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.

Development of an early nurse led intervention to treat children referred to secondary paediatric care with constipation with or without soiling

Background

Constipation is a common chronic childhood condition referred to secondary care. Effective treatment requires early intervention, prolonged medication to soften stools and behavioural support to achieve a regular habit of sitting on the toilet to pass a stool. The purpose of this audit and service development was to assess routine consultant paediatrician-led care against minimum standards and if appropriate to develop a nurse-led intervention. The new care package could then be tried out within general paediatric clinics in Glasgow as a service evaluation. NICE guideline (CG99) has a research recommendation to compare nurse-led care with routine consultant-led care.

Methods

Design was an audit then development of a nurse-led intervention followed by a service evaluation. Participants were children (age 0–13 years), referred by their General Practitioner (GP) to the Royal Hospital for Sick Children Glasgow, with constipation the main problem in the GP letter. The audit covered appointment waiting times, intervention provided, initial follow-up and parental satisfaction with routine consultant-led practice. The nurse-led intervention focused on self-help psychology practice with NICE guideline medical support. This was compared with routine consultant paediatrician care in a service evaluation.

Results

The audit found consultant-led care had long waiting times, delayed initial follow-up and variable intervention. The new nurse-led intervention is described in detail. The nurse-led intervention performed well compared with consultant-led care. Less ‘nurse-led’ children, 3/45 (7%), were still constipated passing less than 3 stools per week compared with 8/58 (14%) receiving consultant-led care. Less ‘nurse-led’ parents, 10/45 (22%), reported their child having pain passing stools in the previous week compared with consultant-led care, 26/58 (45%). The proportion of children, over 4 years, free from soiling accidents was similar, 15/23 (65%) in the nurse-led group and 18/29 (62%) with consultant-led care. Parental satisfaction was slightly better in the nurse-led group.

Conclusion

It is difficult to achieve minimum standards using routine consultant-led care for children referred by their GP with constipation. Nurse-led early intervention is feasible and has produced promising results in a service evaluation. An exploratory trial is planned to develop a teaching module, robust outcomes including costs and benefits, and methodology for a definitive trial recommended by NICE.

Treatment of primary nocturnal enuresis in children: a review

Primary nocturnal enuresis is a common childhood disorder. Treatment approaches bridge the psychological and medical fields. A substantial body of literature addresses the various ways of treating enuresis, from pharmaceuticals to behavioural interventions. The medical and psychological literatures have proceeded relatively independently from one another and there has been little interconnection between the US and international literatures, resulting in a lack of discourse and integration among researchers investigating treatment outcomes for enuresis. This review examined the evidence base for treatments of primary nocturnal enuresis in children. Psychological, pharmaceutical and multi-component interventions are discussed. This review sought to provide an integrated interdisciplinary and international perspective on treatment efficacy for nocturnal enuresis by expressly gathering publications from psychological and medical fields, as well as US and international sources. The literature supported the urine alarm as the most effective intervention for nocturnal enuresis and demonstrated the benefit of combining the urine alarm with other components, both behavioural and pharmaceutical. In particular, recent literature showed that the urine alarm, when used in conjunction with antidiuretic medication (i.e. desmopressin), leads to more dry nights earlier in the conditioning process. Disparities between the different literatures were discussed.

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94).

AUTHORS' CONCLUSIONS

Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

Nocturnal enuresis: behavioral treatments

Nocturnal enuresis is a common problem. Physiologic and environmental factors are thought to have a role in the etiology and treatment of this condition. This article discusses the association between enuresis and behavioral or emotional problems. Common behavioral treatments are described, and evidence for their efficacy is reviewed. A brief discussion of hypnosis and acupuncture is included.

Treating Nocturnal Enuresis in Children

BACKGROUND

Childhood nocturnal enuresis (bedwetting) affects many families. Although it has a high rate of spontaneous remission, bedwetting may bring social and emotional stigma, stress, and inconvenience to both the child with enuresis and his or her family.

DESIGN

Summary of systematic reviews of treatment for nocturnal enuresis in children, published in the Cochrane Library, using evidence only from randomized and quasi-randomized trials to compare interventions. Interventions included behavioral, alarm, and pharmacologic treatments.

SETTING AND METHODS

Six Cochrane Reviews contributed evidence to this review: simple behavioral interventions, alarms, complex behavioral or educational interventions, desmopressin, tricyclics and related drugs, and other drugs.

