- Bedwetting affects approximately 5 million children in the United States.
- Simple bedwetting interventions such as waking a child and fluid restriction work better than no intervention at all.
- Alarm training and medication are more effective than simple interventions.
Bedwetting affects up to 20 percent of five year olds—the age when most children have learned bladder control—and can result in an array of stressful and embarrassing social, emotional and psychological problems.
For concerned parents who want to help, simple treatments are better than nothing at all, but aren’t as effective as more advanced alarm therapy or drug therapy, according to a new meta-analysis in The Cochrane Library.
“As many as two-thirds of children with bedwetting never seek help,” said lead author Patrina Caldwell, B.Med., F.R.A.C.P., Ph.D., a pediatrician at The Children’s Hospital at Westmead and senior lecturer at The University of Sydney in Australia.
Bedwetting, or nocturnal enuresis, is defined as involuntary urine loss at night with no apparent underlying medical cause. Although the condition usually resolves on its own, Caldwell knows well the emotional effects of untreated enuresis in children and adolescents who sought incontinence services at her hospital, where the waiting list time is currently 18 months.
“There’s a huge need here and elsewhere,” Caldwell said. “This condition is easily treatable and children—along with up to two percent of adults—don’t have to suffer. Part of the stigma of bedwetting is that people do suffer in silence instead of getting help.”
For their analysis, the research team ultimately identified 16 appropriate trials involving 1,643 children that tested the effects of simple behavioral interventions to treat bedwetting.
The analysis compared simple behavioral interventions, such as rewarding “dry nights” by using methods like star charts, and other interventions like lifting and waking kids to use the bathroom, fluid restriction and bladder training versus no active treatment. Such simple interventions require minimal professional involvement and have no side effects, safety issues or costs.
The researchers also compared simple behavioral interventions against one another and with more complex interventions such as alarm training. “No one single simple behavioral intervention was better than another—they were all pretty similar,” Caldwell said. “However, alarm training was clearly better than the simple behavioral strategies such as bladder training.”
Finally, they compared simple behavioral interventions versus drug treatment alone, including placebo drugs or drug treatment combined with any other intervention.
The most effective intervention is a bed-wetting alarm which detects initial drops of urine in the child’s undergarments and then sounds off, the authors noted. The second most effective intervention is typically the oral medication desmopressin or DDAVP.
The authors noted that, “The findings from this review should be interpreted cautiously due to the poor quality and small sizes of the trials.”
“I agree with the authors about the limitations of the studies they reviewed—that it’s challenging enough to do bedwetting research with large groups of children in studies, even more difficult when you have small groups that don’t have good controls,” said Howard J. Bennett, M.D., a clinical professor of pediatrics at the George Washington University School of Medicine and in private practice since 1991.
The often hidden problem affects approximately 5 million children in the United States, he said, and may stay under the radar during the doctor-parent-child conversation. “Other research shows that while 82 percent of parents want health care providers to discuss bedwetting, most parents aren’t comfortable bringing it up. Also, 68 percent of parents said their children’s doctor has never asked about bedwetting at routine visits.”
Regarding the intervention of lifting, Bennett said, “There’s not much downside, but it’s more of a temporizing measure than an actual treatment for bedwetting, and there is some discussion that lifting may actually prolong bedwetting. As to restricting fluid intake, children still tend to wet in the majority of cases. Also, if a parent restricts fluids after dinner, a child may misinterpret this as a punishment, especially if he's thirsty.”
“The simple treatments do work, but parents should know more effective treatments are available,” said Caldwell.
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The Cochrane Library (http://www.thecochranelibrary.com) contains high quality health care information, including systematic reviews from The Cochrane Collaboration. These reviews bring together research on the effects of health care and are considered the gold standard for determining the relative effectiveness of different interventions.
Full citation: Caldwell PHY, Nankivell G, Sureshkumar P. Simple behavioural interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews 2013, Issue 7. Art.No.: CD003637. DOI: 10.1002/14651858.CD003637.pub3