NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

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.)

Cover of Nocturnal Enuresis

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

Show details

11Dry bed training for the management of bedwetting

11.1. Introduction

Dry bed training is a multi-component intervention for the management of nocturnal enuresis.

Dry bed training (DBT) was first described in Azrin (1974) 92. The dry bed training procedure was described as a first night of intensive training which included positive practice one hour before bedtime, being given fluid at bed time, an alarm, hourly waking, and cleanliness training when the child was wet. After the initial nights treatment, post training supervision was given which continued to include an alarm, positive practice if the child was wet the night before, waking the child when parent went to bed, cleanliness training if the child wet the bed, and praise if the child was dry in the morning. If the child was dry for 7 consecutive dry nights the alarm was removed, and the parent would continue to check the bed in the morning. If the child was wet, cleanliness training would be used and positive practice was given the following evening. If the child was wet twice in a week, then post training supervision was started again.

Bollard (1981) 93, Nawaz (2002) 94, Bennett (1985) 85, and Bollard (1982) 95 used dry bed training as described in Azrin 1974 92. However, some variations applied: Nawaz (2002) 94 specifically stated they included the trainer staying with the child on the first night. Bennett (1985) 85 adapted it to have the parents as the trainers. Bollard (1982) 95 also included weekly meetings for parents and children. Keating (1983) 96 used the method described in Azrin (1978) 97 which was similar to the method in Azrin (1974) 92, but also included star charts and rewards, training in the afternoon before the first night and hourly waking only until 1 am.

The comparisons included in the evidence review on the effectiveness of dry bed training are dry bed training with or without an alarm compared to no treatment; comparisons of different types of dry bed training with or without an alarm; dry bed training with or without an alarm compared to other treatments; dry bed training with or without an alarm compared to combination of treatments.

11.2. What is the clinical and cost effectiveness of dry bed training for children and young people under 19 years who have bedwetting?

11.2.1. Evidence review

11.2.1.1. Dry bed training (without an alarm) compared to no treatment

Table 11-1Dry bed training without an alarm compared to no treatment - Clinical summary of findings

OutcomeDBT without alarmNo treatmentRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights7/30 (23.3%)2/30 (6.7%)RR 2.9 (0.75 to 11.14)127 more per 1000 (from 17 fewer to 679 more)VERY LOW
Mean number of wet nights per week at the end treatment (no SD)3030-not pooledVERY LOW
Number of children who relapsed2/5 (40%)2/2 (100%)RR 0.5 (0.17 to 1.46)500 fewer per 1000 (from 830 fewer to 460 more)VERY LOW

11.2.1.2. Dry bed training (without an alarm) compared to dry bed training with an alarm

Table 11-2Dry bed training without an alarm compared to dry bed training with an alarm - Clinical summary of findings

OutcomeDBT without alarmDBT with an alarm – therapist at homeRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights7/30 (23.3%)29/30 (96.7%)RR 0.26 (0.14 to 0.48)716 fewer per 1000 (from 503 fewer to 832 fewer)LOW
Mean number of wet nights per week at the end of treatment (no SD)3030-not pooledVERY LOW
Number of children who relapsed or failed6/15 (40%)8/30 (26.7%)RR 1.45 (0.59 to 3.54)120 more per 1000 (from 109 fewer to 678 more)VERY LOW

Table 11-3Dry bed training without an alarm compared to dry bed training with an alarm with therapist at hospital - Clinical summary of findings

OutcomeDBT without alarmDBT with an alarm – therapist at hospitalRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights5/20 (25%)20/20 (100%)RR 0.27 (0.13 to 0.55)730 fewer per 1000 (from 450 fewer to 870 fewer)LOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed2/5 (40%)6/20 (30%)RR 1.33 (0.38 to 4.72)99 more per 1000 (from 186 fewer to 1000 more)VERY LOW

Table 11-4Dry bed training without an alarm compared to dry bed training with an alarm with parent as therapist - Clinical summary of findings

OutcomeDBT without alarmDBT with an alarm – parents as therapistRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights5/20 (25%)20/20 (100%)RR 0.27 (0.13 to 0.55)730 fewer per 1000 (from 450 fewer to 870 fewer)LOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed2/5 (40%)4/20 (20%)RR 2 (0.5 to 8)200 more per 1000 (from 100 fewer to 1000 more)VERY LOW

