Formação em psicologia escolar: implicações para a prática em equipe multiprofissional / The school psychology formation: implications for the practice in multidisciplinary team / Formación en psicología escolar: implicaciones para la práctica en equipo multiprofesional

O objetivo dessa pesquisa foi levantar o perfil sociodemográfico e formativo de psicólogos escolares, e discutir seu impacto nas práticas junto ao coletivo escolar e no trabalho em equipe. No município onde ocorreu a pesquisa, o psicólogo escolar é membro da equipe de especialistas em Educação. Participaram da pesquisa 62 psicólogos que atuam no Ensino Fundamental I, II, e na Educação de Jovens e Adultos. Os participantes responderam um questionário on-line com perguntas abertas e fechadas sobre dados sociodemográficos, de formação e atuação profissional. Realizou-se uma análise qualitativa a partir dos objetivos e itens do instrumento, quais sejam: caracterização do perfil sociodemográfico dos psicólogos escolares, formação acadêmica, atuação em psicologia escolar, atuação em outros campos/áreas da psicologia, e atuação em equipe de especialistas. A média de idade dos profissionais é de 47,46 anos, e apenas um é do sexo masculino. Possuem tempo de atuação de um a 36 anos, e a maioria não possui estágio supervisionado e pós-graduações no campo da psicologia escolar. Parte das equipes que trabalham nas escolas está incompleta, e há uma variabilidade nos dias e horários de reuniões. Reafirma-se que a formação de psicólogos escolares tem repercussões na atuação junto à equipe multidisciplinar, e a importância de intervenções pautadas na perspectiva crítica e psicossocial em Psicologia Escolar. Ademais, conhecer o perfil sociodemográfico e formativo destes profissionais possibilita obter um quadro atualizado sobre o grupo pesquisado e criar estratégias de intervenção que potencializem a atuação desses profissionais junto à equipe de especialistas e demais setores da escola.(AU)

The aim of this research is to identify the sociodemographic and training profile of school psychologists, and discuss their impact on practices within the school collective and the teamwork. In the city where the research took place, the school psychologist is a member of the council's expert team in Education. The research participants included 62 psychologists that work in elementary and intermediate school, and EJA. They answered an open and multiple choice online survey on sociodemographic, formation, and working data. A qualitative analysis was conducted considering its objectives and items, namely: sociodemographic profile, academic education, professional background on school psychology, other psychology fields/ areas, and participation on expert teams. The professionals are 47 and 46 years old, average, only one of them being male. They work in this position from one up to 36 years, and most of them do not have training experience and postgraduate studies in school psychology. Part of the teams working at schools are incomplete, and there is a variability concerning days and hours to team meetings. It is notable that the training profile of psychologists has repercussions in the performance with the multidisciplinary team, and in the importance of interventions based on critical and psychosocial perspectives in School Psychology. Moreover, knowing the sociodemographic and training profile of these professionals allowed us to have an updated chart about the researched group, as well as to create intervention strategies that enhance these professionals' performance within the expert team and other sectors of the school.(AU)

Esta investigación tuvo por objetivo levantar el perfil sociodemográfico y formativo de psicólogos escolares para discutir su impacto en las prácticas junto al colectivo escolar y al trabajo en equipo. En el municipio donde ocurrió la investigación, este profesional es miembro del equipo municipal de especialistas en Educación. Participaron 62 psicólogos que actúan en la educación primaria, secundaria y en la educación para jóvenes y adultos (EJA), y que respondieron a un cuestionario en línea con preguntas abiertas y de opción múltiple sobre datos sociodemográficos, de formación y de actuación profesional. Se realizó un análisis cualitativo según sus objetivos e ítems, o sea: perfil sociodemográfico, formación académica, actuación en Psicología Escolar, en otros campos/áreas de la Psicología o en equipo de especialistas. La edad mediana de los profesionales es de 46-47 años, y solo uno es del sexo masculino. El tiempo de actuación en el área varía entre 1 y 36 años, y la mayoría de los encuestados no tiene formación inicial y posgrado en el campo de la Psicología Escolar. Parte de los equipos que trabajan en las escuelas está incompleta, y existe una variabilidad en los días y horarios de reuniones. Se observó que la formación de los psicólogos escolares tiene repercusiones en la actuación con el equipo multidisciplinario y en la importancia de intervenciones basadas en la perspectiva crítica y psicosocial en Psicología Escolar. Además, conocer su perfil sociodemográfico y formativo posibilita obtener un cuadro actualizado sobre el grupo investigado, además de crear estrategias de intervención que potencialicen la actuación junto al equipo de especialistas y a los demás sectores de la escuela.(AU)

