Article

[Development of intestinal and bladder control from birth until the 18th year of age. Longitudial study]

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Abstract

The development of bowel and bladder control from 0 to 18 years of age in 321 Swiss children of the Zurich Longitudinal Study (1955-1976) is described. 3% of the children had started toilet training by the age of 1 month and 96% by 12 months. Bowel control was completed in 32% at age one, in 75% at age two and in 97% at age three. Complete bladder control by day and at night was established in none of the children at age one, in 20% at ages two and three and in 90% at age five. About one quarter of the boys and one tenth of the girls had a period of incomplete bowel or bladder control between 6 and 18 years. During the prepubertal period, the annual incidence of enuresis was 7-15% in boys and 7-10% in girls, and that of encopresis 2-4% and 1-2% respectively. Some combination of enuresis diurna, enuresis nocturna and encopresis were found in 7% of all children, although in most children, these events did not occur simultaneously. With the exception of primary diurnal enuresis, the different types of enuresis and encopresis were more frequent in males than in females. By the onset of puberty, encopresis resolved in all children and enuresis persisted in only a few children. The role of toilet training and the etiologies and pathogenesis of enuresis and encopresis are discussed from a development point of view.

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... Eine Studie von Loening-Bauke (2002), die 49 Kinder mit Enkopresis und Obstipation in der Altersgruppe von 4-17 Jahren untersuchte, fand, dass 29% der Kinder tagsüber einnässten, nachts demgegenüber 41%. Mehrere Studien(Largo et al., 1978; Loening-Baucke, 1997) zeigen übereinstimmend, dass die funktionelle Harninkontinenz mit Einnässen am Tag und Einkoten häufiger ist als das komorbide Auftreten von Enuresis (nocturna) und Stuhlinkontinenz. Jungen sind im Vergleich zu Mädchen von dieser häufigsten kombinierten Ausscheidungsstörung stärker betroffen(Largo et al., 1978).Berg et al. (1977) fanden bei Kindern mit einer monosymptomatischen Enuresis (nocturna) im Vergleich zu Kindern mit kombiniertem Einnässen am Tag und in der Nacht sehr viel seltener eine Enkopresis. ...
... Mehrere Studien(Largo et al., 1978; Loening-Baucke, 1997) zeigen übereinstimmend, dass die funktionelle Harninkontinenz mit Einnässen am Tag und Einkoten häufiger ist als das komorbide Auftreten von Enuresis (nocturna) und Stuhlinkontinenz. Jungen sind im Vergleich zu Mädchen von dieser häufigsten kombinierten Ausscheidungsstörung stärker betroffen(Largo et al., 1978).Berg et al. (1977) fanden bei Kindern mit einer monosymptomatischen Enuresis (nocturna) im Vergleich zu Kindern mit kombiniertem Einnässen am Tag und in der Nacht sehr viel seltener eine Enkopresis. Kinder mit gleichzeitiger funktioneller Harninkontinenz und Enkopresis hatten nach vonGontard & Hollmann (2004) besonders häufig eine Detrusor-Die Ursachen für Ausscheidungsstörungen werden gesondert für die Enuresis, die funktionelle Harninkontinenz mit ihren wichtigsten Unterformen und die Enkopresis besprochen.Die Enuresis nocturna hat eine multifaktorielle Genese, bei der erzieherische Einflüsse kaum eine Auswirkung haben. ...
... Die fünfte Einheit beinhaltet das Erlernen von Wahrnehmungs-und Entspannungsübungen. Enkopresis eine starke Korrelation zwischen dem Sauberkeitstraining der Eltern und dem Einkoten des Kindes. Dies beschriebenLargo et al. (1977Largo et al. ( ,1978Largo et al. ( , 1996 in zwei identisch von ihnen durchgeführten Längsschnittstudien. So begannen die Eltern in den 50er Jahren durchschnittlich bereits ab dem 7. Lebensmonat mit dem Sauberkeitstraining, Mütter der 70er Jahre erst im Alter von 19-21 Monaten. ...