11.2.1.3. Dry bed training (without an alarm) compared to alarm

Table 11-5Dry bed training without an alarm compared to an alarm - Clinical summary of findings

OutcomeDBT without alarmAlarmRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights5/20 (25%)16/20 (80%)RR 0.31 (0.14 to 0.69)552 fewer per 1000 (from 248 fewer to 688 fewer)LOW
Mean number of wet nights per week at the end treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed2/5 (40%)6/16 (37.5%)RR 1.07 (0.31 to 3.71)26 more per 1000 (from 259 fewer to 1000 more)VERY LOW

11.2.1.4. Dry bed training with an alarm compared to no treatment

Table 11-6Dry bed training with an alarm compared to no treatment - Clinical summary of findings

OutcomeDBT with an alarmNo treatmentRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights29/30 (96.7%)2/30 (6.7%)RR 9.34 (3.2 to 27.27)559 more per 1000 (from 147 more to 1000 more)LOW
Mean number of wet nights per week at the end of treatment (no SD)3030-not pooledVERY LOW
Number of children who relapsed5/20 (25%)2/2 (100%)RR 0.31 (0.13 to 0.76)690 fewer per 1000 (from 240 fewer to 870 fewer)VERY LOW

Table 11-7Dry bed training with an alarm with therapist at hospital compared to no treatment - Clinical summary of findings

OutcomeDBT with an alarm – therapist at hospitalNo treatmentRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights20/20 (100%)2/20 (10%)RR 8.2 (2.56 to 26.3)720 more per 1000 (from 156 more to 1000 more)LOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed6/20 (30%)2/2 (100%)RR 0.37 (0.16 to 0.84)630 fewer per 1000 (from 160 fewer to 840 fewer)VERY LOW

Table 11-8Dry bed training with an alarm with parent as therapist compared to no treatment - Clinical summary of findings

OutcomeDBT with an alarm – parents as therapistNo treatmentRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights20/20 (100%)2/20 (10%)RR 8.2 (2.56 to 26.3)720 more per 1000 (from 156 more to 1000 more)LOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed4/20 (20%)2/2 (100%)RR 0.26 (0.1 to 0.67)740 fewer per 1000 (from 330 fewer to 900 fewer)LOW

11.2.1.5. Types of dry bed training with an alarm

Table 11-9Dry bed training with an alarm with therapist at home compared to dry bed training with an alarm with therapist at hospital - Clinical summary of findings

OutcomeDBT with an alarm – therapist at homeDBT with an alarm – therapist at hospitalRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights20/20 (100%)20/20 (100%)not poolednot pooledLOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed5/20 (25%)6/20 (30%)RR 0.83 (0.3 to 2.29)51 fewer per 1000 (from 210 fewer to 387 more)VERY LOW

Table 11-10Dry bed training with an alarm with therapist at home compared to dry bed training with an alarm with parents as therapist - Clinical summary of findings

OutcomeDBT with an alarm – therapist at homeDBT with an alarm – parents as therapistRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights20/20 (100%)20/20 (100%)not poolednot pooledLOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed5/20 (25%)4/20 (20%)RR 1.25 (0.39 to 3.99)50 more per 1000 (from 122 fewer to 598 more)VERY LOW

Table 11-11Dry bed training with an alarm with therapist at hospital compared to dry bed training with an alarm with parents as therapist - Clinical summary of findings

OutcomeDBT with an alarm – therapist at hospitalDBT with an alarm – parents as therapistRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights20/20 (100%)20/20 (100%)not poolednot pooledLOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed6/20 (30%)4/20 (20%)RR 1.5 (0.5 to 4.52)100 more per 1000 (from 100 fewer to 704 more)VERY LOW

11.2.1.6. Dry bed training with an alarm compared to alarms

Table 11-12Dry bed training with an alarm compared to an alarm - Clinical summary of findings

OutcomeDBT with an alarm – therapist at homeAlarmRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights25/30 (83.3%)20/29 (69%)RR 1.24 (0.99 to 1.55)166 more per 1000 (from 7 fewer to 379 more)VERY LOW
Mean number of wet nights at the end of treatment109-MD 0.4 (− 2.75 to 3.55)VERY LOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who dropped out10/20 (50%)9/18 (50%)RR 1 (0.53 to 1.89)0 fewer per 1000 (from 235 fewer to 445 more)VERY LOW
Number of children who relapsed5/20 (25%)6/16 (37.5%)RR 0.67 (0.25 to 1.79)124 fewer per 1000 (from 281 fewer to 296 more)VERY LOW

