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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.)

8Lifting and waking in the management of bedwetting

8.1. Introduction

Lifting is described as lifting the child from their bed while they sleep or walking the child to the bathroom to pass urine, without necessarily waking the child. Waking is described as waking the child from their sleep and taking them to the bathroom to pass urine. Children can be woken at either set times or randomly during the night. Traditionally these methods have been used by families to manage bedwetting and the GDG were interested in their use and any potential benefits or harms so that families could be appropriately advised.

The evidence review on the effectiveness of waking assessed waking compared to no treatment; waking compared to other treatments; waking compared to combination of treatments. No evidence on lifting was found.

8.2. What is the clinical and cost effectiveness of lifting and waking for children and young people under 19 years who have bedwetting?

8.2.1. Evidence review

8.2.1.1. Random waking compared to placebo

Two randomised controlled trials, Fournier (1987) 81 and Turner (1970) 82 compared random waking to placebo. Fournier (1987) 81 described random waking as the parent waking the child any time before midnight; Turner (1970) 82 described random waking as the parents being given a chart with random times on it at when the child should be woken.

Table 8-1Random waking compared to placebo - Clinical summary of findings

OutcomeRandom wakingPlaceboRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights1/15 (6.7%)4/17 (23.5%)RR 0.28 (0.04 to 2.26)169 fewer per 1000 (from 226 fewer to 296 more)VERY LOW
Mean wet nights per week at 4 weeks1517-MD −0.99 (−2.54 to 0.56)VERY LOW
Mean number of wet nights per week at the end of treatment (no SD)88-not pooledVERY LOW

8.2.1.2. Random waking compared to imipramine

One randomised controlled trial, Fournier (1987) 81 compared random waking to imipramine. Random waking was described as the parent waking the child any time before midnight.

Table 8-2Random waking compared to imipramine - Clinical summary of findings

OutcomeRandom wakingImipramineRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights88-not pooledVERY LOW

8.2.1.3. Random waking compared to enuresis alarm

Two randomised controlled trials, Fournier (1987) 81 and Turner (1970) 82 compared random waking to enuresis alarm. Fournier (1987) 81 described random waking as the parent waking the child any time before midnight; Turner (1970) 82 described random waking as the parents being given a chart with random times on it at when the child should be woken.

Table 8-3Random waking compared to enuresis alarm - Clinical summary of findings

OutcomeRandom wakingEnuresis alarmRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights1/15 (6.7%)3/15 (20%)RR 0.33 (0.04 to 2.85)134 fewer per 1000 (from 192 fewer to 370 more)VERY LOW
Mean wet nights per week at 4 weeks1515-MD 0.33 (−1.23 to 1.89)VERY LOW
Mean number of wet nights per week at the end of treatment (no SD)88-not pooledVERY LOW

8.2.1.4. Random waking compared to enuresis alarm and imipramine

One randomised controlled trial, Fournier (1987) 81 compared random waking to an enuresis alarm and imipramine. Random waking was described as the parent waking the child any time before midnight.

Table 8-4Random waking compared to an enuresis alarm and imipramine - Clinical summary of findings

OutcomeRandom wakingAlarm and imipramineRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights88-not pooledVERY LOW

8.2.1.5. Waking and star chart compared to no treatment

One randomised controlled trial, Baker (1969) 23 compared waking and a star chart to a no treatment, waiting list. Star charts were used to keep a record of the child’s progress and the child was woken at a set time every night (chosen at the start of the trial to be before when the child usually wets), once the child was dry for several nights they were not woken for a week, if dry during the week the parents were told if the child wets to wake them for the two following nights.

Table 8-5Random waking and star chart compared to no treatment - Clinical summary of findings

OutcomeRandom waking and star chartNo treatmentRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights2/14 (14.3%)0/14 (0%)RR 5 (0.26 to 95.61)0 more per 1000 (from 0 fewer to 0 more)VERY LOW
Mean number of wet nights1010-not pooledVERY LOW

8.2.1.6. Waking and star chart compared to enuresis alarm

One randomised controlled trial, Baker (1969) 23 compared waking and a star chart to an enuresis alarm. Star charts were used to keep a record of the child’s progress and the child was woken at a set time every night (chosen at start of trial to be before when the child usually wets), once the child was dry for several nights they were not woken for a week, if dry during the week the parents were told if the child wets wake them for the two following nights.

