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Separating Fact from Fiction in Pediatric Medicine: Nocturnal Enuresis

chirobedwetting

There is no role of chiropractic in treating childhood bedwetting

In pediatrics, very few things are completely black and white. This is an aspect of conventional medicine in general that tends to separate the approach of science-based practitioners from that of proponents of the many forms of irregular medicine commonly discussed on SBM. They appear to experience no shame in claiming absolute certainty while doling out all manner of implausible remedies for ailments ranging from the well-established to the fictional.

While we do face questions from patients and their caregivers regarding largely invented diagnoses in pediatrics, with chronic Lyme disease and non-celiac gluten sensitivity being just two of many increasingly encountered concerns, my experience has been that alternative medical providers tend to focus their efforts on the same real problems that pediatricians and family practitioners deal with on a daily basis. And I don’t believe that it is mere coincidence that these conditions are largely self-limited in nature, a fact often not shared. Parental and patient buy-in is often more easily obtained with certainty rather than nuance.

Chiropractors, for example, seem to pride themselves on their ability to cure ear infections. Of course in greater than 80% of children with acute ear infections, symptoms will resolve without any intervention whatsoever. This is why the AAP has been trying for years to decrease the rates of antibiotic prescriptions for ear infections, unfortunately with little in the way of success thus far. And when the infections don’t resolve on their own, there is no good evidence that anything a chiropractor has to offer can help. The same can be said for their claims regarding colic and gastroesophageal reflux, which I’ve written about before.

Another condition frequently mentioned by chiropractors as being particularly in their wheelhouse is nighttime bedwetting, the medical term for this being nocturnal enuresis. Rarely have I seen a chiropractic website with a section on the benefits for children that does not mention their success in curing bedwetting. Fred Clary, DC, even claims on his website to be able to cure bedwetting in the newborn baby. And to think I’ve just been ignoring the problem as a newborn hospitalist. Is it because the thought of a newborn infant gaining continence is absurd, or am I just a shill for Big Pampers?

With nocturnal enuresis, as with all of pediatric healthcare, there is a science-based approach that takes a variety of factors into account. In fact, bedwetting is an excellent example of the success that comes with considering the biology, psychology and social environment of a patient. You could even call it a holistic approach if that weren’t such a loaded description. I prefer biopsychosocial.

In keeping with my usual pattern, before I delve into the idiocy of the chiropractic conceptualization of bedwetting and its approach to treatment, please allow me to present a science-based understanding:

What is nocturnal enuresis?

Incontinence is essentially universal in infants and toddlers, particularly while asleep for long periods of time. Nobody, with perhaps the exception of Fred Clary, expects a 2-year-old, let alone an infant, to consistently make it through a substantial period of sleep without voiding urine. Most readers, especially those with kids or who have worked with younger children, realize that there is a normal range of a few years during which kids will usually acquire the ability to stay dry through the night. What many readers may not realize is how common it is for kids to take longer than expected. In general, we consider children over the age of 5 years who continue to have intermittent episodes of nighttime incontinence as having the diagnosis of nocturnal enuresis (NE).

As many as 10-15 out of every 100 6-year-old children are unable to hold urine in the bladder for long periods of sleep. As these children age, the numbers tend to decrease with roughly an additional 15 per 100 achieving nighttime continence all on their own each year. When all is said and done, 1%-2% of adults continue to have occasional bedwetting. These older kids, and the few adults, who are unable to ever completely maintain overnight continence for a period of at least 6 months without assistance, and who otherwise are healthy, have primary monosymptomatic nocturnal enuresis (PMNE).

When kids have nocturnal enuresis in the setting of additional conditions, such as urinary tract infections, urine incontinence while awake, anatomical abnormalities, or neurologic bladder dysfunction, they are diagnosed with nonmonosymptomatic nocturnal enuresis (NMNE). Children who are able to go 6 months without wetting the bed, and without any of the treatment approaches I’ll be discussing, who then have a recurrence have secondary nocturnal enuresis. Accuracy of the diagnosis is important when deciding on a treatment plan and for prognostic implications.

When is nocturnal enuresis a problem?

When nighttime incontinence becomes a problem really depends on the individual child and his unique social environment, in particular the expectations of the caregivers. If the parents aren’t worried about their healthy 6-year-old wetting the bed occasionally, and the kid is oblivious, then starting any kind of treatment plan would likely not be worth the trouble. And it may even backfire. Simple reassurance and expectant management usually will suffice.

Some families may only be interested in an approach that will allow for continence on a short-term basis, such as for a summer camp or a slumber party, while still allowing nature to take its course for the most part. Unfortunately, not all parents have such a laid back response to NE. It is common for children to develop feelings of guilt, and to be repeatedly punished for something they have no control over. The potential for physical abuse is a very real concern, especially when parents begin to blame or resent the child.

In general, NE is a problem and requires a comprehensive treatment approach when the family unit asks for help, not just the caregivers. For the child, the desire to achieve continence typically becomes urgent once wetting the bed begins to limit his or her ability to interact socially. And it is important to strike while the iron is hot, so to speak, in order to then prevent untoward psychological repercussions. It is actually critical to the success of any management approach, however, that the child is bothered by the NE enough to demonstrate their readiness to assume responsibility for their own treatment.

Why does primary monosymptomatic nocturnal enuresis happen?

The development of mature bladder function, and the ability to maintain continence while asleep, relies upon the coordination of the autonomic (involuntary) and somatic (voluntary) nervous systems within the spinal cord and brain. Ultimately, we are able to store urine in a relaxed bladder until we consciously decide to urinate. During urination, the muscles in the bladder wall squeeze and the pressure at the bladder outlet decreases to allow urine to exit the bladder via the urethra.

Initially we have no conscious control over this process. As the infant bladder fills, it will eventually begin to contract in order to empty. As we age, awareness of having a full bladder begins to develop followed by the ability to purposefully hold off contraction of the bladder wall muscles. As more time passes, the ability to time bladder contraction with relaxation of the bladder outlet comes online. Thus continence while awake comes first, followed ultimately by the ability to make it through a long sleep period at around age 5 years, give or take a year, for the majority of children.

There are many factors that can contribute to the development of PMNE, which again occurs in otherwise healthy kids and makes up the vast majority of nocturnal enuresis cases. At the core, however, is the absent or inconsistent arousal from sleep in response to the need to urinate, and children are often described by caregivers as especially deep sleepers. Delayed maturation of bladder function likely plays some role, which might explain why it tends to resolve over time even without intervention. But PMNE likely will still occur in many children despite normal bladder function if the limits of their ability to hold urine overnight are pushed to the breaking point and they simply don’t wake up in time.