Table 11-13Dry bed training with an alarm with therapist at hospital compared to an alarm - Clinical summary of findings

OutcomeDBT with an alarm – therapist at hospitalAlarmRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights20/20 (100%)16/20 (80%)RR 1.24 (0.98 to 1.57)192 more per 1000 (from 16 fewer to 456 more)VERY LOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed6/20 (30%)6/16 (37.5%)RR 0.8 (0.32 to 2.01)75 fewer per 1000 (from 255 fewer to 379 more)VERY LOW

Table 11-14Dry bed training with an alarm with parents as therapist compared to an alarm - Clinical summary of findings

OutcomeDBT with an alarm – parents as therapistAlarmRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights20/20 (100%)16/20 (80%)RR 1.24 (0.98 to 1.57)192 more per 1000 (from 16 fewer to 456 more)VERY LOW
Mean number of wet nights per week at the end of treatment (no SD)2020-not pooledVERY LOW
Number of children who relapsed4/20 (20%)6/16 (37.5%)RR 0.53 (0.18 to 1.57)176 fewer per 1000 (from 308 fewer to 214 more)VERY LOW

11.2.1.7. Dry bed training with an alarm compared to stop-start training

Table 11-15Dry bed training with an alarm compared to stop start training - Clinical summary of findings

OutcomeDBT with an alarmStop-start trainingRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights5/10 (50%)2/12 (16.7%)RR 3 (0.73 to 12.27)334 more per 1000 (from 45 fewer to 1000 more)VERY LOW
Mean number of wet nights per week at the end of treatment1012-MD −1.85 (− 5.4 to 1.7)VERY LOW
Number of children who dropped out10/20 (50%)11/23 (47.8%)RR 1.05 (0.57 to 1.93)24 more per 1000 (from 206 fewer to 445 more)VERY LOW

11.2.1.8. Dry bed training with an alarm compared to star charts

Table 11-16Dry bed training with an alarm compared to star charts - Clinical summary of findings

OutcomeDBT with an alarmStar chartRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights5/10 (50%)0/9 (0%)RR 10 (0.63 to 158.87)0 more per 1000 (from 0 fewer to 0 more)VERY LOW
Mean number of wet nights per week at the end of treatment109-MD −3.75 (− 6.79 to − 0.71)VERY LOW
Number of children who dropped out10/20 (50%)3/12 (25%)RR 2 (0.68 to 5.85)250 more per 1000 (from 80 fewer to 1000 more)VERY LOW

11.2.1.9. Dry bed training (without an alarm) compared to no treatment for children with bedwetting wetting

Table 11-17Dry bed training without an alarm with training at hospital for parent and child compared to no treatment for children with bedwetting - Clinical summary of findings

OutcomeDBT without alarm – hospital parent and childNo treatmentRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of treatment (no SD)77-not pooledVERY LOW

Table 11-18Dry bed training without an alarm with training at home for parent and child compared to no treatment for children with bedwetting - Clinical summary of findings

OutcomeDBT without alarm – home parent and childNo treatmentRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of treatment (no SD)97-not pooledVERY LOW

Table 11-19Dry bed training without an alarm at hospital with parent compared to no treatment for children with bedwetting - Clinical summary of findings

OutcomeDBT without alarm – hospital parentNo treatmentRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of treatment (no SD)77-not pooledVERY LOW

11.2.1.10. Dry bed training (without an alarm) compared to types to dry bed training for children with bedwetting

Table 11-120Dry bed training without an alarm with training at hospital for parent and child compared to dry bed training without an alarm with training at home for parent and child for children with bedwetting - Clinical summary of findings

OutcomeDBT without alarm – hospital parent and childDBT without alarm – home parent and childRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights7/7 (100%)5/9 (55.6%)RR 1.7 (0.95 to 3.07)389 more per 1000 (from 28 fewer to 1000 more)VERY LOW
Mean number of wet nights per week at the end of treatment (no SD)79-not pooledVERY LOW
Number of children who relapsed2/7 (28.6%)2/5 (40%)RR 0.71 (0.15 to 3.5)116 fewer per 1000 (from 340 fewer to 1000 more)VERY LOW

