Nocturnal Enuresis: Giving the Child a “Lift”
Article Outline
Although nocturnal enuresis may cause significant stress to the child and family, only one-third of children with nocturnal enuresis in the United States seek advice from health care professionals.1 (The terms enuresis and nocturnal enuresis refer to bedwetting only. Children with day only or day and night wetting have urinary incontinence.)2 Enuretic children express more sadness and isolation, and the resolution of enuresis leads to an improvement of self-esteem. Because of the psychological distress from bedwetting, the International Children's Continence Society believes that longitudinal studies of the natural history of enuresis without intervention is no longer ethical.3 At what age is treatment appropriate? Previous studies have shown a remarkably similar prevalence rate in children around the world, with a fairly consistent resolution rate of 15% per year. Children are generally thought to be ready to participate in an action plan if they are still wetting the bed after the age of 6 years. The etiology of nocturnal enuresis is not clearly understood but revolves around sleep polyuria, small bladder capacity, and an inability to arouse prior to micturition. Therapies have been directed at decreasing nocturnal polyuria (desmopressin), increasing bladder capacity (antimuscarinics, holding exercises, enuresis alarms), and arousal (enuresis alarms). The common association of enuresis and ADHD may result from a common neurobiological dysfunction.
See related article, p 662
Enuresis alarms have been used to awaken the child at the time of voiding. These devices require that the child begin to urinate to trigger the alarm and require active participation of the child and family. The usual dogma has been that setting an alarm or waking a child in the middle of the night might keep the bed dry but would not teach the child to be dry. The study by van Dommelen et al in this issue of The Journal4 suggests that a simple awakening of a 4- or 5-year-old child 1.5 to 2 hours after bedtime might speed the resolution of bedwetting when reevaluated at 6 months. Six children needed to be “lifted” (parental guiding of the child to the bathroom during sleep) for 1 child to respond earlier than the resolution of nocturnal enuresis in the control group.
The findings in this study are similar to the report of El-Anany et al,5 in which children over age 7 were aroused by an alarm set at a predetermined time. Children achieved continence earlier with an alarm clock even if the alarm was not triggered by a bedwetting episode, as is needed with an enuresis alarm. These studies suggest that being awakened in the night to void may hasten the development of nocturnal bladder control even if the trip to the bathroom is not initiated by a wetting episode.
Even very young children, ages 1 to 3 years, arouse with nocturnal voiding, and earlier nocturnal urinary control may be achieved when parents respond to these arousals by taking the child out of the bed to void.6 Despite earlier resolution of enuresis thought to be related to the child sleeping with the parents, the number of children who did not have nocturnal urinary control at age 8 was similar in China to other parts of the world.
The study by van Dommelen et al4 was conducted in children ages 4 to 5 years, a time when treatment has been discouraged because bedwetting at this age is common, and the children have little interest in participating in a “cure.” This study suggests that children do not need to participate actively other than go to the bathroom with parental assistance. Despite little participation needed on the part of the child, the parents did need to participate, and more than 30% of parents in the lifting groups dropped out.
The study does not address whether children with fewer wet nights had better success with “lifting.” The requirement for participation was 2 or more wet nights per week. Whether the “lifting” kept the bed dry or whether the child was wet again later in the night is not apparent in this study. A third of the children had daytime accidents, and they had a trend toward slower nocturnal enuresis resolution in all treatment groups.
Finally, the study shows that after 3 years, the lifted groups, rewards group, and control group had similar enuresis resolution (78%, 76%, and 69%, respectively). All groups had a faster resolution rate than that reported in the literature of 15% per year. Why would families want to address enuresis at ages 4 to 5 when by 7 to 8 years of age there was essentially the same degree of nocturnal urinary control? The authors point out that there may be an environmental benefit from a decreased use of diapers and there may be lower family stress.
After brief evaluation for UTI, daytime bladder symptoms, and constipation, simple advice for the parents of the young enuretic child might be to increase fluid intake early in the day, decrease evening solute load, minimize fluid intake before bed,3 and wake the child 1.5 to 2 hours after bedtime to go to the bathroom. Is it worth the effort in children 4 or 5 years of age? The families will make that decision.
References
- . Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among US children: results from a nationally represented study. J Am Acad Child Adolesc Psychiatry. 2009;48:35–41
- . Standardization and definitions in lower urinary tract dysfunction in children. BJU Int. 1998;81(Suppl):1
- Nocturnal enuresis: an international evidence based management strategy. J Urol. 2004;171:2545–2561
- The short and long term effects of simple behavioral interventions for nocturnal enuresis in young children: a randomized controlled trial. J Pediatr. 2009;154:662–666
- . Primary nocturnal enuresis: a new approach to conditioning treatment. Urology. 1999;53:405–409
- Development of nocturnal urinary control in Chinese children younger than 8 years old. Urology. 2006;68:1103–1108
PII: S0022-3476(09)00023-7
doi:10.1016/j.jpeds.2009.01.041
© 2009 Mosby, Inc. All rights reserved.
Refers to article:
- The Short- and Long-term Effects of Simple Behavioral Interventions for Nocturnal Enuresis in Young Children: A Randomized Controlled Trial , 27 January 2009
