Children enuresis

The American Academy of Child and Adolescent Psychiatrists and the International Children s Continence Society (ICCS) have published practice guidelines for the assessment and treatment of pediatric enuresis.24,25... 

The etiology of enuresis is poorly understood, but there is a clear genetic link. The incidence in children from families in whom there are no members with enuresis, where one parent had enuresis as a child, and where both parents had enuresis as children are 14%, 44%, and 77%, respectively. Loci for enuresis have been located on chromosomes 12,13, and 22. Sleep disorders are not considered major contributors with the exception of sleep apnea. Enuresis occurs in all sleep stages in proportion to the time spent in each stage. However, a small proportion of individuals are not aroused from sleep by bladder distention and have uninhibited bladder contractions preceding enuresis. 

Proper assessment of the child or adolescent with enuresis should explore every aspect of urinary incontinence, especially the genitourinary and nervous systems. The minimum assessment should include24 25 ... 

Interview of child and parent(s), being sensitive to the emotional consequences of the enuresis... 

Fritz G, Rockney R, Bernet W, et al. Practice parameter for the assessment and treatment of children and adolescents with enuresis. J Am Acad Child Adolesc Psychiatry 2004 43 1540-1550. 

Lavigne and colleagues (1996), using categorical approaches with a community sample of 3860 preschoolers aged 2-5 years in a primary care pediatric sample, found the five most frequent axis I diagnoses (DSM IITR) to be ODD (17%), ADHD (2%), avoidant disorder (0.7%), overanxious disorder (0.7%), simple phobia (0.6%), and functional enuresis (0.7%). Five percent of children also met criteria for parent-child relational... 

Historically, interventions for enuresis, as well as en-copresis, have often reflected intolerance, seeming harshness, and/or a poor understanding of child development (Glicklich, 1951). The vast majority of children over the age of 6 or 7 years as well as their parents will request treatment. Very occasional parents or children may be interested in intermittent treatment—for example, treatment may be desirable for overnight sleep-overs or for camping. Trials of interventions will be necessary to determine what approaches will work in such children and how much time is required for the intervention to be effective. 

Forsythe, W.I. and Redmond, A. (1974) Enuresis and spontaneous cure rate. Study of 1129 enuretis. Arch Dis Child 49 259-263. 

Reiner, W.G. (1995) Enuresis in child psychiatric practice. In Riddle, M.A., ed Child and Adolescent Psychiatric Clinics of North America, Pediatric Psychopharmacology II, Vol. 4. Philidelphia W.B. Saunders, pp. 453 60. 

In 1995, Bramble published a study on the prescription frequency of antidepressants by British child psychiatrists (Bramble, 1995). A brief postal questionnaire was circulated to 350 members of the British Royal College of Psychiatrists, Child and Adolescent Psychiatry Specialist Sections. There was a 71% response rate, and 85% of the 238 respondents had employed antidepressants, the most popular of these being amitriptyline and imipramine. Nearly one-third of the psychiatrists at that time used neuroagents occasionally, and the SSRIs were used only very rarely. The antidepressant medication was used for a wide range of child and adolescent disorders beyond those of depression and nocturnal enuresis. Approximately 20% of the prescriptions were given for ADHD (hyperkinetic disorder), conduct disorder, and a few cases of autistic disorder. Clomipramine was apparently given for OCD. On the basis of these 1994 data. Bramble concluded that British child psychiatrists tend to use antidepressant medication far less often than American psychiatrists. 

Harari MD, Moulden A. Nocturnal enuresis what is happening J Paediatr Child Health 2000 36 78-81. 

Spurious hyperthyroidism occurred in a child taking thyroid hormone and imipramine for enuresis (89). The ability of thyroid hormone to increase receptor sensitivity to catecholamines has long been known, and has been used to enhance the clinical response in some refractory patients, especially women. 

Cerebral infarction has also been reported in association with the use of desmopressin in children (31,32). One of these cases involved a 7-month-old child with congenital nephrotic syndrome who developed a cerebral infarction after surgery (31). One child developed cerebral ischemia after Varicella infection and desmopressin for enuresis (32). 

Brodzikowska-Pytel A, Giembicki J. Hyponatremia as a complication of nocturnal enuresis treatment with desmopressin in a child. Pediatr Pol 1999 74 79-83. 

To provide relief from symptoms until the child matures, for example, in enuresis. 

This is quite a common condition affecting some 7% of 7 year olds who continue to wet the bed at least once a week. The cause of nocturnal enuresis is complex and beyond the scope of this volume. It is evident, however, that various treatments are available including retention control, dry-bed training, enuretic night alarms and waking the child to urinate... 

Since the adverse effects of clozapine may be more common in children than adults, perhaps reflecting developmental pharmacokinetic differences, clozapine and its metabolites, norclozapine and clozapine-N-oxide, have been studied in six youths aged 9-16 years, with childhood onset schizophrenia (222). Dose-normalized concentrations of clozapine did not vary with age and were similar to reported adult values. Clinical improvement in five patients correlated with serum clozapine concentrations, and clinical response and total number of common adverse effects (sialorrhea, n = 5 tachycardia, n = 4 sedation, n = 1 enuresis, n = 1) correlated with norclozapine concentrations. One child had a reduced neutrophil count (1.1 x 109/1) and another child had increased hepatic transaminases. 

The essential feature of enuresis is repeated involuntary or intentional voiding of urine by day or night that is not caused by a general medical condition (Table 61-7). Medical causes of inappropriate voiding (e.g., diabetes mellitus, diabetes insipidus, seizure disorders, or urinary tract infections) should be ruled out. Enuresis may be primary or secondary. Primary enuresis, the most common type, is diagnosed if the child has never established urinary continence. Secondary enuresis follows an established period (3 to 6 months) of urinary continence. 

At age 5, prevalence is 15% to 20% at age 10 it is 5% for adolescents it is 1%, and 0.5% of adults wet the bed at least once a month. There is a 15% annual rate of spontaneous remission. The ratio of males to females with enuresis is 3 2. Factors that predispose a child to either type of enuresis include a positive family history. 

Donoghue MB, Latimer E, Pillsbury HL, Hertzog JH. Hyponatremic seizure in a child using desmopressin for nocturnal enuresis. Arch Pe-diatr Adolesc Med 1998 152 290-292. 

Joseph B. Cramer, also a psychoanalyst and a professor of child psychiatry at the Albert Einstein College of Medicine in New York, writing in the authoritative American Handbook of Psychiatry (1959), distinguishes between two types of childhood neurosis — types A and B. Type A, he writes, may be thought of as a pure type.. . . Symptomatically, this type is characterized mainly by fears and phobias. Masturbation, nightmares, and enuresis are other frequent symptoms. Masturbation is here considered a symptom of a mental illness of children. 

It is accepted that evaluation of the child with wetting with a history of infection is indicated because some 30%-50% of children who present with UTI will have VUR demonstrated on voiding cystourethrography (VCU). However, no clear guidelines have been established for the evaluation of wetting children with sterile urine demonstrated at the time of admission or without a history of UTI. In a study on children with enuresis, Sujka et al. (1991) demonstrated that no one symptom or combination of symptoms segregated these patients likely to have VUR 16% of their 83 patients with sterile urine and no history of infection had VUR out of those, 16 showed reflux nephropathy as well. They concluded that one of six children who present with enuresis and sterile urine will have VUR. 

---