Table 11-21Dry bed training without an alarm with training at hospital for parent and child compared to dry bed training without an alarm with training at hospital for parent only for children with bedwetting - Clinical summary of findings

OutcomeDBT without alarm – hospital parent and childDBT without alarm – hospital parentRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights7/7 (100%)6/7 (85.7%)RR 1.15 (0.79 to 1.68)129 more per 1000 (from 180 fewer to 583 more)VERY LOW
Mean number of wet nights per week at the end of treatment (no SD)77-not pooledVERY LOW
Number of children who relapsed2/7 (28.6%)2/6 (33.3%)RR 0.86 (0.17 to 4.37)47 fewer per 1000 (from 276 fewer to 1000 more)VERY LOW

Table 11-22Dry bed training without an alarm with training at home for parent and child compared to dry bed training without an alarm with training at hospital for parent only, for children with bedwetting - Clinical summary of findings

OutcomeDBT without alarm – home parent and childDBT without alarm – hospital parent and childRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights5/9 (55.6%)6/7 (85.7%)RR 0.65 (0.34 to 1.25)300 fewer per 1000 (from 566 fewer to 214 more)VERY LOW
Mean number of wet nights per week at the end of treatment (no SD)97-not pooledVERY LOW
Number of children who relapsed2/5 (40%)2/6 (33.3%)RR 1.2 (0.25 to 5.71)67 more per 1000 (from 250 fewer to 1000 more)VERY LOW

11.2.1.11. Dry bed training with an alarm compared to no treatment for children with bedwetting

Table 11-23Dry bed training with an alarm compared to no treatment for children with bedwetting - Clinical summary of findings

OutcomeDBT with an alarmNo treatmentRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights8/12 (66.7%)1/12 (8.3%)RR 8 (1.17 to 54.5)581 more per 1000 (from 14 more to 1000 more)LOW
Mean number of dry nights per week at the end of treatment1212-MD −4.17 (− 5.67 to − 2.67)MODERATE

11.2.1.12. Dry bed training with an alarm compared to alarms for children with bedwetting

Table 11-24Dry bed training with an alarm compared to an alarm for children with bedwetting - Clinical summary of findings

OutcomeDBT with an alarmAlarmRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights8/12 (66.7%)3/12 (25%)RR 2.67 (0.93 to 7.69)418 more per 1000 (from 17 fewer to 1000 more)LOW
Mean number of dry nights per week at the end of treatment1212-MD −2.42 (− 4.13 to − 0.71)LOW
Number of children who relapsed1/8 (12.5%)1/3 (33.3%)RR 0.38 (0.03 to 4.27)206 fewer per 1000 (from 323 fewer to 1000 more)LOW

11.2.2. Network Meta-Analysis

Dry bed training was amongst the interventions included in a network meta-analyses of interventions used for nocturnal enuresis. The summary of results of this analysis is presented in chapter 24 and a detailed description of the analysis is presented in appendix F. If studies did not meet the inclusion criteria of the network meta-analysis protocol as stated in appendix F they were not included in the network meta-analysis

