Researchers examining 18 randomized controlled trials of a total of 581 children receiving DDAVP found no real benefit.

Although all studies but one showed a significant instant reduction in bedwetting, two weeks later, only a quarter of the children became dry.

Among the 28 children followed long term, only a fifth remained dry for 12 weeks after stopping the drug.

Another study comparing the drugs with conditioning alarms found the alarms to be more effective.

In reporting these results, Journal Watch (published by The New England Journal of Medicine) commented: “Because conditioning alarms are about 70 per cent effective and DDAVP costs about $120 (£80) per month, DDAVP should not be a first line treatment for noctural enuresis.”

* Cyclosporine, the immunosuppression drug originally used for recipients of organ transplants, and now increasingly used for every intractable illness, has been shown to cause an Epstein-Barr virus malignant tumour in a patient with rheumatoid arthritis, plus coma, seizures and other evidence of encephalitis (New England Journal of Medicine., 14 May, The Lancet, 2 May 1992).

* Several patients taking urapidil for high blood pressure have developed chronic bedwetting (enuresis), which vanished when the drug dosage was halved to 30 mg twice daily (The Lancet, 30 May 1992).

In a child, bedwetting happens mostly because a child’s nervous system is still too immature for total bladder control. Stress, anxiety, fever, infections and food intolerances may trigger episodes of bedwetting. In cases of allergies, corn, cow’s milk, cocoa, cola, citrus fruit and food colouring agents have been identified as common causes. Even allergies to inhaled allergens such as dust or housedust mites can be a cause (Crook WG, Genitourinary allergy, in Speer F (ed), Allergy and Immunology in Children, Springfield: Charles C Thomas, 1973: 690-4).

In the case of food sensitivities, my own clinical experience suggests the following sequence of events:

Many allergic reactions involve the fluid retention mechanism think of the swellings in hives, a blocked nose, obstructed bronchial tubes in asthma, swollen meninges in migraine. These are all tissues which have to draw off fluid from the blood to become swollen themselves;

The blood becomes more viscous (thickened) because of this loss of fluid. The body signals that this needs to be corrected, creating thirst, and so the child drinks;

Allergic swellings (except for those in migraine) are painless, and may occur in and around bodily organs, coming and going unnoticed. This is referred to as a ‘masked allergy’ because it is unseen. Many children appear to suffer from these unseen allergies;

When these swellings subside, all that stored fluid is quickly sent to the child’s bladder, causing an urgency to pass urine. This can become a problem when the child is asleep because the bladder can fill very quickly, before the child is fully aroused from sleep.

Although bedwetting is commonly associated with stress, you should also investigate symptomless urinary infections (both bacterial and parasitic) and diabetes. A urine test may rule out or confirm an infection.

Bedwetting can also affect about 15 per cent of the very old. An elderly person suffering from Alzheimer’s disease is likely to become progressively more incontinent. An easy option for doctors and nursing staff at institutions is to introduce an in dwelling catheter into an incontinent elderly individual. As these can cause trauma and infection, such a practice should be resisted.

Helful advice

Never scold the child or an elderly person for wetting the bed

Praise the child for dry nights, but do not comment on this to an elderly person

Ensure that the child or the elderly person with urinary incontinence doesn’t drink anything within two hours of bedtime. (This may be difficult with ‘masked allergies’ because these create thirst)

Encourage the child or elderly person to urinate before going to bed

Wake the child or elderly person two hours later to empty the bladder once more

During the day, make sure that all caffeine drinks coffee, tea, cola, cocoa are avoided

Try to institute bladder training. You can help them achieve this by postponing their trips to the toilet to urinate during the day. Then, at night, you can alter their conditioned sleep pattern by using a bell that is set to sound when the child or elderly person wets a special sensor pad in the bed.

Homoeopathy

Providing there is no physical cause for bedwetting, try one of the following homoeopathic medicines:

Plantago major

Equisetum hyemale

Kreosotum

Ilex paraguayensis.

