Enuresis

The impact of adenotonsillectomy on monosymptomatic primary nocturnal enuresis in children with obstructive sleep apnea syndrome

Objectives:

To analyze the outcome of monosymptomatic primary nocturnal enuresis (MPNE) after adenotonsillectomy in children with obstructive sleep apnea syndrome (OSAS).

Methods:

The study included 74 MPNE children with OSAS qualified for an adenotonsillectomy procedure. MPNE was assessed prior to surgical procedure as well as 3 and 6 months after surgery. In addition to polysomnographic parameters, serum antidiuretic hormone (ADH) and brain natriuretic peptide (BNP) levels were measured preoperatively and 3 months postoperatively.

Results:

The mean age was 9.8 years and the mean number of nocturnal wetting weekly was 4.1. Thirty-eight percent of patients had family history of MPNE. All the patients underwent a successful adenotonsillectomy. Nocturnal enuresis was still reported in 18% of children 6 months after adenotonsillectomy. An increased risk of MPNE was significantly demonstrated in children with high obstructive apnea-hypopnea index (O-AHI), high oxygen desaturation index (ODI), high frequent nocturnal enuresis and family history. After surgery, ADH levels were significantly lower, whereas BNP levels were significantly higher in non-resolution children. Univariate analysis showed that higher O-AHI, higher ODI, severe enuresis, low serum ADH and higher serum BNP levels were indicative of persistent nocturnal enuresis. Multivariate analysis showed that higher ODI and higher BNP levels are independent prognostic markers for MPNE.

Conclusions:

Adenotonsillectomy in MPNE children with OSAS is an effective treatment for resolution of MPNE. Also, higher ODI caused by apnea and elevated serum BNP levels are the most important factors affecting the outcome of MPNE patients.

Level of evidence:

Not applicable for this multicentre audit.

Prevalence of Nocturnal Enuresis Among Children Dwelling in Rural Areas of Sindh

Introduction

Nocturnal enuresis (NE) is usually a condition of childhood and refers to involuntary urinary incontinence during sleep. Due to its impact on a child’s mental and social health, it is important to determine the prevalence of this condition among a population. Therefore, the aim of our study is to evaluate its prevalence and associated risk factors among children living in rural areas of Sindh province, Pakistan.

Methods

Fifteen-hundred children aged between three and 12 years of age who lived in rural areas of Sindh and visited a tertiary care hospital for various complaints were selected at random. Their parents were asked to fill in a questionnaire regarding the symptoms and risk factors of NE. The data were gathered over a period of three months, starting from June 2019 to August 2019. The data were then analyzed to draw associations between the findings.

Results

Out of the total 1500 participants, 570 (38%) were male and the remaining 930 (62%) were female. Among these, the majority with NE were males (70%) and children between the age of six and seven years (65%). The first and fourth to fifth born were more likely to develop symptoms of NE. There was also a positive association between family history (P=0.003), delayed milestones (0.001), psychological problems (0.005), and urinary tract infection (P=0.001). However, a child suffering from chronic illness, parasitic infection, or anemia did not have a significant relationship with developing NE.

Conclusion

The total prevalence of NE among rural areas was 40%, which was higher than in urban areas. This could be due to limited awareness among parents and limited healthcare facilities to manage the condition in rural areas. However, it is important to identify the symptoms of NE earlier among children to reduce the impact it leaves on them.

The effect of using entertainment and communication devices before sleep on nocturnal enuresis

BACKGROUND

Monosymptomatic nocturnal enuresis (MNE) is a common urological problem. The association between the use of entertainment and communication devices (EECDs) at night and enuresis in MNE patients has yet to be reported in the literature. This study aims to determine if an association exists between the use of EECDs before sleep and nocturnal enuresis.

METHODS

Patients with MNE who presented to the pediatric nephrology department of the center between January 30, 2019 and June 30, 2019 were included in the study. A questionnaire was administered both to the patients and to an age- and sex-matched control group to garner details of sleeping features and duration of exposure to EECDs before sleep. A comparison was then made of the answers provided by the patient and control groups.

RESULTS

The study included 138 patients (65 females; 73 males) and 104 controls (44 females; 60 males). The patients who used EECDs for more than 3 h a day before sleep suffered more frequently from bedwetting than those who used EECDs for fewer than 3 h a day (P = 0.007). The time of exposure to EECDs before sleep in the patient group was longer than in the control group (P < 0.001).

