Swiftwater, Pennsylvania, November 27, 2001 -- Recommendations for patient evaluation and treatment of primary nocturnal enuresis were recently published in Infectious Diseases in Children. "Taking a Closer Look at Primary Nocturnal Enuresis," sponsored by Aventis Pasteur and disseminated as a monograph in the publication’s October 17 issue, provides an in-depth discussion among leading pediatricians, pediatric nephrologists and pediatric urologists on the management of enuresis and ways to work with parents to determine effective treatment strategies.
"The assembly of this panel, with its varied and extensive background, represents a very important step to help bring this under-diagnosed condition to the forefront of the pediatrician's mind and prompt more proactive screening and treatment," commented Mark R. Zaontz, MD, Head, Section of Pediatric Urology, the Children's Regional Hospital at Cooper Health System; Professor of Surgery and Pediatrics at Robert Wood Johnson Medical School, Camden, New Jersey and a member of the panel.
In the United States alone, an estimated 5 to 7 million children 6 years of age or older suffer from primary nocturnal enuresis. Nocturnal enuresis, more commonly referred to as bed-wetting, is a source of tremendous frustration for the family and may cause embarrassment for the child. This is further exacerbated when one considers the misconceptions and stigmatism that persist around this condition.
According to the panel, if a child wets the bed beyond the ages of 5 or 6, there is an 85% chance he will wet the bed a year later. Panelists stress that the multi-factorial nature of this under-diagnosed condition, the lack of consensus regarding its treatment and management and the fact that school-aged children are less visible to the pediatrician, further complicates the issue of bedwetting among the nation's pediatricians and specialists. The etiology of enuresis involves the interaction of many factors including disturbances in sleep arousal, overproduction of urine at night, and small nocturnal bladder capacity.
"There is no doubt that bedwetting can impact the entire family dynamic," said Alan R. Greene, MD, Practicing Pediatrician, Assistant Clinical Professor at Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, another member of the panel. According to the panel, it is important that health care providers communicate to parents that children do not wet the bed on purpose. Rather, primary nocturnal enuresis is an involuntary act that is neither behaviorally nor emotionally grounded and can be treated.
Treatment Strategies/Options
The panel identified and discussed a variety of pharmacologic and nonpharmacologic management options available to treat enuresis. First-line in nonpharmacologic approaches is the conditioning alarm, a moisture sensor attaches to the lining of the child's underwear and the alarm sounds as soon as wetness is detected. A drawback to the alarm is that it requires the commitment of the parent to wake up and train the child to go to the bathroom to complete voiding.
A preferred pharmacologic option highlighted by panelists is desmopressin tablets, a synthetic version of vasopressin, an antidiuretic hormone (ADH), which reduces the amount of urine produced at night. DDAVPÒ (desmopressin acetate) is discreet, presents a low side effect profile and provides rapid onset of action. In controlled clinical trials, some patients taking DDAVP tablets experienced headache (4% DDAVP, 3% sugar pill). It is important to restrict nighttime beverages to avoid overloading fluids; which can lead to significant health consequences. According to the panel, DDAVP, which is marketed by Aventis Pasteur, can be used for both short-term and long-term treatment strategies. The latter approach may be particularly beneficial in older children to bridge them to an age in which they can achieve dryness on their own.
Another pharmacological option is imipramine, a tricyclic antidepressant. However, imipramine data show a high relapse rate. Its adverse reactions include increased irritability, disturbances in sleep and loss of appetite. Among other treatment options, the panel also highlighted that in some children, the combination of desmopressin tablets and the conditioning alarm may yield positive results. "Pediatricians can safely and effectively manage most children with uncomplicated primary nocturnal enuresis," said Dr. Greene. "We need to reinforce that long-term treatment options are available, which we should be especially considering when managing enuresis in older children for whom bedwetting has a major impact."
Panelists also emphasize the importance of evaluating the emotional well being of the bedwetting child, explaining that the onset of enuresis occurs during a pivotal developmental stage when the child desires increased independence and control of their lives, including control of basic bodily functions. If untreated, enuresis may affect a child's self-esteem and lead to a general reluctance to engage in and enjoy typical childhood activities such as camps, sleepovers and family/friend visits.
Panel Members
Dr. Philip Brunell, chief medical editor of Infectious Diseases in Children moderated the session.
Panelists include:
Frank R. Cerniglia, Jr, MD, Director of Pediatric Urology, Urologic Institute of New Orleans; Clinical Assistant Professor of Urology, Tulane University School of Medicine, New Orleans, Louisiana
Alan R. Greene, MD, Practicing Pediatrician, Danville, California; Assistant Clinical Professor, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Stanofrd, California
Ronald J. Hogg, MD, Director of Pediatric Nephrology, North Texas Hospital for Children, Dallas, Texas; Director, Southwest Pediatric Nephrology Study Group
Kenneth Miller, MD, Director, Pediatric Nephrology, Hope Children's Hospital, Oak Lawn, Illinois
W. Lane Robson, MD, Chief of Pediatrics, Memorial Hospital of Rhode Island; Professor of Pediatrics, Brown University, Rhode Island
Mark R. Zaontz, MD, Head, Section of Pediatric Urology, the Children's Regional Hospital at Cooper Health System; Professor of Surgery and Pediatrics at Robert Wood Johnson Medical School, Camden, New Jersey
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