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National Clinical Guideline Centre (UK). Nocturnal Enuresis: The Management of Bedwetting in Children and Young People. London: Royal College of Physicians (UK); 2010. (NICE Clinical Guidelines, No. 111.)

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Nocturnal Enuresis: The Management of Bedwetting in Children and Young People.

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1Guidance

The following guidance is based on the best available evidence. These recommendations apply to all healthcare professionals who are involved in the management of bedwetting in children and young people. Healthcare professionals are reminded of their duty under the Disability Discrimination Act (2005) to make reasonable adjustments to ensure that all people have the same opportunity for health.

For the purposes of this guideline we have used the terms ‘bedwetting’ and ‘daytime symptoms’ to describe those symptoms that may be experienced by the population who present for treatment of ‘bedwetting’.

The following definitions were used for this guideline:

  • Bedwetting: involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology.
  • Daytime symptoms: daytime urinary symptoms such as wetting, urinary frequency or urgency.
  • Response to an intervention: the child has achieved 14 consecutive dry nights or a 90% improvement in the number of wet nights per week.
  • Partial response: the child’s symptoms have improved but 14 consecutive dry nights or a 90% improvement in the number of wet nights per week has not been achieved.

1.1. Principles of care

1.1.1.

Inform children and young people with bedwetting and their parents or carers that bedwetting is not the child or young person’s fault and that punitive measures should not be used in the management of bedwetting.

1.1.2.

Offer support, assessment and treatment tailored to the circumstances and needs of the child or young person and parents or carers.

1.1.3.

Do not exclude younger children, for example, those under 7 years, from the management of bedwetting on the basis of age alone.

1.1.4.

Perform regular medication reviews for children and young people on repeated courses of drug treatment for bedwetting.

1.2. Information for the child or young person and family

1.2.1.

Offer information tailored to the needs of children and young people being treated for bedwetting and their parents and carers.

1.2.2.

Offer information and details of support groups to children and young people being treated for bedwetting and their parents or carers.

1.2.3.

Offer information about practical ways to reduce the impact of bedwetting before and during treatment for example, using bed protection and washable and disposable products.

1.3. Assessment and investigation

1.3.1.

Ask whether the bedwetting started in the last few days or weeks. If so, consider whether this is a presentation of a systemic illness.

1.3.2.

Ask if the child or young person had previously been dry at night without assistance for 6 months. If so, enquire about any possible medical, emotional or physical triggers, and consider whether assessment and treatment is needed for any identified triggers.

1.3.3.

Ask about the pattern of bedwetting, including questions such as:

  • How many nights a week does bedwetting occur?
  • How many times a night does bedwetting occur?
  • Does there seem to be a large amount of urine?
  • At what times of night does the bedwetting occur?
  • Does the child or young person wake up after bedwetting?
1.3.4.

Ask about the presence of daytime symptoms in a child or young person with bedwetting, including:

  • daytime frequency ( passing urine more than seven times a day)
  • daytime urgency
  • daytime wetting
  • passing urine infrequently (fewer than four times a day)
  • abdominal straining or poor urinary stream
  • pain passing urine.
1.3.5.

Ask about daytime toileting patterns in a child or young person with bedwetting, including:

  • whether daytime symptoms occur only in some situations
  • avoidance of toilets at school or other settings
  • whether the child or young person goes to the toilet more or less frequently than his or her peers.
1.3.6.

Ask about the child or young person’s fluid intake throughout the day. In particular, ask whether the child or young person, or the parents or carers are restricting fluids.

1.3.7.

Consider whether a record of the child or young person’s fluid intake, daytime symptoms, bedwetting and toileting patterns would be useful in the assessment and management of bedwetting. If so, consider asking the child or young person and parents or carers to record this information.

1.3.8.

Do not perform urinalysis routinely in children and young people with bedwetting, unless any of the following apply:

  • bedwetting started in the last few days or weeks
  • there are any signs of ill health
  • there is a history, symptoms or signs suggestive of urinary tract infection
  • there is a history, symptoms or signs suggestive of diabetes mellitus.
1.3.9.