A smaller than average capacity to hold urine while asleep as well as excessive urine production can exacerbate this problem. This can occur when a child drinks a large amount of fluid right before bed, or if there is a relative insensitivity or underproduction of antidiuretic hormone (ADH, also known as vasopressin), a chemical in the body which helps to regulate water retention in the kidneys. It is thought that ADH secretion is normally increased overnight following a circadian pattern and that this pattern is developmental, perhaps explaining why some children simply grow out of PMNE.

There is a large genetic component to PMNE as well. When one identical twin has delayed continence, there is a 68% chance that the other twin will as well, while the concordance with non-identical twins is still significant at 36%. Three of every four children born to parents with a history of PMNE will also have delayed continence, while the risk is 50% when just one parent was affected.

Naturally, when a child presents with concerns of bedwetting at an older than typical age, it can’t be assumed to be a primary and largely self-limiting condition such as PMNE. It is extremely important to consider and rule out, with a thorough history and physical exam usually being all that is necessary, more worrisome potential causes. A number of serious medical conditions can present with bedwetting, such as seizures and diabetes, as well as anatomical abnormalities involving the spinal cord.

Even simple constipation, although not as serious as a tethered spinal cord or spina bifida, can cause bedwetting in an older child. There are many more examples of pathological causes of NE, some of which are not intuitively linked to bedwetting such as pinworms, obstructive sleep apnea and psychologic comorbidities. I’ll spare you the full differential breakdown. I hope that it is abundantly clear how inappropriate it is for inadequately-trained alternative medicine practitioners to consider themselves experts on this topic.

Science-based treatment of primary monosymptomatic nocturnal enuresis

As I mentioned earlier, our understanding PMNE is biopsychosocial in nature. The approach to treatment also takes into account the psychosocial aspects of the condition as well as the biology. In fact, lifestyle changes, sometimes aided by some nifty technology, are first line treatments. With few exceptions, such as a pressing need to achieve continence quickly in order to preserve declining psychosocial functioning, pharmaceutical interventions take a backseat to lifestyle modifications.

In general, the goals of PMNE intervention don’t include achieving immediate and permanent continence as quickly as possible. In order to reduce the risk of frustration, the focus is on incremental improvement. And treatment shouldn’t even be initiated until the child as well as the caregivers demonstrates readiness. The child must be responsible for his treatment and understand that the process can be lengthy. The parents must be supportive and aware of the need to avoid blaming the child or incorporating punishment into the treatment regimen.

Lifestyle modifications can, and probably always should, include the limiting of fluid intake in the hour before bedtime, keeping in mind that hydration status takes precedence over bedwetting. Establishing a pattern is rarely easy with children, but a consistent bedtime routine, including an appropriate amount of total nightly sleep, can help reduce bedwetting by preventing excessive fatigue. Keeping a calendar for documenting dry versus wet nights, along with other details such as the number of nightly episodes and new symptoms can also be very helpful.

Appropriate means of motivating a child to actively take part in achieving continence overnight can involve the use of reward systems, such as sticker or star charts. When a child makes it through a night without wetting the bed, or meets some other agreed upon goal, he or she can place a sticker or star on the chart. Once requirements have been met, such as a certain number of consecutive dry nights, the child is rewarded. Passive interventions such as this are often tried for several weeks or longer if more urgent continence is not needed.

The use of bedwetting alarms or pharmaceutical intervention, particularly in older children with increasing social concerns or negative psychological sequelae, can be extremely effective. And medication is the only way to achieve immediate continence when desired, although NE may return as soon as the drug is discontinued. Alarms work via a moisture detector typically positioned in the child’s underwear, and can be audible or vibratory. Initially, the alarm simply wakes the child up once he has already begun to wet the bed. Over time, the child is conditioned to wake up prior to actually voiding, or to suppress urination without waking. They work well but are limited to older kids with a strong will to achieve continence, and who will wake up to the alarm. They are not ideal in situations where continence is needed quickly or only for intermittent short periods.

The drug most commonly used to prevent bedwetting is desmopressin, a synthetic version of the antidiuretic hormone naturally secreted by the brain. This is the hormone that is believed to deficient, or less active because of receptor insensitivity, in some children with PMNE. It works by binding to specific receptors in the collecting ducts in our kidneys, increasing the reabsorption of water into the blood and decreasing urine output. This effect is rapid in onset, and the drug is often successful on the first night of use.

It is not risk free, although complications are pretty rare. The most significant potential adverse effect can occur in the setting of a child drinking a large amount of fluid prior to taking the medication. The combination of increased intake and decreased urine output can lead to dilution of the blood and a potentially dangerous drop in the serum sodium level. This dilutional hyponatremia can, in rare instances, cause changes in mental status, seizures, coma and even death. This outcome was more common with intranasal administration of the drug, which is no longer recommended in children with bedwetting.

Medical interventions, whether simple education and reassurance, lifestyle modifications, or pharmaceutical agents, are highly successful. But they aren’t perfect by any means. PMNE is a condition which takes time to resolve. And, as stated previously, it will eventually resolve completely on its own in time in roughly 98% of children.

For a more detailed discussion of the evaluation and treatment of PMNE, here are the 2010 recommendations of the International Children’s Continence Society, which is the worst name for a superhero team ever, just beating out the International League Against Epilepsy. I do admire their work however.

What is the chiropractic approach to noctural enuresis?

Now that you know the science-based medical understanding of why nocturnal enuresis occurs and our approach to treatment, let’s take a look through the looking glass at how this condition is conceptualized by the chiropractic community. As expected, their take runs the gamut from the utterly devoid of rational thought to the only slightly nutty, with many chiropractic websites getting a number of things right. Many, for example, explain how NE is not the child’s fault and that punishment can be counterproductive.