Personal and familial factors associated with toilet training

ABSTRACT Purpose: Toilet training (TT) is an important marker in a child's physical and psychosocial development. The present study aimed to evaluate aspects associated to delayed TT. Material and Methods: We interviewed 372 parents of children who had completed TT up to 48 months before the interview. The questionnaires were applied at school exits when parents went to pick their children up and at public parks. Questions included demographics, aspects related to TT, dysfunction voiding symptom score and evaluation of constipation. Results: The interviews were performed at a mean of 15.3±10.4 (0 to 47) months after the end of TT. Girls accounted for 53% of the sample. The mean age at finishing TT was 31.6±9.3 months and similar in both genders (p=0.77). TT occurred before school entry in 45.7% of the children and medical advice for TT was sought only by 4.8% of the parents. No association was observed of age at completing TT and presence of lower urinary tract symptoms (LUTS) (p=0.57) and/or constipation (p=0.98). In the univariate analysis, prematurity (OR=2.7 [95% CI 2.3-3.1], p <0.0001) and mothers who work outside their household (OR=1.8 [95% CI 1.4-2.3], p <0.0001) were associated to delayed TT. Conclusion: Children completed TT at a mean of 2 years and 7 months of age. The age of completing TT was not related to LUTS and/or constipation. Premature children and those whose mothers work outside the home finish TT later.

Prolonged toilet training in children with Down syndrome: a case-control study / Treinamento esfincteriano em crianças com síndrome de Down: estudo caso-controle

Abstract Objectives Children with Down syndrome have delayed psychomotor development, which is a factor that influences the level of difficulty in toilet training. The current study aims to estimate the age toilet training starts and completes in children with DS compared to children with normal psychomotor development and to evaluate the method and type of toilet training most frequently used, as well as its association with lower urinary tract symptoms and functional constipation. Methods A case-control study was carried out from 2010 to 2015. All parents completed a questionnaire designed to assess the toilet training process. Lower urinary tract symptoms were assessed through the application of the Dysfunctional Voiding Symptom Score. The presence of functional constipation was assessed according to the Rome III criteria. Results The study included 93 children with Down syndrome and 204 children with normal psychomotor development (control group [CG]). The mean age of toilet training onset was 22.8 months in those with DS and 17.5 months in the CG (p = 0.001). In children with DS, the mean age when completing toilet training was 56.2 months and 27.1 months in the CG (p = 0.001). Among children with DS, females completed toilet training earlier (p = 0.02). The toilet training method used most often was child-oriented approach in both groups. No association was observed with the presence of lower urinary tract symptoms or functional constipation and the age of beginning and completing toilet training in both groups. Conclusion Children with Down syndrome experienced prolonged toilet training time. Prospective longitudinal studies are essential to gain insight into the toilet training of these children.

Resumo Objetivos Crianças com síndrome de Down apresentam desenvolvimento psicomotor atrasado, fator que influencia o nível de dificuldade do treinamento esfincteriano. O presente estudo tem como objetivo estimar a idade em que o treinamento esfincteriano é iniciado e concluído em crianças com SD em comparação com crianças com desenvolvimento psicomotor normal, avaliar o método e o tipo de treinamento esfincteriano utilizado com maior frequência, bem como sua associação com sintomas do trato urinário inferior e constipação funcional. Métodos Um estudo caso-controle foi realizado de 2010 a 2015. Todos os pais preencheram um questionário destinado a avaliar o processo de treinamento esfincteriano. O sintomas do trato urinário inferior foram avaliados por meio da aplicação do Dysfunctional Voiding Symptom Score. A presença de constipação funcional foi avaliada de acordo com os critérios Roma III. Resultados O estudo incluiu 93 crianças com síndrome de Down e 204 crianças com desenvolvimento psicomotor normal (Grupo de Controle [GC]). A idade média em que as crianças iniciaram o treinamento esfincteriano foi de 22,8 meses naquelas com SD e 17,5 meses no GC (p = 0,001). Em crianças com SD, a idade média ao concluir o treinamento esfincteriano foi de 56,2 meses e 27,1 meses no GC (p = 0,001). Entre as crianças com SD, as do sexo feminino concluíram o treinamento esfincteriano mais cedo (p = 0,02). O método de treinamento esfincteriano mais utilizado foi a abordagem voltada para a criança em ambos os grupos. Não houve associação com a presença de sintomas do trato urinário inferior ou constipação funcional e a idade no início e na conclusão do treinamento esfincteriano em ambos os grupos. Conclusão Crianças com síndrome de Down apresentaram tempo de treinamento esfincteriano prolongado. Estudos longitudinais prospectivos são essenciais para obter uma visão do treinamento esfincteriano dessas crianças.