Table 8-6Waking and star chart compared to enuresis alarm - Clinical summary of findings

OutcomeWaking and star chartAlarmRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights2/14 (14.3%)11/14 (78.6%)RR 0.18 (0.05 to 0.68)645 fewer per 1000 (from 252 fewer to 747 more)VERY LOW
Mean wet nights per week at 4 weeks1010-Not pooledVERY LOW

8.2.1.7. Waking (part of a 3 step program) compared to imipramine

One randomised controlled trial, Iester (1991) 24 was identified. Children in the waking group took part in a three step program which was 1) reassurance to the parents and trying to encourage the child; 2) bladder retention training (drink more during the morning and afternoon, reduce the number of times voiding during the day, trying to hold for at least 8 hours and interrupt voiding – stop start training) and behaviour training (drink as little as possible after 7 pm, urinate before going to bed and wake up once or twice using an alarm clock); 3) parents were involved in the treatment to help the child practice and avoid family conflicts.

Table 8-7Waking (part of a 3 step program) compared to imipramine - Clinical summary of findings

OutcomeWakingImipramineRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights24/36 (66.7%)14/36 (38.9%)RR 1.71 (1.07 to 2.74)276 more per 1000 (from 27 more to 677 more)VERY LOW
Number of children who relapsed after 12 months2/24 (8.3%)2/14 (14.3%)RR 0.58 (0.09 to 3.69)60 fewer per 1000 (from 130 fewer to 385 more)VERY LOW

8.2.1.8. Waking (part of a 3 step program) compared to motivational therapy and 3 step program

One randomised controlled trial, Iester (1991) 24 compared waking (part of a 3 step program) to motivational therapy and a 3 step program. Children in the waking group took part in a three step program which was 1) reassurance to the parents and tried to encourage the child; 2) bladder retention training (drink more during the morning and afternoon, reduce the number of times voided during the day, trying to hold for at least 8 hours and interrupt voiding – stop start training) and behaviour training (drink as little as possible after 7 pm, urinate before going to bed and wake up once or twice using an alarm clock); 3) parents were involved in the treatment to help the child practice and avoid family conflicts. Children in the motivation therapy group had the 3 step program as described and motivational therapy where child, in a group, discussed their problems with a psychiatrist.

Table 8-8Waking (part of a 3 step program) compared to motivational therapy and 3 step program - Clinical summary of findings

OutcomeWakingMotivational therapyRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights24/36 (66.7%)81/96 (84.4%)RR 0.79 (0.62 to 1.01)177 fewer per 1000 (from 321 fewer to 8 more)VERY LOW
Number of children who relapsed after 12 months2/24 (8.3%)3/81 (3.7%)RR 2.25 (0.4 to 12.69)46 more per 1000 (from 22 fewer to 433 more)VERY LOW

8.2.1.9. Waking combined with fluid restriction and parents avoiding punishment of children and placebo compared to imipramine

One randomised controlled trial, Bhatia (1990) 78 compared waking combined with fluid restriction and parents avoiding punishment of children and placebo to imipramine. Fluid restriction was described as “restricting fluids in the evening” as well as avoiding punitive attitude of the parents and waking the child one hour after sleep.

Table 8-9Waking combined with fluid restriction and parents avoiding punishment of children and placebo compared to imipramine - Clinical summary of findings

OutcomeWaking and fluid restrictionImipramineRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights4/20 (20%)12/20 (60%)RR 0.33 (0.13 to 0.86)402 fewer per 1000 (from 84 fewer to 522 fewer)VERY LOW

8.2.1.10. Waking combined with fluid restriction and parents avoiding punishment of children and placebo compared to waking combined with fluid restriction and parents avoiding punishment of children and imipramine

One randomised controlled trial Bhatia (1990) 78 compared waking combined with fluid restriction and parents avoiding punishment of children and placebo to waking combined with fluid restriction and parents avoiding punishment of children and imipramine. Fluid restriction was described as “restricting fluids in the evening” as well as avoiding punitive attitude of the parents and waking the child one hour after sleep.

Table 8-10Waking combined with fluid restriction and parents avoiding punishment of children and placebo compared to waking combined with fluid restriction and parents avoiding punishment of children and imipramine - Clinical summary of findings

OutcomeWaking and fluid restrictionWaking and imipramineRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights4/20 (20%)18/20 (90%)RR 0.22 (0.09 to 0.54)702 fewer per 1000 (from 414 fewer to 819 fewer)VERY LOW

8.2.1.11. Waking with alarm clock set before child wets compared to waking with alarm clock set 2 to 3 hours after child goes to bed for children with monosymptomatic NE

One randomised controlled trial El Anany (1999) 83 compared waking with alarm clock set before child wets to waking with alarm clock set 2 to 3 hours after child goes to bed. El Anany (1999) 83 considered children with monosymptomatic NE.

