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obstructed airways makes the child paradoxically difficult to rouse from sleep. • Inefficient breathing causes an increased negative intrathoracic pressure, which in turn causes an increase in atrial natriuretic polypeptide secretion, which leads to increased urine production. Initial management strategies3 Enuresis is not a trivial condition as it affects a child in many ways. These include:3 • Poor self esteem. • Limited socialisation, eg, school camps, social outings with peers, Scouts/Girl Guides. • Increased stress on the family unit. • Chronically disturbed sleep, which can affect: » Daytime drowsiness. » Daytime concentration, especially in school. » Daytime behaviour. » Executive functioning. • Developing into a teenager and then an adult with enuresis as a medical condition can lead to many issues, particularly in forming relationships. Children with severe behavioural issues or psychiatric conditions, eg, attention deficit hyperactivity disorder (ADHD), may have bedwetting as a comorbidity. It’s important that both conditions are treated in parallel due to the close relationship between them.3 The family and the child may have tried many strategies and remedies before presenting for an expert opinion. It’s important that the level of evidence for strategies are weighed against how effective that strategy was for the child. As the child grows older, they must be an active participant in the management of their condition. Their wishes need to be listened to and discussed.3 Constipation and detrusor (bladder smooth muscle) overactivity are strongly linked in children with bedwetting issues.3 The child may have bladder dysfunction, faecal impaction, and sometimes gastrointestinal symptoms.3 Investigation and treatment of constipation is one of the cornerstones of enuresis management. It’s unusual to find bacteriuria as a cause of bedwetting in children, but they should be investigated for urinary tract infection to rule out this possible contributing cause.3 Asymptomatic bacteriuria, common in children with bladder dysfunction, should not be treated with antibiotics. Antibiotics are not required if the child has no symptoms or has recent onset of daytime Figure 2. Initial management guidelines for enuresis in children (NICE Guidelines 2020)4. Child or young person who wets the bed CPD ACTIVITY 57 Children under 5 Children and young people aged 5 and over Fluids and diet Lifting and waking Reward options Using the toilet during the day Training programs bladder symptoms.3 Figure 2 outlines the initial management strategies from the 2020 UK NICE Guidelines.4 The treatment plan has many steps. Treatments that may have been unsuccessful in the younger years may be retried as the child becomes older and has a better understanding of the treatment plan.3 Management strategies for enuresis in children under five years4,6 • Support parents/carers to trial daytime toilet training. • Suggest bed protection measures. • Suggest a trial of one to two nights a week without nappies or pull-ups once the child has been toilet trained and dry during the day for six months. • Lift and carry the child to the toilet if they wake at night. • Ensure the child has no issues such as constipation or illness. Management strategies for enuresis in children five years and over4,6 • Assess fluid intake: » Excessive or insufficient. » Abnormal toileting patterns. • Suggest bed protection measures. • Suggest a trial of one to two nights a week without nappies or pull ups once the child has been toilet trained and dry during the day for six months. • Lift and carry the child to the toilet if they wake at night. • Ensure the child has no issues such as constipation or illness. • Suggest a reward system for initial treatment of bedwetting in children who have some dry nights. • Provide advice on the importance of using the toilet at regular intervals throughout the day and before sleep. Toileting should occur between four and seven times during the day. Assessment Children should complete a voiding chart/ bladder diary7 and the initial evaluation should include a urine dipstick test.3 The voiding chart is essential if the child has both daytime and nighttime symptoms. A voiding chart gives the doctor comprehensive information to enable a diagnostic criteria pathway to be followed, dependent on the information obtained. Voiding charts should include night and day continence patterns for at least one week, plus void volumes and daily fluid intake. The chart may give the doctor a perspective on how the family is managing the continence issues of the child. A urine dipstick to detect abnormalities is an essential initial evaluation criterion.3 This may be followed up with a blood sample if there is glucosuria or warning signs of polyureic renal failure.3 Imaging may be performed to confirm an issue of constipation or faecal impaction that the family may not have been aware of.3 Comorbidities that may contribute to enuresis issues need to be assessed. These include:3,5,6 • Psychiatric disorders. • Constipation. • Urinary tract infections • Snoring. • Sleep apnoea. • Adenotonsillar hypertrophy. Non-pharmacological and pharmacological treatment options Urotherapy is defined as ‘the conservative and behavioural adjustments that patients and parents can make, and encompasses management from a wide field of healthcare professionals’.6 Some of the strategies of urotherapy include:4,6 Constipation • Bowel movement size, texture and frequency should be determined. • Appropriate treatment and retraining should occur if the child is constipated. • It’s necessary to avoid large bolus stools that may become impacted and contribute to enuresis. TO PAGE 58 First line treatment RETAIL PHARMACY • JAN/FEB 2021