Nocturnal enuresisImplementing NICE guidance

October 2010

NICE clinical guideline 111

What this presentation covers

Background

Scope

Key priorities for implementation

Costs and savings

Discussion

Find out more

Background

• Involuntary wetting during sleep without any inherent suggestions of frequency of bedwetting or pathophysiology

• Prevalence decreases with age

• Causes not fully understood

• Treatment has a positive effect on the self-esteem of children and young people. Healthcare professionals should persist in offering treatments

Scope

Recommendations on the assessment and management of bedwetting in children and young people.

Groups that are covered •No minimum age limit for inclusion.

•Children and young people (including those with special needs) aged under 19 years who continue to have episodes of night-time bedwetting, with or without daytime urinary symptoms.

Key priorities for implementation

The key priorities for implementation can be classified into the following areas:

•Principles of care

•Assessment and investigation

•Planning management

•Advice on fluid intake, diet and toileting patterns

•Reward systems

•Initial treatment – alarms

•Initial treatment – desmopressin

•Lack of response to initial treatment options

• Inform children and young people with bedwetting and their parents or carers that it is not the child or young person’s fault and that punitive measures should not be used in the management of bedwetting (KPI)

• Offer tailored support, assessment and treatment to all children and young people with bedwetting and their parents or carers (KPI)

• Do not exclude younger children (for example, those under 7 years) from the management of bedwetting on the basis of age alone (KPI)

Principles of care

Assessment and investigation: 1

History taking

Ask about onset of bedwetting, pattern of bedwetting, daytime symptoms, toileting patterns, fluid intake and practical issues.

Assess for comorbidities and other factors that may be associated with bedwetting.

Assessment and investigation: 2

• Discuss with the parents or carers whether they need support, particularly if they are having difficulty coping with the burden of bedwetting, or if they are expressing anger, negativity or blame towards the child or young person (KPI)

• Consider assessment, investigation and/or referral when bedwetting is associated with

– severe daytime symptoms– a history of recurrent urinary infections– known or suspected physical or neurological

problems– comorbidities or other factors

• Explain the condition and possible treatments with the child or young person and parents or carers

• Clarify what the child or young person and parents or carers hope the treatment will achieve

• Explore the child or young person’s views about their bedwetting

• Consider whether or not it is appropriate to offer alarm or drug treatment, depending on the age of the child or young person, the frequency of bedwetting and the motivation and needs of the child or young person and their family (KPI)

Planning management

• Address excessive or insufficient fluid intake or abnormal toileting patterns before starting other treatment for bedwetting in children and young people (KPI)

• Adequate daily fluid intake is important

Advice on fluid intake, diet and toileting patterns

Age Sex Total drinks per day

4 – 8 years FemaleMale

1000 – 1400 ml1000 – 1400 ml

9 – 13 years FemaleMale

1200 – 2100 ml1400 – 2300 ml

14 – 18 years

FemaleMale

1200 – 2500 ml2100 – 3200 ml

• Explain that reward systems with positive rewards for agreed behaviour rather than dry nights should be used either alone or in conjunction with other treatments for bedwetting (KPI)

• Inform parents or carers that they should not use systems that penalise or remove previously gained rewards

• Advise parents or carers to try a reward system alone for the initial treatment of bedwetting in young children who have some dry nights

Reward systems

Initial treatment: alarms Who to consider

• Offer an alarm as the first-line treatment to children and young people whose bedwetting has not responded to advice on fluids, toileting or an appropriate reward system, unless the alarm is inappropriate or undesirable.

• Alarm may be inappropriate when:• bedwetting is very infrequent (that is, less than 1–2

wet beds per week) • the parents or carers are having emotional

difficulty coping with the burden of bedwetting• the parents or carers are expressing

anger, negativity or blame towards the child or young person

Initial treatment: alarms Information needs

Ensure that advice and support are available.

Inform children and young people and their parents or carers about:

•the benefits of combining alarm treatment with a reward system

•the high long-term success rate of alarm treatment

•the aims of alarm treatment

•practical issues for using the alarm (such as impact on sleep, commitment needed)

•the early and late signs of response.

Offer desmopressin to children and young people over 7 years, if:

• rapid-onset and/or short-term improvement in bedwetting is the priority of treatment or

• an alarm is inappropriate or undesirable (see recommendation 1.8.1)

Initial treatment: desmopressin

Do not exclude desmopressin as an option for the management of bedwetting in children and young people:

• who also have daytime symptoms. However, do not use in only daytime wetting

• with sickle cell disease*

• with emotional, attention or behavioural problems or developmental or learning difficulties*.

Do not routinely measure weight, serum electrolytes, blood pressure or serum osmolality.

* If they can comply with night time fluid restriction.

Desmopressin: other factors

Refer children and young people with bedwetting that has not responded to courses of treatment with an alarm and/or desmopressin for further review and assessment of factors that may be associated with a poor response, such as an overactive bladder, an underlying disease or social and emotional factors (KPI)

Lack of response to initial treatment

• Lifting and waking

• Anticholingerics

• Tricyclics

• Training programmes for the management of

bedwetting

• Children under 5 years with bedwetting

Other recommendation areas

Costs and savings

The guideline on nocturnal enuresis is unlikely to result in a significant change in resource use in the NHS. However, recommendations in the following areas may result in additional costs/savings depending on local circumstances:

• Offering an alarm as first-line treatment • Using combination treatment with alarm and

desmopressin when there has been no response to initial treatment with an alarm

• Offering desmopressin• Training of healthcare professionals• Considering imipramine if there is no

response to any other treatments

Discussion

• How can alarms be accessed for children who meet the criteria? How can we ensure enough alarms are available to meet local needs?

• How can we ensure that the service is well integrated and that the team have a good awareness and understanding of the guideline?

• Who would prescribe the medications recommended?

• How can we provide the information recommended to parents and carers, including how to take desmopressin?

Find out more

Visit www.nice.org.uk/guidance/CG111 for:

• the guideline • the quick reference guide• ‘Understanding NICE guidance’• costing statement and template• audit support• baseline assessment tool• guide to resources (also includes childhood constipation)

• commissioning guide