Reassuringly low carriage of enteropathogens among healthy Swedish children in day care centres.

OBJECTIVES: Infectious gastroenteritis is one of the most common diseases among children and has a considerable impact on health and socio-economy. Day care centres are high-risk environments for infections. The aim of this study was to investigate if asymptomatic preschool children constitute a reservoir for potential enteropathogens. STUDY DESIGN: In total, 438 individual diapers were collected from day care centres in Uppsala, Sweden, during spring and autumn, and molecular techniques were used to estimate the prevalence of asymptomatic carriage of multiple enteropathogens. METHODS: Faecal samples were analysed with multiplex polymerase chain reaction (PCR) (xTAG® Gastrointestinal Pathogen Panel; Luminex Corporation, Toronto, Canada) targeting 21 different pathogens. Samples with a median fluorescence intensity above threshold were re-analysed with a second PCR assay. RESULTS: Sixteen of the 438 samples were positive for enteropathogens, 1.6% for enteric adenovirus, 0.7% for Campylobacter spp., and 0.7% for norovirus. CONCLUSIONS: Preschool children in Uppsala constitute a limited reservoir for potential enteropathogens.

The amount of urine voided in bed by children with enuresis.

INTRODUCTION: Enuretic children wet their beds either because of nocturnal polyuria or nocturnal detrusor overactivity. Polyuric children often respond to desmopressin, whereas children with nocturnal detrusor overactivity are often therapy resistant and may have low daytime voided volumes. It is logical to assume that the enuretic event in children with nocturnal polyuria occurs with a full bladder, i.e. with the enuretic voided volume (EVV) close to the child's expected bladder capacity (EBC) for his/her age. However, the EVV has only rarely been studied, and little is known about how it relates to case history, polyuria, or daytime bladder function. The aim of this study was to look at EVV and relate it to voiding chart data and treatment response. METHODS: Anamnestic data and voiding charts, including measurement of nocturnal urine production and EVV, in enuretic children with or without concomitant daytime incontinence attending a tertiary center were retrospectively reviewed. The EVV was analyzed and compared to anamnestic data, voiding chart data, and response to therapy in accordance with the guidelines of the International Children's Continence Society. RESULTS: Data were available for 220 children (age 5-24, median 9), 40 of whom were girls. The prevalence of previous or present daytime incontinence was 42.4%, and 50.5% sometimes experienced urgency. The average EVV was 54.9 ± 32.8% of EBC. EVV correlated highly significantly to nocturnal urine production (p < 0.001). Still, EVV ≥ EBC was observed in only 16 children. EVV was slightly larger in girls (p = 0.013) and in children with urgency (p = 0.034), but there were no significant EVV differences between children responding or not responding to antidiuretic, anticholinergic, or antidepressant therapy. Relevant data are summarized in the Table below. DISCUSSION: Case history and daytime voiding chart data give very little information about nocturnal bladder function. The EVV is strongly influenced by nocturnal urine production but only rarely reaches up to a level close to or exceeding the EBC. The enuretic event only very rarely represents the emptying of a full bladder. Thus, a component of nocturnal detrusor overactivity can be assumed to be present in almost all enuretic children, even in children with nocturnal polyuria. The value of the EVV is limited in predicting response to therapy.

Sleep of children with enuresis: a polysomnographic study.

OBJECTIVE: To evaluate relationships between bladder voiding and sleep in children with enuresis. METHODS: Polysomnographic recordings were obtained from 25 children, aged 7 to 17 years, with monosymptomatic nocturnal enuresis. During 52 recorded nights, 37 enuretic events were detected. Responders (n = 7) and nonresponders (n = 16) to desmopressin treatment were compared. RESULTS: The mean latency between sleep onset and the first bladder voiding was 3 hours 20 minutes (SD = 2 hours 5 minutes). The number of voidings were 19, 7, 10, and 1 occurring during stages 2, 3, and 4, and rapid-eye movement sleep, respectively. Desmopressin responders were found to void during the early or late part of the night, whereas the voidings of the nonresponders were dispersed evenly throughout the night (chi2 = 8.09). CONCLUSIONS: The enuretic event is a predominantly non-rapid eye movement sleep phenomenon. Responders and nonresponders to desmopressin treatment void during different parts of the night.

[Alarm defends its position. Comments to meta-analysis of alarm treatment of nocturnal enuresis]. / Kisslarmet försvarar sin plats. Kommentar till en metaanalys av larmbehandling vid nattväta.

Glazener and Evans have, on behalf of the Cochrane Library, performed a systematic literature review of alarm interventions in nocturnal enuresis. An extensive, and probably exhaustive, search yielded 22 studies which were of sufficient methodological quality and in which the enuresis alarm was included as one treatment alternative. From these studies it could be concluded that 1) the enuresis alarm is clearly more effective than non-treatment, 2) different types of enuresis alarms do not differ significantly as regards efficacy, and 3) alarm treatment is not clearly superior or inferior to pharmacological treatment.