Fecal Retention in Overactive Bladder (OAB) in Children: Perspective of a Pediatric Gastroenterologist

Coexisting voiding and bowel dysfunction in children are common in the clinic. The idea that overactive bladder (OAB) and constipation arise from one single pathophysiology has been reinforced in many studies. In Korea, a nationwide multicenter study conducted in 2009 showed that overall prevalence of OAB in children, 5-13 years of age, was 16.59% and this number has increased more recently. The initial step to manage coexisting fecal retention and OAB in children is to characterize their bowel and bladder habits and to treat constipation if present. Although diagnosing constipation in children is difficult, careful history-taking using the Bristol Stool Form Scale, and a scoring system of plain abdominal radiography, can help to estimate fecal retention more easily and promptly. Non-pharmacological approaches to manage functional constipation include increasing fluids, fiber intake, and physical activity. Several osmotic laxatives are also effective in improving OAB symptoms and fecal retention. Additionally, correction and education in relation to toilet training is the most important measure in treating OAB with fecal retention.

Fecal Retention in Overactive Bladder (OAB) in Children: Perspective of a Pediatric Gastroenterologist

Coexisting voiding and bowel dysfunction in children are common in the clinic. The idea that overactive bladder (OAB) and constipation arise from one single pathophysiology has been reinforced in many studies. In Korea, a nationwide multicenter study conducted in 2009 showed that overall prevalence of OAB in children, 5-13 years of age, was 16.59% and this number has increased more recently. The initial step to manage coexisting fecal retention and OAB in children is to characterize their bowel and bladder habits and to treat constipation if present. Although diagnosing constipation in children is difficult, careful history-taking using the Bristol Stool Form Scale, and a scoring system of plain abdominal radiography, can help to estimate fecal retention more easily and promptly. Non-pharmacological approaches to manage functional constipation include increasing fluids, fiber intake, and physical activity. Several osmotic laxatives are also effective in improving OAB symptoms and fecal retention. Additionally, correction and education in relation to toilet training is the most important measure in treating OAB with fecal retention.

Clinical Guideline for Childhood Urinary Tract Infection (Second Revision)

To revise the clinical guideline for childhood urinary tract infections (UTIs) of the Korean Society of Pediatric Nephrology (2007), the recently updated guidelines and new data were reviewed. The major revisions are as follows. In diagnosis, the criterion for a positive culture of the catheterized or suprapubic aspirated urine is reduced to 50,000 colony forming uits (CFUs)/mL from 100,000 CFU/mL. Diagnosis is more confirmatory if the urinalysis is abnormal. In treating febrile UTI and pyelonephritis, oral antibiotics is considered to be as effective as parenteral antibiotics. In urologic imaging studies, the traditional aggressive approach to find primary vesicoureteral reflux (VUR) and renal scar is shifted to the targeted restrictive approach. A voiding cystourethrography is not routinely recommended and is indicated only in atypical or complex clinical conditions, abnormal ultrasonography and recurrent UTIs. 99mTc-DMSA renal scan is valuable in diagnosing pyelonephritis in children with negative culture or normal RBUS. Although it is not routinely recommended, normal scan can safely avoid VCUG. In prevention, a more natural approach is preferred. Antimicrobial prophylaxis is not supported any more even in children with VUR. Topical steroid (2-4 weeks) to non-retractile physiologic phimosis or labial adhesion is a reasonable first-line treatment. Urogenital hygiene is important and must be adequately performed. Breast milk, probiotics and cranberries are dietary factors to prevent UTIs. Voiding dysfunction and constipation should be properly treated and prevented by initiating toilet training at an appropriate age (18-24 months). The follow-up urine test on subsequent unexplained febrile illness is strongly recommended. Changes of this revision is not exclusive and appropriate variation still may be accepted.