CONCLUSIONS

The use of EECDs for more than 3 hours before sleep is associated with bedwetting and enuresis frequency in patients with MNE. Patients suffering from MNE should be advised not to use EECDs before sleep.

Frequency and features of nocturnal enuresis in Pakistani children aged 5 to 16 years based on ICCS criteria: a multi-center cross-sectional study from Karachi, Pakistan

Background

Nocturnal enuresis (NE) is a common symptom in children worldwide. International Children’s Continence Society (ICCS) defines enuresis as either mono-symptomatic, NE with lower urinary tract symptoms and NE with co-morbid conditions. The objectives of this study were to determine the frequencies and types of NE and associated symptoms and conditions in children aged 5 to 16 years based on ICCS criteria.

Methods

A multi-center cross sectional study was conducted between November 2012 and December 2013 in the primary care clinics of four hospitals in Karachi. Children aged five to fifteen years were included through consecutive sampling. Informed consent was obtained from the parents and a pre-coded semi-structured questionnaire was used to obtain the information. Data was entered on SPSS version 20.0 and multivariable logistic regression analysis was used for data analysis.

Results

Out of 429 children aged between five and sixteen years, 243(56.9%) were boys and the remaining 186(43.1%) were girls. One hundred and eighty three children (43%) had nocturnal enuresis (NE). Forty four (10.3%), had mono-symptomatic NE, 57(31.1%) had associated lower urinary tract symptoms (NE-LUTS), whereas 30 (16.3%) had NE with a co-morbid condition. Fifty two (28.4%) NE’s had at least one of both LUTS and a co-morbid condition. Out of the 246(57%) non-enuretic’s, 31(12.6%) had a LUTS, 95(38.6%) had a co-morbid condition and 57(23.2%) had at least one of both LUTS and a co-morbid condition. The remaining 63 (25.6%) were symptom free. Increased voiding frequency, urgency, dysuria, suprapubic pain and daytime incontinence were the LUTS significantly associated with NE. Co-morbid conditions significantly associated with NE included constipation, congenital defects, developmental delay, and learning and sleep problems.

Conclusion

Although NE can be an only symptom, it is often associated with lower urinary tract symptoms like dysuria, urgency, suprapubic pain, and daytime incontinence. Children presenting with NE often have co-morbid conditions like constipation, urinary tract infection, sleep disorders, and developmental delay. Many children presenting with these conditions as the primary complaint may also have NE. It should be addressed as unrecognized and untreated NE can cause additional morbidity and distress.

Prevalence of nocturnal enuresis among children in Primary Health Care Centers of Family and Community Medicine, PSMMC, Riyadh City, KSA

Background:

Nocturnal enuresis (NE) is commonly known as any intermittent incontinence while asleep in a child being at least 5-year old. The families of the children having this disorder can be greatly worried because this disorder can lead to considerable emotional distress and some psychological consequences. This study is aimed to estimate the prevalence of NE among children and to identify the characteristics of children who has NE. The third aim is to identify the consultation pattern to solve this problem.

Methods:

A cross-sectional survey was performed in Primary Health Care Centers of Family and Community Medicine, PSMMC, Riyadh City, KSA, during 2017.

Results:

Out of 65 families that have children with NE, 38.7% was the frequency of bedwetting every night; 22.6% of the children were stressed as a result of new child birth; 14% of the families did not feel a family load of having children with NE; 29% of the families did not try to treat their children because of their improvement with time; and 12% of the families that tried to treat their children used fluid restriction and waked their children up frequently at night.

Conclusions:

The prevalence of NE was 18.5% among families with a higher prevalence in boys. Prevalence of NE decreased with increasing age with many children found of having stressful events in their life other than parents’ divorce. We would like to refer that it is important for families that have children with NE to seek medical consultation immediately, which can lead to behavioral modifications.