... An increase of the age for starting toilet training has been noted in several countries [24,25]. In one of their studies, Largo et al. reported that 97% of children gained complete bowel control by the age of 3 years, these results being similar to our study where daytime bowel control was gained at the age of 2.4 years [26]. Toilet training is initiated quite late in children, most of the times after the age of 2 years, which could be explained by the involvement of both parents in their professional and social life and the convenient use of single use diapers, as well as the sheer neglect of toilet training in children from singleparent households or institutionalized ones. ...
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We conducted an observational study over a 1-year period, including 234 children aged 4–18 years and their caregivers and a matching control group. 60.73% of the children from the study group were males. Average age for the onset of constipation was 26.39 months. The frequency of defecation was 1/4.59 days (1/1.13 days in the control group). 38.49% of the patients in the sample group had a positive family history of functional constipation. The majority of children with functional constipation come from single-parent families, are raised by relatives, or come from orphanages. Constipated subjects had their last meal of the day at later hours and consumed fast foods more frequently than the children in the control sample. We found a statistically significant difference between groups regarding obesity/overweight and constipation ( χ2=104.94, df=2, p<0.001 ) and regarding physical activity and constipation ( χ2=18.419; df=3; p<0.001 ). There was a positive correlation between the number of hours spent watching television/using the computer and the occurrence of the disease ( F = 92.162, p<0.001 , and 95% Cl). Children from broken families, with positive family history, defective dietary habits, obesity and sedentary behavior, are at higher risk to develop chronic functional constipation.
... First-born children have been reported to be at lower risk for nocturnal enuresis than second-or thirdborn children (Kalo and Bella, 1996;Rona et al., 1997), supporting our speculation. However, historical changes in the toilet-training practices from the 1950s to the 1970s in Switzerland were not found to influence the age of attaining dryness (Largo et al., 1978). On the other hand, there are also unexplained transcultural and/or biological differences, with prevalence rates ranging from 8.2% of Finnish 7-year-olds (Järvelin ENURESIS AND BEHAVIORAL PROBLEMS 1.0 0.9 (0.5-1.5) 1.5 (0.9-2.5) 2.7 (1.5-4.9)** 3. (95% CI) 1.0 1.0 (0.6-1.7) 1.5 (0.9-2.7) 3.6 (1.9-6.6)** ...
Article
To estimate the prevalence of nocturnal enuresis and to examine associations between nocturnal urinary control or enuresis and behavioral problems in Chinese children. A community sample of 3,600 children aged 6 through 16 years was drawn from Shandong Province of China in 1997; 3,344 (93%) returned completed questionnaires. The Child Behavior Checklist and Teacher's Report Form were used to measure children's behavioral problems. The proportion of children attaining nocturnal urinary control before age 2 was 7.7%; by age 3, this had increased to 53.1%, and by age 5 to 93%. The overall prevalence of nocturnal enuresis was 4.3%, with a significantly higher prevalence in boys than girls. There was no significant decrease in the prevalence of enuresis between 6 and 16 years of age. Multiple logistic regression analyses showed that attaining nocturnal urinary control after age 4 and current enuresis were significantly associated with an increased risk of behavioral, emotional, and academic problems. Chinese children attain nocturnal urinary control earlier than Western children. The prevalence of nocturnal enuresis is low but fairly stable in children between 6 and 16 years. The findings support the link between nocturnal enuresis and psychopathology in children and adolescents.
