The impact of bowel and bladder problems on children's quality of life and their parents: A scoping review

Management of the refractory nocturnal enuresis patient to desmopressin in a pediatric population: Desmopressin + oxybutynin vs. desmopressin + imipramine

INTRODUCTION AND OBJECTIVE

Desmopressin is well accepted as first-line medical therapy for enuresis. If ineffective, combination therapy of desmopressin + oxybutynin or desmopressin + imipramine has been used. This study assessed the efficacy of adjunct therapy with either imipramine or oxybutynin in the management of enuresis patients who failed desmopressin treatment.

STUDY DESIGN

A retrospective chart review of our database for patients with enuresis was performed. Patients who were prescribed desmopressin, oxybutynin, and imipramine over 14 years for enuresis were included. Two cohorts of patients were examined; group OXY was treated with desmopressin and oxybutynin, and group IMP received desmopressin and imipramine. Pretreatment measurement of Vancouver Symptom Scores (VSS) were used to compare groups using the VSS question "I wet my bed at night" where 4: every night, 3: 4-5 nights per week, 2: 1-2 nights per week, 1: 3-4 nights per month, and 0: never. International Children's Continence Society (ICCS) criteria for continence success was utilized to determine outcomes.

RESULTS

2521 patients prescribed one of the 3 medications were identified. Among them, 81 patients (mean age: 10.5 ± 2.8 years) received combination therapy. Of which, 55 were male and 26 female. Specifically, 58 were prescribed both desmopressin and imipramine (group IMP), 23 desmopressin and oxybutynin (group OXY), and 4 transitioned from OXY to IMP. Mean pretreatment VSS showed no difference between groups. Both groups experienced minimal drops in wet nights with desmopressin alone. A comparison revealed that group IMP reduced wet nights significantly more than group OXY (VSS wet night score 0.7 ± 1.2 vs. 2.3 ± 1.1 respectively, p < 0.0001). Non-intent-to-treat complete response rate was 68% vs 5% (OR = 42.5, p < 0.001) (IMP vs. OXY respectively). Intent-to-treat response rates were 58%.

DISCUSSION

Although first-line desmopressin treatment for enuresis is effective, it does not work for all patients, and many parents and children desire nighttime dryness. Clinicians have combined desmopressin with oxybutynin or imipramine for improved results, but research comparing these modalities is scarce. Our study suggests that the desmopressin and imipramine combination is superior at reducing nights wet compared to desmopressin and oxybutynin, attributed to imipramine's probable central mechanism rather than its secondary anticholinergic properties. Limitations include a modest sample size, retrospective design, and subjective responses to the Vancouver questionnaire.

CONCLUSION

A combination of desmopressin and imipramine was more effective in reducing wet nights and had a complete response rate that was 42.5 times greater than desmopressin and oxybutynin.

Self-guided Online Medical Hypnosis Program Improves Dry Nights in Children With Nocturnal Enuresis in a Prospective Single-Center Pilot Study

Bedwetting is a common condition in children. We evaluated the effectiveness of medical hypnosis as a first-line therapy in children with primary monosymptomatic nocturnal enuresis (PMNE). The study enrolled children in a prospective single-center pilot clinical trial consisting of 1 month diary of dry nights prior to using the commercially available hypnosis intervention (www.keepingthebeddry.com), followed by 3 consecutive months diary following intervention. Seventeen children aged 8 to 15 years old were enrolled and 12 recorded at least 1 month data after the hypnosis intervention. The median dry nights prior to intervention was 8 (0-17) days and improved to 15.5 (7-28) days by the third month post-intervention (P = .0033). All patients who completed the study showed an improvement. Self-guided medical hypnosis therapy showed significant improvement in dry nights without any side effects and any identifiable risk to patients. It should be considered for use in children as first-line therapy for PMNE.

Parental Knowledge, Beliefs, Practices, and Barriers Related to Children's Bladder Health in the School Environment

BACKGROUND

Pediatric lower urinary tract symptoms (LUTS) are a set of common childhood problems. Community-level interventions that target behavioral change among children with LUTS can improve symptoms outside of the clinic environment. Parents, navigating the home and school environments, are key in supporting healthy bladder behaviors. Thus, we asked parents about their perceptions and barriers related to pediatric bladder health.

METHODS

English-speaking parents (n = 30) of children ages 5-10 years with and without LUTS were interviewed. Transcripts were coded iteratively by two independent coders using deductive and inductive approaches that emphasized consensus coding and peer debriefing.

RESULTS

Ninety-three percent of participants were women, 50% were 30-39 years old, and 60% held a graduate degree. Parents identified school-, classroom-, and child-based barriers to bladder health. These included the bathroom environment, restrictive policies for bathroom use, and anxiety on how and when to use the bathroom.