One common theme I discovered on my journey was the blaming of bedwetting on an immature “phrenic reflex” and subsequent development of elevated levels of carbon dioxide in the blood, with one chiropractor going so far as to claim that “The typical bed wetting child sleeps in a high state of carbon dioxide intoxication.” Their explanation goes like this: infants are incontinent because an elevated carbon dioxide level fails to stimulate the phrenic reflex, which causes diaphragmatic contraction and increased respiratory activity which in turn lowers carbon dioxide levels. Carbon dioxide acts as a relaxant for smooth muscles (muscles we don’t control consciously, like the bladder wall), so high levels cause relaxation of the smooth muscle in the bladder outlet and undesired nocturnal urination. (1)(2)(3)(4)(thousands more)

And what is to blame for this supposed delayed maturity of the “phrenic reflex?” After a brief mention of the possibility of a genetic contribution, which is of course true but not in the way they are claiming, the bulk of their discussions focus on, you guessed it, the subluxation. This fictional cause of all ailments is behind the poor functioning of the phrenic nerves. Something, something, something nerve interference of the 3rd, 4th and 5th cervical spinal nerves which innervate the diaphragms by way of the phrenic nerves, one for each of the left and right hemidiaphragm. Many chiropractic websites also claim that subluxations involving lower thoracic, lumbar and sacral spinal nerves directly lead to incontinence.

It may sound compelling, but it’s all complete baloney. First off, their version of the “phrenic reflex” is a fiction. In newborns, there is a little-known reflex called the intercostal-phrenic reflex which actually inhibits breathing when the rib cage is distorted. It has absolutely nothing to do with levels of carbon dioxide in the blood and it doesn’t increase respiration.

Speaking of carbon dioxide, rising levels do tend to increase the respiratory drive, but by stimulating chemoreceptors in the aorta, carotid arteries, and brainstem, rather than by a “phrenic reflex.” The increase in breathing keeps the levels in check in healthy individuals. If a young infant were to fail to respond to this signal to increase the respiratory drive, as sometimes happens for reasons poorly understood, they die. This is actually one of the proposed mechanisms of Sudden Infant Death Syndrome (SIDS).

Hypercapnia, the abnormal persistent elevation of carbon dioxide in the blood, can cause acidosis and a number of symptoms including but not limited to difficulty breathing, headache, altered mental status, cardiac arrhythmias, seizures, coma and death. It does not cause isolated bedwetting. In fact, if elevated levels of carbon dioxide in the blood caused relaxation of bladder smooth muscle it would cause urinary retention rather than incontinence. Urination requires contraction of the bladder wall, not just relaxation of the bladder outlet. Medications that relax smooth muscle in the bladder are actually often used to treat incontinence related to overactive bladder syndrome.

Finally, if both phrenic nerves, which again contain contributions from the 3rd, 4th and 5th cervical spinal nerves, were not functioning properly a child would have paralyzed diaphragms (C, 3, 4, 5, keeps the diaphragm alive!) and severe respiratory problems if not an inability to breath at all. This actually happens sometimes during vaginal deliveries when significant lateral force on the head and neck is required to deliver a large baby that has become stuck at the shoulders. This can stretch the cervical spinal nerves to the point of injury or even complete transection, causing diaphragmatic paralysis as well as other unfortunate injuries.

Despite hours of reading chiropractic claims regarding bedwetting, I failed to find any legitimate discussion of the potentially serious causes of nocturnal enuresis. Parents could likely search hundreds of chiropractic websites without coming across any mention of red flags for conditions that would need evaluation and treatment by a real physician or surgeon. These are the people that want to work as primary care providers to children.

In addition to chiropractic, a wide variety of alternative medical treatments have been used to treat nocturnal enuresis in children. The folks at Cochrane reviewed the available evidence in 2011, and didn’t have anything positive to say in their conclusion:

There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture, chiropractic and medicinal herbs but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects clearly reported.

That’s about as negative as Cochrane gets, but I disagree with any calls for more research. This pattern of weak evidence is typical of modalities that work via the many placebo effects when investigated as a treatment for a largely self-resolving condition. Let’s think of an activity off the top of our heads. How about knitting? Knitting by a caregiver in the same room as a sleeping child. Wait. Knitting in a different country while simply thinking of the little bedwetter. I am confident that intercessory knitting would be found to have weakly positive benefits for children with PMNE if studied by proponents. Some kind of an alternative sewing circle perhaps.

Here is a nice breakdown of two of the frequently cited, but painfully weak, studies cited by chiropractors to support their claims of success treating nocturnal enuresis.

Conclusion

Bedwetting is a common pediatric complaint with a multifactorial etiology. It is usually benign and almost always improves over time, with 98% of children with primary monosymptomatic nocturnal enuresis eventually becoming fully continent. Interventions exist which can involve simple reassurance and education, bedwetting alarms, or pharmaceutical agents. They all have solid evidence of success and relatively few risks.

Any time a child continues to wet the bed past the typical age of roughly 6 years, and whenever a continent child has a recurrence of nocturnal enuresis, it is vital to rule out a number of potentially-serious problems. When practitioners of chiropractic, or any field inadequately trained in pediatric healthcare, believe that they are capable of assuming the role of primary care provider for children, there is a very real risk of a delayed diagnosis of one of these conditions. One need look no further than the information available for caregivers online to see that chiropractic education is vastly inferior to that of practitioners of science-based medicine.

Posted in: Science and Medicine

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91 thoughts on “Separating Fact from Fiction in Pediatric Medicine: Nocturnal Enuresis

  1. Windriven says:

    Has anyone done a study of nocturnal CO2 in bedwetting children? I can’t find one in Pubmed. It would seem a simple matter to fit 100 kids with tcPCO2 monitors and graph CO2 versus enuresis. This should prove conclusively that the quacks, as usual, have it dead wrong.

    1. Earthman says:

      But if there is no reason to suppose that raised CO2 is involved then such a study may be unethical. You do not experiment on children without just cause. Wakefield fell into that trap.

      1. Windriven says:

        I don’t see the ethical issue here, Earthman. tcpCO2 is non-invasive, the ‘tc’ is transcutaneous. The chiroquacksters have made a claim that should be trivial to prove false without so much as a pin prick to the test subjects.

      2. Chris Hickie says:

        You might be able to obtain this data by going through sleep studies in children (done at sleep study labs) to see what exhaled CO2 was–provided they are documenting whether enuresis occurred during the sleep study. But, again, if CO2 is involved in muscle relaxation, it’s almost certainly via changes in pH due to CO2/HCO3- , and not by direct effect of CO2 via some sort of CO2 receptor on muscle. And as mentioned, voiding requires both relaxation of some muscles and contraction of others, so now you’d have to proposed different mechanisms in different muscles in response to CO2 as well.

        This is an excellent review of nocturnal enuresis and why chiropractors have no basis for their theories but will still come out smelling like freshly cleaned bedsheets most of the time when they “treat” nocturnal enuresis.