Chapter
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Einnässen im Kindes- und Jugendalter ist ein häufiges Symptom, das die Lebensqualität der betroffenen Patienten und ihres sozialen Umfelds erheblich beeinflusst. Verbesserte diagnostische und therapeutische Maßnahmen haben die Behandlung betroffener Kinder in den letzten 10 Jahren auch in Deutschland erheblich verbessert. Mithilfe einer oftmals ausreichenden nichtinvasiven Basisdiagnostik gelingt die Zuordnung des Symptoms in eine diagnostische Kategorie. Diese bildet die Grundlage für eine erfolgreiche Therapie. Eine hohe Motivationsbereitschaft und Kooperationswilligkeit der Kinder und ihrer Familie sind therapeutische Voraussetzungen. In der Behandlung der Harninkontinenz haben heute urotherapeutische Maßnahmen den höchsten Stellenwert. * Erstveröffentlichung des Beitrags in: Akt Urol 2014; 45: 221–231
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Urinary incontinence (bedwetting, enuresis) is the commonest urinary symptom in children and adolescents and can lead to major distress for the affected children and their parents. Physiological and non-physiological types of urinary incontinence are sometimes hard to tell apart in this age group. This article is based on selected literature retrieved by a PubMed search and on an interdisciplinary expert consensus. Nocturnal enuresis has a variety of causes. The main causative factors in monosymptomatic enuresis nocturna (MEN) are an impaired ability to wake up when the bladder is full, due to impaired or absent perception of fullness during sleep, and an imbalance between bladder capacity and nocturnal urine production. On the other hand, non-monosymptomatic enuresis nocturna (non-MEN) is usually traceable to bladder dysfunction, which is also the main cause of diurnal incontinence. A basic battery of non-invasive diagnostic tests usually suffices to determine which type of incontinence is present. Further and more specific testing is indicated if an organic cause is suspected or if the treatment fails. The mainstay of treatment is urotherapy (all non-surgical and non-pharmacological therapeutic modalities). Some patients, however, will need supportive medication in addition. Urinary incontinence has different causes in children and adults and must therefore be diagnosed and treated differently as well. All physicians who treat the affected children (not just pediatricians and family doctors, but also pediatric nephrologists, urologists, pediatric surgeons, and child psychiatrists) must be aware of the specific features of urinary incontinence in childhood.
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Nocturnal enuresis is associated with emotional suffering. Psychoanalytic claims of a psychogenic aetiology are not tenable. The rate of behavioural disorders is significantly higher among wetting children, especially among day wetters and secondary nocturnal enuretics. Still, most wetting children are not psychiatrically disturbed. A symptom-oriented therapy with an alarm can raise the self-concept and feelings of self-worth. Play-therapies are indicated only when emotional disorders co-exist. A case of a sandplay therapy is presented, which demonstrates that in addition to empirical methodology, a hermeneutic approach is needed to understand the child's subjective experience and meaning.
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This study aimed to investigate the family situation, personal behaviour and current micturition habits, the time of beginning and the method of potty-training in two groups of children with different outcomes of bladder control. Parents of 140 children, between 7 and 15 years old, filled in a questionnaire comprising 43 questions. They were divided into a symptom group (n = 73) and a symptom-free group (n = 67) according to the outcome of bladder control. Parents remembered clearly the method of training and the time of starting the potty-training to achieve continence in their child, and the exact age at which these objectives were achieved. There was some confusion regarding the term incontinence: the majority of the parents (70%) considered their child to be continent in spite of day-wetting several times a week. All children with urge syndrome who had undergone a urodynamic investigation (n = 50) had an objective functional bladder disorder. Methods of training differed between the groups with and without lasting problems. The symptom group started training at a later age, had more tendency to punish and were more demanding when micturition did not start readily. The findings from the questionnaire strengthen the hypothesis that urge syndrome can be due to poor methods of potty-training. Very few parents searched spontaneously for help, which should prompt practitioners and paediatricians to be more alert to this problem.
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The terminology used to describe wetting children is defined. The etiologies of monosymptomatic nocturnal enuresis and nonneuropathic bladder-sphincter dysfunction are described. Treatment strategies and the results of recent large scale studies are presented.