11.2.3. Evidence statements

Studies include children with bedwetting and possible daytime symptoms

Dry bed training with an alarm versus dry bed training without an alarm
Bollard (1981) 93, Bollard (1982)95
  • Two studies showed children treated with dry bed training and an alarm were more likely to achieve 14 consecutive dry nights compared to children treated with dry bed training without an alarm. Relative risk 0.26, 95% CI 0.14, 0.48. Children in Bollard (1981)93 had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks; children in Bollard (1982)95 had a mean age of 8 years and 9 years and 4 months and had treatment for 8 weeks.
  • Two studies showed children treated with dry bed training and an alarm had 3.2 to 3.8 fewer wet nights per week at the end of treatment compared to children treated with dry bed training without an alarm. 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. Children in Bollard (1981)93 had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks; children in Bollard (1982)95 had a mean age of 8 years and 9 years and 4 months and had treatment for 8 weeks.
Dry bed training without an alarm versus no treatment
Bollard (1981)93, Bollard (1982)95
  • Two studies showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training (without an alarm) and children who had no treatment. Relative risk 2.9, 95% CI 0.75, 11.14. Children in Bollard (1981)93 had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks; children in Bollard (1982)95 had a mean age of 8 years and 9 years and 4 months and had treatment for 8 weeks.
  • Two studies showed children treated with dry bed training (without an alarm) had 0.6 to 2.05 fewer wet nights per week at the end of treatment compared to children who had no 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. Children in Bollard (1981) 93 had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks; children in Bollard (1982)95 had a mean age of 8 years and 9 years and 4 months and had treatment for 8 weeks.
  • Two studies showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training without an alarm and children treated with dry bed training and an alarm. Relative risk 1.45, 95% CI 0.59, 3.54. Children in Bollard (1981) 93 had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks; children in Bollard (1982)95 had a mean age of 8 years and 9 years and 4 months and had treatment for 8 weeks.
Bollard (1981) 93
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training (without an alarm) and children who had no treatment. Relative risk 0.5, 95% CI 0.17, 1.46. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training with an alarm with therapist at hospital were more likely to achieve 14 consecutive dry nights compared to children treated with dry bed training without an alarm. Relative risk 0.27, 95% CI 0.13, 0.55. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training and an alarm with therapist at hospital had 3.8 fewer wet nights per week at the end of treatment compared to children treated with dry bed training without an alarm. 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. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training without an alarm and children treated with dry bed training and an alarm with therapist at hospital. Relative risk 1.33, 95% CI 0.38, 4.72. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training with an alarm with parents as the therapist were more likely to achieve 14 consecutive dry nights compared to children treated with dry bed training without an alarm. Relative risk 0.27, 95% CI 0.13, 0.55. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training and an alarm with parent as therapist had 3.8 fewer wet nights per week at the end of treatment compared to children treated with dry bed training without an alarm. 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. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training without an alarm and children treated with dry bed training and an alarm with parent as therapist. Relative risk 2, 95% CI 0.5, 8. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with an alarm were more likely to achieve 14 consecutive dry nights compared to children treated with dry bed training (without an alarm). Relative risk 0.31, 95% CI 0.14, 0.69. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with an alarm had 3.2 fewer wet nights per week at the end of treatment compared to children treated with dry bed training (without an alarm). 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. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training (without an alarm) and children treated with an alarm. Relative risk 1.07, 95% CI 0.31, 3.71. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
Dry bed training with an alarm
Bollard (1981) 93, Bollard (1982) 95
  • Two studies showed children treated with dry bed training and an alarm were more likely to achieve 14 consecutive dry nights compared to children who had no treatment. Relative risk 9.34, 95% CI 3.2, 27.27. Children in Bollard (1981)93 had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks; children in Bollard (1982) 95 had a mean age of 8 years and 9 years and 4 months and had treatment for 8 weeks.
  • Two studies showed children treated with dry bed training and an alarm had 4.4 to 5.1 fewer wet nights per week at the end of treatment compared to children who had no 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. Children in Bollard (1981)93 had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks; children in Bollard (1982) 95 had a mean age of 8 years and 9 years and 4 months and had treatment for 8 weeks.
Bollard (1981) 93
  • One study showed children who had no treatment were more likely to relapse compared to children treated with dry bed training and an alarm. Relative risk 0.31, 95% CI 0.13, 0.76. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training and an alarm with the therapist at the hospital were more likely to achieve 14 consecutive dry nights compared to children who had no treatment. Relative risk 8.2, 95% CI 2.56, 26.3. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training and an alarm with the therapist at the hospital had 4.4 fewer wet nights per week at the end of treatment compared to children who had no 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. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children who had no treatment were more likely to relapse compared to children treated with dry bed training and an alarm with the therapist at the hospital. Relative risk 0.37, 95% CI 0.16, 0.84. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training and an alarm with the parents as the therapist were more likely to achieve 14 consecutive dry nights compared to children who had no treatment. Relative risk 8.2, 95% CI 2.56, 26.3. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training and an alarm with parents as the therapist had 4.4 fewer wet nights per week at the end of treatment compared to children who had no 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 Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children who had no treatment were more likely to relapse compared to children treated with dry bed training and an alarm with the parents as the therapist. Relative risk 0.26, 95% CI 0.1, 0.67. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training with an alarm with the therapist at home and children treated with dry bed training with an alarm and the therapist at hospital. Both groups had 20 out of 20 achieving 14 consecutive dry nights. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no difference in the number of wet nights per week at the end of treatment between children treated with dry bed training with an alarm with the therapist at home and children treated with dry bed training with an alarm and the therapist at hospital. Both groups had 0 wet nights. 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. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training with an alarm with the therapist at home and children treated with dry bed training with an alarm and the parents as the therapist. Both groups had 20 out of 20 achieving 14 consecutive dry nights. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no difference in the number of wet nights per week at the end of treatment between children treated with dry bed training with an alarm with the therapist at home and children treated with dry bed training with an alarm and the parents as the therapist. Both groups had 0 wet nights. 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. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training with an alarm with the therapist at home and children treated with dry bed training with an alarm and the parents as the therapist. Relative risk 1.25, 95% CI 0.39, 3.99. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training with an alarm with the therapist at hospital and children treated with dry bed training with an alarm and the parents as the therapist. Both groups had 20 out of 20 achieving 14 consecutive dry nights. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no difference in the number of wet nights per week at the end of treatment between children treated with dry bed training with an alarm with the therapist at hospital and children treated with dry bed training with an alarm and the parents as the therapist. Both groups had 0 wet nights. 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. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training with an alarm with the therapist at hospital and children treated with dry bed training with an alarm and the parents as the therapist. Relative risk 1.5, 95% CI 0.5, 4.52. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training and an alarm had 0.6 fewer wet nights per week at the end of treatment compared to children treated with an alarm. 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. Children in had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training and an alarm with the therapist at hospital and children treated with an alarm. Relative risk 1.24, 95% CI 0.98, 1.57. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training and an alarm with the therapist at hospital had 0.6 fewer wet nights per week at the end of treatment compared to children treated with an alarm. 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. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training and an alarm with the therapist at hospital and children treated with an alarm. Relative risk 0.8, 95% CI 0.32, 2.01. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training and an alarm with the parents as the therapist and children treated with an alarm. Relative risk 1.24, 95% CI 0.98, 1.57. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed children treated with dry bed training and an alarm with the parents as the therapist had 0.6 fewer wet nights per week at the end of treatment compared to children treated with an alarm. 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. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training and an alarm with the parents as the therapist and children treated with an alarm. Relative risk 0.53, 95% CI 0.18, 1.57. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training and an alarm, with the therapist at home and children treated with an alarm. Relative risk 0.67, 95% CI 0.25, 1.79. Children had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.
Bennett (1985) 85
  • 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 dry bed training and an alarm and children treated with an alarm. Mean difference 0.4, 95% CI −2.75, 3.55. Children had a mean age of 8.5 years and had treatment for 12 weeks.
  • One study showed there was no difference in the number of children who dropped out between children treated with dry bed training and an alarm and children treated with an alarm. Relative risk 1, 95% CI 0.53, 1.89. Children in had a mean age of 8.5 years and had treatment for 12 weeks.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training and an alarm and children treated with stop-start training. Relative risk 3, 95% CI 0.73, 12.27. Children had a mean age of 8.5 years and had treatment for 12 weeks.
  • One study showed children treated with dry bed training and an alarm had fewer wet nights per week at the end of treatment compared to children treated with stop-start training. Mean difference −1.85, 95% CI −5.4, 1.7. Children had a mean age of 8.5 years and had treatment for 12 weeks.
  • One study showed there was no statistically significant difference in the number of children who dropped out between children treated with dry bed training and an alarm and children treated with stop-start training. Relative risk 1.05, 95% CI 0.57, 1.93. Children had a mean age of 8.5 years and had treatment for 12 weeks.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training and an alarm and children who had star charts. Relative risk 10, 95% CI 0.63, 158.87. Children had a mean age of 8.5 years and had treatment for 12 weeks.
  • One study showed children treated with dry bed training and an alarm had fewer wet nights per week at the end of treatment compared to children who had star charts. Mean difference −3.75, 95% CI −6.79, −0.71. Children had a mean age of 8.5 years and had treatment for 12 weeks.
  • One study showed there was no statistically significant difference in the number of children who dropped out between children treated with dry bed training and an alarm and children who had star charts. Relative risk 2, 95% CI 0.68, 5.85. Children had a mean age of 8.5 years and had treatment for 12 weeks.
Bennett (1985) 85, Bollard (1981) 93
  • Two studies showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training and an alarm and children treated with an alarm. Relative risk 1.24, 95% CI 0.99, 1.55. Children in Bennett (1985) 85 had a mean age of 8.5 years and had treatment for 12 weeks; children in Bollard (1981) 93 had a mean age of 8.1 and 9.3 years and had treatment for 20 weeks.