CONCLUSIONS

Addressing school-, classroom-, and child-based barriers is necessary to promote healthy bladder habits among children in the school environment and beyond. Recommended school-based interventions include bathroom use and sanitation policies that support students' voiding needs, teachers' professional development, and school readiness initiatives. Limitations include participation of English-speaking parents only.

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis

Background

Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear.

Objective

To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented.

Methods

Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains.

Results

Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps.

Scoping review

651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations.

Effectiveness systematic reviews

studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators.

Conclusions

Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children.

Study registration

This study is registered as PROSPERO CRD42019159008.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

Prevalence and associated skills of Australian general practice registrars seeing children with functional bowel and bladder problems

AIM

Functional bowel (constipation and faecal incontinence) and bladder (urinary incontinence and enuresis) problems in children are often treated by paediatricians yet should mostly be managed by general practitioners (GPs). To understand whether the necessary skills and knowledge are being built in general practice, this study aimed to establish the prevalence and associated skills of Australian general practice registrars managing children with functional bowel and bladder problems. Together as paediatricians and GPs, we use these data to determine how best to ensure high quality, equitable care for children.

METHODS

We drew on 16 rounds of data collection from the Registrar Clinical Encounters in Training (ReCEnT) multi-site cohort study (2010-2017) of general practice registrars' in-consultation experience. It included a measure of paediatric consultations in which a functional bowel or bladder problem was managed, as well as demographic information.

RESULTS

Out of 62 721 problems/diagnoses for paediatric patients (0-17 years), 844 (1.4%) were coded as functional bowel (n = 709; 1.13% (95% confidence interval, CI: 1.05-1.22)) and/or bladder (n = 135; 0.22% (95% CI: 0.18-0.25)) presentations. Registrars were more likely to prescribe medication for bowel problems (odds ratio (OR) = 2.22 (95% CI: 1.86-2.64)) than for all other problems, but less likely to prescribe medication (OR = 0.31 (95% CI: 0.18-0.52)) for night-time wetting and more likely to make a specialist referral (OR = 1.99 (95% CI: 1.22-3.25)) compared to all other problems.

CONCLUSIONS

Only a small proportion of children with functional bowel and bladder problems were seen by registrars despite high prevalence in the community and amenability to management in the general practice setting (i.e. generally low morbidity and low complexity) versus need for specialists. Registrars appeared to be managing functional bowel and bladder problems according to evidence-based guidelines, but with relatively high levels of referral. Given the inequitable access to specialist care, paediatricians should support local general practice management of these problems. This might include (i) engaging with training programs to ensure appropriate education and (ii) liaising with individual registrars/practices to provide management advice for individual or example cases.

A prospective and randomized study comparing the use of alarms, desmopressin and imipramine in the treatment of monosymptomatic nocturnal enuresis

BACKGROUND

Monosymptomatic enuresis (MNE) results from a pathogenic triad that may include lack of vasopressin secretion during sleep, reduced functional bladder capacity and inability to wake up during sleep. The treatment of MNE can be performed through behavioral therapy, use of alarms or medications such as desmopressin and imipramine.

OBJECTIVE

To compare the effectiveness of different treatments of MNE.

STUDY DESIGN

Prospective and randomized study comparing different intervention and a control group (receiving only behavior therapy) for MNE.

INCLUSION CRITERIA

age between 5 and 16 years old, with MNE, evaluated at the pediatric urology outpatient clinic of Hospital Infantil Menino Jesus. At first visit children were submitted to behavior therapy (urotherapy) for 3 months, children were subsequently characterized according to the ICCS as non-responders, partial responders, or full responders. Those partial responders or non-responders received a patient ID and were randomized to four groups: Alarm Group (G1), Desmopressin Group - DDAVP (G2), Imipramine Group (G3) and Control (G4). All groups were monitored monthly, for a period of 6 months. After 6 months, the children were reevaluated for MNE.

RESULTS

93 patients were enrolled. Mean age was 10.96 years with a standard deviation of 2.28 years, 59,1% were male. All groups had improvement in the number of dry nights (Table). Taking in account success the population full responders and partial responders: Alarm Group (G1) achieve success in 100% of cases, Desmopressin Group - DDAVP (G2) in 63.6% of cases, Imipramine Group (G3) in 73.7% of cases (Table 3). No drugs side effects were observed in both groups (G2 and G3), there was no dropout in patients who used alarms.

DISCUSSION

Our data suggests that the use of alarms is the most effective treatment of ENM with superior results when compared to imipramine and DDAVP. The small number of participants is a weakness of the study, as well as the lack of a voiding diary at the end of the study.

CONCLUSION

All therapeutics options utilized in the treatment of MNE are safe, effective and has a low rate of abandonment.

Functional urination or defecation disorders may be warning signs of attention-deficit/hyperactivity disorder among children in rural China

BACKGROUND

This study was designed to investigate the prevalence of attention-deficit/hyperactivity disorder (ADHD) and its association with functional urination and defecation disorders among children in rural China.

