Alarm interventions for nocturnal enuresis (bedwetting) in children

Review question

Is alarm training an effective treatment for bedwetting in children?

Background

Bedwetting is common in childhood and affects up to 20% of five-year-olds. Although children may spontaneously recover from this, bedwetting can have significant social, emotional and psychological effects on the child and their family. Treatments for bedwetting include alarms (activated by urination), behavioural interventions and drugs.

How up-to-date is this review?

The evidence is current up to 25 June 2018.

Study characteristics

This review includes 74 trials involving 5983 children.

Study funding sources

Three of the studies included in the review were funded or supported by a pharmaceutical company.

Key results

Alarms may be better than no treatment in terms of reducing the number of wet nights a week and increasing the number of children achieving 14 consecutive dry nights. Alarms may increase the number of children remaining dry after stopping treatment, compared to no treatment.

We are uncertain if there is any difference between alarms and behavioural interventions (such as bladder training), or between alarms and desmopressin medication in terms of reducing the number of wet nights a week, increasing the number of children achieving 14 consecutive dry nights and increasing the number of children remaining dry after stopping treatment.

We are uncertain whether alarms reduce the number of wet nights more than placebo drugs, other types of alarms, tricyclics medication, or various treatments such as hypnotherapy or restricted diet.

Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin alone. It may increase the number of children achieving 14 consecutive dry nights and increase the number of children remaining dry after stopping treatment. Alarm plus dry-bed training may increase the number of children achieving 14 consecutive dry nights compared to dry-bed training alone, but we are uncertain if the response is maintained after stopping treatment.

Due to very low-quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone.

Alarm therapy probably reduces the number of children experiencing adverse events compared with desmopressin. We think there is probably a slight increase in adverse events between code-word alarms and standard alarms but until we have more evidence from more children we cannot be certain about this. We are uncertain about the safety of alarm therapy compared to other treatments, because the quality of evidence is very low.

Quality of the evidence

The quality of the evidence means that, in general, the level of certainty in our conclusions is low.

Authors' conclusions

Alarm therapy may be more effective than no treatment, but due to the low-quality evidence we do not know how much alarm therapy is more effective than none at all. Adding alarm therapy to desmopressin may be more effective than desmopressin alone. Despite the large number of trials we identified, the low certainty of the evidence means that we cannot tell from these studies whether or not alarm therapy is better than most other therapies for reducing bedwetting in children. We cannot be sure about its effects until there are better-designed trials.

Authors' conclusions: 

Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately-powered trials with robust randomisation are still needed to determine the full effect of alarm therapy.

Read the full abstract...
Background: 

Enuresis (bedwetting) affects up to 20% of five-year-olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs.

Objectives: 

To assess the effects of enuresis alarms for treating enuresis in children.

Search strategy: 

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles.

Selection criteria: 

We included randomised or quasi-randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old.

Data collection and analysis: 

Two review authors independently assessed risk of bias and extracted data.

Main results: 

We included 74 trials (5983 children).

At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) −2.68, 95% confidence interval (CI) −4.59 to −0.78; 4 trials, 127 children; low-quality evidence). Low-quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post-treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low-quality evidence).

At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD −0.96, 95% CI −2.32 to 0.41; 1 trial, 47 children; very low-quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low-quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post-treatment.

Compared with control alarms, code-word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate-quality evidence) but there is probably little to no difference in the number of children remaining dry post-treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate-quality evidence). Very low-quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm.

At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry-bed training, and star chart plus rewards) (MD -0.81, 95% CI -2.01 to 0.38; low-quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low-quality evidence) and may slightly increase the number of children remaining dry post-treatment (RR 1.39, 95% CI 0.81 to 2.41; low-quality evidence).

The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD −0.64, 95% CI −1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low-quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post-treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate-quality evidence).

At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post-treatment, because the quality of evidence is very low.

Due to very low-quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet.

Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD −0.88, 95% CI −0.38 to −1.38; 2 trials, 156 children; low-quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low-quality evidence) and the number of children remaining dry post-treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low-quality evidence) compared with desmopressin alone.

Alarm plus dry-bed training may increase the number of children achieving a complete response compared to dry-bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low-quality evidence). It is unclear if there is any difference in the number of children remaining dry post-treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low-quality evidence). Due to very low-quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone.

Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain.

There is probably a slight increase in adverse events between code-word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate-quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate-quality evidence). Very low-quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments.

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