  2. goodnightirene says:

    This is a great rundown of NE, something I didn’t encounter with my brood, but some friends did, one in which the NE persisted into his teens, but did ultimately resolve–without a chiro, thank you. In those days I don’t ever recall encountering a friend who considered an alternative practitioner for ANY medical problem, yet today I bump up against such rot almost constantly. What gives?

    Yesterday I informed a neighbor that chiros don’t go to any kind of medical school and advised her to peruse what little is revealed of actual chiro education. She, of course, declined and made it clear that HER chiro is a saint and his training simply doesn’t matter to her. The upshot was that she would prefer it if I do not bring up the subject again. Sigh.

    The awful thing is that the value of education itself seems to be under threat. People do not want to hear anything about what “experts” (the quotes are theirs, not mine) might think. Being better educated than my neighbors holds no advantage. Being better informed than equally educated friends fares no better. It’s getting lonely out there.

    1. Windriven says:

      “Being better informed than equally educated friends fares no better.”

      Sadly Irene, there is a growing (in my perception) disconnect between schooling and education. How is it that a person can attain a university degree and lack the ability to reason coherently or to employ the scientific method?

      Our growing interconnectedness and the torrent of information available at a keystroke demands ever more finely tuned critical thinking skills lest we be lost in a whirlpool of intrigues and superstitions and gossip. Instead we get college graduates who hang their thoughts from skyhooks and splice them together with hopes and dreams. These same nitwits vote, breed, and fuel naked economic bubbles.

      Western civilization has come a long way since the Enlightenment. But I fear that continued progress is being carried by a diminishing fraction of the population.

    2. nurseratchet says:

      My uneducated sister married a chiropractor and now is an expert on all diseases and medical problems! She has taken no classes just parrots whatever crap he spouts as reality. It is enormously difficult to keep biting my tongue in the interest of family unity. And now, my niece is training to be a naturopath. She never showed any interest in real medicine until her mom married the chiro……. family parties will be even more uncomfortable!

      1. Clay Jones says:

        And I thought it was a tragedy when I found a Feng Shui book at my brother’s house. No more complaining from me.

      2. Thor says:

        That’s why a mind infused with irrational belief systems, to which CAM and pseudoscience belong, is like a virus that easily gets transmitted among close contact with others. And as has been said, once one starts believing crazy, make-believe things, the mind gets primed for more and more. Almost anything becomes acceptable, plausible, believable. The confirmation bias will ensure that all three will actively continue to acquire the “evidence” for their investment (mental, emotional, financial). All information, facts, evidence to the contrary will go in one ear and out the other. Sorry if I’m pessimistic but often minds don’t recover from this virus. For many, “healing” does take place.
        At least loosen the grip of teeth on tongue temporarily to let out one or two thoughtfully chosen, well-timed sentences to plant as seeds. Someone, somewhere might just think about it sometime. Good luck!

  3. Thor says:

    This really must be Chiropractic Month at SBM. ;-)
    Perhaps commenters are a bit weary of the subject though, judging from the paucity of comments. I, for one, am not. We should never tire from actively countering the claims made by the mostly pseudo-profession that is chiropractic. We owe it to humanity.

    Excellent, thorough job, Dr. Jones. And thanks for two new terms (to me, at least):
    “irregular medicine” and “biopsychosocial”, which you may have even coined.

    1. Clay Jones says:

      The term Biopsychosocial was well established long before I came along. I might have coined irregular medicine. I first used it in the title of a Grand Rounds I gave at Vanderbilt Children’s Hospital as a senior resident in 2003. I’ll have to google it.

      1. Clay Jones says:

        Nope, goes back to at least the late 18th century.

        1. Thor says:

          I’ll be. They’re certainly not used often (couldn’t find bps in the dictionary), so thanks for the exposure.

      2. Clay Jones says:

        Oops, 2006 not 2003. Not that it really matters.

      3. Chris Hickie says:

        Sadly, “holistic” has a better marketing ring to it than “biopsychosocial”. I’ve gotten sideways looks from parents when I’ve talked about using the biopsychocial model to help care for patients. Besides being a many-syllable hybrid word, it’s got “psycho” in it. Maybe something like “body-mind-world model” might sound better.

  4. Nicole says:

    Thanks for a great rundown! Not that I had any intention of visiting a chiropractor for anything…but my youngest daughter suffers from nocturnal enuresis. She has been under the care of a pediatric urologist for about 3 years, because of recurrent UTIs; he has reached the point of giving up – he just says, let’s wait and see if she grows out of it. Which is incredibly frustrating as a parent. I appreciate the links to the real science!

    1. Clay Jones says:

      It’s always okay to get a second opinion. I’m perhaps a bit biased, but I think that the appropriate specialty, when a specialist is needed for this, is pediatric nephrology rather than a surgeon.

  5. n brownlee says:

    Dr. Jones- My nephews had serious and persistent NE into their teen years, and beyond. In one boy it did resolve pretty well by his early teens. But they both have a return of symptoms if they drink milk! When they were kids, I could hardly credit it- their mother, my sister, believes in every possible alternative medical crackpottery, and every time a new one comes along she adds it to her list of remedies and ailments.

    However, these guys are now well into middle age- and still react when they consume uncooked milk. They have no other symptoms of lactose intolerance or milk allergy. I’ve never heard ‘milk allergy’ given as a possible cause of NE. Do you know of any basis for plausibility?

    1. Clay Jones says:

      Food sensitivities are one of the many likely bogus theories out there. I couldn’t find anything remotely legitimate on pubmed. It’s all anecdotal for the most part.

  6. Stephen S. Rodrigues, MD says:

    “They all have solid evidence of success and relatively few risks.”

    Your use of the team “solid” is not science based but your own opinionated concept.
    Abandoning CAMs just because of a belief system is kinda will unscientific.

    We do not know a lot of the pathophysiology of these problems, let the family’s decide, collect the data after a few years and compare the results. That’s science!

    1. Clay Jones says:

      No, an opinion is that you have contributed nothing to this discussion. A fact is that the science-based interventions for PMNE are effective and safe, but it is often okay to simply allow time to solve the problem.

      1. Windriven says:

        “No, an opinion is that you have contributed nothing to this discussion. ”

        And that particular opinion is widely enough held to be nearly a fact.

      2. No contribution? So why comment?

        If the problem will eventually resolve by nature, why bother with any interventions at all.

        Why not just pacify the problem with diapers and alarmes until them.

        What you guys are up to is an attempt to dictate to the public what options they are allowed based on your agendas. NO that is not equitable or fair or even ethical.