METHODS

A cross-sectional study was conducted with children aged 6-18 in rural schools in southwest China using a survey questionnaire. The Swanson, Nolan, and Pelham Questionnaire-IV (SNAP-IV) was used to measure ADHD symptoms, and standardized questions about urination and defecation were used to measure lower urinary tract symptoms (LUTS) and functional defecation disorders (FDDs). The association of ADHD with LUTS and FDDs was analyzed by matched logistic regression after propensity score matching was performed to minimize the influence of potential confounders, including demographic characteristics.

RESULTS

A total of 17,279 participants were included in the analyses. The prevalence of ADHD was 2 % mainly among boys before age 12, after which it showed a decreasing trend with age, resulting in a concomitant reduction in gender differences. The risk of ADHD was positively associated with the presence of enuresis, holding maneuvers, intermittency, and encopresis, with encopresis having the strongest association (P = 0.001). The presence of holding maneuvers, intermittency, excessive volitional stool retention, and encopresis were associated with a higher risk of ADHD at 6-15 years-old, with intermittency exhibiting an increasingly positive association with ADHD risk across ages 6-15.

CONCLUSIONS

ADHD was associated with LUTS and FDDs, which highlights that functional urination and/or defecation disorders could serve as warning signs for ADHD that should trigger screening, especially in relatively backward regions with little ADHD awareness.

Outcomes of a pilot evaluation of a group urotherapy programme for children with complex elimination disorders: An Australian experience

Evidence-based interventions have continued to show positive effects on both reducing symptoms and helping children with elimination disorders achieve continence and manage troubling psychological distress. Despite this, there is a group of children who do not respond to standard treatments and are classified as having a complex elimination disorder. As a means of addressing the broader clinical challenge and implications of complex elimination disorders, a team of clinicians in Germany developed the Urinary and Faecal Incontinence Training Program for Children and Adolescents. A pilot investigation was undertaken to apply the Urinary and Faecal Incontinence Training Program for Children and Adolescents programme to children aged 6-12 years in an Australian context who met the complex elimination disorder diagnostic criteria, to determine if any subsequent change in the measures of life quality and general well-being was achieved. Findings suggest a reduction in the frequency of the child's symptoms and improvements in family quality of life measures. Qualitatively, children and parents perceived that their child's ability to now respond to stimuli and in so doing avert severe accidents was a major outcome of the programme and was able to increase a child's sense of acceptance of incontinence, improve levels of self-efficacy and increase self-awareness.

What do cochrane systematic reviews say about interventions for enuresis in children and adolescents? An overview of systematic reviews

OBJECTIVE

To conduct an overview of Cochrane systematic reviews about treatment alternatives for children and/or adolescents with enuresis.

SOURCES

An overview of Cochrane systematic reviews about interventions for enuresis in children/adolescents was developed between September/2021 and December/2021. The protocol was registered on PROSPERO and the search was conducted only in the Cochrane Library database without any restriction. Reviews involving any type of intervention for the treatment of enuresis in children/adolescents were included. The risk of bias was assessed using Risk of Bias in Systematic Reviews (ROBIS) and the quality of reviews was assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR-2).

SUMMARY OF THE FINDINGS

Seven systematic reviews were identified. Based on the ROBIS assessment, all reviews were classified as low risk of bias. According to the AMSTAR-2 assessment, the three oldest systematic reviews were rated as critically low quality, one review was moderate quality, and the three most recent systematic reviews were rated as high quality. No difference was shown between alarm and desmopressin for a complete response to therapy after treatment (RR = 1.30; 95%CI: 0.92 to 1.84), but alarm use is related to a lower risk of adverse events (RR = 0.38; 95%CI: 0.20 to 0.71). There is a moderate certainty that the association between imipramine and oxybutynin is better than placebo to reduce the risk of children who do not achieve 14 consecutive dry nights after treatment (RR = 0.43; 95%CI: 0.23 to 0.78).

CONCLUSIONS

There is no difference between alarm and desmopressin for enuresis treatment. However, alarm therapy had fewer adverse events than desmopressin. Moreover, combination therapy between imipramine and oxybutynin is better than placebo.

Tuina for Enuresis in Children: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

To evaluate the effects of Tuina (massage) vs. non-Tuina traditional Chinese medicine (TCM) treatments on nocturnal enuresis in children.

Methods

A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted following the Preferred Reported Items for Systematic Review and Meta-analysis (PRISMA) guidelines. RevMan 5.3 software was used for meta-analysis.