Trends in Pharmacotherapy for Bladder Dysfunction Among Children in the United States, 2000 to 2013

Bladder-related issues such as nocturnal enuresis and incontinence have long been a part of general pediatric practice. Increasingly, clinicians are prescribing medications directed at a variety of types of bladder dysfunction, but no prior population-based data exist. We used MarketScan health care claims data on 32 074 638 insured children to estimate utilization patterns by age, sex, year, and geographic region in the United States from 2000 to 2013, and to assess related diagnosis codes. Approximately 1 in 500 children filled an antimuscarinic prescription. The most common prescriptions were for oxybutynin (78%) and tolterodine (17%). Rates were highest at ages 6 to 10 years (65/100 000 person-months), 31% higher for girls versus boys, peaked in 2011 (44/100 000 person-months), and were highest in the Midwest (59/100 000 person-months). Seventy-three percent of children with prescriptions had diagnosis codes for genitourinary symptoms, and 13% had codes for congenital anomalies. Research is needed regarding the comparative effectiveness and safety of these drugs in children.

Prevalence of nocturnal enuresis and related risk factors in school-age children in Egypt: an epidemiological study

PURPOSE

To determine the prevalence of mono-symptomatic nocturnal enuresis (MNE) and its risk factors among school-age children in our community.

METHODS

A cross-sectional study included school-age children from two governorates in south of Egypt. A questionnaire was presented to randomly selected students. It consisted of 3 domains: Domain 1 included questions about MNE, domain 2 was about risk factors for MNE, and domain 3 was about management of MNE.

RESULTS

The study included 4652 students (9 ± 2 years) from 12 primary schools (51 % males and 49 % females). Of 4652 students, 834 (18 %) had NE, with no significant difference between rural and urban areas (17.5 vs. 18.4 %, p = 0.4). Younger age categories showed higher prevalence of MNE than in older children. MNE caused moderate-to-severe bother for 44.5 and 87.8 % of students and parents, respectively. Urinary tract infection, pinworm infestation, constipation, and caffeine over-consumption significantly associated with MNE. Family history of MNE was positive in 84.7 %. Daytime incontinence coexisted in 16 % of cases. Children with ≥4 siblings and birth order ≥3 had more prevalent MNE. Deep sleepers and exposure to problems/violence correlated positively with occurrence of MNE. Father's level of education and work status, mother education, number of children per room, and socioeconomic status significantly associated with occurrence of MNE. There was no significant correlation between gender and prevalence of MNE. No treatment was used in 53.2 % of cases.

CONCLUSION

In the Egyptian community, pinworm infestation, UTI, constipation, and overconsumption of caffeine-containing beverages are potential reversible risk factors for MNE in school-age children.

Advances in the management of primary monosymptomatic nocturnal enuresis in children

Intermittent incontinence of urine in a sleeping child who has previously been dry for less than 6 months without any other lower urinary tract symptoms is considered to be primary monosymptomatic nocturnal enuresis (PMNE). Although, most children outgrow PMNE with age, the psychological impact on the child warrants parental education and patient motivation and treatment. Motivational therapy, alarm therapy and drug therapy are the mainstay of treatment. Motivational and alarm therapy have better success rates than drug therapy alone. Desmopressin is the commonly used first-line drug and is best for short-term relief. Other drugs such as anti-cholinergics, imipramine and sertraline are used in resistant cases. This review focuses on the assessment and treatment of PMNE.

Efficacy of posterior tibial nerve stimulation in the treatment of children with primary mono-symptomatic nocturnal enuresis

Background/Aims:

Primary monosymptomatic nocturnal enuresis is the most frequent (85%) type of enuresis in children. However, there is limited research on the effect of posterior tibial nerve stimulation on monosymptomatic nocturnal enuresis in children. This study investigated the effect of posterior tibial nerve stimulation on primary monosymptomatic nocturnal enuresis in children.

Methods:

This controlled exposure study was conducted using a pretest–posttest design between March and December 2014. Participants (n=80) were randomly distributed to two study groups (control and intervention) using block randomisation. Participants in the control group were given and instructed on how to use a bedwetting alarm in addition to medical treatment for 12 weeks, whereas participants in the intervention group received posterior tibial nerve stimulation in addition to medical treatment for 12 weeks. The frequency of nocturnal enuresis, maximum voided volume and quality of life were evaluated before and after treatment.

Results:

Comparative analysis between pre- and post-treatment data revealed significant differences in both groups across all measured variables (p<0.05), with significant improvements in all three outcome measures found in the intervention group. Post-treatment, the intervention group demonstrated decreased frequency of nocturnal enuresis and improved maximum voided volume and quality of life.

Conclusions:

Posterior tibial nerve stimulation is an effective and safe approach for the treatment of primary monosymptomatic nocturnal enuresis and control of bedwetting in children.

