Recommended management of nocturnal enuresis in children
Prescribing in children
nocturnal enuresis in children Anthony Cohn MRCP, FRCPC Our series Prescribing in children gives practical advice for successful man- agement of childhood prob- lems in general practice. Here, the author describes the three systems approach used in the treatment of nocturnal enuresis. Figure 1. Bed-wetting alarms are available from enuresis clinics and can also be bought over the Internet; they may help accelerate the time to natural dryness
Night-time wetting is common, Prevalence and treatment cant questions about treatment considerations
nearer to 1 per cent in all age groups. using methods such as a star chart,
ie rewarding a child through incen-
considered as ‘testing a theory’, and
– other than those caused by wetting. Prescribing in children
your control, rewarding or punish-ing you the next morning is likelyto be futile. General measures There is much debate about what general measures should be recom- mended. Certainly there is no dis- pute about avoiding caffeinated drinks. Some people advocate avoidance of blackcurrant juice. Increasing daytime drinking is also generally agreed upon, with more diverse opinions about when to stop drinking at night.
seems sound. I recommend tryingto stop drinks for an hour or twobefore bedtime. It is also essentialto go to bed with an empty bladder– urinating once or twice beforebedtime. The child should beencouraged to urinate if they wake.
lem that makes all urinary problemsharder to deal with and is oftenoverlooked. For many children whodo not wet every night, their wetnights are linked to when they havenot opened their bowels. It is there-fore essential to check for underly-ing constipation and treat it asnecessary – enuresis is almostimpossible to treat otherwise.
tions, most drug treatments do notaccelerate the time to natural dry-ness. This can lead to their under-use: ‘they don’t really treat theproblem’. I usually counter this bysaying that if you are destined to bedry in three years’ time, and youcould spend the next thousand
Prescribing in children
check for constipation/stool withholding – child should pass soft, easystool regularly; if necessary treat with appropriate combination of:• fluid• fibre• laxatives
General measures• increase daytime drinks• avoid caffeine (and blackcurrant juice)• stop drinks for 2 hours before bedtime• urinate once prior to bedtime• urinate upon waking – if child wakes in the night but does not go to
the toilet, identify what would make going to the toilet easier
• star chart – abandon quickly if not successful• information – ERIC (www.enuresis.org.uk)
• small bladder volume• some children may manage
bladder overactivity by limit-ing fluid intake)
for approx 3 months initially,may need long-term use
try combination of oxybutynin and desmopressin
NB success may be less than total dryness, eg that only the nappy
wait a few months and then try again: ‘Your body will be a bit stronger’
Figure 2. Recommended management of nocturnal enuresis Prescribing in children Primary – no significant Secondary – wetting period of dryness after a significant (6 months) period of
few months, at which time it is worthtaking a break to see if natural dry-
and so on, until it is no longer nec-essary. Some people prefer to
reserve it for ‘special occasions’. Table 1. Nomenclature and treatments for nocturnal enuresis
clearly more of an issue in thosechildren where controlling night-
time drinking may be difficult, eg
a little narrower (see Tables 1 and 2). The three systems approach
bursting – ‘your world record wee’. Prescribing in children
very helpful if they work and may accelerate the time
a third of children who wet the bedwill wake before wetting, but then
works for the night and is worn off by the morning –
if ineffective, there is little point persevering with it
now licensed for long-term use, so if effective it can
be continued for a few months then stopped to see
main risk is hyponatraemia if the child drinks large
‘bladder’ stabilisers may take many weeks to attain
bladder overactivity may be transient, so could try
What shall we tell the children? Table 2. Common treatments for enuresis
The most important messages totell any child with bedwetting are:
• it will get better as you get older.
nificant amount of ‘reversibility’ in
can help children feel less isolated.
to stop and start the flow of urine.
In reality it is rare that this is effec-
Further reading Constipation, withholding and your child:a family guide to soiling and wetting. Cohn
A. Jessica Kingsley Publishers, 2006.
its continued use is really necessary.
Differences in characteristics of noctur-
lescents: a critical appraisal from a large
epidemiological study. Yeung Chung K,et al. BJU International 2006;97(5):
Management of disorders of bladder andbowel control. Gontard A, et al. Mac Keith
Butler RJ, et al. Scand J Urol Nephrol
age, which is detailed in the BNF forChildren. It is best to start at a low
Dr Cohn is a consultant in paediatrics
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