Assess whether the child or young person has any comorbidities or there are other factors to consider, in particular:

  • constipation and/or soiling
  • developmental, attention or learning difficulties
  • diabetes mellitus
  • behavioural or emotional problems
  • family problems or a vulnerable child, young person or family.
1.3.10.

Consider assessment, investigation and/or referral when bedwetting is associated with:

  • a history of recurrent urinary infections
  • known or suspected physical or neurological problems
  • comorbidities or other factors for example, those listed in recommendation 1.3.9.
1.3.11.

Investigate and treat children and young people with suspected urinary tract infection in line with ‘Urinary tract infection’ (NICE clinical guideline 54).

1.3.12.

Investigate and treat children and young people with soiling or constipation in line with ‘Constipation in children and young people’ (NICE clinical guideline 99).

1.3.13.

Children and young people with suspected type 1 diabetes should be offered immediate (same day) referral to a multidisciplinary paediatric diabetes care team that has the competencies needed to confirm diagnosis and to provide immediate care.

[This recommendation is from ‘Type 1 diabetes’ (NICE clinical guideline 15).]

1.3.14.

Consider investigating and treating daytime symptoms before bedwetting if daytime symptoms predominate.

1.3.15.

Consider involving a professional with psychological expertise for children and young people with bedwetting and emotional or behavioural problems.

1.3.16.

Discuss factors that might affect treatment and support needs, such as:

  • sleeping arrangements for example, does the child or young person have his or her own bed or bedroom
  • the impact of bedwetting on the child or young person and family
  • whether the child or young person and parents or carers have the necessary level of commitment, including time available, to engage in a treatment programme.
1.3.17.

Discuss with the parents or carers whether they need support, particularly if they are having difficulty coping with the burden of bedwetting, or if they are expressing anger, negativity or blame towards the child or young person.

1.3.18.

Consider maltreatment1 if:

  • a child or young person is reported to be deliberately bedwetting
  • parents or carers are seen or reported to punish a child or young person for bedwetting despite professional advice that the symptom is involuntary
  • a child or young person has secondary daytime wetting or secondary bedwetting that persists despite adequate assessment and management unless there is a medical explanation, for example, urinary tract infection, or clearly identified stressful situation that is not part of maltreatment, for example, bereavement, parental separation.
    [This recommendation is adapted from ‘When to suspect child maltreatment’ (NICE clinical guideline 89).]
1.3.19.

Use the findings of the history to inform the diagnosis (according to table 1) and management of bedwetting.

Table 1. Findings from the history and their possible interpretation.

Table 1

Findings from the history and their possible interpretation.

1.4. Planning management

1.4.1.

Explain the condition, the effect and aims of treatment, and the advantages and disadvantages of the possible treatments to the child or young person and parents or carers (see recommendations 1.8.13 and 1.10.9).

1.4.2.

Clarify what the child or young person and parents or carers hope the treatment will achieve. Ask whether short-term dryness is a priority for the family or for recreational reasons for example, for a sleep-over.

1.4.3.

Explore the child or young person’s views about their bedwetting, including:

  • what they think the main problem is
  • whether they think the problem needs treatment.
1.4.4.

Explore and assess the ability of the family to cope with using an alarm for the treatment of bedwetting.

1.4.5.

Consider whether or not it is appropriate to offer an alarm or drug treatment, depending on the age of the child or young person, the frequency of bedwetting and the motivation and needs of the child or young person and their family.

1.5. Advice on fluid intake, diet and toileting patterns

1.5.1.

Advise children and young people with bedwetting and their parents or carers that:

  • adequate daily fluid intake is important in the management of bedwetting
  • daily fluid intake varies according to ambient temperature, dietary intake and physical activity. A suggested intake of drinks is given in table 2:
1.5.2.

Advise the child or young person and parents or carers that the consumption of caffeine-based drinks should be avoided in children and young people with bedwetting.

1.5.3.

Advise the child or young person and parents or carers to eat a healthy diet and not to restrict diet as a form of treatment for bedwetting.