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.

Prevalence and factors affecting enuresis amongst primary school children

Aims and Objectives:

The aim of the study was to establish the prevalence of enuresis in school children and to determine contributing factors along with treatment methods used in these children.

Materials and Methods:

The parents of 1473 children aged between 6-10 years completed a self-administered semi-structured questionnaire. Socio-demographic profiles, enuresis data, medical and psychiatric disorders and family stressors were collected. The data was analyzed and the results presented.

Results:

The response rate was 89.22%. The overall prevalence of enuresis was 7.61%. Enuresis was more common in boys. A positive family history of enuresis was seen in 28.57% children; 14.29% of the children had daytime wetting as well. Only 24.11% of the parents had taken their child to a doctor for the problem. Family stressors, significant birth history and lower socioeconomic status was present to a larger extent in the enuretic group. Scholastic backwardness was also an important factor in this group.

Conclusions:

This study reports on the prevalence of enuresis in school-going children and stresses on the need for parental education and awareness about this problem.

Nocturnal enuresis in adolescents with anorexia nervosa: prevalence, potential causes, and pathophysiology

OBJECTIVE

The aim of this study was to determine the prevalence and potential causes of secondary nocturnal enuresis (NE) in adolescents with anorexia nervosa (AN).

METHOD

Adolescents with AN completed the Incontinence Symptom Index-Pediatric (ISI-P), a self-report urinary incontinence survey. Those who had NE associated with the onset of AN on the ISI-P completed a comprehensive clinical and laboratory evaluation, including urinary flow measurements.

RESULTS

The prevalence of NE in adolescents with AN was 17.0% (10 of 59). The overall frequency of day- and night-time urinary incontinence symptoms in adolescents with AN was 62.7%; urgency incontinence, 57.6%; stress incontinence, 32.2%; and insensate incontinence, 17.0%. Nine of the 10 adolescents with NE had secondary NE and confirmed that bedwetting ceased after weight restoration.

DISCUSSION

Decreased functional bladder capacity and detrusor instability may contribute to the NE observed in this population. The high prevalence of NE in adolescents with AN warrants further study to determine the potential causative pathways. Clinicians who work with adolescents with AN should assess for this problem.

Caffeine consumption in young children

Two hundred twenty-eight surveyed parents reported that their 5 to 7 year old children drank approximately 52 mg of caffeine daily and their 8 to 12 year old children drank 109 mg daily. Caffeine consumption and hours slept were significantly negatively correlated, but caffeine consumption and enuresis were not significantly correlated. Spanish-speaking parents reported fewer bedwetting events than their English-speaking peers.

Incidence of Nocturnal Enuresis And Nocturia in Children with Tuberculosis

Nocturnal enuresis is a common problem and occurs in 15 to 20 percent of 5-year-old children. The etiology of nocturnal enuresis remains unknown and is probably multifactorial. In this study 52 children aged between 6-17 years with tuberculosis were questioned for nocturia and nocturnal enuresis, retrospectively. Nocturnal, enuresis was found in 12 (23%) and nocturia in 22 (42%) of the children, respectively. After specific treatment with antituberculosis drugs nocturnal enuresis and nocturia were improved in 5 and 21 children, respectively. However, it could not be explained why these disorders were much higher in children with tuberculosis than healthy children. The findings suggest that nocturnal enuresis and nocturia may be in a high frequency in children with tuberculosis; however, the authors think that prospective and more extensive studies should be performed to clarify these preliminary findings.

Enuresis is a common and persistent problem among children and young adults with sickle cell anemia

OBJECTIVES

Enuresis and nocturia are common among children with sickle cell anemia (SCA). The objectives of this study were to describe the prevalence of enuresis and nocturia among children and young adults with SCA and determine the relationship, if any, between these symptoms and SCA-related morbidity.

METHODS

A prospective infant cohort of African-American children with SCA was previously established from the Cooperative Study for Sickle Cell Disease. Included in this cohort were children with SCA enrolled before 6 months of age for whom questions about enuresis and nocturia had been completed.

RESULTS

A total of 213 participants were included in this analysis. Sixty-nine individuals (33%) experienced enuresis over the course of the study. No children under 6 years of age were asked about enuresis. Thereafter, enuresis was most prevalent between the ages of 6 and 8 years (42%) and continued to be common in young adults ages 18 to 20 years (9%). Seventy-nine percent of individuals reported a history of nocturia. There was no association between enuresis or nocturia and an increased rate of pain or acute chest syndrome (ACS) episodes.