Studies include children with bedwetting only

Dry bed training without an alarm
Keating (1983) 96
  • One study showed children who had no treatment had 0.7 fewer wet nights per week at the end of treatment compared to children treated with dry bed training (without an alarm) with training at hospital for parent and child. 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. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed children who had no treatment had 0.5 fewer wet nights per week at the end of treatment compared to children treated with dry bed training (without an alarm) with training at home for parent and child. 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. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training (without an alarm) with training at hospital for parent and child and children treated with dry bed training (without an alarm) with training at home for parent and child. Relative risk 1.7, 95% CI 0.95, 3.07. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed children treated with dry bed training (without an alarm) with training at home for parent and child had 0.2 fewer wet nights per week at the end of treatment compared to children treated with dry bed training (without an alarm) with training at hospital for parent and child. 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. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training (without an alarm) with training at hospital for parent and child and children treated with dry bed training (without an alarm) with training at home for parent and child. Relative risk 0.71, 95% CI 0.15, 3.5. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training (without an alarm) with training at hospital for parent and child and children treated with dry bed training (without an alarm) with training at hospital for parent only. Relative risk 1.15, 95% CI 0.79, 1.68. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed children treated with dry bed training (without an alarm) with training at hospital for parent only had 0.8 fewer wet nights per week at the end of treatment compared to children treated with dry bed training (without an alarm) with training at hospital for parent and child. 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. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training (without an alarm) with training at hospital for parent and child and children treated with dry bed training (without an alarm) with training at hospital for parent only. Relative risk 0.86, 95% CI 0.17, 4.37. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training (without an alarm) with training at home for parent and child and children treated with dry bed training (without an alarm) with training at hospital for parent only. Relative risk 0.65, 95% CI 0.34, 1.25. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed children treated with dry bed training (without an alarm) with training at hospital for parent only had 0.6 fewer wet nights per week at the end of treatment compared to children treated with dry bed training (without an alarm) with training at home for parent and child. 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. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training (without an alarm) with training at home for parent and child and children treated with dry bed training (without an alarm) with training at hospital for parent only. Relative risk 1.2, 95% CI 0.25, 5.71. Children had a mean age of 8.1 years and had treatment for 5 weeks.
  • One study showed children treated with dry bed training (without an alarm) with training at hospital for parent only had 0.1 fewer wet nights per week at the end of treatment compared to children who had no 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. Children had a mean age of 8.1 years and had treatment for 5 weeks.
Dry bed training with an alarm
Nawaz (2002) 94
  • One study showed children treated with dry bed training and an alarm were more likely to achieve 14 consecutive dry nights compared to children who had no treatment. Relative risk 8, 95% CI 1.17, 54.5. Children had a mean age of 9.93 years and had treatment for 16 weeks.
  • One study showed children treated with dry bed training and an alarm had fewer wet nights per week at the end of treatment compared to children who had no treatment. Mean difference −4.17, 95% CI −5.67 to −2.67. Children had a mean age of 9.93 years and had treatment for 16 weeks.
  • One study showed there was no statistically significant difference in the number of children who achieved 14 consecutive dry nights between children treated with dry bed training and an alarm and children treated with an alarm. Relative risk 2.67, 95% CI 0.93, 7.69. Children had a mean age of 9.93 years and had treatment for 16 weeks.
  • One study showed children treated with dry bed training and an alarm had fewer wet nights per week at the end of treatment compared to children treated with an alarm. Mean difference −2.42, 95% CI −4.13 to −0.71. Children had a mean age of 9.93 years and had treatment for 16 weeks.
  • One study showed there was no statistically significant difference in the number of children who relapsed between children treated with dry bed training and an alarm and children treated with an alarm. Relative risk 0.38, 95% CI 0.03, 4.27. Children had a mean age of 9.93 years and had treatment for 16 weeks.