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To analyse if family situation, personal habits and toilet training methods can influence the achievement of bladder control. A questionnaire with 41 questions was distributed to 4332 parents of children completing the last 2 years of normal primary school. The questionnaire had been tested for reproducibility of the answers in a random subgroup of 80 parents. The aims of the investigation were explained in an accompanying letter and the response rate was 76.7%. The result were analysed using the chi-square test (Yates corrected). Two groups of children were identified, one with no lower urinary tract symptoms (3404) and one with complaints of daytime and night-time wetting, and urinary tract infections (928). The groups were termed the 'control' and 'symptom' groups, respectively. There were no differences in the family situation between the groups. The symptom group reported more 'below average' school results and less independence in homework and hygiene. The age at which toilet training started was significantly higher in the symptom group and scheduled voiding was used significantly less. The reaction of the parents when the attempt at voiding was unsuccessful was significantly different; in the control group most parents just postponed the effort and had the child try again later, whereas in the symptom group more parents asked the child to push, made special noises or opened the water tap. These data show significant differences in toilet training between children with and with no lasting problems of bladder control. Postponing the onset of the training after 18 months of age and using certain methods to provoke voiding (asking to push, opening the water tap) probably increases the risk of later problems with bladder control.
Article
Aim: To analyse the number of urinary tract infections, uroflowmetry, behavioural symptoms and intrafamilial interaction in two groups of daytime wetting children in a paediatric and a child psychiatric unit. Methods: Ninety-four children with either voiding postponement (52) or urge incontinence (42) were examined prospectively for history of urinary tract infections (UTIs), uroflowmetry, the syndrome scales of the Child Behaviour Checklist (CBCL 4/18-Achenbach) and the Family Adaptability and Cohesion Evaluation Scales (FACES-III) (Olson) questionnaire. Results: Children with urge incontinence had a significantly higher rate of previous urinary tract infections (50%) than children with voiding postponement (19.2%; p < 0.001), who showed a high rate of plateau (12.2%) and staccato (20.4%) curves and were characterized by a wide variety of behavioural symptoms, including withdrawn (11.6%), aggressive (11.8%), delinquent (19.6%) behaviour and attention problems (13.7%). Clinically relevant behavioural scores were 4-10 times higher for the voiding postponers, and 2-3 times higher for children with urge incontinence. Furthermore, families of voiding postponers had significantly fewer balanced types of intrafamilial function (FACES-III). Problematic "rigid/disengaged" and "rigid/separated" types predominated. Conclusion: Urge incontinence is characterized by a higher rate of UTIs, a lower urine volume in uroflowmetry, a lower rate of behavioural scores in the clinical range and well-functioning families. Voiding postponement children, on the other hand, have a higher, though not significant, rate of abnormal uroflow curves, a wide variety of clinically relevant behavioural symptoms, which were significantly higher for attention and delinquent problems. Conduct problems predominated; only 13.7% of the children had attention problems in the clinical range. The findings lend empirical support to the entity of voiding postponement as an acquired or behavioural syndrome characterized by wetting in association with a delay of micturition and other externalizing conduct problems.
Article
Functional urinary incontinence and encopresis are common comorbid disorders in childhood. We analyze the specific somatic and behavioral symptoms associated with functional enuresis/urinary incontinence and encopresis when they occur together. A total of 167 consecutive children 5 to 10 year olds, with day and/or night wetting were examined prospectively with ultrasound, uroflowmetry, electroencephalography, the Child Behavior Checklist, Culture Fair Intelligence Test and ICD-10 child psychiatric diagnoses. The main findings for the comorbid group (20 patients) with wetting and soiling were a significantly higher rate of daytime incontinence and micturition problems, thickened bladder walls and pathological electroencephalography. There were higher, although not significant, rates of previous urinary tract infections, antibiotic prophylaxis, residual volume and abnormal uroflow curves in this group. Behaviorally, hyperkinetic syndromes, and emotional and conduct disorders (according to ICD-10) were more common. Of the 20 patients 65% had a Child Behavior Checklist total score (greater than 90th percentile) in the clinical range. The externalizing, internalizing, delinquent and anxious/depressed problem scales were also significantly higher. This risk group requires detailed assessment and specific treatment. In addition to the symptomatic treatment of the wetting and soiling, many of these children are in need of specific behavioral, psychotherapeutic and pharmacological treatment.