CONCLUSIONS

Enuresis and nocturia are common in children with SCA. Among adults with SCA, enuresis and nocturia are more persistent compared with adults in the general population. Enuresis and nocturia are not associated with an increased rate of pain or ACS.

The effect of obesity on treatment efficacy in children with nocturnal enuresis and voiding dysfunction

PURPOSE

Obesity continues to be a leading public health concern in the United States. Our previous studies have suggested that there is a high rate of obesity in children with dysfunctional voiding, especially nocturnal enuresis. We investigated the correlation between body mass index and the efficacy of treatment in obese patients.

MATERIALS AND METHODS

We evaluated retrospectively records from patients seen with a diagnosis of nocturnal enuresis or dysfunctional voiding between January 2004 and July 2005. Bladder and bowel symptoms and urinary diary data were evaluated, and body mass index percentile was determined. Response to treatment was evaluated and correlated with body mass index percentile.

RESULTS

We evaluated 250 children, of whom 96 (38%) had nocturnal enuresis and 154 (62%) had dysfunctional voiding. Body mass index was normal in about half of the patients, and half were above the 85th percentile for body mass index. Patients with a body mass index above the 85th percentile had a reduced response to therapy. After treatment patients with a normal body mass index had a lower nocturnal accident frequency than those above the 85th percentile. Similarly, in those with voiding dysfunction the response rate was 65% in association with a normal body mass index vs 35% with a high body mass index. Furthermore, patients with a normal body mass index had a significantly higher rate of completing a urinary diary compared to those with a high body mass index.

CONCLUSIONS

Obesity correlates with a lower voiding diary completion rate and lower efficacy of treatment in children with nocturnal enuresis or dysfunctional voiding.

Resolution of diurnal incontinence and nocturnal enuresis after adenotonsillectomy in children

PURPOSE

Adenotonsillar hyperplasia causes upper airway obstruction, leading to obstructive sleep apnea. We reviewed the incidence of nocturnal enuresis in a population of children with adenotonsillar hyperplasia. In addition, we investigated the rate of resolution or improvement in enuresis following surgery for relief of adenotonsillar hyperplasia.

MATERIALS AND METHODS

We studied 86 consecutive prepubertal children, 46 boys and 40 girls, who underwent adenotonsillectomy. Severity of adenotonsillar obstruction was graded on a scale of 1 to 4. A questionnaire regarding voiding problems, including nocturnal enuresis, voids per day and daytime enuresis episodes, was filled out preoperatively and postoperatively by the patients and their parents.

RESULTS

Among the 86 patients who underwent adenotonsillectomy 36 (42%) had nocturnal enuresis. In patients with nocturnal enuresis the number of episodes was significantly less after adenotonsillectomy. Overall, 12 patients (33%) had complete resolution, 11 (31%) had significant improvement and 13 (36%) showed no change. In addition, we noted a significant decrease in daytime enuresis episodes and voids per day.

CONCLUSIONS

Children with upper airway obstruction have a high rate of nocturnal enuresis that improves at twice the anticipated rate after treatment of the airway obstruction. In addition, we observed that daytime voiding dysfunction improves in these patients.

Meeting the needs of parents and pediatric patients: results of a survey on primary nocturnal enuresis

Primary nocturnal enuresis (PNE) affects about 7 million children and adolescents in the United States. A telephone survey of 745 parents/guardians of children aged 3 to 14 years was conducted to determine their knowledge and attitudes about PNE. Most did not know that PNE is a physical problem. Although 82% would want healthcare providers to discuss PNE with them if their child older than 6 years wet the bed, most would be uncomfortable initiating the dialogue. According to parents, healthcare providers either never or rarely discuss PNE. For the benefit of their young patients, healthcare providers must initiate discussion about PNE.