Síndrome de la cola de caballo secundario a hernia discal traumática / Horse-tail syndrome secondary to traumatic disc herniation

La cola de caballo representa la continuación caudal de la médula espinal. Esta porción del sistema nervioso es asiento de numerosas patologías. Se presenta un caso clínico que debutó de forma aguda con un síndrome de la cola de caballo, secundario a una hernia discal lumbar traumática. Se trata de un paciente masculino de 45 años de edad, que acude al servicio de urgencias, porque refiere síntomas que inician siete días antes de forma aguda y progresiva, luego de haber caído de una altura de tres metros. Al interrogarlo existía debilidad muscular del miembro inferior izquierdo y dificultad para caminar. El examen físico corroboró la disminución de la fuerza muscular y arreflexia Aquileo-plantar. Se realizó estudio de resonancia magnética, que demostró una hernia discal extruída en el interespacio L5-S1. El paciente se llevó al salón de urgencia y se realizó exeresis de la hernia. Egresó al séptimo día con discreta mejoría clínica. Se ha seguido en consulta externa durante un periodo de 8 meses, con muy poca recuperación del control esfinteriano, de la actividad motora y sensitiva

Horse-tail represents the caudal continuation of the spinal cord. This portion of the nervous system is the seat of numerous pathologies. We present a case report of acute debuted with a syndrome of the cauda equina, secondary to traumatic lumbar disc herniation. This is a male patient aged 45, who was admitted to the emergency room because he referred acute and progressive symptoms starting seven days before, after falling from three meters high. By questioning, we found muscle weakness in his left leg and difficulty at walking. The physical examination confirmed the decrease in muscle strength and Achilles-plantar areflexia. We performed MRI, which showed extruded disc herniation in L5-S1 interspace. The patient was taken to the emergency room and we performed the hernia excision. He was discharged at the seventh day with mild clinical improvement. We have continued the follow up as outpatient for a period of eight months. There is very little recovery of sphincter control, motor and sensory activity

Treinamento esfincteriano anal: estudo transversal em crianças de 3 a 6 anos de idade / Bowel toilet training: a cross-sectional study in children between 3 and 6 years old

OBJETIVO: Avaliar o treinamento do controle esfincteriano anal em crianças, por meio de entrevista aplicada aos pais ou cuidadores. MÉTODOS: Estudo de corte transversal em crianças sadias, aplicando-se um questionário estruturado para 100 responsáveis por crianças entre três e seis anos de idade. RESULTADOS: 97 por cento das crianças foram treinadas em casa pelas mães e 92 por cento delas utilizaram a intuição, a experiência com o filho anterior e o aprendizado com as avós. O treinamento do controle esfincteriano anal e vesical foi iniciado simultaneamente em 84 por cento dos casos, sendo o controle anal adquirido primeiramente em 41 por cento das crianças. As mães com escolaridade menor e das classes C-D-E iniciaram o treinamento mais precocemente, sendo um dos fatores relatados o custo das fraldas. Não houve diferença entre meninos e meninas para idade de início e duração do treinamento. As crianças apresentavam a maioria dos "sinais de prontidão" para o início do treinamento e, das crianças que foram treinadas no vaso sanitário, uma pequena parcela utilizou redutor e apoio para os pés. Não houve aumento significativo de constipação intestinal após o treinamento e não foram observados casos de encoprese. CONCLUSÕES: As mães foram as responsáveis pelo treinamento esfincteriano anal e o iniciaram sem auxílio especializado. Nas classes sociais C-D-E, o custo das fraldas foi determinante para o início do treinamento esfincteriano anal.