This should be taken at potency 6CH, taking four pilules every night for three weeks. If there is no improvement at this time, higher potencies should be used until the problem is resolved.

Another tried and tested remedy is five drop doses of the mother tincture of Verbascum thapsus both in the morning and at night (Boericke W, Homoeopathic Materia Medica, 9th edition, Philadelphia, PA: Boericke & Runyon, 1927: 671).

Manipulative therapies

Osteopathy, chiropractic or cranial osteopathy can correct any structural problem in the spine or pelvic basin which may be putting pressure on

the nerves to the bladder (J Am Ost Assoc, 1994, 94(7): 606-9). Manipulative therapy is also of value for urinary incontinence in older patients (Dodson D, Osteopathic Annals, 1979; 7(3): 115-9).

Oriental Medicine

In China, the praying mantis’ egg case commonly used in powders or pills usually in a dry fried form, successfully treats bedwetting in children. A good quality sample should be dry, yellow, lightweight and intact. It is administered in three gram doses (Bensky D and Gamble A, Chinese Herbal Medicine Materia Medica, revised edition, Seattle, WA: Eastland Press Inc, 1993: 393-4).

North American Indian Medicine

In the traditional medicine of North American Indians, 20 drops three times daily of the tincture of the bark of Rhus aromatica (sweet sumac) is useful for bedwetting (Weiss RF, Herbal Medicine, 1st English edn, Gothenburg: Ab Arcanum, 1988: 250-1).

Hypnotherapy

In isolated cases, hypnotherapy has helped bedwetting teenagers. However, this is not considered suitable for young children.

!AHarald Gaier

Harald Gaier is a registered naturopath, homoeopath and osteopath.

The authors themselves were surprised to report that in this period 73 per cent of GPs and 68 per cent of consultant child psychiatrists prescribed a psychotropic drug to a child of l7 or under.

“There should also be some concern that several prescriptions of antidepressants for depression were made by general practitioners on their own initiative without the recommendation of a consultant,” wrote the authors.

In an editorial in the same issue of the British Medical Journal, Dora Black, consultant psychiatrist with the Royal Free Hospital in London, pointed out that psychopharmacology in children is in its infancy and should only be the final port of call. The most worrying aspect of the study was that most prescriptions were being written for problems not shown to benefit from a drug. Antidepressants like imipramine have only been shown to have short term benefit in controlling bedwetting, unlike an alarm, and sedative antihistamines like trimeprazine tartrate are far less effective than behavioural methods in reestablishing normal sleep patterns for infants and toddlers.

My son has always wet his bed. Recently he has been given the nasal spray Desmospray by his GP. This step has been taken because my son has reached the age when school trips involve nights away with his school.

I have learned that this spray sends messages to the pituitary gland, which is responsible for regulating the concentration of urine. As such, the spray has worked, since it reduces the amount of urine and enables my son either to be dry at night or only slightly wet.

I have spoken to several doctors about this spray and have been assured that “there are no side effects”.

Frankly, I do not believe it. I have spoken to a homeopath about this, and she tells me that the pituitary gland is part of the endocrine system, which includes the thyroid. The spray may therefore have affected his thyroid, and be responsible for what I believe is an increased tension and hyperactivity. This creates a spiralling problem, since he becomes alienated at school and gets into increasing problems with the teachers.

I would like to have some medical evidence to support my feeling that this spray does in fact have the above side effects, because I would like to convey this to my son’s GP if this is correct then GPs and parents should be aware that there may be behavioral side effects to this drug. C M, Dulwich…..

A:Your doctors are wrong Desmospray has plenty of side effects. One reason your doctors don’t know this is that the UK’s Data Sheet Compendium lists almost none, unlike the American Physician’s Desk Reference, which lists a page of substantial warnings.