        1. WilliamLawrenceUtridge says:

          No contribution? So why comment?

          Because it’s like trying to explain long division to a walrus. No matter how often you repeat yourself, no matter how many analogies you use, all you get is some bellowing and a blank stare.

          If the problem will eventually resolve by nature, why bother with any interventions at all.

          Read the post, Dr. Jones discusses several reasons why. Plus, the problem doesn’t resolve in all cases.

          Why not just pacify the problem with diapers and alarmes until them.

          These don’t pacify there champ, and way to be an asshole to people with embarrassing problems. Do you treat kids? If they cry when getting a shot, do you slap them and tell them to stop being sissies? Again, Dr. Jones discusses the use of alarms and how they can help. Read the post instead of sounding off to…I’m not even sure what your goal is, trolling?

          What you guys are up to is an attempt to dictate to the public what options they are allowed based on your agendas. NO that is not equitable or fair or even ethical.

          Oh bullshit. Seriously, do you think this is the official blog of the CDC or something? Do you see any problem with Dr. Jones analysis of the conventional treatment of nocturnal enuresis or his criticism of chiropractic?

          Of course not. This is simply more attempts to bash and bring down real medicine so you can offer your preferred quackery of acupuncture without having to justify why you use such an unethical, unscientific, unproven approach. It’s sour grapes because you can’t hack being a real doctor.

          Also, you appear to be applying “fairness” and “equability” (synonyms by the way) and “ethics” because you don’t have the evidence that would justify your current treatment of patients. Medical interventions don’t need to be fair they need to be evidence-based. What, should we make patients get acupuncture rather than dolasetron because a certain number of quacks think it is effective? How about we apply this to history as well – some kids learn Columbus was the first non-Aboriginal to see the Americas, some learn about Zheng He, so we can be fair to Gavin Menzies? Oh, how about planet formation – some kids learn about gravity while others learn about God? Should we Teach the Controversy and Treat with Quackery?

    2. Windriven says:

      “We do not know a lot of the pathophysiology of these problems, let the family’s decide, collect the data after a few years and compare the results.”

      What the eff does that garbage pail of words even mean, Steve? I understand each word by itself. But you have ordered them in such a way that the resulting sentence could get its own prescription for clozapine.

      1. Thor says:

        Yeah, it really boggles the mind.
        The way you’ve ordered your words makes me laugh, W.
        You deserve a prize for some of the best retorts.

        1. When someone has a vast amount of real life experiences, the concepts expressed can seem improbable or inconceivable. Once you have gained this knowledge and experience ( If ) you may one day understand.

          1. WilliamLawrenceUtridge says:

            When someone has a vast amount of real life experiences, the concepts expressed can seem improbable or inconceivable. Once you have gained this knowledge and experience ( If ) you may one day understand.

            If that person’s real-life experience is contradicted by 3,000 clinical trials that suggest that person’s beliefs are erroneous, and they still won’t change them, that suggests the person’s knowledge and experience may not be worth much. Which isn’t really a novel or dramatic thing – people are notoriously bad at imputing causality, which is why science is necessary.

            Further, if that person’s abilities are in an area where placebo effects are strong, and those abilities disappear when scientific controls are applied, doesn’t that suggest that the effects are pure placebo? If not, why not?

          2. Windriven says:

            “the concepts expressed can seem improbable or inconceivable”

            Steve, no “concepts” are in evidence in that slag heap of a sentence above. Launching a bunch of words to orbit the illusion that you do something useful is obfuscation not communication.

        2. Windriven says:

          (Blush)

          Rodrigues is my muse. Whenever he puts fingers to keypad the result is what the military terms a ‘target rich environment.’

          1. n brownlee says:

            And you’re so… creative. I just want to hit him in the head with a pig bladder.

            1. Windriven says:

              Well he is pig-headed. Maybe somebody beat you to it.

    3. WilliamLawrenceUtridge says:

      Jebus, can we finally say that steve-o has crossed the douche horizon, contributes nothing to the discussion, and just ban him already? I’m wearing out my keyboard replying to his tedium, and there’s nutters quacking about Ebola on the other thread just begging for some attention.

      We do not know a lot of the pathophysiology of these problems, let the family’s decide, collect the data after a few years and compare the results. That’s science!

      How on earth would your suggestion illuminate the pathophysiology of the problem? Not to mention, that work has already been done – note Dr. Jones’ statement that NE gets better by about 15% every year, dropping steadily until it reaches a steady-state of 1-2%. What you are describing is observation, not science.

      I really wish you’d stop lecturing people about what science is, since it’s pretty obvious you don’t know. Can you give a coherent definition of science is? Have you ever?

      1. MadisonMD says:

        I think SSR should stay. Exposing his barely comprehensible irrational ideas to the view of the casual reader of SBM illustrates the intellectual vacuity of altmed and reinforces the need for a rational, scientific approach. This is plain to all but the most ardent confused altmed acolyte, so it is needless to respond to all his posts.

        1. WilliamLawrenceUtridge says:

          Ugh, want to assume responsibility for it? His borderline-incomprehensible output is repetitive and tedious. There’s no joy in it, and I spend too much time trying to figure out what half-formed thought he’s trying to express.

          1. MadisonMD says:

            The inanity is self evident so not all posts need to be refuted. Just ignore.

      2. Windriven says:

        I agree with Madison. Besides, responding to his serial inanities is a pleasant enough pastime. I do wish he’d step up his game though.

        I wonder why he visits here at all? It is clear he is earning no converts, he attracts heaps of withering criticism, and he never advances discourse.

        I’ve come to believe that it is simply because people will engage him. I would guess that the professional community in Texas just rolls its collective eyes and pretends to read the Sports page when SSR comes around.

        Commenting here and being engaged by serious physicians like Madison and weing and Andrey allows him to maintain the self delusion that he is a lonely warrior battling the establishment. Good for his self esteem, probably not so much for his mental health.

        1. brewandferment says:

          concur wholeheartedly

        2. WilliamLawrenceUtridge says:

          I do wish he’d step up his game though.

          You’re not the only one. As said above, tedious.

          I wonder why he visits here at all? It is clear he is earning no converts, he attracts heaps of withering criticism, and he never advances discourse.

          Masturbation.

          1. Windriven says:

            Now I understand why my iPad is sticky.

            1. WilliamLawrenceUtridge says:

              Imagine what his is like :)

        3. n brownlee says:

          “Commenting here and being engaged by serious physicians like Madison and weing and Andrey allows him to maintain the self delusion that he is a lonely warrior battling the establishment. Good for his self esteem, probably not so much for his mental health.”

