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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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7Fluid and diet restriction for the management of bedwetting

7.1. Introduction

The experience of health professionals is that parents or carers may consider the restriction of fluids a possible management strategy when trying to help a child with bedwetting. Restriction of fluids particularly before bed will have been tried by many families before they seek professional help. Children with bedwetting may also have daytime urinary symptoms and fluid restriction during the day may be used by children and young people themselves to manage symptoms of frequency and urgency when out of the home. Optimum hydration is essential for general health of children and children who are restricting fluids during the day may in fact take excessive fluid before bedtime to balance their relative dehydration during the day. The presence or absence of toilet facilities and drinks in schools, and the condition of facilities available may also affect toileting behaviour and drinking habits

The hypothesis that dietary restrictions may be beneficial to children with bedwetting is based on the idea that food allergies may provoke bladder instability.

7.2. What is the clinical and cost effectiveness of fluid and/or diet restriction for children and young people under 19 years who have bedwetting?

7.3. Fluid restriction

7.3.1. Evidence review

7.3.1.1. Fluid restriction combined with parents avoiding punishment of children and waking and placebo compared to imipramine

One randomised controlled trial Bhatia (1990) 78 compared fluid restriction combined with parents avoiding punishment of children and waking and placebo to imipramine. The study population were children who had bedwetting and possible daytime wetting. 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 7-1Fluid restriction and avoiding punishment with placebo compared to imipramine - Clinical summary of findings

OutcomeFluid 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

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

One randomised controlled trial Bhatia (1990) 78 compared fluid restriction combined with parents avoiding punishment of children and waking and placebo to fluid restriction combined with parents avoiding punishment of children and waking and imipramine. The study population and methods are as described above.

Table 7-2Fluid restriction and avoiding punishment with placebo compared to fluid restriction and avoiding punishment with imipramine - Clinical summary of findings

OutcomeFluid restrictionFluid restriction 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

7.3.2. Evidence statements

Studies which include children with bedwetting and possible daytime symptoms

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 fluid restriction combined with avoiding punishment and waking 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.
  • One study showed that children treated with fluid restriction combined with avoiding punishment and waking and imipramine were more likely to achieve 14 consecutive dry nights compared to children treated with fluid restriction combined with avoiding punishment and waking and placebo. Relative risk 0.22 95% CI 0.09, 0.54. Children had an age range of 4 to 12 years and treatment was for 6 weeks.

7.3.3. Evidence to recommendations

Relative values of different outcomes

The GDG considered that complete dryness was the outcome most wanted by children, young people and their families and carers.

Trade off between clinical benefit and harms

The GDG felt that restriction of fluids was likely to be unhealthy for children and young people generally and may be counterproductive in helping children and young people recognise the sensation of full bladder and developing control.

Economic considerations

No economic evidence regarding the cost-effectiveness of fluid and/or dietary restriction was available, however the GDG felt that encouraging adequate fluid intake (and thus discouraging fluid restriction) should be one element of advice offered to all patients seeking initial treatment for bedwetting. Adequate fluid intake during the day may naturally reduce a child or young person’s intake just before bed and could therefore reduce their burden of bedwetting without requiring further, costlier treatment.

Quality of evidence (this includes clinical and economic)

No evidence for fluid restriction was found. One RCT which compared fluid restriction, waking and lack of punitive approach in evenings with imipramine was found. This evidence was considered very low quality.

Other considerations

The evidence found no benefit from restricting fluid intake. The consensus of the GDG was that it is important to actively raise the issue of fluid intake with children and young people and families and carers to counter any misconceptions about fluid restriction. The presence or absence of daytime symptoms may also not be apparent if children, young people or families or carers are restricting fluids. Ensuring adequate intake during the day also may prevent children and young people from needing to drink larger amounts nearer bedtime.

The GDG considered it important to provide children, young people and families and carers with a guide to desirable fluid intake. There is no single recommended figure for fluid intake in children and young people as fluid requirements are influenced by numerous factors including size, dietary intake, activity levels and ambient temperature. The human body can regulate its water content over a wide range of fluid intakes and prevent both dehydration and over hydration. Water intake comes from both drinks and food intake and both these values can vary enormously between individuals.

The GDG considered the information provided by government bodies and experts and the most comprehensive source of information on water requirements is:

Dietary reference intakes for water, potassium, sodium, chloride, and sulphate. Panel on Dietary Reference Intakes for Electrolytes and Water Standing Committee on the Scientific Evaluation of Dietary Reference Intakes Food and Nutrition Board. Institute of Medicine (U.S). 2004. 79

The reference values provided in this document describe “Adequate Intake” as the median intake of total water in different age bands documented in the U.S Third National Health & Nutrition Survey 1988–1994. These values were chosen because of data demonstrating that hydration was maintained over a wide range of fluid intakes varying from the 10 percentile to the 90th percentile of fluid intake. The document is very clear that it is not possible to provide a recommended fluid intake.

In applying these figures to children and young people with bedwetting in the UK, the GDG considered that the extremes of fluid intake were undesirable in that insufficient fluid intake may inhibit the development of normal toileting patterns and mask the symptoms of bladder disorders whilst excessive fluid intake, especially before bedtime, may provoke wetting. We have therefore given guidance on the ranges of total intake from drinks (this is easier to measure and hence influence than including fluid associated with non-drinks intake) and have taken this as the inter-quartile range of fluid intakes (rounded to nearest 100 ml). This then provides a guideline minimum and maximum fluid intake although these figures need to be considered in relation to each individual’s circumstances and health status and adapted accordingly.

