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
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| Outcome | Random waking | Placebo | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 1/15 (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 weeks | 15 | 17 | - | MD −0.99 (−2.54 to 0.56) | VERY LOW |
| Mean number of wet nights per week at the end of treatment (no SD) | 8 | 8 | - | not pooled | VERY 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
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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
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| Outcome | Random waking | Enuresis alarm | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 1/15 (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 weeks | 15 | 15 | - | MD 0.33 (−1.23 to 1.89) | VERY LOW |
| Mean number of wet nights per week at the end of treatment (no SD) | 8 | 8 | - | not pooled | VERY 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
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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
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| Outcome | Random waking and star chart | No treatment | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 2/14 (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 nights | 10 | 10 | - | not pooled | VERY 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
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| Outcome | Waking and star chart | Alarm | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 2/14 (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 weeks | 10 | 10 | - | Not pooled | VERY 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
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| Outcome | Waking | Imipramine | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 24/36 (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 months | 2/24 (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
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| Outcome | Waking | Motivational therapy | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 24/36 (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 months | 2/24 (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
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| Outcome | Waking and fluid restriction | Imipramine | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 4/20 (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
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| Outcome | Waking and fluid restriction | Waking and imipramine | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 4/20 (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
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| Outcome | Alarm clock set before child wets | Alarm clock set 2–3 hours after child goes to bed | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Dry for 14 consecutive nights in first month | 54/70 (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 months | 8/54 (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 months | 13/54 (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 |
8.2.3. 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.
