresis and Punishment: The Adverse Effects on Child Development and on Treatment

OBJECTIVE

To investigate the role of punishment in enuretic children and how the punishments can influence therapy response.

METHODS

We enrolled 218 enuretic children. The children and their families were asked to participate in the study at the end of the clinical evaluation.

RESULTS

The analysis of the questionnaires shows that at least one punishment because of nocturnal enuresis (NE) had been applied to 27 out of 218 (12.4%) children. Punishment methods were reprimanding in 19 out of 27 (70.4%), depriving of sleep in 11 out of 27 (40.7%), mildly beating in 3 out of 27 (11.1%), leaving the child wet in 1 out of 27 (3.7%) and other methods in 2 out of 27 (7.4%). In the group of punished children, a full or partial response in terms of a decreased number of wet nights was achieved in 40.7 vs. 59.2% in children who had not been punished.

CONCLUSIONS

Parents should be sensitized on the adverse effects of punishment on child development. It is important in childcare to explain the definitions of the disorder and find the best treatment (behavioural and/or medicinal) depending on the single patient, his/her family and compliance of both. Successful management of NE has benefits to both the child and the family.

Chiropractic Care of an 8-Year-Old Girl With Nonorganic, Primary Nocturnal Enuresis: A Case Report

OBJECTIVE

The purpose of this case report is to describe the chiropractic management of an 8-year-old girl with nonorganic, primary nocturnal enuresis.

CLINICAL FEATURES

An 8-year-old female patient presented to a chiropractic clinic with persistent nighttime bedwetting. The patient experienced enuresis, on average, 7 nights per week. The patient presented with no other comorbidities or complaints, such as low back or pelvic pain.

INTERVENTION AND OUTCOMES

Chiropractic treatment included high-velocity, low-amplitude manipulation of the left sacroiliac joint over 3 visits. Follow-up at 3 months revealed only 3 subsequent episodes of nocturnal enuresis.

CONCLUSION

This patient reported the resolution of nonorganic, primary nocturnal enuresis after receiving a series of side-posture chiropractic manipulations of the left sacroiliac joint.

Tricyclic and related drugs for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) affects up to 20% of five year-olds and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Tricyclics have been used to treat enuresis since the 1960s.

OBJECTIVES

To assess the effects of tricyclic and related drugs compared with other interventions for treating children with enuresis.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (containing trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings), on 30 November 2015, and reference lists of relevant articles.

SELECTION CRITERIA

We included all randomised and quasi-randomised trials comparing a tricyclic or related drug with another intervention for treating enuresis. We also included combination therapies that included tricyclics. We excluded trials for treating daytime wetting.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of the eligible trials, and extracted data. We settled differences by discussion with a third review author.

MAIN RESULTS

Sixty-four trials met the inclusion criteria, involving 4071 children. The quality of many trials was poor, with comparisons addressed by single studies. Minor adverse effects were common, and reported in 30 trials. These included dizziness, headache, mood changes, gastrointestinal discomforts and neutropenia. More serious side-effects can occur but were not reported. Seven trials reported no adverse effects.Tricyclics are more effective than placebo, particularly for short-term outcomes. Compared to placebo, imipramine resulted in one fewer wet nights per week (mean difference (MD) -0.95, 95% confidence interval (CI) -1.40 to -0.50; 4 trials, 347 children), with fewer failing to achieve 14 consecutive dry nights (78% versus 95% for placebo, RR 0.74, 95% CI 0.61 to 0.90; 12 trials, 831 children). Amitriptyline and desipramine were more effective than placebo, but nortriptyline and mianserin showed no difference. Most tricyclics did not have a sustained effect after ceasing treatment, with 96% wetting at follow-up for imipramine versus 97% for placebo.Imipramine combined with oxybutynin is also more effective than placebo, with 33% failing to achieve 14 consecutive dry nights at the end of treatment versus 78% for placebo (RR 0.43, 95% CI 0.23 to 0.78; 1 trial, 47 children) and 45% wetting at follow-up versus 79% for placebo (RR 0.58, 95% CI 0.34 to 0.99; 1 trial, 36 children).There was insufficient evidence to judge the effect between different doses of tricyclics, and between different tricyclics. Treatment outcomes between tricyclic and desmopressin were similar, but were mixed when tricyclic was compared with an anticholinergic. However, when imipramine was compared with desmopressin plus oxybutynin (1 trial, 45 children), the combination therapy was more effective, with one fewer wet nights per week (MD 1.07, 95% CI 0.06 to 2.08) and 36% failing to achieve 14 consecutive dry nights versus 87% for imipramine (RR 2.39, 95% CI 1.35 to 4.25). Tricyclics were also more effective or showed no difference in response when compared to other drugs which are no longer used for enuresis.Tricyclics were less effective than alarms. Although there was no difference in the number of wet nights, 67% failed to achieve 14 consecutive dry nights for imipramine versus only 17% for alarms (RR 4.00, 95% CI 1.06 to 15.08; 1 trial, 24 children). Alarm therapy also had a more sustained effect after ceasing treatment with 100% on imipramine versus 58% on alarms wetting at follow-up (RR 1.67, 95% CI 1.03 to 2.69; 1 trial, 24 children).Imipramine was more effective than simple behavioural therapies during treatment, with one fewer wet nights per week compared with star chart plus placebo (MD -0.80, 95% CI -1.33 to -0.27; 1 trial, 250 children). At follow-up 40% were wet with imipramine versus 80% with fluids and avoiding punishment (RR 0.50, 95% CI 0.28 to 0.89; 1 trial, 40 children). However, imipramine was less effective than complex behavioural therapies, with 61% failing to achieve 14 consecutive dry nights for imipramine versus 33% for the three-step programme (RR 1.83, 95% CI 1.08 to 3.12; 1 trial, 72 children) and 16% for the three-step programme combined with motivational therapy and computer-led education (RR 3.91, 95% CI 2.30 to 6.66; 1 trial, 132 children) at the end of treatment, with similar results at follow-up.Tricyclics were more effective than restricted diet, with 99% failing to achieve 14 consecutive dry nights versus 84% for imipramine (RR 0.84, 95% CI 0.75 to 0.93; 1 trial, 147 children).There was insufficient evidence to judge the effect of tricyclics compared to the other miscellaneous interventions studied.At the end of treatment there were about two fewer wet nights for imipramine plus oxybutynin compared with imipramine monotherapy (MD -2.10, 95% CI -2.99 to -1.21; 1 trial, 63 children) and 48% on imipramine plus oxybutynin failed to achieve 14 consecutive dry nights compared with 74% on imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.92; 2 trials, 101 children). At follow-up, 45% on imipramine plus oxybutynin were wetting versus 83% on imipramine monotherapy (RR 0.55, 95% CI 0.32 to 0.92; 1 trial, 36 children).When imipramine combined with desmopressin was compared with imipramine monotherapy, there was no difference in outcomes. However, when imipramine plus desmopressin was compared with desmopressin monotherapy, the combination was more effective, with 15% not achieving 14 consecutive dry nights at the end of treatment for imipramine plus desmopressin versus 40% for desmopressin monotherapy (RR 0.38, 95% CI 0.17 to 0.83; 1 trial, 86 children). Tricyclics combined with alarm therapy were not more effective than alarm monotherapy, alarm combined with desmopressin or alarm combined with nortriptyline. The addition of a tricyclic to other behavioural therapies did not alter treatment response.