Enuresis--background and treatment.

Nocturnal urinary continence is dependent on 3 factors: 1) nocturnal urine production, 2) nocturnal bladder function and 3) sleep and arousal mechanisms. Any child will suffer from nocturnal enuresis if more urine is produced than can be contained in the bladder or if the detrusor is hyperactive, provided that he or she is not awakened by the imminent bladder contraction. Urine production is regulated by fluid intake and several interrelated renal, hormonal and neural factors, foremost of which are vasopressin, renin, angiotensin and the sympathetic nervous system. Detrusor function is governed by the autonomic nervous system which under ideal conditions is under central nervous control. Arousal from sleep is dependent on the reticular activating system, a diffuse neural network that translates sensory input into arousal stimuli via brain stem noradrenergic neurons. Disturbances in nocturnal urine production, bladder function and arousal mechanisms have all been firmly implicated as pathogenetic factors in nocturnal enuresis. The group of enuretic children are, however, pathogenetically heterogeneous, and two main types can be discerned: 1) Diuresis-dependent enuresis - these children void because of excessive nocturnal urine production and impaired arousal mechanisms. 2) Detrusor-dependent enuresis - these children void because of nocturnal detrusor hyperactivity and impaired arousal mechanisms. The main clinical difference between the two groups is that desmopressin is usually effective in the former but not in the latter. There are two first-line therapies in nocturnal enuresis: the enuresis alarm and desmopressin medication. Promising second-line treatments include anticholinergic drugs, urotherapy and treatment of occult constipation.

"Nobody asked us if we needed help": Swedish parents experiences of enuresis.

OBJECTIVE: To explore the everyday dilemmas of parents living with a child with nocturnal enuresis and to describe their support needs in relation to healthcare professionals. SUBJECTS AND METHODS: The study was conducted in 2011 in Uppsala County, Sweden. Parents of 13 children with enuresis, 10 mothers and three fathers, participated in qualitative semi-structured in-depth interviews, which were analysed using systematic text condensation. RESULTS: The analysis of the material resulted in six themes: enuresis is socially stigmatising and handicapping; all practices and home remedies are tested; it creates frustration in the family; protecting the child from gossip or teasing; support from healthcare providers would have helped; it's something we just have to live with. Two patterns of coping were identified: the Unworried wet-bed-fixers and the Anxious night-launderers. CONCLUSION: Having a child with enuresis can be stressful for parents, although they tried hard not to blame their child. Because parents can feel reluctant to bring up enuresis themselves, they want child health nurses to routinely raise the issue of bedwetting at the yearly check-up. Parents' information needs included causes of and available treatment options for enuresis as well as access to aids and other support for affected families.

Lower urinary tract function in childhood; normal development and common functional disturbances.

This review aims to provide researchers and clinicians involved with the adult lower urinary tract with background knowledge regarding the early development of bladder function and its most common disturbances in childhood. Bladder development begins in weeks 4-6 and the detrusor muscle is formed during weeks 9-12 of gestation. Higher CNS centres are involved in micturition at birth, and the infant usually wakes up, at least briefly, to void. Voiding during the first years of life is often incomplete, owing to detrusor-sphincter dyscoordination, but this disappears when bladder control is attained. Approximately 5-10% of 7-year-old children suffer from daytime incontinence and/or nocturnal enuresis, and a few per cent of them will not outgrow it. Daytime incontinence in childhood is usually attributable to detrusor overactivity, although it is unclear to what extent it is the detrusor or the micturition reflex per se that is overactive. Enuresis - nocturnal incontinence - is caused by either nocturnal polyuria and/or nocturnal detrusor overactivity, in both cases combined with high arousal thresholds. Bladder problems in childhood constitute a risk factor for the development or persistence of bladder problems in adulthood.

The role of sleep and arousal in nocturnal enuresis.

AIM: To review what is known about the role of sleep and arousal mechanisms in the pathogenesis of nocturnal enuresis. METHODS: A review of the literature was carried out. RESULTS: The sleep of enuretic children, although polysomnographically quite normal, is exceedingly "deep"; that is enuretic children have high arousal thresholds. Apart from some overlap between enuresis and the (other) classic parasomnias, the sleep of enuretic children is no more problematic than that of the general population. Recently, the exciting possibility has arisen that the low arousability of enuretic children may be linked to the autonomous nervous system and to disturbances in the upper pons. CONCLUSIONS: Enuresis is not just a nocturnal problem but a disorder of sleep. The high arousal threshold is one of three major pathogenetic factors in enuresis-nocturnal polyuria and detrusor hyperactivity being the other two.