The GDG noted there was no evidence about the effect of fizzy drinks. The GDG were concerned that many children and young people might be drinking caffeine containing drinks (which are diuretic) and that these might not be helpful in general or specifically for urinary symptoms and felt this was a good opportunity to reiterate these messages.

The GDG wished to give children, young people and families and carers some indication of normal toileting frequency and consensus was to use the standardized International Children’s Continence Society (ICCS) criteria. The ICCS suggest <3 times per day is abnormal and >8 itimes per day is abnormal. These figures were judged by the GDG to be extremes indicating abnormality and a midway figure of 4-7 was more reasonable range when recommending to parents and carers.

It was the experience of the GDG that children, including children and young people with behavioural or attention difficulties, may be managed by parents and carers in pull ups/nappies and that a trial without this should be considered if they are toilet trained by day.

7.3.4. Recommendations

7.3.4.1.

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:

[1.5.1]

7.3.4.2.

Advise the child or young person and their parents or carers that the consumption of caffeine-based drinks should be avoided in children and young people with bedwetting. [1.5.2]

7.3.4.3.

Advise the child or young person of the importance of using the toilet at regular intervals throughout the day.[1.5.4]

7.3.4.4.

Advise parents or carers to encourage the child or young person to use the toilet to pass urine at regular intervals during the day (typically between four and seven times in total). This should be continued alongside the chosen treatment for bedwetting.[1.5.5]

7.3.4.5.

Address excessive or insufficient fluid intake or abnormal toileting patterns before starting other treatment for bedwetting in children and young people.[1.5.6]

7.3.4.6.

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.[1.5.7]

7.4. Dietary restriction

7.4.1.1. Diet restriction compared to imipramine

One randomised controlled trial, McKendry (1975) 80 compared diet restriction to imipramine. Diet restriction was described as a diet containing no milk, butter, cheese, eggs, citrus fruit juices, tomato, cocoa or chocolate. Children were allowed apple juice, ginger ale and water as fluid substitutes. The study population was children who had bedwetting and possible daytime wetting.

Table 7-3Diet restriction compared to Imipramine - Clinical summary of findings

OutcomeDiet restrictionImipramineRelative risk (95% CI)Absolute effectQuality
Number of children who became completely dry1/64 (1.6%)13/62 (21%)RR 0.07 (0.01 to 0.55)195 fewer per 1,000LOW
Number of children who had a greater than 50% improvement in the number of dry nights34/64 (53.1%)28/62 (45.2%)RR 1.18 (0.82 to 1.68)81 more per 1,000VERY LOW
Number of children completely dry at follow up1/1 (100%)19/34 (55.9%)RR 1.35 (0.57 to 3.16)195 more per 1,000VERY LOW
Number of children who had a greater than 50% improvement in the number of dry nights at follow up0/1 (0%)8/34 (23.5%)RR 1.03 (0.09 to 12.18)7 more per 1,000VERY LOW
Number of children who dropped out of the trial9/73 (12.3%)12/74 (16.2%)RR 0.76 (0.34 to 1.69)38 fewer per 1,000VERY LOW

7.4.2. Evidence statements

Studies which include children with bedwetting and possible daytime symptoms

McKendry (1975) 80
  • One study showed that children treated with imipramine were more likely to become completely dry at the end of treatment compared to children treated with diet restriction. Relative risk 0.07, 95% CI 0.01, 0.55. Children had a mean age of 9 years and treatment was for 2 months.
  • One study showed there was no statistically significant difference in the number of children who achieved greater than 50% improvement in the number of dry nights at the end of treatment between children treated with diet restriction and children treated with imipramine. Relative risk 1.18, 95% CI 0.82, 1.68. Children had a mean age of 9 years and treatment was for 2 months.
  • One study showed there was no statistically significant difference in the number of children who were completely dry at follow up between children treated with diet restriction and children treated with imipramine. Relative risk 1.35, 95% CI 0.57, 3.16. Children had a mean age of 9 years and treatment was for 2 months.
  • One study showed there was no statistically significant difference in the number of children who achieved greater than 50% improvement in the number of dry nights at follow up between children treated with diet restriction and children treated with imipramine. Relative risk 1.03, 95% CI 0.09, 12.18. Children had a mean age of 9 years and treatment was for 2 months.
  • One study showed there was no statistically significant difference in the number of children who dropped out between children treated with diet restriction and children treated with imipramine. Relative risk 0.76, 95% CI 0.34, 1.69. Children had a mean age of 9 years and treatment was for 2 months.

7.4.3. Evidence to recommendations

Relative values of different outcomes

The GDG considered the outcome of complete dryness was the outcome wanted by children and families.

Trade off between clinical benefit and harms

No evidence of harms.

Economic considerations

No economic evidence was identified.

Quality of evidence (this includes clinical and economic)

The quality of evidence for outcomes was low or very low..

Other considerations

The GDG wished to explore this area as they were aware of families who asked about associations between dietary intolerance and bedwetting. No evidence was found that routinely restricting diet is effective in improving bedwetting in the short or long term. The GDG felt it was important to ensure the child was eating healthily.

7.4.4. Recommendations

7.4.4.1.

Advise the child or young person and their parents or carers to eat a healthy diet and not to restrict diet as a form of treatment . [1.5.3]

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.

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Bookshelf ID: NBK62715

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