          He wants your respect, as a worthy adversary. Most of you (doctors and frequent commenters) have some feeling that he sincerely believes in what he does as effective therapy, but I don’t think so. I don’t believe he thinks in those terms at all, about the practice of medicine in general. He’s faking it, and as long as he fools some patients, he thinks that’s okay. That makes it real.

          1. Windriven says:

            “I don’t think so. I don’t believe he thinks in those terms at all, about the practice of medicine in general. He’s faking it, and as long as he fools some patients, he thinks that’s okay. That makes it real.”

            The most frightening thing about your comment Nancy, is that I think you may be right.

        4. Andrey Pavlov says:

          Commenting here and being engaged by serious physicians like Madison and weing and Andrey allows him to maintain the self delusion that he is a lonely warrior battling the establishment</blockquote!

          Hey now! I've only ever made a very small handful of comments to him and it has been to very briefly mock him and point out his inanity (and insanity).

          1. n brownlee says:

            Well yeah, but he wants to play with the real guys. He wants to be cool, like you, surfer-dude-doctor.

            1. Windriven says:

              Rimshot

            2. Andrey Pavlov says:

              LOL. Three more years. Then I go back to the surf.

  7. Rob Cordes, DO says:

    While a medical student I became friendly with a classmate who had been a practicing chiropractor before med (DO) school. I once asked him his thoughts on children being “successfully” treated for bed wetting with manipulation. He said it was bogus and felt the kids were so neurologically ready to stop bed wetting you could shake a chicken bone at them. Since then I have always wondered about the placebo effect on bed wetting.

    1. Clay Jones says:

      Nocebo as well. Secondary enuresis, which I didn’t get into, is largely a result of significant psychological stress. Think 6 year old get s a new baby brother or parents divorce. I have little doubt that a child could be conditioned to wet the bed when exposed to certain variables, like the uncooked milk mentioned by n Brownlee.

  8. jr says:

    @n brownlee: As was briefly mentioned in the article, constipation can be a cause of NE because it can prevent a person from being able to empty the bladder fully, so it then fills up again quickly. At least, that was how our pediatrician explained it to me when my daughter had this issue. (We treated the constipation and now, at 7, she’s finally started getting through the night dry.) So if milk gives your nephews constipation, which isn’t uncommon, maybe that’s contributing.

    1. n brownlee says:

      Er, I’m thinking my description wasn’t clear. These are kids who NEVER had a dry night, EVER, right through their teen years. As you can imagine, it curtailed their social lives.

      Multiple exams by urologists and a nephrologist turned up no problems. Later, an allergist (the whole family has galloping allergies) suggested milk sensitivity- and a couple of days milk-free stopped it. Until- a challenge caused a recurrence. And it still does cause recurrence- and both are now men in their forties.

      It’s so weird, and it seemed so utterly unlikely to me, that I have privately assumed there was some confounding element that we just couldn’t identify.

      1. KayMarie says:

        There are mast cells and histamine receptors in the bladder, so some allergy might be involved (but usually there would be other allergy symptoms and I don’t know if they had other issues or not from your description) But then why milk especially if they have other allergies is hard to say.

        One other weird thought is along that FODMAP idea. Lactose increases gas, maybe they have something just a bit off with the pelvic floor and if they fart at night they also relax enough to pass urine even if when awake they can separate the two things?? But that is just a major guess.

        1. n brownlee says:

          The whole FODMAP thing, plus this recent post, started me thinking about it, again. But it seems to be milk and uncooked milk only – cheese is okay. They don’t drink milk or eat ice cream- under strict wifely supervision! (It’s not a slightly damp bed, it’s bladder-emptying, like a child.)

          One urologist, a couple decades ago, had the grace to tell me, “Occasionally, it seems to be completely unfixable, and it’s almost always men. We don’t know why; we don’t see it much. But if these guys respond to stopping milk, good for them. Some people never find an answer.”

          I’m just fixated about mechanism, I think. I always have to know how something works.

          1. KayMarie says:

            Most cheese has very little lactose, and if they can eat cheese it probably isn’t an allergy to dairy proteins as the people I know with that allergy usually have to avoid all dairy.

            And there is always that “conditioned response” I had one of those to raisins where every possible mechanism had to be improbable as anything else that would set off the same reaction was just fine and dandy.

            Avoding raising completely for the better part of 10 years finally broke the connection. The problem with a conditioned response is retesting before the conditioning has completely faded reinforces the conditioning.

            About the only way to know if it really was lactose would be to have them eat two meals that seem identical but one has about a glass worth’s of lactose added to it. A fair number of people in clinical studies who swear they have lactose intolerance, but test normal for lactose have been shown to only react to meals that obviously have lactose in them. So the conclusion is they have a conditioned response like the one I had when I knew I ate raisins.

          2. brewandferment says:

            AFAIK commercial ice cream cooks the milk/cream into a sort of runny custard until it is churned while cooling. Anyone know if I’m wrong? If cooking the ice cream is truly the case, seems like it also points to a lactose issue (cheese making process depletes lactose, right?)

            any idea what would result from a challenge with cheese made from raw milk? (although I’m not suggesting it be done, just that, like you I’m curious about mechanism)

            1. n brownlee says:

              Commercial ice cream isn’t usually made with a custard base- though some ultra-premium brands use it for some flavors, it’s too expensive and would require the cooking of thousands of gallons of custard. Every operation I’ve ever seen Just uses milk and cream.

          3. Chris says:

            My sister was born lactose intolerant. She was a three pound premie a bit over fifty years ago, so it is a miracle she lived, especially since she had constant diarrhea her first few days.

            Though she can eat a little bit of cheese. It does give her a bit of an upset stomach. That is her price for a piece of pizza. And she was really happy when tofu based cream cheese and ice cream came on to the market.

            I sometimes wonder how much grief my mother got in the 1960s from others because her youngest did not drink milk.

          4. WilliamLawrenceUtridge says:

            I’m just fixated about mechanism, I think. I always have to know how something works.

            It’s always possible that one of Dr. Hall’s old observations on why sometimes CAM actually might work. There’s always the possibility that there is some odd feature about that one person’s metabolism that doesn’t generalize to anyone else. Milk might, in this case only, cause this one person (people?) to wet the bed whenever they drink milk because of some rare or even unique mechanism.

  9. Preston Garrison says:

    A peripheral topic on this one, but I can’t resist noting that I saw Jim Parsons on the Letterman show a couple of weeks ago and he said, “I gave myself to the gluten cause, and it turned out to be completely worthless.”

