Simple behavioral modification may be effective first-line treatment in resolution of nocturnal enuresis

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Copyright

van Dommelen P, Kamphuis M, van Leerdam F, de Wilde J, Rijpstra A, Campagne A, et al. The short- and long-term effects of simple behavioral interventions for nocturnal enuresis in young children: a randomized controlled trial. J Pediatr 2009;154:662-6.

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Question 

Among young children with nocturnal enuresis, how well do simple behavioral interventions improve the number of dry nights?

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Design 

Randomized controlled trial.

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Setting 

Academic medical center in The Netherlands.

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Participants 

570 children (aged 4-5 years) with monosymptomatic nocturnal enuresis.

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Intervention 

Lifting the child to the restroom 1.5 to 2 hours after falling asleep (with or without a password to assess if the child were awake), a reward (star chart), and a control group with no intervention.

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Outcomes 

The percentage of children who achieved the continence criterion of 14 consecutive dry nights.

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Main Results 

After 6 months, lifting the child to the toilet without the use of a password was the only intervention that resulted in significantly more dry children than the control group (37% vs 21%, P < .01, number needed to treat = 7). Three years later, both lifting groups had the highest (78%) and the control group the lowest (69%) percentage of dry children.

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Conclusions 

Lifting to urinate without the use of a password leads to more dry children compared with no active treatment in children aged 4 to 5 years with nocturnal enuresis.

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Commentary 

The authors are to be commended for attempting to assess outcomes for conservative treatment options in this age group. These interventions may be of interest to pediatricians, most of whom would likely hesitate to use pharmacotherapy (eg, DDAVP) in a 4- or 5-year-old and may have families unable or unwilling to purchase a bedwetting alarm. As the authors note in their discussion, tension can be high in families with children who fail to gain nighttime bladder control by this age, notwithstanding the detrimental environmental effects of prolonged diaper use. Of the methods studied, lifting the child to the restroom without a password had the highest success rate (37%, P < .01) but also had a rather high drop-out rate of 30%. It wasn't clear from the Methods whether the parents continued the lifting technique after achieving a successful run of 14 straight dry nights. Did the parents stop the intervention and the children stayed dry or did the children learn to rise on their own to void? Obviously this method requires a motivated and agreeable child and parent and that the child only wets once at night. It also was not clear what difference the password would make if the parents are ultimately responsible for getting the child out of bed to void. At the 3-year follow-up, approximately three-quarters of the children had achieved nighttime control, irrespective of the initial treatment regimen. At this point, 25% of the children still used some form of intervention, most commonly the lifting method without the use of a password. This study may assist pediatricians in guiding parents of young bed wetters for whom reassurance is not sufficient.