bedwetting-nocturnal-enuresis-in-children-and-young-people-assessment-and-investigation-of-nocturnal-enuresis-in-children-and-young-people.pdf

Assessment andinvestigation of nocturnalenuresis in children andyoung people

A NICE pathway brings together all NICE guidance, qualitystandards and materials to support implementation on a specifictopic area. The pathways are interactive and designed to be usedonline. This pdf version gives you a single pathway diagram anduses numbering to link the boxes in the diagram to the associatedrecommendations.

To view the online version of this pathway visit:

http://pathways.nice.org.uk/pathways/bedwetting-nocturnal-enuresis-in-children-and-young-people

Pathway last updated: 02 April 2015. To see details of any updates to this pathway since its launch,visit: About this Pathway. For information on the NICE guidance used to create this path, see:Sources.Copyright NICE 2015. All rights reserved

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Assessment and investigation of nocturnal enuresis in children andyoung people

NICE Pathways

Bedwetting (nocturnal enuresis) in children and young people pathwayCopyright NICE 2015.

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1 Child or young person with bedwetting

No additional information

2 Ask about bedwetting and related factors

Ask about the bedwetting, daytime symptoms, toileting patterns and fluid intake (see below).Use the findings to inform the diagnosis and management of bedwetting.

Consider asking the child or young person and parents or carers to keep a record of these, if itwould be useful for assessing and treating bedwetting.

Pattern of bedwetting

How many nights a week does bedwetting occur?How many times a night does bedwetting occur?Does there seem to be a large amount of urine?At what times of night does bedwetting occur?Does the child or young person wake up after bedwetting?

Bedwetting that occurs every night is severe bedwetting, which is less likely to resolvespontaneously than infrequent bedwetting.

A large volume of urine in the first few hours of the night is typical of bedwetting only.

A variable volume of urine, often more than once a night, is typical of bedwetting and daytimesymptoms with possible underlying overactive bladder.

Daytime symptoms

Does the child or young person need to pass urine frequently (more than seven times) orinfrequently (less than four times) during the day?Does the child or young person need to pass urine urgently during the day?Is the child or young person wetting during the day?Does the child or young person have abdominal straining when passing urine or a poorurinary stream?Does the child or young person have pain passing urine?


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Daytime symptoms may indicate a bladder disorder such as overactive bladder.

Pain passing urine may indicate a urinary tract infection.

Perform urinalysis.

If daytime symptoms are severe:

consider assessment, investigation and/or referralconsider investigating and treating daytime symptoms before bedwettingthis may rarely indicate an underlying urological disease.

Toileting patterns

Does the child or young person avoid using certain toilets, such as school toilets?Does the child or young person go to the toilet more or less often than his or her peers?Do daytime symptoms happen only in certain situations?

Give advice about encouraging normal toileting patterns (see information on toileting patterns inthis pathway).

Fluid intake

How much does the child or young person drink during the day?Are they drinking less because of the bedwetting?Are the parents or carers restricting drinks because of the bedwetting?

Inadequate fluid intake may mask an underlying bladder problem and may impede developmentof adequate bladder capacity.

Give advice on fluid intake (see information on fluid intake in this pathway).

Quality standards

The following quality statement is relevant to this part of the pathway.

1. Assessment


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3 Consider systemic causes, triggers, comorbidities and other factors

If bedwetting started in the last few days or weeks perform urinalysis and consider whether itcould be caused by a systemic illness.

If bedwetting is secondary (the child or young person has previously been dry at night withoutassistance for 6 months or more) ask about possible triggers.

Assess for comorbidities and other factors that may be associated with bedwetting and considerassessment, investigation and/or referral.

Action if systemic causes, triggers, comorbidities and other factors are suspected

Urinary tract infection:

investigate and treat in line with the NICE pathway on urinary tract infection in children.

Constipation and/or soiling:

investigate and treat in line with the NICE pathway on constipation.

Diabetes mellitis:

offer immediate (same day) referral to a multidisciplinary paediatric diabetes care team fordiagnosis and immediate care, in line with the NICE pathway on diabetes.

Medical, emotional or physical triggers:

consider whether assessment or treatment is needed for any identified triggers.

Behavioural or emotional problems:

consider assessment, investigation and/or referralconsider involving a professional with psychological expertisetreatment may need to be tailored to the specific needs of the family.

Maltreatment:

consider maltreatment if:a child or young person is reported to be deliberately bedwettingparents or carers are seen or reported to punish a child or young person forbedwetting despite professional advice that the symptom is involuntary


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a child or young person has secondary daytime wetting or secondary bedwettingthat persists despite adequate assessment and management unless there is amedical explanation (for example, urinary tract infection) or clearly identifiedstressful situation that is not part of maltreatment (for example, bereavement,parental separation).

For more information, see the NICE pathway on when to suspect child maltreatment.

Consider assessment, investigation and/or referral for:

history of recurrent urinary infectionsknown or suspected physical or neurological problemsdevelopmental, attention or learning difficultiesfamily problems or vulnerable child, young person or family.

Quality standards

The following quality statement is relevant to this part of the pathway.

1. Assessment

4 Do not perform urinalysis routinely

Do not perform urinalysis routinely unless the child or young person has:

started bedwetting recently (in the last few days or weeks)

daytime symptoms

any signs of ill healtha history, symptoms or signs suggestive of urinary tract infectiona history, symptoms or signs suggestive of diabetes mellitus.

5 Planning management and initial treatment

See Bedwetting (nocturnal enuresis) in children and young people / Planning management andinitial treatment of nocturnal enuresis in children and young people


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Glossary

Daytime symptoms

Daytime urinary symptoms such as wetting, urinary frequency or urgency.

Dry-bed training

A training programme that may include combinations of a number of different behaviouralinterventions, and that may include rewards, punishment, training routines and waking routines,and may be undertaken with or without an alarm.

Lifting

Carrying or walking a child to the toilet. Lifting without waking means that effort is not made toensure the child is fully woken.

Partial response

The child's bedwetting has improved but 14 consecutive dry nights or a 90% improvement in thenumber of wet nights per week has not been achieved.

Response

The child has achieved 14 consecutive dry nights or a 90% improvement in the number of wetnights per week.

Secondary onset bedwetting

The child or young person has previously been dry at night without assistance for 6 months ormore.

Waking

Waking a child from sleep to take them to the toilet.

Sources

Nocturnal enuresis: the management of bedwetting in children and young people. NICE clinicalguideline 111 (2010)


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Your responsibility

The guidance in this pathway represents the view of NICE, which was arrived at after carefulconsideration of the evidence available. Those working in the NHS, local authorities, the widerpublic, voluntary and community sectors and the private sector should take it into account whencarrying out their professional, managerial or voluntary duties. Implementation of this guidanceis the responsibility of local commissioners and/or providers. Commissioners and providers arereminded that it is their responsibility to implement the guidance, in their local context, in light oftheir duties to avoid unlawful discrimination and to have regard to promoting equality ofopportunity. Nothing in this guidance should be interpreted in a way which would be inconsistentwith compliance with those duties.

Copyright

Copyright National Institute for Health and Care Excellence 2015. All rights reserved. NICEcopyright material can be downloaded for private research and study, and may be reproducedfor educational and not-for-profit purposes. No reproduction by or for commercial organisations,or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE

National Institute for Health and Care ExcellenceLevel 1A, City TowerPiccadilly PlazaManchesterM1 4BT

www.nice.org.uk

[email protected]

0845 003 7781


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bedwetting-nocturnal-enuresis-in-children-and-young-people-assessment-and-investigation-of-nocturnal-enuresis-in-children-and-young-people.pdf