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How is nocturnal enuresis defined?

involuntary wetting during sleep, without any inherent suggestion of frequency or pathophysiology.
generally considered to be normal in children younger than 5 years of age


Describe the different types of enuresis

primary without daytime symptoms - the child has never achieved sustained continence at night and does not have daytime symptoms.

primary with daytime symptoms - the child has never achieved sustained continence at night and has daytime symptoms such as urgency, frequency, daytime wetting, abdominal straining, or poor urinary stream, or pain passing urine.

secondary - bedwetting occurs after the child has been dry at night for more than 6 months


What are the causes of primary enuresis without daytime symptoms

Sleep arousal difficulties — inability to wake to noise, the sensation of a full bladder, or bladder contractions.

Polyuria — a larger than normal production of urine at night which is greater than bladder capacity.

Bladder dysfunction — a small bladder capacity or overactive bladder.


What are the causes of primary enuresis with daytime symptoms

An overactive bladder.
Structural abnormalities (for example ectopic ureter).
Neurological disorders (for example neurogenic bladder secondary to spinal dysraphism).
Chronic constipation.
Urinary tract infection.


What are the causes of secondary enuresis

underlying cause:
urinary tract infection,
psychological problems (for example behavioural or emotional problems),
family problems (vulnerable child or family)


What are the risk factors for enuresis

delay in development
psych or behavioral problems - ADHD, ASD, anxiety, depression, conduct disorder
sleep apnoea


What questions are important to ask in a history of enuresis

primary or secondary
any day time symptoms
medical or physical tigger
social, emotional or enviromental problems
?child maltreatment


What would be red flags for child maltreatment in an enuresis history

parents blaming the child - think the child is wetting onpurpose
punishments for bedwetting
bedwetting persists after adequate managment


What investigaitons could be done in enuresis

urinalysis if started recently, daytime symptoms, child seems unwell or history suggesting UTI/diabetes

ask parents to keep diary with fluid intake, toilet use and wetting recorded


What is the management for enuresis

<7y - usually resolves over time. ensure fluid intake not excessive, encourage to empty bladder before bed

>7y - first line is enuresis alarm
next desmopressin

if daytime symptoms, need referral

if secondary, exclude cause before referral


Describe the enuresis alarm and its usefulness

most effective long term treatment
useful in those >7y

An enuresis alarm has a sensor pad which senses wetness. The sensor is linked to an alarm which wakes the child if it becomes wet. There are two main types of enuresis alarms:
Beside alarms — where a noise box is placed next the child's bed and a sensor pad is positioned under a draw sheet beneath the child in the bed.
Body-worn alarms — where a tiny sensor is attached to the child's pants for example between two pairs of tightly fitting underpants and the alarm is worn on the pyjama top.

contunue to use until 14 dry nights in a row


Who might an enuresis alarm not be suitable for?

The child or parents and carers do not want to use one.
The child wets the bed (infrequently) less than once or twice a week.
Parents or carers have emotional difficulty coping with the burden of bedwetting.
Parents or carers express anger, negativity, or blame towards the child.
The child is younger than 7 years of age and is not able to use an alarm.


What are the signs of response to enuresis alarm treatment

Smaller wet patches.
Waking to the alarm.
The alarm going off later and fewer times per night.
Fewer wet nights.


Describe the mechanism of action of desmopressin and its usefulness in managing enuresis

ADH analogue so reduces quantity of urine produced

used in short term management if:
A rapid onset in improvement or a short-term improvement is required (for example for sleepovers or school trips).
The child or parents or carers are unable to use an alarm or do not want to use a alarm as first-line treatment.
The child or parents and carers are currently using an alarm and want to stop.


How should desmopressin be taken?

take at bedtime
sips only from one hour before taking until 8 hours after taking - reduces risk of hyponatraemia and fluid overload


When can desmopressin not be prescribed

heart failure
taking diuretics
psychogenic polydipsia


What is necrotising enterocolitis

vascular, mucosal, toxic and other insults to the immature gut leads to serious intestinal injury
damage to the mucosa leads to the spread of commensal organisms


What are the features of necrotising enterocolitis

occurs in preterm or very low birth weight neonates
in first two weeks of life
bilious vomiting
bloody mucoid stool
feeding difficulties
abdominal distension and erythema
intestinal loops visible
abdominal mass present/ascites
reduced bowel sounds
bradycardia, lethargy, shock, apnoea, resp distress


What investigations should be done in suspected necrotising enterocolitis



What can be seen on AXR in necrotising enterocolitis

wall thickening
gas filled loops of bowel
pneumatosis intestinalis = intramural gas
portal venous gas


What is the management of necrotising enterocolitis

NBM - bowel rest
NG tube to decompress bowel with intermittent suction
IV fluids
IV abx - cefotaxime + metronidazole
intubation or ventilation if apnoea
surgery if perforation/necrotic bowel


What are the potential complications of necrotising enterocolitis

Acquired short bowel syndrome (following surgery).
Sepsis and shock.
Intestinal strictures (~30%).
Enterocolic fistulae.
Abscess formation.
Iatrogenic complications - eg, central venous catheter-related thrombotic events and nosocomial infections, metabolic complications secondary to prolonged hyperalimentation (a nutrient mixture given to premature babies before giving milk).


How can necrotising enterocolitis be prevented?

breast milk
small feeds - increase volume slowly


What is coeliac disease?

autoimmune condition in which glutens activate an abnormal mucosal response leading to chronic inflammation and damage (mucosal atrophy) to the lining of the small intestine


What are the risk factors for coeliac disease

FH - first degree relatives
genetic - HLA DQ2 and HLA DQ8
other automimmune - T1DM, automimmune thyroid
down's, turner's william's syndromes


What are the symptoms of coeliac disease

failure to thrive
prolonged and unexplained diarrhoea, bloating, constipation, indigestion
weight loss
mouth ulcers - severe or persistent


What skin condition is associated with coeliac disease

dermatitis herpetiformis


Describe dermatitis herpetiformis

on extensor surfaces, scalp and natal cleft
vesciles or papules on erythematous patch of skin
intensely itchy


How is dermatitis herpetiformis treated

Dapsone PO


How is coeliac disease investigated

serology testing - IgA and tTGA
FBC, B12, ferritin, LFTs, calcium
jejunal biopsy