Combined treatment with enuresis alarm and desmopressin for nocturnal enuresis. [Results of a therapeutic strategy against monosymptomatic nocturnal enuresis]. A comparison of two approaches to the treatment of nocturnal enuresis and the prediction of effectiveness using pre-treatment variables. Comparing alarms, desmopressin, and combined treatment in Chinese enuretic children. Efficacy of desmopressin combined with alarm therapy for monosymptomatic nocturnal enuresis. The relative efficacy of two brief treatments for sleep problems in young learning disabled (mentally retarded) children: a randomised controlled trial. Primary nocturnal enuresis: a new approach to conditioning treatment. Behavioral and self-concept changes after six months of enuresis treatment: a randomized, controlled trial. Comparison of desmopressin and enuresis alarm for nocturnal enuresis.
Seventy-one children with nocturnal enuresis were enrolled in a controlled trial. The children were allocated to two matched groups. Children in both groups used an enuresis alarm until the end of treatment. Children in the first group were treated with 40 micrograms of intranasal desmopressin (Desmospray) for up to 6 weeks at the start of treatment with the alarm. During the observation period treatment there were 2.3 dry nights per week in both groups. At the end of treatment there was a significant difference in the mean number of dry nights per week between the two groups (6.3 in the alarm and desmopressin group and 4.8 in the alarm group) and also in the number of children becoming reliably dry. The combination of desmopressin and alarm was particularly helpful for children with severe wetting and those with family and behavioural problems. There are many therapeutic options against enuresis.
                To evaluate several therapies introduced progressively to treat monosymptomatic nocturnal enuresis.
                Eighty-four patients, aged 6 to 14 years old, were studied. The 67 year olds were treated with desmopressin and oxybutynin was added in nonresponders. If enuresis persisted, Alarm was given. Children over 7 years of age were randomly divided and treated with Alarm or Alarm plus desmopressin. Nonresponders were treated with desmopressin alone.
                In children aged 6-7 years the cumulative response was 72%. Those who wetted themselves less responded to desmopressin. In children over 7 years of age, response to Alarm was 73.3% and response to Alarm plus desmopressin was 58.6%. In nonresponders the cumulative response after desmopressin treatment increased to 80% and 62% respectively.
                In the group of 6 to 7 year-olds desmopressin was indicated as first line therapy. Treatment efficacy was increased by adding oxybutynin especially in the children who wetted themselves the most. In children over 7 years of age Alarm was the most effective treatment and relapses were fewer. No advantages were observed with the combination of Alarm and desmopressin in our protocol. This study compared the effectiveness of the enuresis alarm alone with a brief version of Dry Bed Training in treating 74 enuretic children. Both procedures were equally effective, and in the total sample a better response to treatment was predicted by the child's report of being teased by siblings. Maternal anger was associated with a greater drop-out rate. The objective of this multicenter randomized controlled trial was to compare the efficacy of enuresis alarms, oral desmopressin, and combined treatment in Chinese children with monosymptomatic primary nocturnal enuresis. We assigned 105 children aged 7-15 years to receive alarms (group 1, 35 patients), oral desmopressin 400 mug (group 2, 38 patients), or combined therapy (group 3, 32 patients) for 12 weeks; patients were then followed for 12 weeks after treatment. The wetting frequency decreased during treatment by 46%, 52%, and 73% in groups 1, 2, and 3, respectively. In groups 2 and 3, but not in group 1, there was rebound post treatment, but significant improvements persisted at 12 weeks. The complete and partial response rates were 22.9% and 20%, respectively in group 1, 42% and 10.5% in group 2, and 62.5% and 15.6% in group 3. By Kaplan-Meier analysis, group 1 had a significantly poorer response than groups 2 and 3. Of the responders, 20%, 60%, and 40% in groups 1, 2, and 3, respectively, relapsed after stopping treatment. In conclusion, enuresis alarms and/or oral desmopressin were less efficacious in Chinese than in Western societies. Desmopressin produced an immediate effect but relapses were common. Alarms took several weeks to produce a benefit, which was persistent on follow-up. We evaluated the combination of alarm and desmopressin versus alarm monotherapy for the treatment of nocturnal enuresis.
                A double-blind, placebo controlled study of alarm therapy combined with desmopressin for children with nocturnal enuresis is described. Of 93 patients 47 were randomized to receive alarm therapy and 40 microg. intranasal desmopressin for 3 weeks followed by 20 microg. desmopressin for 3 weeks (group 1) and 46 received alarm therapy and placebo (group 2). After 6 weeks on alarm therapy and medication or placebo, both groups received an additional 3 weeks of alarm monotherapy. A specialized nurse practitioner advised patients and families of the treatment to be given at home and in the outpatient department. Bed-wetting frequency was evaluated before during and 2 weeks and 6 months after treatment.
                A significantly greater reduction in the number of wet nights was observed after the first 3 weeks of treatment in group 1. However, after long-term followup no significant differences in bed-wetting frequency were noted.
                There is a temporary, positive effect on enuresis using desmopressin combined with alarm therapy. However, both treatment modalities have a low long-term success rate of 36% to 37%. Settling and night waking problems are particularly prevalent, persistent, and generally considered difficult to treat in children with a learning disability, although intervention trials are few. Scarce resources, however, limit access to proven behavioural treatments.