1.5.4.

Advise the child or young person of the importance of using the toilet at regular intervals throughout the day.

1.5.5.

Advise parents or carers to encourage the child or young person to use the toilet to pass urine at regular intervals during the day and before sleep (typically between four and seven times in total). This should be continued alongside the chosen treatment for bedwetting.

1.5.6.

Address excessive or insufficient fluid intake or abnormal toileting patterns before starting other treatment for bedwetting in children and young people.

1.5.7.

Suggest a trial without nappies or pull-ups for a child or young person with bedwetting who is toilet trained by day and is wearing nappies or pull-ups at night. Offer advice on alternative bed protection to parents and carers.

Table 2. Suggested daily intake of drinks for children and young people.

Table 2

Suggested daily intake of drinks for children and young people.

1.6. Lifting and waking2

1.6.1.

Offer advice on waking and lifting during the night as follows:

  • Neither waking nor lifting children and young people with bedwetting, at regular times or randomly, will promote long-term dryness.
  • Waking of children and young people by parents or carers, either at regular times or randomly, should be used only as a practical measure in the short-term management of bedwetting.
  • Young people with bedwetting that has not responded to treatment may find self-instigated waking for example, using a mobile phone alarm or alarm clock, a useful management strategy.

1.7. Reward systems

1.7.1.

Explain that reward systems with positive rewards for agreed behaviour rather than dry nights should be used either alone or in conjunction with other treatments for bedwetting. For example, rewards may be given for:

  • drinking recommended levels of fluid during the day
  • using the toilet to pass urine before sleep
  • engaging in management, for example, taking medication or helping to change sheets.
1.7.2.

Inform parents or carers that they should not use systems that penalise or remove previously gained rewards.

1.7.3.

Advise parents or carers to try a reward system alone (as described in recommendation 1.7.1) for the initial treatment of bedwetting in young children who have some dry nights.

1.8. Initial treatment – alarms

1.8.1.

Offer an alarm as the first line treatment to children and young people whose bedwetting has not responded to advice on fluids, toileting or an appropriate reward system, unless:

  • an alarm is considered undesirable to the child or young person or their parents or carers or
  • an alarm is considered inappropriate, particularly if:
    • bedwetting is very infrequent (less than 1–2 wet beds per week)
    • the parents or carers are having emotional difficulty coping with the burden of bedwetting
    • the parents or carers are expressing anger, negativity or blame towards the child or young person.
1.8.2.

Assess the response to an alarm by 4 weeks and continue with treatment if the child or young person is showing early signs of response3. Stop treatment only if there are no early signs of response.

1.8.3.

Continue alarm treatment in children and young people with bedwetting who are showing signs of response until a minimum of 2 weeks uninterrupted dry nights has been achieved.

1.8.4.

Assess whether it is appropriate to continue with alarm treatment if complete dryness is not achieved after 3 months. Only continue with alarm treatment if the bedwetting is still improving and the child or young person and parents or carers are motivated to continue.

1.8.5.

Do not exclude alarm treatment as an option for bedwetting in children and young people with:

1.8.6.

Consider an alternative type of alarm for example, a vibrating alarm for the treatment of bedwetting in children and young people who have a hearing impairment.

1.8.7.

Consider an alarm for the treatment of bedwetting in children and young people with learning difficulties and/or physical disabilities. Tailor the type of alarm to each individual’s needs and abilities.

1.8.8.

Consider an alarm for the treatment of bedwetting in children under 7 years, depending on their ability, maturity, motivation and understanding of the alarm.

Using an alarm

1.8.9.

Inform children and young people and parents or carers about the benefits of alarms combined with reward systems. Advise on the use of positive rewards for desired behaviour, such as waking up when the alarm goes off, going to the toilet after the alarm has gone off, returning to bed and resetting the alarm.

1.8.10.

Encourage children and young people with bedwetting and their parents or carers to discuss and agree on their roles and responsibilities for using the alarm and the use of rewards.

1.8.11.