Results

Twelve RCTs recruiting a total of 1,007 children were included. Meta-analysis results showed that, compared with non-Tuina TCM treatments, Tuina could significantly improve the total effective rate of children's enuresis [RR = 1.29, 95%CI (1.22–1.36), P < 0.00001]. The results of subgroup analyses indicated that the total effective rate of Tuina combined with acupuncture in the treatment of nocturnal enuresis was higher than acupuncture alone [RR = 1.24, 95%CI (1.12–1.37), P < 0.0001]. The total effective rate of Tuina in the treatment of enuresis in children was better than that of herbal medicine alone [RR = 1.45, 95%CI (1.31–1.61), P < 0.00001]. The total effective rate of Tuina combined with herbal medicine in the treatment of enuresis in children was better than that of herbal medicine alone [RR = 1.16, 95%CI (1.06–1.26), P = 0.0007]. No adverse reactions of Tuina were reported in all included studies.

Conclusion

From the available evidence, Tuina, or Tuina combined with non-Tuina TCM treatments (acupuncture, or herbal medicine) can improve the clinical outcome of children with enuresis, indicating Tuina is a promising treatment choice for children's enuresis. However, because of the intrinsic limitations of the included studies, more high-quality randomized controlled trials with longer follow-up are still needed to further confirm the efficacy and safety of Tuina in the treatment of nocturnal enuresis in children.

Systematic review and meta-analysis: relationships between attention-deficit/hyperactivity disorder and urinary symptoms in children

Lower urinary tract symptoms (LUTS), e.g., urinary frequency, pressure, urgency, and overactive bladder syndrome, are commonly reported in children with attention-deficit/hyperactivity disorder (ADHD). Understanding the co-occurrence of these conditions has implications regarding clinical approaches, treatments, and improved quality of life. We conducted a systematic review and meta-analysis to examine the relationships between LUTS and ADHD in children. We searched for articles published between January 1990 and July 2019, in PubMed, CENTRAL, and PsycNet. Two authors independently screened all articles and extracted data. We performed random-effect meta-analyses for ADHD with pooled outcomes for LUTS. We identified 119 relevant articles in the literature and 18 articles fulfilled the inclusion criteria for the systematic review, of which, 5 articles had sufficient data for meta-analysis. Examining ADHD among individuals with LUTS, the odds ratio was 2.99 (95% CI 1.13, 7.88, p < 0.001), compared to controls. In multiple studies, the mean overall score for LUTS, using a standardized measure, was significantly higher in patients with ADHD in comparison to controls, and the severity of ADHD was positively associated with the severity of LUTS. Younger age in children was correlated with a higher LUTS score. Different subtypes of urinary incontinence demonstrated differences in behavioral problems and psychiatric comorbidity. Sex differences in LUTS were not consistent across articles. Our results indicate clinically significant associations between ADHD and LUTS in children. Because LUTS and ADHD are common disorders in children, clinicians should be aware of these associations as they inform optimal assessment and treatment strategies.

Evaluation of a new frequency-volume chart for children with primary monosymptomatic nocturnal enuresis: a prospective, comparative study

INTRODUCTION

To improve compliance with voiding diaries in children with primary monosymptomatic nocturnal enuresis (PMNE), a new modified 3-day weekend frequency-volume chart (FVC) was designed, and the compliance and validity of this modified FVC was evaluated by comparing with the International Children's Continence Society (ICCS) recommended voiding diary.

METHODS

A total of 1200 patients with PMNE were enrolled in the study from 13 centers in China and were randomly assigned to record this modified FVC or the ICCS-recommended voiding diary. The primary outcome measure was the compliance, assessed by comparing the completing index and the quality score of diaries between two groups. The secondary outcome measure was the validity, evaluated by comparing the constituent of subtypes, micturition parameters and response rate to desmopressin.

RESULTS

Among the 1200 participants enrolled in the study, 447 patients completed the ICCS-recommended voiding diary and 469 completed the modified diary. The diurnal completing index and the quality score of the modified FVC group were better than those of the ICCS group. In addition, there was no significant difference between these two groups in the subtype classification, or in the response rate to desmopressin.

CONCLUSIONS

The modified FVC could be applied to obtain the voiding characteristics of children with PMNE as the ICCS-recommended voiding diary does and offers a reasonable and better choice for children with PMNE from the unselected population in the future.

A randomised, double-blind, placebo-controlled clinical trial found that a novel herbal formula Urox® (Bedtime Buddy®) assisted children for the treatment of nocturnal enuresis

BACKGROUND

Nocturnal enuresis or 'bedwetting', is a form of night-time urinary incontinence occurring in younger children. A diagnosis can be socially disruptive and psychologically stressful for a child. The most common strategies used by parents are waking the child during the night to use the bathroom and limiting the child's water intake before going to bed.

HYPOTHESIS/PURPOSE

To determine if a herbal capsule formulation taken once daily can reduce incidence and frequency of nocturnal enuresis in children.