  10. Earthman says:

    Looking up Fred Clary I found this

    http://www.startribune.com/local/112134254.html

    1. Windriven says:

      Your link provided some amusing breakfast reading:

      “Koltes admitted having sex with a prostitute on two occasions at his Richfield clinic, Back to Health Chiropractic, in 2008. He was ordered to take classes in “moral turpitude” and ethics. He failed the ethics class and was ordered to retake it.”

      Apparently one can twist and poke to treat non-existent subluxations and be perfectly ethical but boning a hooker is off base. I dunno … Probably I’d fail chiropractic ethics too.

    2. Gee this is not science. You can dig up crap on thousands of varied providers, this is a weak attempt at correlating the smut of one to smear it on all.

      1. WilliamLawrenceUtridge says:

        Gee this is not science. You can dig up crap on thousands of varied providers, this is a weak attempt at correlating the smut of one to smear it on all.

        For instance, we can point to you taking patient information and pictures and posting them online, which is a HIPAA violation. Yes, it’s quite easy to find doctors doing stupid and illegal things.

        You are correct that chiropractors, herbalists, acupuncturists and naturopaths all can have smut dug up on the profession and be found guilty. That’s why when people do it regarding doctors, we discount it as an indictment of the whole profession.

        No, the problem with chiropractors (and acupuncturists, and herbalists, and nautropaths) is that their approach to treating disease is fundamentally unsound, unverified, and often quite stupid. In the rare case where their approach is tested and found to be effective (spinal manipulation for back pain, St. John’s Wort) real medicine will acknowledge the change in evidence base and adopt it. So yay for scientific medicine, boo for unscientific nutjobs promising patients the moon.

  11. KillCurve says:

    Fantastic article. I taught as a professor at a chiropractic college for > 5 years until I recently resigned in disgust (I’m a biologist by training, not a chiropractor). I’ve seen the often cited studies for chiropractic treatment of NE, and as pointed out in this article, they are worthless (actually they are much worse than worthless since they negatively impact public health).

    One of the classes I taught was a research methodology course, and I required students to conduct research projects, which helped me become more familiar with the stunningly poor quality (and highly inbred) pool of most chiropractic literature. I, at least, tried to get my students to take a critical look at the limitations of many of these chiropractic studies, and met with a surprising degree of acceptance by them. Luckily I had chiropractic students from day one in their degree program, so I at least got to influence them before they got completely inundated with the chiro philosophy kool-aid. That was, of course, until a vitalistic, straight chiropractor took over the department chair position and immediately removed me from the course, which he then abolished (or rather re-branded to be philosophy based rather than science based) Naturally the department chair had very little science background (actually he was incredibly hostile to scientific methodology), but that was because the this research research course was (absurdly) offered in the philosophy department, rather than the science department. This is just one of many, many fatal flaws of chiropractic education. It is mind boggling that regional accreditation completely ignores stuff like this.

    1. Clay Jones says:

      You should write about your experience. I could see that being very interesting. I’d love to know more about the experiences of the non-chiropractic faculty at these colleges.

      1. KillCurve says:

        I am working on it Dr. Jones, although I am treading carefully, as I have been advised by the legal counsel I hired. I strongly believe I have valuable information and I want to disseminate it, but there seems to be an impact/risk trade-off depending on what details I report on.

    2. Windriven says:

      It takes both intellectual honesty and real guts to walk away from what I presume to have been a tenure track professorship. You have my sincere respect.

      1. KillCurve says:

        Thank you Windriven. It was not a tenure track position though. Actually those are quite rare in US chiropractic programs as far as I understand. My new job is, however, a tenure track position, and now I get another chance at conducting benchtop science. So, at the risk of sounding too Panglossian, maybe all is for the best.

        1. Windriven says:

          Well, tenure track or not, my enduring esteem is yours.

    3. Andrey Pavlov says:

      I would like to add my voice of commendation and ask you write about your experiences as well. A guest post here would be most welcomed.

      1. KillCurve says:

        Thank you, it is very encouraging to hear there is interest. I have privately communicated about this to several of the SBM contributors and editors on various occasions, so my interest in doing so is known. This is still a complex issue, but it is somewhat less complex now that I have moved on to a different job.

        I literally just moved, my stuff is still in boxes, and my wife still has secure new employment at a hospital–I am just thankful she has been so amazingly supportive about all this. I have two small chilcdren, and I resigned before I had secured a new job, but hey I got lucky!

        Anyways, I have plenty of stuff to sort out for the short term, but the iron is definitely in the fire. I still need to feel out how my new employers will view this sort of activism. It is a rural and conservative culture here and chiropractors seems to have a heavy influence.

        1. Jopari says:

          A pseudonym perhaps. I’m sure it’s been done before. Though on books regarding science I suppose not. But on the bright side, a personal story just might get through, with all the quackery already on the market.

          1. WilliamLawrenceUtridge says:

            SBM doesn’t usually accept pseudonymous submissions (I’m guessing it makes “PHARMA SHILL” a lot easier to shout) but perhaps Quackwatch.

            1. Jopari says:

              I suppose so, what about a book?

              1. WilliamLawrenceUtridge says:

                Depending on your goals, why not a blog? A book is a lot of work, and a reputable publisher will demand evidence if Names are Named, to avoid lawsuits. A blog may be less convincing to some, but it’s easier.

              2. Jopari says:

                True, thanks for the feedback on my questions.

  12. Avijit says:

    Clay Jones

    ……The drug most commonly used to prevent bedwetting is desmopressin …. This effect is rapid in onset, and the drug is often successful on the first night of use…

    What is the outcome when the drug is stopped? You write

    ……It is not risk free, although complications are pretty rare… and then continue to say: … adverse effect can occur……. child drinking a large amount of fluid prior to taking the medication….

    Does the doctor define large amount in liters?

    …. The combination of increased intake and decreased urine output can lead to dilution of the blood and a potentially dangerous drop in the serum sodium level. This dilutional hyponatremia can, in rare instances, cause changes in mental status, seizures, coma and even death….

    This rare case can happen even if I have only one child?

    ….This outcome was more common….

    You defined it as rare a little while ago?

    …with intranasal administration of the drug, which is no longer recommended in children with bedwetting…

    Until which year it was recommended? How many children reported adverse effect?