Ensure that advice and support are available to children and young people and their parents or carers who are given an alarm, and agree how these should be obtained. Be aware that they may need a considerable amount of help in learning how to use an alarm.

1.8.12.

Inform the child or young person and their parents or carers that the aims of alarm treatment for bedwetting are to train the child or young person to:

  • recognise the need to pass urine
  • wake to go to the toilet or hold on
  • learn over time to hold on or to wake spontaneously and stop wetting the bed.
1.8.13.

Inform the child or young person and their parents or carers that:

  • alarms have a high long-term success rate
  • using an alarm can disrupt sleep
  • that parents or carers may need to help the child or young person to wake to the alarm
  • using an alarm requires sustained commitment, involvement and effort from the child or young person and their parents or carers
  • they will need to record their progress for example, if and when the child or young person wakes and how wet they and the bed are
  • alarms are not suitable for all children and young people and their families.
1.8.14.

If offering an alarm for bedwetting, inform the child and young person and their parents or carers how to:

  • set and use the alarm
  • respond to the alarm when it goes off
  • maintain the alarm
  • deal with problems with the alarm, including who to contact when there is a problem
  • return the alarm when they no longer need it.
1.8.15.

Inform the child and young person and their parents or carers that it may take a few weeks for the early signs of a response to the alarm to occur and that these may include:

  • smaller wet patches
  • waking to the alarm
  • the alarm going off later and fewer times per night
  • fewer wet nights.
1.8.16.

Inform the child or young person and their parents or carers that dry nights may be a late sign of response to the alarm and may take weeks to achieve.

1.8.17.

Inform the parents or carers that they can restart using the alarm immediately, without consulting a healthcare professional, if the child or young person starts bedwetting again following a response to alarm treatment.

1.9. Lack of response to alarm treatment

1.9.1.

If bedwetting does not respond to initial alarm treatment, offer:

  • combination treatment with an alarm and desmopressin or
  • desmopressin alone if continued use of an alarm is no longer acceptable to the child or young person or their parents and carers.
1.9.2.

Offer desmopressin alone to children and young people with bedwetting if there has been a partial response to a combination of an alarm and desmopressin following initial treatment with an alarm.

1.10. Initial treatment – desmopressin

1.10.1.

Offer desmopressin to children and young people over 7 years, if:

  • rapid-onset and/or short-term improvement in bedwetting is the priority of treatment or
  • an alarm is inappropriate or undesirable (see recommendation 1.8.1).
1.10.2.

Consider desmopressin for children aged 5 to 7 years if treatment is required and:

  • rapid-onset and/or short-term improvement in bedwetting is the priority of treatment or
  • an alarm is inappropriate or undesirable (see recommendation 1.8.1).
1.10.3.

Do not exclude desmopressin as an option for the management of bedwetting in children and young people who also have daytime symptoms. However, do not use desmopressin in the treatment of children and young people who only have daytime wetting.

1.10.4.

In children and young people who are not completely dry after 1 to 2 weeks of the initial dose of desmopressin (200 micrograms for Desmotabs or 120 micrograms for DesmoMelt), consider increasing the dose to 400 micrograms for Desmotabs or 240 micrograms for DesmoMelt.

1.10.5.

Assess the response to desmopressin at 4 weeks and continue treatment for 3 months if there are signs of a response. Consider stopping if there are no signs of response. Signs of response include:

  • smaller wet patches
  • fewer wetting episodes per night
  • fewer wet nights.
1.10.6.

Do not exclude desmopressin as an option for the treatment of bedwetting in children and young people with sickle cell disease if an alarm is inappropriate or undesirable and they can comply with night time fluid restriction. Provide advice about withdrawal of desmopressin at times of sickle cell crisis.

1.10.7.

Do not exclude desmopressin as an option for the treatment of bedwetting in children and young people with emotional, attention or behavioural problems or developmental and learning difficulties if an alarm is inappropriate or undesirable and they can comply with night time fluid restriction.

1.10.8.

Do not routinely measure weight, serum electrolytes, blood pressure and urine osmolality in children and young people being treated with desmopressin for bedwetting.