STUDY DESIGN

This randomised double-blind placebo-controlled trial evaluated the efficacy of an herbal medicine product to reduce the symptoms of nocturnal enuresis. Participants, aged between 6 and 14 years of age, were recruited from the community in Australia. They were randomised via computerised random-number generation at study enrolment to receive one or two oral capsules in the morning of either Urox® (Bedtime Buddy®) or placebo. The Paediatric Quality of life (Pin-Q) was used as a quality-of-life measure and waking wet, fluid intake and urinary urgency per week were monitored.

RESULTS

Forty-one children completed the trial with an attrition rate of 16%. There were more males (64.6%) compared to females (35.4%) and the mean age was 8.6 years. Forty-one point seven percentages (41.7%) of participants had improvements in bed wetting by two months which was a highly clinically relevant effect (Cohen's D = 0.98). The primary outcome found that there was a statistically significant reduction in NE (p = 0.034; CI 0.086-2.095) and between groups using longitudinal analysis (p = 0.04, Coefficient -1.12, CI 95% -2.20 - -0.04). In the secondary outcomes, urinary urgency reduced statistically significantly for the intervention (p = 0.002; a reduction of 18.3% difference for Bedtime Buddy compared to an increase of 3.7% for the placebo).

CONCLUSION

Urox® (Bedtime Buddy®) may assist children in reducing nocturnal enuresis compared to placebo. In addition, it may assist in reducing daily incontinence and urinary urgency.

The evaluation of urinary incontinence in secondary school children and risk factors: An epidemiological study

AIM

Urinary incontinence is an important problem that can arise due to neurogenic or functional reasons and negatively affect the psychological, social and personality development of children. This study was conducted on secondary school students to determine the prevalence and risk factors of urinary incontinence at night and/or in the daytime.

METHODS

The study universe included all secondary school students attending public elementary schools in the city centre of Eskişehir (N = 34 000). Ethics Committee and Provincial Directorate of National Education approvals were obtained before conducting the study. A data collection form prepared by the researchers and a consent form were delivered in a sealed envelope to the parents via the students. The study data were collected over the period 09 May 2018-30 May 2018. A total of 6957 questionnaires that were fully completed among the 7370 surveys were taken into consideration. The statistical analysis was carried out using the SPSS software package.

RESULTS

The number of children found to have urinary incontinence was 215 (3.1%). It was seen that 33 children had urinary incontinence only in the daytime, 61 children experienced it both at night and during the day and 121 children at night. It was observed that 56% of the children suffering from urinary incontinence had not applied to any health facility for treatment prior to the study. It was found that among the risk factors for urinary incontinence were young age, late start of toilet training and presence of a family history of urinary incontinence.

CONCLUSIONS

Children with urinary incontinence and their families need medical information and support to reach the root of the problem and seek solutions. Accompanying pathologies in detected cases can be determined in the early period by means of school screenings, and medical evaluation and support can prevent adverse effects on children's psychosocial and personality development.

Nocturnal Enuresis in Sickle Cell: Sociodemographic, Medical, and Quality of Life Factors

OBJECTIVE

Nocturnal enuresis is more prevalent in youth with sickle cell disease (SCD) compared to the general population. The purpose of this study is to estimate prevalence of nocturnal enuresis using diagnostic criteria and identify associated sociodemographic, medical, and health-related quality of life (HRQOL) factors.

METHODS

Youth with SCD (N = 248; ages 6.00-17.99 years) and their caregivers completed semi-structured interviews and questionnaires. HRQOL was measured using the Pediatric Quality of Life (PedsQL) Inventory. Medical information was abstracted from medical record. We generated multivariable logistic regression models to examine associations between factors and current nocturnal enuresis and nocturnal enuresis occurring any time in the past (lifetime).

RESULTS

Among participants (mean age, 11.3 ± 3.6 years; 50.8% male), 21.4% reported current nocturnal enuresis and 46% reported lifetime nocturnal enuresis. Male sex [odds ratio (OR), 2.57; p = .001], difficulty arousing from sleep (OR, 3.57; p < .001), higher school functioning HRQOL (OR, 1.02; p = .014), and higher fetal hemoglobin levels (OR, 1.03; p = .048) were associated with lifetime nocturnal enuresis. Younger age (OR, 1.16; p = .005), higher youth-reported fatigue (OR, 1.01; p = .045), difficulty arousing from sleep (OR, 4.92; p < .001), and higher lactate dehydrogenase levels (OR, 1.00; p = .042) were associated with current nocturnal enuresis.

CONCLUSIONS

Nocturnal enuresis is prevalent in youth with SCD and is associated with HRQOL, diminished sleep, greater fatigue, and disease severity markers. Routine assessment of sleep behaviors and fatigue are necessary when treating patients with SCD to understand the impact of nocturnal enuresis on HRQOL.

Online psychosocial group intervention for parents: Positive effects on anxiety and depression

Objective

To evaluate the efficacy of an online psychosocial group intervention for parents of children with a chronic illness, in terms of anxiety and depression, and disease-related coping skills.