Article
This population-based study investigated the psychological problems associated with daytime wetting in children. A sample of 8213 children (age range: 7 years 6 months to 9 years 3 months) who were enrolled in the population-based Avon Longitudinal Study of Parents and Children participated in this study. Parents completed a postal questionnaire asking about their children's toileting behavior and assessing psychological problems, including childhood emotional and behavioral problems (99% completed the questionnaire by the time their child was 8 years 3 months of age). The rate of psychological problems was compared in children with daytime wetting and in those with no daytime wetting. Analyses adjusted for developmental delay, gender, sociodemographic background, stressful life events, and soiling. Chi2 tests of association and multivariable logistic regression indicate that children with daytime wetting have a higher rate of parent-reported psychological problems than children who have no daytime wetting. It is particularly notable that the reported rates of attention and activity problems, oppositional behavior, and conduct problems in daytime wetting children were around twice the rates reported in children with no daytime wetting. The increased vulnerability to psychological problems in children as young as 7 years of age with daytime wetting highlights the importance of parents seeking early intervention for the condition to help prevent later psychological problems. Although treatment in a pediatric setting is often successful, clinicians should be aware of the increased risk of disorders, such as attention-deficit/hyperactivity disorder, in children with daytime wetting, because this is likely to interfere with treatment.
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The objectives of this report are to determine the following: (1) the effectiveness of the toilet training methods, (2) which factors modify the effectiveness of toilet training, (3) if the toilet training methods are risk factor for adverse outcomes, and (4) the optimal toilet training method for achieving bowel and bladder control among patients with special needs. MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid OLDMEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, PsycINFO, ERIC, EBM Reviews, HealthSTAR, AMED, Web of Science, Biological Abstracts, Sociological Abstracts, OCLC ProceedingsFirst, OCLC PapersFirst, Dissertation Abstracts, Index to Theses, National Research Register's Projects Database, and trials registers. Two reviewers assessed the studies for inclusion. Studies were included if they met the following criteria: Study design: RCT, CCT, prospective or retrospective cohort, case-control, cross-sectional or case-series; Population: infants, toddlers, or children with or without co-morbidities, neuromuscular, cognitive, or behavioral handicaps disabilities; Intervention: at least one toilet training method; and Outcome: bladder and/or bowel control, successes, failures, adverse outcomes. Methodological quality was assessed independently by two reviewers. Data were extracted by one reviewer and a second checked for accuracy and completeness. Due to substantial heterogeneity, meta-analysis was not possible. Twenty-six observational studies and eight controlled trials were included. Approximately half of the studies examined healthy children while the remaining studies assessed toilet training of mentally or physically handicapped children. For healthy children, the Azrin and Foxx method performed better than the Spock method, while child-oriented combined with negative term avoidance proved better than without. For mentally handicapped children, individual training was superior to group methods; relaxation techniques proved more efficacious than standard methods; operant conditioning was better than conventional treatment, and the Azrin and Foxx and a behavior modification method fared better than no training. The child-oriented approach was not assessed among mentally handicapped children. For children with Hirschsprung's disease or anal atresia, a multi-disciplinary behavior treatment was more efficacious than no treatment. Both the Azrin and Foxx method and the child-oriented approach resulted in quick, successful toilet training, but there was limited information about the sustainability of the training. The two methods were not directly compared, thus it is difficult to draw definitive conclusions regarding the superiority of one method over the other. In general, both programs may be used to teach toilet training to healthy children. The Azrin and Foxx method and operant conditioning methods were consistently effective for toilet training mentally handicapped children. Programs that were adapted to physically handicapped children also resulted in successful toilet training. A lack of data precluded conclusions regarding the development of adverse outcomes.
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