Articles

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

Leave a Comment (91) ↓