Methods

Parents (N = 73) participated in a parallel multicenter randomized controlled trial comparing an intervention group to a waitlist control group. In the group intervention Op Koers Online (English: On Track Online) parents learned how to use adaptive coping strategies taught with cognitive behavioral therapy and acceptance and commitment therapy techniques. Assessments (online questionnaires) took place at baseline (T0), 6-months (T1), and 12-months (T2) follow-up. Mixed-model analyses were performed to test the difference in change in outcomes between intervention (N = 34) and waitlist control group (N = 33).

Results

When compared with the waitlist control group, the intervention had a significant positive effect (p < .05) on changes in anxiety, depression, and total score T1 versus T0 (β = −.47 to −.51) and T2 versus T0 (β = −.39 to −.46), the coping skills open communication, relaxation, social support, acceptance, predictive control (β = .42–.88) and helplessness (β = −.47) T1 versus T0 and relaxation and positive thinking T2 versus T0 (β = .42–.53).

Conclusions

Parental anxiety and depression decreased, and use of adaptive coping skills improved after the intervention. The online character, the focus on parents themselves instead of on their child and the possibility for parents of children with rare illnesses to participate, are innovative and unique aspects of Op Koers Online for parents. The next step is to implement the intervention in clinical practice.

Challenging the view that lack of fibre causes childhood constipation

OBJECTIVES

To assess evidence supporting the view that 'low fibre causes childhood constipation'.

DESIGN

Triangulation integrated three approaches: a systematic review NICE guideline CG99 examining effectiveness of increasing fibre; a cohort study, Avon Longitudinal Study of Parents and Children (ALSPAC), to assess if constipation (or hard stools) can precede fibre intake at weaning; and a literature search for twin studies to calculate heredity.

SETTING

CG99 examined the literature regarding the effectiveness of increasing fibre. ALSPAC asked parents about: hard stools at 4 weeks, 6 months and 2.5 years and constipation at age 4-10 years, as well as fibre intake at 2 years. Twin studies and data from ALSPAC were pooled to calculate concordance of constipation comparing monozygotic and dizygous twin pairs.

PARTICIPANTS

CG99 reported six randomised controlled trials (RCTs). ALSPAC hard stool data from 6796 children at 4 weeks, 9828 at 6 months and 9452 at 2.5 years plus constipation data on 8401 at 4-10 years were compared with fibre intake at 2 years. Twin studies had 338 and 93 twin pairs and ALSPAC added a further 45.

RESULTS

Increasing fibre did not effectively treat constipation. Hard stools at 4 weeks predated fibre and at 6 months predicted lower fibre intake at 2 years (p=0.003). Heredity explained 59% of constipation.

CONCLUSIONS

RCTs indicate that increasing fibre is not an effective treatment for constipation in children. Hard stools can precede and predict later fibre intake. Genetic inheritance explains most childhood constipation. Extended treatment with stool softeners may improve fibre intake and limit long-term damaging sequelae of constipation.

Caregiver-reported physical health status of children and young people with fetal alcohol spectrum disorder

While fetal alcohol spectrum disorder (FASD) has primarily been thought of as a neurodevelopmental condition, research is beginning to highlight its 'whole-body' implications. Accordingly, the current study sought to provide a snapshot of potential health issues. Caregivers of children (median age of 12 years) with an FASD diagnosis were invited to participate in an online survey. Information relating to sample demographics, FASD status of the child and health outcomes were collected. The prevalence of health conditions reported in the FASD sample was compared against national prevalence data. Multiple linear regression utilising a stepwise approach was used to investigate potential predictors of the number of diagnosed health conditions. Survey data were from an international cohort (n = 197), with the majority of respondents based in Australia (40.2%) or the United States (27.7%). The most commonly reported diagnosed health conditions were eye conditions (44.7%), asthma (34.5%), heart conditions (34.0%) and skin conditions (27.4%). Binomial testing indicated the proportion of children diagnosed with these disorders was generally higher in the current FASD population, compared to national prevalence data. Indicators of metabolic dysfunction including diabetes and obesity were not significantly different compared to national prevalence data. Age of FASD diagnosis, existence of comorbid mental health conditions and the primary caregiver being in paid work were identified as being associated with the prevalence of diagnosed health conditions. Overall, the study has provided an up-to-date snapshot of health problems reported in a sample of children with FASD, confirming their increased risk of adverse health outcomes.

Morning glory seed keeps laxative effect while retains less subchronic toxicity after being fried

ETHNOPHARMACOLOGICAL RELEVANCE

Morning glory seed (MGS), has been widely used in treating constipation especially towards children. Clinically, people usually take fried MGS (MGSF) in formulas to reduce its side effect. However, the safety of MGSF other than MGS has yet to be explored.

OBJECTIVE

The study aimed to reveal the potential mechanisms of using MGSF instead of MGS basing on chemistry, pharmacodynamics and toxicology.

