Part of Contemporary Pediatrics’ coverage of the 2015 AAP Annual Conference. For more coverage, click here.
Keys for treating children with enuresis include viewing toilet troubles holistically and convincing parents to let children find their own way, said Michael A Keating, MD, FAAP, in his presentation “The Child Who Wets: What’s a Doctor to Do?”
Children who are aggressively toilet trained appear to be at higher risk of developing more toilet problems. Many of them have excessive sphincter control, including bowel problems with constipation, which is a common contributor to the bedwetting spectrum.
Keating explained that his biggest message for parents is not to over-reward during toilet training. Little children are like puppies; they want to please you. However if the bladder is not ready to be held, the child starts having problems such as accidents and urinary tract infections.
His advice to parents is to let children find their own level. Toilet training is a variable spectrum, and early mastery is not a sign of intelligence.
Many bedwetting children actually have a diurnal toilet problem. They are able to compensate during the day while awake. Then, when they’re in a deep sleep, they often wet at night. If a pediatrician treats bedwetting in a child who has global bladder problems or bladder immaturity, the bedwetting solution will not succeed.
Conversely, if daytime toilet behavior is improved, the night-time problems often follow. In his practice, Keating sees many children who wait too long during the day to go to the bathroom. Or, when they do void, they do not empty all their urine. They might be going frequently because they’re going in small amounts or because their bladders are small for their age.
Often, he will reassure parents about the bedwetting, have them refocus on the daytime toilet patterns, and reinstitute toilet behavioral modification. This includes having the child go to the bathroom on a regular schedule, perhaps teaching them how to relax the sphincter muscles, and starting them on medications during the day to relax the bladder and allow it to hold more.
Also, watch for bowel issues. Wetting dysfunction is probably better classified as toilet dysfunction in many children because the bowels are often involved. If a retentive child waits too long to go to the bathroom, the same sphincter muscle complex that holds urine holds the bowels, too. A full rectum alters bladder dynamics, making it smaller and more prone to accidents. It can also impair bladder emptying. And, many times, once the bowels are improved, the wetting issues follow.
Michael A Keating, MD, FAAP, is director of pediatric urology, Florida Hospital for Children, Orlando.
Dr Keating is “right on” in his assessment. Both potty training and enuresis must be treated individually and holistically. Each family has a different approach and attitude, and indeed even culture plays a role. For example, although “aggressive” potty training is associated with toileting problems, there are Asian cultures in which very early training (aged 9 to 12 months) is the norm and is not associated with a higher risk of future problems. Interestingly, this is not applicable to those same Asian cultures in the United States.
I would also emphasize, as Dr Keating has, the association with bowel problems. Stool holding, for whatever reason, will no doubt lead to dysfunction of the sphincter, and this in turn will lead to voiding dysfunction, as the bowel and urinary sphincters are interconnected. Dietary and behavioral modifications to promote regular, normal bowel movements are essential.
I also totally agree on the need to identify and focus on daytime urinary function before night-time problems can be solved. Many times, if the daytime issues are addressed, the night-time wetting will resolve spontaneously. On the other hand, parents often focus on the night-time wetting and prefer that be addressed first. I think it is important to educate them about this. As noted, it is very unlikely that the night-time wetting can be resolved when there are daytime issues that are not fully addressed.
Medications and alarms are sometimes used in nocturnal enuresis, but I would suggest that education and treatment of constipation and daytime voiding problems almost always should come first. And, of course, treatment plans should always be individualized. This is not a “one-size-fits-all” condition. The management must be tailored to each family and child.
Barry A Kogan, MD, FAAP, is chair, Department of Urology, Albany Medical College, Albany, New York.