NCGC network meta-analysis (see appendix F)

For children with bedwetting and possible daytime symptoms
  • The NCGC NMA showed there was no statistically significant difference in the number of children who achieved a full response between children treated with dry bed training without alarm and no treatment / placebo. Relative risk 2.497, 95% CI 0.754, 5.528. Children had an age range of 5 to 17 years and treatment for a minimum of 12 weeks.
  • The NCGC NMA showed there was a statistically significant difference in the number of children who achieved a full response between children treated with dry bed training with alarm and no treatment / placebo. Relative risk 8.919, 95% CI 7.736, 9.319. Children had an age range of 5 to 17 years and treatment for a minimum of 12 weeks.
For children with bedwetting only
  • The NCGC NMA showed there was a statistically significant difference in the number of children who achieved a full response between children treated with dry bed training with alarm and no treatment / placebo. Relative risk 8.116, 95% CI 2.538, 9.523. Children had an age range of 5 to 17 years and treatment for a minimum of 12 weeks.

For estimates of treatment effect relative to other active comparators, please see section 24.4 in chapter 24.

11.2.4. Evidence to recommendations

Relative values of different outcomes

The GDG identified a number of important relevant outcomes both in achieving dryness and in relapse: number of children and young people who achieved 14 consecutive dry nights, mean number of wet nights per week at the end of treatment and the number of children and young people who relapsed.

Trade off between clinical benefits and harms

No evidence was found on the harms of dry bed training or the comparators the evidence considered. However the GDG highlighted the punitive elements of dry bed training and amount of effort and disruption caused by the programme.

Economic considerations

No economic evidence was identified. The GDG experience with dry bed training was limited, but they understood it to involve much more intensive follow-up, including multiple phone calls each week. Based on this, and the fact that dry bed training with or without an alarm was not shown to be more effective than treatment with an alarm alone, the GDG concluded that the incremental benefit is very unlikely to be justified by the increased cost relative to alarm alone.

Quality of evidence

The clinical evidence identified was of small RCTs which gave wide confidence intervals in the outcomes of interest. The quality was low or very low for all outcomes.

Other considerations

The evidence indicated that DBT without an alarm is unlikely to be any more effective than no treatment. However the data was of very limited methodological quality and neither study which examined this comparison was adequately powered to show a difference.

The evidence showed that when comparing DBT without an alarm to DBT with an alarm for 14 consecutive dry nights, DBT with an alarm was better than DBT without an alarm. This was statistically significant and the associated confidence interval was narrow.

The GDG considered the comparison of DBT with an alarm to an alarm alone. In the population of children and young people with bedwetting and possible daytime symptoms, both studies had a small sample size. The associated confidence interval was narrow, with no statistically significant difference between DBT and an alarm and alarm alone. In the study of children and young people with bedwetting, Nawaz (2002) 94 showed that there was no statistically significant difference in children and young people having 14 consecutive dry nights, but did show that children and young people treated with dry bed training and an alarm were statistically dryer than children and young people treated with an alarm alone. The GDG regarded the evidence insufficient to consider DBT with an alarm over an alarm alone due to inconsistnet results and the magnitude of effort required for possible improvement in one outcome of interest.

The GDG considered that some components of DBT as described by Azrin (1974) 92 were unacceptably punitive, inappropriate and potentially psychologically damaging. The punitive elements were identified as: repetitive (20 times) positive practice, being told they were wet and informing visitors to the house they were trying to become dry, sleep loss even when dry (being woken to check if they were dry), and reprimanding as listed in Azrin (1974) 92. The GDG considered that some aspects of ‘positive practice” are part of using an alarm e.g. described in the study as a good practice if the alarm goes off and the child gets up and goes to the toilet. There is insufficient evidence that this should be practised as many times as described in Azrin (1974) 92. The GDG supported praising the child or young person for a dry night and for older children it was felt they should be involved with helping to clean (changing bedding and night clothes) the bed if there was a wet night. However as all dry bed training programmes included punitive elements it could not be recommended.

11.2.5. Recommendations

11.2.5.1.

Do not use dry bed training9 with or without an alarm for the treatment of bedwetting in children and young people [1.15.2].

Footnotes

9

A training programme that combines a number of different behavioural interventions that may include rewards, punishment training routines and waking routines and may be undertaken with or without an enuresis alarm.

Copyright © 2010, National Clinical Guideline Centre.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of the National Clinical Guideline Centre to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

Bookshelf ID: NBK62698

Views

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...