METHODS

The chemical compositions of the extracts of MGS and MGSF were compared using UPLC-Q-TOF/MS method. Simultaneously, to prove the availability and safety of MGSF, we investigated the laxative effect and subchronic toxicity of MGS and MGSF and addressed the mechanism of laxative effect of them.

RESULTS

In this study, less phenolic acids and more fatty acids were detected in MGSF compared with the compounds in MGS. Moreover, we found that MGS group had stronger laxative effect than MGSF group via downregulating the expression of AQP3 protein. As for subchronic toxicity test, the body weights of MGS group were lower than MGSF group. In serum biochemistry and histopathological examinations, MGS group could cause more serious toxicity in liver, kidney and colon than MGSF group with higher values of BUN, Cr, AST and ALP.

CONCLUSION

Based on the findings in this study, MGSF with varied compounds contents could still keep the laxative effect while retain less subchronic toxicity, which emphasized the necessity of processing and provided an insight into the rational use of MGSF in clinical practice.

Evaluation of health-related quality of life and affecting factors in child with enuresis

BACKGROUND

Enuresis is a common problem in children and distressing condition that can have an impact on the child's behavior and on their emotional and social life. Health-related quality of life (HRQoL) is defined as an individual's perception of the impact of the disease and treatment.

OBJECTIVE

The aim of this study was to evaluate the HRQoL in Turkish children with enuresis and to investigate the effect of independent sociodemographic and clinical variables on HRQoL in children with enuresis.

STUDY DESING

110 children with enuresis and their mothers and 120 healthy children and their mothers were included in the study. The German quality of life questionnaire (KINDL®) scales were used to assess the children's HRQoL. For comparing the data of children with enuresis and healthy children, a two-sided unpaired t-test and linear regression model were used.

RESULT

The total HRQoL score for the children with enuresis group was 63.14 ± 21.98 and for the children in the control group was 75.6 ± 10.1 (P < 0.001). After adjusting for sex and age using the unstandardized coefficient of regression model, HRQoL score for the children with enuresis still remained statistically significant lower than that for healthy peers (64.21 ± vs 75.11 ± P < 0.001). The HRQoL subscale scores showed that children with enuresis had lower emotional well-being scores (64.23 ± 14.2 vs 78.9 ± 11.4, P < 0.001), self-esteem score (62.23 ± 11 vs 68.6 ± 17.4, P = 0.001), family relationship score (76.23 ± 2 vs 83.4 ± 12.2, P = 0.042), and friendship score (62.4 ± 13.2 vs 68.8 ± 15.3, P = 0.023) compared to the control group. When the effects of independent sociodemographic factors and clinical variables on HRQoL were evaluated, it was seen that the presence of lower urinary tract symptoms (LUTS) negatively affected total HRQoL score (59.89 ± 11.2 vs 69.29 ± 10.9 P = 0.028). Also the total HRQoL score was higher in treated children with enuresis than in nontreated children (65.96 ± 12.1 vs 55.27 ± 10.1 P = 0.032). Among the treated children, complete treatment response group had higher total HRQoL score compared to partial treatment response group and nonresponse group (respectively, 70.98 ± 9.7, 65.25 ± 10.1, 60.45 ± 10.9, P = 0.034, P = 0.01) (Summary Figure). Family income level affected total HRQoL score, low-income group had lower total HRQoL score compared to high-income group (62.17 ± 11.9 vs 69.25 ± 10 P = 0.039).

DISCUSSION

This study demonstrated that enuresis negatively affects the HRQoL of children and most affected domains in HRQoL were self-esteem, emotional well-being, and their relationship for family and friends. Our presented study showed that HRQoL was lower in non-primary monosymptomatic nocturnal enuresis (non-PMNE) children, nontreated patients. Also there were higher HRQoL scores in patients who had a total or partial response to treatment.

CONCLUSION

Our study may indicate that, low-income children with enuresis, nontreated enuretic children, and presence of LUTS should be considered as a risk group for low HRQoL.

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.

Management and treatment of nocturnal enuresis-an updated standardization document from the International Children's Continence Society

BACKGROUND

Enuresis is an extremely common condition, which, although somatically benign, poses long-term psychosocial risks if untreated. There are still many misconceptions regarding the proper management of these children.

AIM

A cross-professional team of experts affiliated with the International Children's Continence Society (ICCS) undertook to update the previous guidelines for the evaluation and treatment of children with enuresis.

METHODS

The document used the globally accepted ICCS terminology. Evidence-based literature served as the basis, but in areas lacking in primary evidence, expert consensus was used. Before submission, a full draft was made available to all ICCS members for additional comments.