OBJECTIVE: To assess the practice of children's toilet training through interviews with parents and caretakers. METHODS: A cross-sectional study of healthy children using a questionnaire applied to parents or caretakers of 100 consecutive children aged 3 to 6 years old. RESULTS: 97 percent of the children were home-trained by their mothers and 92 percent of them used their intuition, previous experience with an older child and grandmothers' experience. Bowel and bladder toilet training started simultaneously in 84 percent of the cases, whereas 41 percent of the children mastered stool control earlier. Mothers with lower educational level and of social classes C, D and E initiated the training earlier and one of the related reasons was the cost of disposable diapers. Age in initiation or duration of toilet training was similar for boys and girls. Children presented most of the "readiness symptoms" for toilet training and only a small number of them used a seat reducer or a foot support. There was no increase in constipation prevalence after toilet training and there was no encopresis. CONCLUSIONS: Mothers were responsible for bowel toilet training and initiated it with no specialized help. In C-D-E social classes, the cost of diapers was determinant to initiate bowel toilet training.

Constipation in Children: Novel Insight Into Epidemiology, Pathophysiology and Management

Constipation in children is a common health problem affecting 0.7% to 29.6% children across the world. Exact etiology for developing symptoms is not clear in children and the majority is considered to have functional constipation. Alteration of rectal and pelvic floor function through the brain-gut axis seems to play a crucial role in the etiology. The diagnosis is often a symptom-based clinical process. Recently developed Rome III diagnostic criteria looks promising, both in clinical and research fields. Laboratory investigations such as barium enema, colonoscopy, anorectal manometry and colonic transit studies are rarely indicated except in those who do not respond to standard management. Treatment of childhood constipation involves several facets including education and demystification, toilet training, rational use of laxatives for disimpaction and maintenance and regular follow-up. Surgical options should be considered only when medical therapy fails in long standing constipation. Since most of the management strategies of childhood constipation are not evidence-based, high-quality randomized controlled trials are required to assess the efficacy of currently available or newly emerging therapeutic options. Contrary to the common belief that children outgrow constipation as they grow up, a sizable percentage continue to have symptoms beyond puberty.

Avaliação longitudinal do controle esfincteriano em uma coorte de crianças Brasileiras / Longitudinal study of sphincter control in a cohort of Brazilian children

OBJETIVOS: Avaliar a trajetória do controle esfincteriano em uma coorte de nascimento. MÉTODO: Quatro mil duzentos e trinta e uma crianças nascidas no ano de 2004, em Pelotas, RS, foram incluídas em um estudo longitudinal. Em visitas domiciliares realizadas aos 12, 24 e 48 meses, as mães responderam a um questionário com questões sociodemográficas, características dos hábitos miccionais e intestinais das crianças, com atenção ao treinamento esfincteriano. RESULTADOS: Aos 48 meses, a maioria das crianças estava sem fraldas durante o dia (98,5 por cento) e à noite (83 por cento), sem diferença entre os sexos. A idade média de início de treinamento esfincteriano foi 22 meses, com início mais precoce nas meninas. A duração média do treinamento foi de 3,2 meses, sem diferença entre os sexos. Crianças com atraso de desenvolvimento apresentaram controle esfincteriano mais tardio, havendo relação direta entre a intensidade do desvio da normalidade e a idade da retirada de fraldas. A orientação médica foi fornecida a 15,9 por cento das mães. O treinamento iniciado antes dos 24 meses esteve relacionado com uma maior idade de controle esfincteriano e maior duração do treinamento. Crianças prematuras ou com baixo peso não apresentaram diferença significativa no tempo de treinamento e idade de aquisição do controle esfincteriano. CONCLUSÕES: Até os quatro anos de idade, a maioria das crianças, inclusive prematuros e de baixo peso ao nascer, obtém controle esfincteriano independentemente de fatores externos e do sexo. O início do treinamento (antes dos 24 meses) não antecipou o controle esfincteriano, apenas prolongou o tempo de treinamento.

OBJECTIVES: To analyze sphincter control acquisition in a birth cohort. METHOD: 4,231 children born in 2004 in Pelotas, Brazil, were included in a longitudinal study. During home visits at the ages of 12, 24 and 48 months, the mothers answered a questionnaire about sociodemographic questions and characteristics of their children's voiding and bowel habits, with special attention to toilet training. RESULTS: At 48 months, most children were off diapers during the day (98.5 percent) and by night (83 percent), with no difference between sexes. The average age for starting toilet training was 22 months, with earlier initiation in girls. The training was, on average, 3.2 months long, showing no difference between sexes. Children with developmental delay had late voiding and bowel control; the higher the deviation from normality, the later the child was off diapers. Medical advice was given to 15.9 percent of mothers. The training initiated before the age of 24 months was inversely correlated with an older age of sphincter control and longer training. Premature and low birth weight children showed no significant difference in training time and age of acquisition of sphincter control. CONCLUSIONS: At the age of 48 months, most children, including premature and low birth weight ones, acquired sphincter control regardless of external factors and sex. The beginning of training (before 24 months) did not anticipate sphincter control, but only prolonged the duration of training.

