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

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

NICE Clinical Guidelines - National Clinical Guideline Centre (UK)

Version: 2010

Treatment for children who do not respond to initial treatment with desmopressin and / or enuresis alarms for the management of bedwetting

This section presents the evidence outlining which treatment should be considered when children have not responded to first line treatment. The question for the health care professional and patient is – should I continue with the treatment I have tried already or should I try an alternative treatment and if so what treatment should I use?

Desmopressin and the management of bedwetting

What is it? Desmopressin is a synthetic analogue of the naturally occurring anti diuretic hormone (ADH).

Key priorities for implementation

Inform children and young people with bedwetting and their parents or carers that bedwetting is not the child or young person’s fault and that punitive measures, should not be used in the management of bedwetting. [1.1.1]

Dose escalation in the management of bedwetting

This section presents the evidence outlining the effectiveness of dose escalation in drug treatment of bedwetting. The important question for the health care professional and patient is whether it is useful to increase the dose of medication if the patient has not responded to the initial dose. This review considers the cost and clinical effectiveness of increasing the dose of a drug if the patient has not responded to an initial lower dose.

Treatment for children who have recurrence of bedwetting after previous successful treatment for bedwetting

The evidence review searched for studies which considered the clinical and cost effectiveness of treating relapses in children and young people with nocturnal enuresis who had previously been successfully treated. The evidence review did not identify any studies which considered the clinical effectiveness of treating recurrence in children who have previously responded to treatment. The recommendations are informed by the clinical experience of the GDG and the health economic modelling.

Anticholinergic medication for the management of Nocturnal Enuresis

What are they? These are a group of medicines that have an effect on the bladder. Oxybutynin is the medicine that is commonly used in children. Anticholinergic medicine reduces the number of involuntary bladder contractions and also has a relaxant effect on the smooth muscle of the bladder.

Network Meta-Analysis

Some pairs of alternative strategies have not been directly compared in a randomised controlled trial for example, dry bed training with alarm vs desmopressin.

Guidance

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

Enuresis Alarms in the management of bedwetting

An enuresis alarm is a device that is activated by getting wet. According to Mowrer (1938) , the first enuresis alarms were bed-based, with the child sleeping on a pad or mat containing an electrical circuit. A bell would then ring as a result of the urine contacting the electrical circuit. There are several types of enuresis alarms available: pad-and-bell alarms where the sensor pad is positioned under a draw sheet beneath the child in the bed; body-worn alarms where the tiny sensor is attached to the child’s pants e.g. between 2 pairs of tightly fitting underpants and the alarm is worn on the pyjama top; and vibrating alarms.

Tricyclic medication and the management of bedwetting

What are they? The tricyclic drugs have been used for treating bedwetting for many years. The need for close follow up and the potential for serious cardiac consequences in overdose mean they are considered for use in specialist centres only.

Patient Choice in children and young people with bedwetting

Management of bedwetting can require significant effort from child and family and offering choice and involvement in decisions may help engagement with treatments. The GDG were interested in whether there was any evidence particular to nocturnal enuresis in the literature.

Assessment for children with Bedwetting

This section presents the evidence outlining different assessment methods which may be considered for use in the assessment of children with bedwetting. The main aims of conducting an assessment are to establish the diagnosis; find out what the parent/child wants, to rule out or identify underlying causes and to indentify the factors that will influence choice of management strategy.

Bladder training and retention control training for the management of bedwetting

Although the terms bladder training and retention control training are used by healthcare professionals working in the area of childhood wetting there is currently no universally agreed definition of bladder training or retention control training and the evidence in this area was difficult to evaluate. Both terms seem to describe the aim of treatment rather than a specific programme. Highman (1953) and Muellner (1960) introduced the idea that bladder training, understood as drinking and practice in holding urine, might be a useful treatment to improve enuresis. Retention control training most commonly means that children are encouraged to hold voiding as long as possible once a day, as a means of expanding their bladder capacity. In the evidence found for this area, both strategies are mixed with other managementtechniques but the components are poorly described and are combined in different ways.

Alternative treatments for the management of bedwetting

Parents and carers are often reluctant to use pharmacological agents in children. Many children do not respond to alarms and desmopressin and parents and carers are interested in using alternative treatments for the management of bedwetting. The GDG considered it an important topic as parents and carers regularly ask for advice ask for advice and if useful it may be appropriate to offer these treatments.

Methods

The Nocturnal Enuresis guideline was commissioned by NICE and developed in accordance with the guideline development process set out by ‘The guidelines manual’ . The versions of the guideline manual used for each stage of guideline development are detailed in table 3-1.

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