Table 8-11Waking with alarm clock set before child wets compared to waking with alarm clock set 2 to 3 hours after child goes to bed - Clinical summary of findings

OutcomeAlarm clock set before child wetsAlarm clock set 2–3 hours after child goes to bedRelative risk (95% CI)Absolute effectQuality
Dry for 14 consecutive nights in first month54/70 (77.1%)34/55 (61.8%)RR 1.25 (0.98 to 1.59)154 more per 1000 (from 12 fewer to 365 more)VERY LOW
Number of children who relapsed after 3 months8/54 (14.8%)3/34 (8.8%)RR 1.68 (0.48 to 5.89)60 more per 1000 (from 46 fewer to 430 more)VERY LOW
Number of children who relapsed after 6 months13/54 (24.1%)5/34 (14.7%)RR 1.64 (0.64 to 4.18)94 more per 1000 (from 53 fewer to 467 more)VERY LOW

8.2.2. Evidence statements

No evidence was found on the clinical and cost effectiveness of lifting.

Random waking

Studies include children with bedwetting and possible daytime symptoms
Turner (1970) 82
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with random waking and children treated with placebo tablet. Relative risk 0.28, 95% CI 0.04, 2.26. Children had a mean age of 7.5 years and had 4 weeks of treatment.
  • One study showed there was no statistically significant difference in the number of wet nights per week at the end of treatment between children treated with random waking and children treated with placebo tablet. Mean difference −0.99, 95% CI −2.54, 0.56. Children had a mean age of 7.5 years and had 4 weeks of treatment.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with random waking and children treated with an enuresis alarm. Relative risk 0.33, 95% CI 0.04, 2.85. Children had a mean age of 7.5 years and had 4 weeks of treatment.
  • One study showed there was no statistically significant difference in the mean number of wet nights per week at the end of treatment between children treated with random waking and children treated with an enuresis alarm. Mean difference 0.33, 95% CI −1.23, 1.89. Children had a mean age of 7.5 years and had 4 weeks of treatment.
Fournier (1987) 81
  • One study showed children treated with random waking had 1.7 fewer wet nights per week at the end of treatment compared to children treated with placebo tablet. Children had a mean age of 8.5 years and had 6 weeks of treatment. No information on variability was given in the study, therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable.
  • One study showed children treated with imipramine had 1.4 fewer wet nights per week at the end of treatment compared to children treated with random waking. Children had a mean age of 8.5 years and had 6 weeks of treatment. No information on variability was given in the study, therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable.
  • One study showed children treated with an enuresis alarm had 0.8 fewer wet nights per week compared to children treated with random waking. Children had a mean age of 8.5 years and had 6 weeks of treatment. No information on variability was given in the study, therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable.
  • One study showed children treated with an enuresis alarm and imipramine had 2.3 fewer wet nights per week compared to children treated with random waking. Children had a mean age of 8.5 years and had 6 weeks of treatment. No information on variability was given in the study, therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable.

Waking

Studies include children with bedwetting and possible daytime symptoms
Baker (1969) 23
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with waking and star charts and children who had no treatment. Relative risk 5, 95% CI 0.26, 95.61. Children had a median age of 8 years and had 10 weeks of treatment.
  • One study showed children treated with waking and star charts had 2.8 fewer wet nights per week compared to children who had no treatment. Children had a median age of 8 years and had 10 weeks of treatment. No information on variability was given in the study, therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable.
  • One study showed children treated with an enuresis alarm were more likely to achieve 14 consecutive dry nights compared to children treated with waking and star charts. Relative risk 0.18, 95% CI 0.05, 0.68. Children had a median age of 8 years and had 10 weeks of treatment.
  • One study showed children treated with an enuresis alarm had 1.3 fewer wet nights per week compared to children treated with waking and star charts. Children had a median age of 8 years and had 10 weeks of treatment. No information on variability was given in the study, therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable.
Bhatia (1990) 78
  • One study showed that children treated with imipramine were more likely to achieve 14 consecutive dry nights compared to children treated with waking combined with fluid restriction and parents avoiding punishment of children and placebo. Relative risk 0.33 95% CI 0.13, 0.86. Children had an age range of 4 to 12 years and treatment was for 6 weeks.