A study on the toilet training and influencing factors / 소아과

PURPOSE: We aimed to determine the ideal age for initiating toilet training and investigate the factors influencing the training. METHODS: The study population comprised 1,370 children aged 2-6 years, who visited the pediatric clinics in Jeonju, Iksan, and Gunsan. Their parents were given questionnaires in order to gather data about the types of diapers used, ages when toilet training was initiated and completed for each day and night, its adverse effects, and the educational level and employment and economic status of the mothers. RESULTS: The toilet training initiation age was low for those living in the country, having an elder sibling(s), and using cloth diapers, and for those whose mothers were employed and had a low economic status. The training completion age was 22.9 months when the training was initiated before the age of 18 months; this was lower than the training completion ages of 25.9 and 31.0 months when the training was initiated at the age of 18-24 months and after 25 months, respectively. However, the required durations in these cases were 8.4, 5.6, and 3.8 months, respectively. Encopresis and refusal occurred more often when the training was initiated before the age of 18 months than when initiated after this age. CONCLUSION: Toilet training should begin at least after the age of 18 months considering the developmental status of infants. It is recommended for the future researchers to develop specific guidelines regarding toilet training.

Aquisição do controle esfincteriano em uma coorte de nascimentos: situação aos 2 anos de idade / Toilet training: situation at 2 years of age in a birth cohort

OBJETIVOS: O aprendizado do controle esfincteriano é influenciado por fatores fisiológicos, psicológicos e socioculturais. O objetivo deste estudo foi avaliar a prevalência de crianças sem fraldas aos 24 meses e seus fatores associados. MÉTODOS: Um total de 3.281 crianças nascidas no ano de 2004 em Pelotas (RS) foi incluído em um estudo longitudinal. Aos 24 meses, as mães responderam a um questionário domiciliar com questões sociodemográficas, características dos hábitos miccionais e intestinais das crianças, com atenção ao treinamento esfincteriano. Foi empregada a regressão de Poisson para as análises multivariáveis. RESULTADOS: Do total, 24,3 por cento estavam sem fraldas durante o dia, com predomínio do sexo feminino (27,8 versus 21,1 por cento, p < 0,001) e 8,6 por cento sem fraldas durante a noite, também com predomínio do sexo feminino (10,6 versus 6,8 por cento, p < 0,001). As habilidades necessárias ao aprendizado do controle esfincteriano estavam presentes em 85,5 por cento das crianças. Orientação pediátrica ocorreu em 10 por cento das crianças, mais freqüente nas mães mais ricas em relação às mais pobres (22,9 versus 4,8 por cento). Mães mais escolarizadas (13,2 por cento) e mais ricas (14 por cento) retiram as fraldas mais tardiamente; maior número de crianças em casa (risco relativo = 1,32) e indicar a necessidade de ir ao vaso (risco relativo = 11,74) aumentam a probabilidade de retirar as fraldas; tentativa anterior sem sucesso retarda a retirada de fraldas (risco relativo = 0,59). CONCLUSÕES: Embora as habilidades necessárias para a aquisição do controle esfincteriano já estejam presentes aos 24 meses, indicando que um treinamento esfincteriano pode ser iniciado, a maioria das crianças ainda não tinha iniciado esse treinamento. As mães com melhor nível de informação retardam mais esse treinamento.