                To investigate the efficacy of a media based brief behavioural treatment of sleep problems in such children by comparing (1) face-to-face delivered treatment versus control and (2) booklet delivered treatment versus controls.
                The parents of 66 severely learning disabled children aged 2-8 years with settling and/or night waking problems took part in a randomised controlled trial with a wait-list control group. Behavioural treatments were presented either conventionally face-to-face or by means of a 14 page easy to read illustrated booklet. A composite sleep disturbance score was derived from sleep diaries kept by parents.
                Both forms of treatment were almost equally effective compared with controls. Two thirds of children who were taking over 30 minutes to settle five or more times per week and waking at night for over 30 minutes four or more times per week improved on average to having such settling or night waking problems for only a few minutes or only once or twice per week (H = 34.174, df = 2, p<0.001). These improvements were maintained after six months.
                Booklet delivered behavioural treatments for sleep problems were as effective as face-to-face treatment for most children in this population. Conditioning treatment is the most effective therapy for nocturnal enuresis, precluding the use of drugs. An ordinary alarm clock can be used as an enuresis alarm. We sought to assess its clinical utility as a new means of conditioning treatment.
                Using the ordinary home alarm clock, 125 enuretic children were enrolled into two treatment groups. Group I included 70 children who set the alarm so as to get up and void in the toilet at a critical time when the bladder was full and they were still dry. Group II included 55 children who used the alarm to be awakened for voiding after 2 to 3 hours of sleep regardless of whether they were dry or wet. All children were motivated to use the alarm clock continuously for 4 months.
                Initial success was achieved in 54 (77.1%) of 70 group I and 34 (61.8%) of 55 group II children. Three months after treatment was stopped, success was still maintained in 46 (65.7%) and 31 (56.4%) children in groups I and II, respectively, but dropped to 41 (58.6%) and 29 (52.7%), respectively, after 6 months. The relapse rate after 3 and 6 months was 14.8% and 24.1% for group I and 8.8% and 14.7% for group II, respectively.
                The ordinary alarm clock performs as well as currently used enuresis alarms. It is an effective, elective, noncontact alarm that does not wait for bedwetting to initiate a conditioning reflex. It is both reliable and safe. Previous studies have suggested changes in self-concept with successful treatment of primary nocturnal enuresis (PNE), but behavioral changes have not been reported as a consistent associated finding.
                To determine if self-concept and behavior change after 6 months of treatment of monosymptomatic PNE by conditioning alarm or desmopressin acetate (DDAVP).
                Randomized, controlled trial in an inner-city hospital clinic. Subjects were 182 children referred or recruited through media publicity, randomly assigned both to 1 of 8 pediatricians and 1 of 3 treatment groups (alarm, DDAVP, or placebo). Included were children >7 years old with PNE, no daytime symptoms, bladder capacity >50% expected, and wetting >3 times a week. Excluded were children with central nervous system disorders or developmental delays, and those currently on DDAVP or alarm. Subjects completed the Piers-Harris Children's Self-Concept Scale and Harter's Perceived Competence Scale for Children (PCSC) at initial visit and after 6 months of treatment. Parents completed the Achenbach Child Behavior Checklist (CBCL) at the same times.
                After 6 months of treatment the Piers-Harris total score showed a highly significant treatment by period interaction effect for DDAVP, a significant effect for alarm, and no effect for placebo. For children who achieved 75% dryness the CBCL showed a treatment by improvement interaction effect that was highly significant for DDAVP and placebo with no effect for alarm. For the PCSC there were no treatment or outcome interaction effects. After 6 months of treatment there were significant changes over time unrelated to outcome or treatment in the Piers-Harris Subscales and in the CBCL Internalizing and Externalizing Scores, and the Social Thought and Attention Problems Subscales. The PCSC was more stable with no changes in total score, and positive changes over time in only 2 Subscales, Scholastic and Social.
                Children's self-concept improved with the type of treatment and amount of success. Parents' perceptions of behavior improve with type of treatment and amount of success. Children rate their self-concept and some physical attributes better after treatment with any of DDAVP, alarm, or placebo regardless of outcome. Frequent follow-up with emotional support and encouragement appear to be important components of an efficacious intervention for children with nocturnal enuresis. Fifty children with primary nocturnal enuresis were randomised for a study comparing desmopressin (DDAVP) and enuresis alarm. Forty six completed the trial, 24 of whom were treated with 20 micrograms intranasal desmopressin nightly and 22 with enuresis alarm for three months. Failures were crossed over and relapses were continued on the same treatment for a further three months. The improvement rate was 70% in the group given desmopressin and 86% in the group treated with alarm; the difference was not significant. During the first week of treatment the group given desmopressin was significantly dryer, and at the end of the study 10 of these patients relapsed compared with one patient in the group given the alarm. No serious side effects were observed. This study confirms the role of conditioning treatment as preferable in long term treatment of nocturnal enuresis. When this fails or when a safe drug with rapid effect is needed, however, desmopressin is a useful alternative.
Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.