    And you continue to write:

    ……Medical interventions, whether simple education and reassurance, lifestyle modifications, or pharmaceutical agents, are highly successful. But they aren’t perfect by any means………

    Successful for the scientific medical practice (?) but not perfect for the parent with a child with changed mental status or seizures, in coma or dead who wanted a simple condition to be resolved.

    ……..PMNE is a condition which takes time to resolve. And, as stated previously, it will eventually resolve completely on its own in time in roughly 98% of children……

    Doctors send back parents with this message or start treatment with Desmopressin?

    1. WilliamLawrenceUtridge says:

      This rare case can happen even if I have only one child?

      I’m not sure what you’re getting at with the rest of your comments, but yes – it can certainly happen even if you have only one child. It just means it doesn’t happen with a lot of other children who don’t happen to be yours.

      Successful for the scientific medical practice (?) but not perfect for the parent with a child with changed mental status or seizures, in coma or dead who wanted a simple condition to be resolved.

      If your child died or was otherwise harmed by this drug, you have my sympathies. But why are you taking it out on Dr. Jones?

      1. Avijit says:

        I used the reference from the message of Clay Jones above.

        ..”98% children get well automatically. Interventions exist …. They all have solid evidence of success and relatively few risks”…

        And then goes on to define the level of risk:

        “. This dilutional hyponatremia can, in rare instances, cause changes in mental status, seizures, coma and even death….”. No data for rare instances?

        Can a chiropractor also kill the child during the treatment process?

        There is no requirement from you to be sorry. I am quite wary of the Scientific Medical System. The above write up proves the point.

        I would never expose my child to such harmful treatment with odds that he would recover automatically (98%) and can become vegetable or even die.

        1. WilliamLawrenceUtridge says:

          Dr. Jones does note that NE gets better for most patients, and goes into the treatments you might use if you wanted to speed it up or had some sort of specific event coming up for which control of NE would be warranted. A sleepover is an obvious example. The he discusses risks. Would you rather he left the risks out? That seems a little paternalistic and dishonest.

          Can a chiropractor also kill the child during the treatment process?

          Yes, it’s called a coronary artery dissection. Plus, if chiropractic treatment doesn’t work for NE, why would you ever want to waste time or money on it? Of course, you’ll probably never know if chiropractic treatments work or not because chiros never actually conduct research on their treatments approach.

          There is no requirement from you to be sorry. I am quite wary of the Scientific Medical System. The above write up proves the point.

          Your rather incoherent and disjointed attempt to comment on the above write-up doesn’t really prove anything beyond your inability to mount a coherent argument. I still don’t know what your point is.

          I would never expose my child to such harmful treatment with odds that he would recover automatically (98%) and can become vegetable or even die.

          Well two points:

          1) Dr. Jones doesn’t exactly say you have to use drugs, does he?

          2) What if your kid is among the 2% who experiences NE for their entire lifetime? I suppose once they are no longer under your care they might seek some form of medical intervention, and during that intervention the doctor will be sure to brief them on the risks and benefits of treatment.

        2. Iqbal says:

          Avijit

          “I would never expose my child to such harmful treatment with odds that he would recover automatically (98%) and can become vegetable or even die.”

          The medicine for bed wetting is Cauasticum H 30 -2 times a day for 2 weeks. The child will be cured.

          Zero risk.

          1. Harriet Hall says:

            Zero risk. Zero effectiveness. If you think it works, show us your evidence.

            1. Sawyer says:

              Heck I’m not even willing to give him the zero risk. Telling a child you “cured” them of a very embarrassing ailment, and then having them wake up in the middle of the night still wetting the bed can’t be too health for their psychological development.

              I’m frightened to think what the children of quacks have to go through pretending their parent’s idiotic treatments worked, just to satisfy their massive egos.

            2. Iqbal says:

              Harriet Hall

              ” If you think it works, show us your evidence.”

              Causticum works for all ages for bed wetting. It even is helpful if a person has spasmodic loss of control: during cough, or sneezing and even laughter.

              This is being used for ages- you can pick it off a store and try it.
              And it is not that you stop the medicine and the problem comes back. IT CURES.

              1. KayMarie says:

                So cures, problem never comes back, then why on earth would a homeopathic college design a study where not only do they have to give the potion more than once, they are doing the placebo control AFTER dosing with the homeopathic medication.

                http://clinicaltrials.gov/show/NCT02154152

                One would think they’d at least do a cross over protocol where half get the placebo first and half get the potion…

              2. n brownlee says:

                Nonsensical blather. Saying it’s a “cure” is not evidence of anything except your ignorant obduracy. Evidence. EVIDENCE.

              3. Harriet Hall says:

                I asked for evidence. You responded with a repetition of your claim. I consider this an admission that there is no evidence. And now you are appealing to the ancient wisdom fallacy and demonstrating that you fail to understand the fallibility of personal experience. In case you haven’t noticed, this is a science-based website. Please keep reading and try to understand why scientific evidence matters.

              4. Chris says:

                Argument by blatant assertion is useless. Provide some real evidence in the form of a PubMed indexed study by a reputable qualified researcher (not a homeopath) that shows it is effective.

                By the way, where is that real evidence to support Andre Saine’s contention that homeopathy works better for rabies than the modern vaccine?

                What evidence shows homeopathy is effective at preventing or curing malaria?

          2. Chris says:

            Iqbal, where is that evidence proving Andre Saine’s contention that homeopathy works better for rabies than the modern vaccine? Also where is that evidence showing homeopathy can prevent and/or cure malaria?

            Why won’t you answer my two very simple questions?

          3. WilliamLawrenceUtridge says:

            The medicine for bed wetting is Cauasticum H 30 -2 times a day for 2 weeks. The child will be cured.

            Zero risk.

            I can forsee four risks:

            1) A homeopathic preparation in liquid form could drown them

            2) A homeopathic preparation of liquid sprayed on lactose balls could choke them

            3) They may be convinced by the apparent effectiveness of homeopathy (i.e. waiting until something gets better on its own) to use it to treat dangerous conditions.

            4) The child could use homeopathy instead of effective management strategies and become socially ostracized.

            In reality, Avijit and I agree – the best treatment in most situations is simply waiting until the chiild develops sufficiently to stop wetting the bed.

            1. MadisonMD says:

              5) homeopathic liquid, if failing to drown, could increase systemic H2O load, increasing the proclivity to nocturnal enuresis.

              And the most interesting thing about Ickball’s recommendation is that, even to magic-believers, causticum is as elusive as the philosopher’s stone. So if the remedy fails, we have an issue with ‘no true causticum.’

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