OBJECTIVES: Acquisition of bladder and bowel control is influenced by physiological, psychological and sociocultural factors. The objective of this study was to evaluate the prevalence of children out of diapers by 24 months of age and the factors associated with this finding. METHODS: A total of 3,281 children born in Pelotas, RS, Brazil in 2004 were enrolled on a longitudinal study. At 24 months their mothers were visited at home and replied to a questionnaire containing questions about sociodemographic data and the characteristics of their children's urinary and intestinal evacuation habits, with special attention to toilet training. Multivariate analyses were carried out using Poisson regression. RESULTS: From the total, 24.3 percent were out of diapers during the day, with the female sex predominating (27.8 vs. 21.1 percent, p < 0.001) and 8.6 percent were out of diapers at night, also with the female sex predominating (10.6 vs. 6.8 percent, p < 0.001). The abilities needed to start toilet training were present in 85.5 percent of the children. Guidance was received from a pediatrician in 10 percent of cases, and more frequently among richer mothers than among poorer mothers (22.9 vs. 4.8 percent). Mothers who spent more years in education (13.2 percent) and were from higher social classes (14 percent) took their children out of diapers later; a greater number of children living at home (relative risk = 1.32) and being able to communicate the need to go to the toilet (relative risk = 11.74) both increased the probability of being out of diapers; previous unsuccessful attempts delayed removal of diapers (relative risk = 0.59). CONCLUSIONS: Although the abilities needed for acquisition of bladder and bowel control were already present at 24 months, indicating that toilet training could be started, the majority of children had not yet started this training. Better-informed mothers delayed training the most.

Treinamento esfincteriano: métodos, expectativas dos pais e morbidades associadas: [revisão] / Toilet training: methods, parental expectations and associated dysfunctions: [review]

OBJETIVO: Revisar a literatura científica e leiga sobre o treinamento esfincteriano, abordando expectativas dos pais, métodos disponíveis para aquisição do controle esfincteriano e morbidades associadas. FONTES DOS DADOS: Publicações no período de 1960 a 2007, obtidas a partir das bases bibliográficas MEDLINE, Cochrane Collaboration, ERIC, Web of Science, LILACS, SciELO e Google; busca em artigos relacionados, referências dos artigos, por autor e nas sociedades de pediatria. Foram examinados 473 artigos, sendo selecionados 85. SÍNTESE DOS DADOS: Os pais apresentam expectativas irreais sobre idade de retirada de fraldas, sem levar em conta o desenvolvimento infantil. As estratégias de treinamento não se modificaram nas últimas décadas, e a idade vem sendo postergada na maioria dos países. Métodos de treinamento raramente são utilizados. O início precoce do treinamento esfincteriano e eventos estressantes durante o período podem prolongar o processo de treinamento. Uma maior freqüência de enurese, infecção urinária, disfunção miccional, constipação, encoprese e recusa em ir ao banheiro é observada nas crianças com treinamento inadequado. A literatura leiga para os pais é abundante e adequada, veiculada através de livros e da Internet, mas não largamente disponível para a população brasileira. Apenas três sociedades internacionais de pediatria disponibilizam diretrizes sobre treinamento esfincteriano. CONCLUSÕES: O controle esfincteriano vem sendo postergado na maioria dos países. Os métodos de treinamento existentes são de décadas passadas, sendo pouco utilizados pelas mães e pouco valorizados pelos pediatras; o treinamento inadequado pode ser um dos fatores causadores de distúrbios miccionais e intestinais, que causam transtornos para as crianças e famílias.

OBJECTIVE: To review both the scientific literature and lay literature on toilet training, covering parents' expectations, the methods available for achieving bladder and bowel control and associated morbidities. SOURCES: Articles published between 1960 and 2007, identified via the MEDLINE, Cochrane Collaboration, ERIC, Web of Science, LILACS and SciELO databases plus queries on the Google search engine; a search of related articles, references of articles, by author and of pediatrics societies. A total of 473 articles were examined and 85 of these were selected for this review. SUMMARY OF THE FINDINGS: Parents have unrealistic expectations about the age at which diapers can be withdrawn, not taking child development into account. Toilet training strategies have not changed over recent decades, and in the majority of countries the age at which children are trained has been postponed. Training methods are rarely used. Starting toilet training prematurely and stressful events during this period can extend the training process. Children who have not been trained correctly present with enuresis, urinary infection, voiding dysfunction, constipation, encopresis and refusal to go to the toilet more frequently. Literature intended for lay parents is both abundant and adequate, available in book form and on the Internet, but it is not widely available to the Brazilian population. Just three international pediatrics societies have published guidelines on toilet training. CONCLUSIONS: Toilet training is occurring later in the majority of countries. The training methods that exist are the same from decades ago and are rarely used by mothers and valued little by pediatricians; incorrect training can be a causative factor for bladder and bowel disorders, which in turn cause problems for children and their families.