AUTHORS' CONCLUSIONS

There was evidence that tricyclics are effective at reducing the number of wet nights during treatment, but do not have a sustained effect after treatment stops, with most children relapsing. In contrast, there was evidence that alarm therapy has better short- and long-term outcomes. There was some evidence that tricyclics combined with anticholinergics may be more effective that tricyclic monotherapy.

Nocturnal enuresis with spina bifida occulta: Does it interfere behavioral management success?

PURPOSE

We aimed to investigate the incidence of spina bifida occulta (SBO) in patients with nocturnal enuresis (NE) and its effect on the success of behavioral interventions. We also aimed to identify predictive factors related to success of behavioral interventions.

METHODS

A total of 163 patients with NE and 160 patients without NE were enrolled to study. Urinalysis, urine culture, biochemical evaluation, plain radiography and urinary system ultrasonography were performed before treatment. Patients with NE received behavioral interventions for 3 months. Response to behavioral interventions was analyzed according to the presence and absence of SBO. Possible predictive factors for treatment success were also evaluated.

RESULTS

Spina bifida occulta was detected in 47 (28.8 %) children at NE group and 24 (15.0 %) at control group (p = 0.138). Non-monosymptomatic NE was more prevalent in patients with SBO (p < 0.001), and response to the treatment was significantly lower (p = 0.037). Presence of SBO (OR 8.8, 95 % CI 3.1-25.6), NE severity (OR 7.2, 95 % CI 2.4-21.7) and NE frequency on 3-day voiding diary (OR 9.4, 95 % CI 3.7-24.3) were significantly related to the success.

CONCLUSIONS

The presence of SBO, severe NE and higher frequency of NE in voiding diary affect the response to behavioral interventions. Other treatment options such as medical treatment or enuresis alarm may be recommended for those patients.

Behavioural and Cognitive-Behavioural Treatments of Parasomnias

Parasomnias are unpleasant or undesirable behaviours or experiences that occur predominantly during or within close proximity to sleep. Pharmacological treatments of parasomnias are available, but their efficacy is established only for few disorders. Furthermore, most of these disorders tend spontaneously to remit with development. Nonpharmacological treatments therefore represent valid therapeutic choices. This paper reviews behavioural and cognitive-behavioural managements employed for parasomnias. Referring to the ICSD-3 nosology we consider, respectively, NREM parasomnias, REM parasomnias, and other parasomnias. Although the efficacy of some of these treatments is proved, in other cases their clinical evidence cannot be provided because of the small size of the samples. Due to the rarity of some parasomnias, further multicentric researches are needed in order to offer a more complete account of behavioural and cognitive-behavioural treatments efficacy.

Nocturnal enuresis: A topic review and institution experience

The objective is to provide a review of nocturnal enuresis (NE), including its epidemiology, etiology, pathophysiology, evaluation, and current management. We also set to provide further insight on the treatment of this condition from the experience derived from patients cared for at our tertiary-care institution. NE affects approximately 15% of all children at 5-year-old, affecting boys more frequently than girls. At our large university tertiary pediatric urology center, NE and incontinence, in general, is one the most common chief complaints prompting urologic care. In this review, we examine the condition in detail, highlighting specific goals of the initial evaluation and treatment. We contrast the commonly implemented treatment recommendations, available from the literature with strategies we have found valuable from our extensive experience in treating patients with this disorder. Using current urologic reference textbooks, book chapters, Medline, journal articles and reviews describing the many aspects of NE were reviewed in order to describe NE and the current practices at our institution. Although, this is not a systematic literature review, it includes relevant available research, institutional experience and urological expert opinion and current practices at a tertiary state health facility. The treatment of NE remains a challenge for many pediatricians and pediatric urologists. This likely stems from the multiple possible etiologies of the disorder. We have established a treatment algorithm at our institution, which we have found successful in the majority of our patients. This consists of starting patients on urotherapy, then offering both the enuresis alarm device and medication therapy as first line treatments, and finally adding anticholingerics for combination therapy. Our hope is with further research the treatment of NE will continue to improve.