1.10.9.

If offering desmopressin for bedwetting, inform the child or young person and their parents or carers:

  • that many children and young people, but not all, will experience a reduction in wetness
  • that many children and young people, but not all, will relapse when treatment is withdrawn
  • how desmopressin works
  • of the importance of fluid restriction from 1 hour before until 8 hours after taking desmopressin
  • that it should be taken at bedtime
  • if appropriate, how to increase the dose if there is an inadequate response to the starting dose
  • to continue treatment with desmopressin for 3 months
  • that repeated courses of desmopressin can be used.
1.10.10.

Consider advising that desmopressin should be taken 1–2 hours before bedtime in children and young people with bedwetting that has either partially responded or not responded to desmopressin taken at bedtime. Ensure that the child or young person can comply with fluid restriction starting from 1 hour before the drug is taken.

1.10.11.

Consider continuing treatment with desmopressin for children and young people with bedwetting that has partially responded, as bedwetting may improve for up to 6 months after starting treatment.

1.11. Children and young people experiencing recurrence of bedwetting

1.11.1.

Consider alarm treatment again if a child or young person who was previously dry with an alarm has started regularly bedwetting again.

1.11.2.

Offer combination treatment with an alarm and desmopressin to children and young people who have more than one recurrence of bedwetting following successful treatment with an alarm.

1.11.3.

Consider using repeated courses of desmopressin for children and young people with bedwetting that has responded to desmopressin treatment but who experience repeated recurrences. Withdraw desmopressin treatment at regular intervals (for 1 week every 3 months) to check if dryness has been achieved when using it for the long-term treatment of bedwetting.

1.11.4.

Gradually withdraw desmopressin rather than suddenly stopping it if a child or young person has had a recurrence of bedwetting following response to previous desmopressin treatment courses.

1.11.5.

Consider alarm treatment as an alternative to continuing drug treatment for children and young people who have recurrences of bedwetting, if an alarm is now considered appropriate and desirable.

1.12. Lack of response to initial treatment options

1.12.1.

Refer children and young people with bedwetting, that has not responded to courses of treatment with an alarm, and/or desmopressin for further review and assessment of factors that may be associated with a poor response, such as; an overactive bladder, an underlying disease, social and emotional factors.

1.13. Anticholinergics

The use of anticholinergics for bedwetting in children and young people is discussed in the recommendations in this section. Not all anticholinergics have UK marketing authorisation for treating bedwetting in children and young people. If a drug without a marketing authorisation for this indication is prescribed, informed consent should be obtained and documented.

1.13.1.

Do not use an anticholinergic alone for the management of bedwetting in children and young people without daytime symptoms.

1.13.2.

Consider an anticholinergic combined with desmopressin for bedwetting in children and young people who also have daytime symptoms and have been assessed by a healthcare professional with expertise in prescribing the combination of an anticholinergic and desmopressin.

1.13.3.

Consider an anticholinergic combined with desmopressin for children and young people who have been assessed by a healthcare professional with expertise in the management of bedwetting that has not responded to an alarm and/or desmopressin and have any of the following:

1.13.4.

Consider continuing treatment for children and young people with bedwetting that has partially responded to desmopressin combined with an anticholinergic, as bedwetting may continue to improve for up to 6 months after starting treatment.

1.13.5.

Consider using repeated courses of desmopressin combined with an anticholinergic in children and young people who have responded to this combination but experience repeated recurrences of bedwetting following previous response to treatment.

1.13.6.

If offering an anticholinergic combined with desmopressin for bedwetting, inform the child or young person and their parents or carers:

  • that success rates are difficult to predict, but more children and young people are drier with this combination than with desmopressin alone
  • that desmopressin and an anticholinergic can be taken together at bedtime
  • to continue treatment for 3 months
  • that repeated courses can be used.
1.13.7.

Do not offer an anticholinergic combined with imipramine for the treatment of bedwetting in children and young people.

1.14. Tricyclics

1.14.1.

Do not use tricyclics as the first-line treatment for bedwetting in children and young people.

1.14.2.