Waking (part of a 3 step program)

Studies include children with bedwetting and possible daytime symptoms
Iester (1991) 24
  • One study showed children treated with waking (part of a 3 step program) were more likely to achieve 14 consecutive dry nights compared to children treated with imipramine. Relative risk 1.71, 95% CI 1.07, 2.74. Children had an age range of 6 to 11 years and were treated for 6 months.
  • One study showed there was no statistically significant difference in the number of children who relapsed at 12 months between children treated with waking (part of a 3 step program) and children treated with imipramine. Relative risk 0.58, 95% CI 0.09, 3.69. Children had an age range of 6 to 11 years and were treated for 6 months.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with waking (part of a 3 step program) and children treated with motivational therapy and 3 step program. Relative risk 0.79, 95% CI 0.62, 1.01. Children had an age range of 6 to 11 years and were treated for 6 months.
  • One study showed there was no statistically significant difference in the number of children who relapsed at 12 months between children treated with waking (part of a 3 step program) and children treated with motivational therapy and 3 step program. Relative risk 2.25, 95% CI 0.4, 12.69. Children had an age range of 6 to 11 years and were treated for 6 months.

Waking

Studies include children with monosymptomatic NE
El Anany (1999) 83
  • For children with bedwetting one study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights in the first month between children treated with waking with alarm clock set before the child wets and children treated with waking with alarm clock set 2 to 3 hours after the child goes to bed. Relative risk 1.25, 95% CI 0.98, 1.59. Children had a mean age of 13.23 (children treated with alarm set before wetting) and 12.49 (children treated with alarm set 2 to 3 hours after bed) and had 4 months of treatment.
  • For children with bedwetting one study showed there was no statistically significant difference in the number of children who relapsed after 3 months between children treated with waking with alarm clock set before the child wets and children treated with waking with alarm clock set 2 to 3 hours after the child goes to bed. Relative risk 1.68, 95% CI 0.48, 5.89. Children had a mean age of 13.23 (children treated with alarm set before wetting) and 12.49 (children treated with alarm set 2 to 3 hours after bed) and had 4 months of treatment.
  • For children with bedwetting one study showed there was no statistically significant difference in the number of children who relapsed by 6 month follow up between children treated with waking with alarm clock set before the child wets and children treated with waking with alarm clock set 2 to 3 hours after the child goes to bed. Relative risk 1.64, 95% CI 0.64, 4.18. Children had a mean age of 13.23 (children treated with alarm set before wetting) and 12.49 (children treated with alarm set 2 to 3 hours after bed) and had 4 months of treatment.

8.2.3. Evidence to recommendations

Relative values of different outcomes

The GDG considered that achieving and maintaining dryness is the outcome wanted by children, young people and families and carers. The GDG recognized however that families and carers are also likely to need strategies that allow them to achieve dryness on a short term basis such as when away from home, on holiday etc.

Trade off between clinical benefit and harms

No evidence of harms was identified.

Economic considerations

No economic evidence was identified.

Quality of evidence (this includes clinical and economic)

No evidence on lifting was found.

The evidence on waking was of very low quality, from small trials with wide confidence intervals, inadequately powered to show a difference in the treatment effects. Some RCTs did not provide statistical data. Comparison treatments were not always equivalent e.g. one RCT had delivered interventions for different lengths of time and two RCTs did not give enough time (only 4 or 6 weeks) for comparison treatment (enuresis alarm) to be fully effective. One RCT had a high drop out rate.

Other considerations

The GDG made a distinction between lifting and waiking as measures which families and carers may use to manage bedwetting e.g. when away from home and lifting and waking as measures to help achieve dryness. The GDG considered that lifting without waking was potentially counterproductive as the child or young person does not learn to recognise the sensation of a full bladder. For this reason the GDG were reluctant to consider that lifting without waking had a place even in short term management but did agree that at times families might use it.

There was some evidence waking may increase the number of dry nights.

The studies suggest that other treatments (imipramine, enuresis alarms, enuresis alarm and imipramine) are more effective than waking. The evidence shows positively no difference between the two types of waking (at a set time or before the child or young person wets). In combination with other treatments waking was shown to have some effect, more dry nights compared to no treatment however it was unclear which part of the combination was effective. Waking in combination with other behavioural techniques was not shown to be more effective than enuresis alarms. The GDG did not consider there was enough evidence to support the use of waking in combination with other treatments.

The health care professionals on the GDG stated that waking may be useful as a temporary measure but should not be used for treatment. GDG members reported that young people who have not found success with any other treatment do sometimes use waking to ensure dry nights and should not be dissuaded from this.

8.2.4. Recommendations

8.2.4.1.

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.[1.6.1]
Copyright © 2010, National Clinical Guideline Centre.

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Cover of Nocturnal Enuresis
Nocturnal Enuresis: The Management of Bedwetting in Children and Young People.
NICE Clinical Guidelines, No. 111.
National Clinical Guideline Centre (UK).

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