SUBJECTS

The participants were children (usually up to the age of 16).

RESULTS

Much of the available evidence was of poor quality, and there were few direct comparisons between different types of intervention. Simple behavioral Interventions, such as reward systems, are widely used as standard first-line treatment, but they require a high level of parental involvement. There is currently little evidence to show that these interventions work, but they may be worth trying because they have only a few adverse effects. The use of an alarm intervention reduced nighttime bed wetting in a majority of children both during and after treatment. Overlearning or dry-bed training may reduce the relapse rate. Before embarking on alarm treatment, families need to be made aware of both the time and the high level of parental involvement necessary to attain success. Drug therapy, such as desmopressin and tricyclics, reduced the number of wet nights per week compared with placebo but only while the drug was used. Patients and their families need to be warned about possible side effects of some of the drugs.

CONCLUSIONS

Alarms are the most effective treatment for nocturnal enuresis in children, but desmopressin may be considered for temporary relief.

Complex behavioural and educational interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002.

SELECTION CRITERIA

All randomised or quasi-randomised trials of complex behavioural or educational interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and physical behavioural methods, alarms, desmopressin, tricyclics, and miscellaneous other interventions.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Sixteen trials involving 1081 children were identified which included a complex or educational intervention for nocturnal enuresis. The trials were mostly small and some had methodological problems including the use of a quasi-randomised method of concealment of allocation in three trials and baseline differences between the groups in another three.A complex intervention (such as dry bed training (DBT) or full spectrum home training (FSHT)) including an alarm was better than no-treatment control groups (eg RR for failure or relapse after stopping DBT 0.25; 95% CI 0.16 to 0.39) but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. A complex intervention on its own was not as good as an alarm on its own or the intervention supplemented by an alarm (eg RR for failure or relapse after DBT alone versus DBT plus alarm 2.81; 95% CI 1.80 to 4.38). On the other hand, a complex intervention supplemented by a bed alarm might reduce the relapse rate compared with the alarm on its own (eg RR for failure or relapse after DBT plus alarm versus alarm alone 0.5; 95% CI 0.31 to 0.80).There was not enough evidence to judge whether providing educational information about enuresis was effective, irrespective of method of delivery. There was some evidence that direct contact between families and therapists enhanced the effect of a complex intervention, and that increased contact and support enhanced a package of simple behavioural interventions, but these were addressed only in single trials and the results would need to be confirmed by further randomised controlled trials, in particular the effect on use of resources.

REVIEWER'S CONCLUSIONS

Although DBT and FSHT were better than no treatment when used in combination with an alarm, there was insufficient evidence to support their use without an alarm. An alarm on its own was also better than DBT on its own, but there was some evidence that combining an alarm with DBT was better than an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was also some evidence that direct contact with a therapist might enhance the effects of an intervention.

A nocturnal enuresis service for a deprived inner city

AIM

Glasgow is a city where 80% of the most deprived children in Scotland live within 20% of the overall population. Of 168,000 children in Glasgow, an estimated 5000 aged 5-15 y have primary nocturnal enuresis. The aim of this study was to establish a nocturnal enuresis service for Glasgow.

METHODS

Needs assessment was performed and the incident cases were documented at school entry healthcare appraisal, at the age of 5 y. A cohort of these children was followed up at 8 y of age and symptom resolution was no better than natural remission. Parents, general practitioners, clinical medical officers and a hospital paediatrician were interviewed face-to-face about their need for a service.

RESULTS

Ten of 11 general practitioners expressed a need for a specialist service. Ten school nurse-led local nocturnal enuresis clinics were established. Accommodation, funding, default and managing alarms were major problems. School nurses enjoyed extra training and quickly became skilled therapists. Two research projects highlighted that most children at first attendance did not believe they could ever be dry, which predicted outcome. Deprived families, once motivated, could successfully undertake complex behavioural therapies.

CONCLUSION

A comprehensive nocturnal enuresis service begins when children stop using night nappies at the age of 3-4 y. Appropriate waterproof mattress, duvet and pillow coverings should be advocated until 5 y, when desmopressin may be helpful. For continued wetting at the age of 7 y, a local service should be led by a team of well-trained nurses using enuretic alarms.