If offering a tricyclic, imipramine should be used for the treatment of bedwetting in children and young people.

1.14.3.

Consider imipramine for children and young people with bedwetting who:

  • have not responded to all other treatments and
  • have been assessed by a healthcare professional with expertise in the management of bedwetting that has not responded to an alarm and/or desmopressin.
1.14.4.

If offering imipramine for bedwetting, inform the child or young person and their parents or carers:

  • that many children and young people, but not all, will experience a reduction in wetness
  • how imipramine works
  • that it should be taken at bedtime
  • that the dose should be increased gradually
  • about relapse rates for example, more than two out of three children and young people will relapse after a 3 month course of imipramine
  • that the initial treatment course is for 3 months and further courses may be considered
  • about the particular dangers of imipramine overdose, and the importance of taking only the prescribed amount and storing it safely.
1.14.5.

Perform a medical review every 3 months in children and young people who are using repeated courses of imipramine for the management of bedwetting.

1.14.6.

Withdraw imipramine gradually when stopping treatment for bedwetting in children and young people.

1.15. Training programmes for the management of bedwetting

1.15.1.

Do not use strategies that recommend the interruption of urinary stream or encourage infrequent passing of urine during the day.

1.15.2.

Do not use dry-bed training4 with or without an alarm for the treatment of bedwetting in children and young people.

1.16. Children under 5 years with bedwetting

Children are generally expected to be dry at night by a developmental age of 5 years, and historically it has been common practice not to offer advice to families of children who are younger than 5 years and are bedwetting. This section provides recommendations specific to the under 5 age group indicating situations where healthcare professionals can offer useful advice and interventions.

1.16.1.

Reassure parents or carers that many children under 5 years wet the bed, for example, approximately one in five children of 4 and a half years wets the bed at least once a week.

1.16.2.

Ask whether toilet training has been attempted, and if not, ask about the reasons for this and offer support and advice. If there are no reasons why toilet training should not be attempted, advise parents or carers to toilet train their child.

1.16.3.

Suggest a trial of at least 2 nights in a row without nappies or pull-ups for a child with bedwetting who is under 5 years and has been toilet trained by day for longer than 6 months. Offer advice on alternative bed protection to parents and carers. Consider a longer trial in children:

  • who are older
  • who achieve a reduction in wetness
  • whose family circumstances allow the trial to continue.
1.16.4.

Advise the parents or carers of a child under 5 years with bedwetting that if the child wakes at night, they should take him or her to the toilet.

1.16.5.

Consider further assessment and investigation to exclude a specific medical problem for children over 2 years who, despite awareness of toileting needs and showing appropriate toileting behaviour, are struggling to not wet themselves during the day as well as the night.

1.16.6.

Assess children under 5 years with bedwetting for constipation, in line with ‘Constipation in children and young people’ (NICE clinical guideline 99), as undiagnosed chronic constipation is a common cause of wetting and soiling in younger children.

For the purposes of the child mistreatment guideline, to consider maltreatment means that maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis.

Lifting is carrying or walking a child to toilet. Lifting without waking means that effort is not made to ensure the child is fully woken. Waking means waking a child from sleep to take them to the toilet.

Early signs of a response may include smaller wet patches, waking to the alarm, the alarm going off later and fewer times per night and fewer wet nights.

Dry-bed training is a training programme that may include combinations of a number of different behavioural interventions, and that may include rewards, punishment, training routines and waking routines, and may be undertaken with or without an alarm.

Footnotes

1

For the purposes of the child mistreatment guideline, to consider maltreatment means that maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis.

2

Lifting is carrying or walking a child to toilet. Lifting without waking means that effort is not made to ensure the child is fully woken. Waking means waking a child from sleep to take them to the toilet.

3

Early signs of a response may include smaller wet patches, waking to the alarm, the alarm going off later and fewer times per night and fewer wet nights.

4

Dry-bed training is a training programme that may include combinations of a number of different behavioural interventions, and that may include rewards, punishment, training routines and waking routines, and may be undertaken with or without an alarm.

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