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58 CPD ACTIVITY FROM PAGE 57 Posture • • Voiding posture is important for complete bladder and bowel emptying. • Consider a ‘potty stool’ to ensure the child’s posture when voiding is ideal, to reduce the risk of residual volume. Biofeedback6 • Involves pelvic floor muscle retraining. • Effective in the treatment of children with a functionally small bladder capacity. • Allows children to hold larger volumes for longer periods. Fluids and diet4 • Adequate fluid intake is important, especially in the morning and at lunch. • Consumption of caffeine-based drinks should not occur. • A healthy diet is important. • There is no place for dietary restrictions in the treatment plan. Waking and lifting4 • Waking and/or lifting the child from bed at regular times, or random times, will NOT promote long-term dryness. This should be used only as a short-term measure. • Self-instigated waking, eg, alarm clock/ mobile phone alarm, may be a useful management strategy in young people. Reward systems4 Positive rewards for agreed behaviour rather than dry nights can be used either alone or in conjunction with other treatment options. Examples of why a positive reward may be given include: • Drinking recommended levels of fluid during the day. • Using the toilet before bed to pass urine. • Engaging in management, eg, taking medications, changing the sheets, and remaking the bed. The child/younger person should never be made to feel penalised or of no worth due to their inability to maintain nighttime dryness. Psychologist, psychiatrist or child health counsellor involvement • A child psychologist, psychiatrist and/or behaviour counsellor may be required as part of the treatment plan for children who may have emotional or behavioural issues linked to the bedwetting.3,4 Teachers should be informed the child has enuresis issues, especially if there are daytime wetness issues and/or poor concentration due to daytime drowsiness. child to move to the toilet. • Should be evaluated after six weeks but stopped if there is no change. • Should be continued until 14 consecutive dry nights are achieved. • Has a success rate moving to a cure of 50-70 per cent. Alarm therapy may have limited efficacy if parents are heavy sleepers, wear sleep apnoea or insomnia apparatus that prevents them from hearing the alarm or are not motivated, or if the child shares a room with other children and the alarm disturbs them.3 Concomitant behavioural issues such as ADHD, autism, etc, may make alarm therapy adherence difficult.3 Alarm therapy works better in children who have frequent enuresis. It’s not as effective in children with intermittent enuresis.3 Alarm therapy alone may not be as effective if the child wets more than once a night.3 Pharmacotherapy Desmopressin3 • Has an antienuretic effect leading to decreased nocturnal urine production and a urine volume the bladder can better accommodate. • Can be used long term. • Side effects are rare, but hyponatraemia could occur in those patients who have excessive fluid intake water intoxication. • The child should be restricted to 200ml of fluid in the last hour before bed and no fluid to be given through the night. • About one third of children will be reliably dry while taking desmopressin, one third will show no response and one third will have an intermittent response. • Best response is seen in children who have nocturnal polyuria and normal daytime void volumes. • Should be given in the evening, 60 minutes before bedtime. • Therapy should cease if no benefit is seen after two weeks. • If desmopressin is successful, a discussion as to whether to trial tapering the dose or to trial ‘drug holidays’ is important to evaluate whether therapy needs to continue. • Therapy may need to continue for several Non-monosymptomatic enuresis initial treatment3 The group with NMSE have concomitant daytime lower urinary tract symptoms as well as nighttime symptoms. The consensus is if daytime symptoms are considered major, these require treatment before nighttime symptoms.3 If daytime symptoms are minor and not concerning the family, specific antienuretic therapy may be started.3 Initial treatment plans include:3 • Establishing regular voiding patterns of approximately six micturitions per day. • Drinking adequate levels of fluid, especially in the morning and at lunchtime. • Adopting a good voiding posture, especially with the thighs supported. Monosymptomatic enuresis initial treatment3 All MSE therapies require the motivation of parent and child.3 The choice of therapy should be discussed with both. There needs to be strong family motivation for alarm therapy to be effective, as this can be a long-term requirement. If both the alarm system and medication therapies are trialled as single therapies and are ineffective, the two strategies can be trialled in combination.3 Alarm therapy3,6 Alarm therapy is the most effective treatment modality available for children older than six years.1 Alarm therapy: • Is activated when urine is detected by a sensor in the child’s pyjamas or bed clothes. • Gives a strong arousal stimulus. • Requires the family and child to be very adherent to the therapy every night. • Requires parents to be very motivated to wake up every night and motivate the JOIN TODAY TO ENJOY THESE MEMBER BENEFITS • CPD guarantee – four new topics each month • Learning plan and CPD credits summary transcript • Comprehensive and non-biased clinical education modules with online assessment questions LEARN MORE www.acp.edu.au info@acp.edu.au RETAIL PHARMACY • JAN/FEB 2021