Primary nocturnal enuresis: omega-3 fatty acids may be of therapeutic value

Primary nocturnal enuresis (PNE), or bed-wetting, is a distressing urinary condition which can persist through childhood and beyond. Altered prostaglandin and nitric oxide production have been observed in children with PNE, and prostaglandin inhibitors are known to be of therapeutic value. Omega-3 fatty acids have the potential to influence the symptoms of PNE by inhibition of prostaglandin and renal nitric oxide production. In addition, children with PNE have an inappropriate startle response and an apparent maturational delay of the central nervous system. Research clearly shows that omega-3 fatty acids play a critical role in the development and function of the central nervous system. It is our contention that inadequate omega-3 intake may play a role in the lack of inhibitory input to the startle and micturition centers in PNE.

Atomoxetine for the treatment of pediatric nocturnal enuresis

Current treatments for pediatric nocturnal enuresis rely upon the use of behavioral interventions, such as enuresis alarms, and pharmacological interventions, such as antidiuretic hormone analogs, tricyclic antidepressants, and anticholinergics. However, a considerable number of patients do not respond fully to any of these interventions, in spite of optimal behavioral management and medication dosing. This report describes 4 children with attention deficit hyperactivity disorder (ADHD) comorbid with nocturnal enuresis. Each child was treated with atomoxetine for ADHD and experienced serendipitous resolution of enuresis.

Nocturnal enuresis: medical management

Nocturnal enuresis is a problem that affects many children and their families. The etiology seems to be multifactorial and may include a combination of genetic factors,abnormal urodynamics, alterations in vasopressin secretion, sleep factors, psychologic factors, organic disease, and maturational delay. Generally, a complete history and physical examination, with a specific focus on the genitourinary, gastrointestinal, and neurologic systems, is all is that is needed in the evaluation of a patient with enuresis.Currently, the mainstays of medical therapy are DDAVP, imipramine, and oxybutynin. Medications can help to control the symptoms of enuresis, but they generally do not provide a cure; therefore, behavioral therapy is often recommended in conjunction with pharmacotherapy.

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.

Child abuse: behavioral aspects and other associated problems

Although researchers in psychology and the social sciences will need to continue to identify the behavioral consequences of abuse and treatment strategies, pediatricians may still be the first line professionals to suspect and intercept victims. Remember that, especially in cases where there have been threats or falsification of illness, it is wise to enlist integrated multidisciplinary services to ensure the safety of the child before confronting any potential perpetrators. Physicians have become better trained to be more vigilant in detecting signs of physical abuse, but it seems that psychologic and sexual maltreatment may cause more long-term problems but are more difficult to detect. Although a book by Everett and Gallop is written for mental health professionals, the chapters on why a history of childhood trauma is often missed, recognizing signs and symptoms, and asking about abuse, are all helpful for pediatricians and other health care professionals. In certain situations, physicians should attempt to talk to children privately, so that those who are old enough might have an opportunity to relate events that are traumatic, and so that abusive parents will not have an opportunity to interrupt, instill additional fear in the child, or abruptly change providers. Children need someone to ask them directly about their experiences and act on any suspicions. Asking once may not be enough, because a frightened child may initially deny physical or sexual abuse, but be ready to tell at another time. A vocal adult survivor of Munchausen syndrome by proxy and severe physical abuse explains: The dilemma is how to be loved and accepted. Even once a child recognizes that it is wrong, victims may be afraid to speak up for fear of anger and more abuse at the hand of the abuser. By the time I reached eleven, I was angry enough at what my mother had gotten away with, I would have been more truthful. It would have been a relief to have someone else voice their own suspicions. But, no one ever asked and I could not be the one to give away my mother or the love of my family. Although society is still struggling with its ability to prevent abuse, it must also be concerned with dealing with its consequences. The problem seems overwhelming in its enormity and the resources do not seem to be adequate to tackle these issues so basic to the care and nurturing of children. Nonetheless, physicians must keep their eyes open to behaviors that signal distress, recognize and strive to eliminate the underlying cause, and make certain that children receive treatment to minimize the myriad of behavioral and other long-term problems that are associated with child abuse.

Nocturnal enuresis

Nocturnal enuresis is a benign condition, yet needs treatment to relieve the child and parents of the accompanying anxiety and the stigma attached to it. It is defined as normal nearly complete evacuation of the bladder at a wrong place and time at least twice a month after the fifth year of life. The underlying cause of enuresis is functional and various proposed pathophysiological mechanisms like maturational delay, genetics, role of sleep, antidiuretic hormone, and bladder capacity are discussed. These factors have a bearing on the management. As no treatment plan is ideal, various treatment modalities currently available including good supportive care are elaborated and a plan of management discussed.