RESULTS

The enuretic child does, in the absence of certain warning signs (i.e., voiding difficulties, excessive thirst), not need blood tests, radiology or urodynamic assessment. Active therapy is recommended from the age of 6 years. The most important comorbid conditions to take into account are psychiatric disorders, constipation, urinary tract infections and snoring or sleep apneas. Constipation and daytime incontinence, if present, should be treated. In nonmonosymptomatic enuresis, it is recommended that basic advice regarding voiding and drinking habits be provided. In monosymptomatic enuresis, or if the above strategy did not make the child dry, the first-line treatment modalities are desmopressin or the enuresis alarm. If both these therapies fail alone or in combination, anticholinergic treatment is a possible next step. If the child is unresponsive to initial therapy, antidepressant treatment may be considered by the expert. Children with concomitant sleep disordered breathing may become dry if the airway obstruction is removed.

Supporting parents of children aged 2-13 with toileting difficulties: Group-based workshops versus individual appointments

INTRODUCTION

Toileting is a key activity of daily living and an important milestone in children's development. Difficulties with this process can cause stress to both child and parents and negatively affect their wellbeing. This study compared the perceived parental competence and child wellbeing of families attending a group-based workshop on toileting issues with families attending an individual appointment at a continence clinic.

METHODS

All parents attending the workshops and attending the clinic between July 2016 and December 2017 were invited to participate in the study. The children were aged between 2 and 13 years. Three measures were used: 1) Parenting Sense of Competence Scale; (2) the Revised Quality of Life Questionnaire for Children (KINDLR) and (3) Parent self-assessment of information and support needs. Participants completed all measures at three points: prior to intervention, 1 week and 1 month post-intervention.

RESULTS

Data were collected from 89 parents attending the workshops and 46 parents attending the clinic. Children were not assessed. Non-parametric tests were used to examine between group differences. Within group changes overtime were examined using Friedman's two-way analysis of variance. Parents who attended the workshop showed significant increases in parenting sense of competence and perceived child quality of life post-intervention. Although there were significant differences between and pre- and post-measures for workshop attendees, there were no significant differences found between the two groups indicating that both forms of intervention had beneficial results.

CONCLUSION

These results suggest that group-based workshops can positively impact parents' perceived competence in managing their child's toileting issues and wellbeing. Further research is recommended to explore the relationship between parenting competence and child wellbeing and to determine which aspects of the workshops were most beneficial.

Complementary and Integrative Management of Pediatric Lower Urinary Tract Dysfunction Implemented within an Interprofessional Clinic

Lower urinary tract dysfunction in children is a common multifactorial functional problem that often correlates with bowel dysfunction and behavioral disorders. Ideal management combines integrative therapies that optimize bladder and bowel habits, address behavioral issues, foster mind–body connection, and improve pelvic floor muscle dysfunction. Movement therapies that teach diaphragmatic breathing and relaxation, mind–body awareness, and healthy pelvic floor muscle function are vital for long-term symptom improvement in children. This paper outlines recommendations for integrative management of these patients and discusses a recently developed interprofessional clinic that aims to better meet these patients’ complex needs and to provide patients with an integrated holistic plan of care. Additional work is needed to scientifically assess these treatment models and educate providers across the various disciplines that evaluate and treat these patients.

A randomized controlled double blinded trial to evaluate efficacy of oral administration of black strap molasses (sugarcane extract) in comparison with polyethylene glycol on pediatric functional constipation

ETHNOPHARMACOLOGICAL RELEVANCE

As a significant health issue, Functional Constipation (FC) has a high prevalence of 0.7%-29% worldwide. In Persian ethnomedicine, several formulations of sugarcane extracts including faniz, shekar-e- sorkh and black strap molasses have been used to treat pediatric constipation.

AIM OF THE STUDY

To evaluate efficacy and safety of oral intake of black strap molasses syrup (BSM) on FC in children.

MATERIALS AND METHODS

A randomized controlled double blinded trial was performed on children aged 4-12 years diagnosed with FC according to ROMIII Constipation Measurement Questionnaire. Ninety-two patients were randomly divided in two groups of BSM or PEG syrups (40%) with a dose of 1 mL/kg body weight/day for 1 month. Symptoms were evaluated every two weeks. Possible serological side-effects and changes in children's body weight were investigated. BSM syrup constituents were determined by pharmacognostic methods.

RESULTS

Treatment was successful with both interventions with no significant difference between the groups. Defecation per week was significantly improved in both groups. Symptoms including volitional stool retention, large diameter stool, painful or hard stool and large fecal mass in the rectum decreased significantly two and four weeks after intervention (P < 0.05). There was no significant difference between groups except for the rate of large diameter stool. No side -effects were observed. The BSM naturally contained polyphenols (960 μg/mL), potassium (12430 μg/mL), iron (80 μg/mL) and calcium (3320 μg/mL).

CONCLUSION

BSM and PEG syrups had similar efficacy on FC. Compared with PEG, BSM syrup contained different natural micronutrients.