Effects of Bladder Training and/or Tolterodine in Female Patients with Overactive Bladder Syndrome: A Prospective, Randomized Study

We compared the effects of bladder training and/or tolterodine as first line treatment in female patients with overactive bladder (OAB). One hundred and thirty-nine female patients with OAB were randomized to treatment with bladder training (BT), tolterodine (To, 2 mg twice daily) or both (Co) for 12 weeks. Treatment efficacy was measured by micturition diary, urgency scores and patients' subjective assessment of their bladder condition. Mean frequency and nocturia significantly decreased in all treatment groups, declining 25.9% and 56.1%, respectively, in the BT group; 30.2% and 65.4%, respectively, in the To group; and 33.5% and 66.3%, respectively in the Co group (p<0.05 for each). The decrease in frequency was significantly greater in the Co group than in the BT group (p<0.05). Mean urgency score decreased by 44.8%, 62.2% and 60.2% in the BT, To, and Co groups, respectively, and the improvement was significantly greater in the To and Co groups than in the BT group (p<0.05 for each). Although BT, To and their combination were all effective in controlling OAB symptoms, combination therapy was more effective than either method alone. Tolterodine alone may be instituted as a first-line therapy, but may be more effective when combined with bladder training.

Intensive behavioral therapy for primary enuresis

To assess the effect of intensive behavioral therapy on Saudi children with primary enuresis. Twenty-six children, aged 6-14-years, presented with complains of bed wetting during a 12-months period from January 2001 through to January 2002, ArAr Central Hospital, Kingdom of Saudi Arabia were studied in an interventional, non-randomized trial without control. After complete verbal autopsy, physical examination and laboratory investigation, they were offered intensive behavioral therapy. They were evaluated for response, regularity, esteem and recurrence of enuresis. Mean age of the study group was 9.6-years [SD = +/- 2.6] and boys were affected almost twice of girls [P<0.05]. Family history, social history and school performance did not show any significant [P>0.05] association with enuresis. Sixty point five% were regular and out of those 27.9% never missed any visits. 91.7% were completely dry out of regular patients. There was 75% success rate in those, who visited 4-8 times while 25% in those, who visited 1-3 times. Ninety-six% of the parents and 80.7% of the children were fully satisfied with this therapy. Socio-economic status seems to play a significant [P<0.05] role in regularity of follow up and response to behavioral therapy. This result shows an excellent response to intensive behavioral therapy in primary enuresis if the follow up is regular

The 'Overlooked' Cause of Vesicoureteral Reflux in Children - Urethral Abnormalities / 대한비뇨기과학회지

PURPOSE: To emphasize the significance of urethral abnormalities as the cause of vesicoureteral reflux in children. MATERIALS AND METHODS: Current literatures were evaluated and the data in my laboratories were added. RESULTS: Vesicoureteral reflux in boys which is more common in neonates and infants, has the tendency of quicker spontaneous resolution compared to girls in spite of its bilaterality and high grade. On the other hand, vesicoureteral reflux in girls, more commonly found after the first year of life, shows slower spontaneous resolution than boys although it shows lower grades when compared to boys. Such findings are attributed to sexual difference and the urethra is suspected to play an important role. The urethra influences the bladder function through sphincter to bladder reflex during the filling phase, and urethra to bladder reflex during the voiding phase. Cobb's collar which is an obstructive urethral lesion in males, is supposed to disappear after a short existence during fetal or neonatal period. However, if it causes severe obstruction or fails to disappear, it is suspected to result in the typical male type of vesicoureteral reflux caused by voiding dysfunction and increased intravesical pressure created by obstruction itself and urethral instability. Meanwhile, urethral abnormalities in girls such as mucosal web or female hypospadias causes vaginal voiding leading to dysfunctional voiding after toilet training and consequently results in vesicoureteral reflux through bladder instability, increased intravesical pressure and urinary tract infection as well as urethral instability. CONCLUSIONS: Since the meaning of surgery in vesicoureteral reflux, in view of kidney preservation, is becoming limited to the extent of recognizing the merit of surgical correction as merely discontinuing prophylactic antibiotics, studies of urethra in children with vesicoureteral reflux is another filed in (pediatric) urology which requires more active research and treatment.