Desmospray (or DDAVP Nasal Spray, as another brand is known in the States) contains the drug desmopressin acetate, an antidiuretic hormone (ie, it helps patients to retain water). It works quickly and over a long period of time after each spray, which is the equivalent of one-tenth of the dose given by injection. The usual dosage for children six and over is 20 mcg, or up to double that if the patient doesn’t respond. Since the spray can’t deliver less than a 10 mcg dose, smaller doses are given via a nasal tube delivery system.

The PDR first warns that in young and elderly patients in particular, fluid intake should be adjusted (that is, scaled down) to decrease the potential of water intoxication (poisoning) or hypoatremia (abnormally low concentration of sodium in the blood). Ferring Pharmaceuticals, which manufactures the drug in the UK, says that the fluid intake at the two meals following the administration of the drug should be restricted to 50 per cent of ordinary intake to avoid this water overload. It also warns that “particular attention should be paid to the possibility of the rare occurrence” of an extreme decrease in plasma water permeability and seizures occurring as a result.

The spray has caused headaches and nausea at high doses; nasal congestion, rhinitis and flushing, mild abdominal cramps, nosebleed, sore throats, cough and upper respiratory infections have been reported. Other problems include conjunctivitis, edema eyes (that is, water retention in the eyes), excessive tearing, depression, dizziness and rash, particularly leg rash. Most symptoms are worse with the 40 mcg dosage.

Desmopressin spray has also been known to produce a slight elevation of blood pressure, a side effect that disappears when dosage is reduced. Nevertheless, the drug should not be given to patients with high blood pressure, cardiovascular disease, reduced kidney function or cystic fibrosis. It can also cause scarring, edema or other problems in the nasal passages.

Perhaps most disturbing is that the manufacturer has only tested the drug for safety and effectiveness over the short-term (between four and eight weeks). “Adequately controlled studies with intranasal DDAVP in primary noctural enuresis have not been conducted” beyond this time, says Rhone-Poulec Rorer Pharmaceutials, the Pennsylvania manufacturer of DDAVP.

There are also reports of an “occasional change” in the response to the DDAVP Nasal Spray over time usually after six months. Some patients show a growing tolerance to the drug; others, a shortened duration of effect. This may be one reason that Ferring recommends that continued treatment be reassessed after three months by having the patient go for a week without Desmospray.

The biggest problem with this drug is that it only forces your child to retain water; it doesn’t cure the condition causing him to wet his bed in the first place or even help to keep him dry. Researchers in the journal Pediatrics recently examined 18 randomized, controlled trials in which a total of 581 children received DDAVP. Although all but one study showed that the drug reduced bedwetting frequency, only one-quarter of the children became dry after two weeks. In the single study reporting long-term results, only six of 28 children (21 per cent) remained dry for 12 weeks after stopping DDAVP. Furthermore, there was no relation between dryness and the amount of the drug used.

Another study comparing the drug with conditioning alarms found the alarms (which supposedly work in nearly three out of four cases) to be more effective.

In reporting this study (see WDDTY vol 4 no 9) Journal Watch concluded: DDAVP should not be a first-line treatment for nocturnal enuresis.” An editorial accompanying the Pediatrics study suggests that DDAVP may be appropriate in special circumstances, such as an overnight stay or when other therapies don’t work.

Since you mention hyperactivity and behavioral difficulties as additional problems, we would urge you to explore the possibility that your son has an allergy or nutritional deficiencies. Indeed, bedwetting and hyperactivity often go hand in hand.

Our Alternatives columnist Harald Gaier has seen many cases of bedwetting (and hyperactivity) resolve as soon as the offending allergen was located. (The reason for the connection, he says, is that allergies cause swelling and fluid retention, which is then eliminated by the body as soon as the effect of the allergenic substance wears off often too quickly for a child to wake up and get to the toilet.)

Locating the source of hyperactivity, which may be a vitamin deficiency, the result of too much sugar or additives, or an allergy, requires painstaking detective work. See WDDTY vol 4 no 4, our issue on hyperactivity, for a few ideas about causes and how to locate and treat them.

Bunions: try iodine on them, but they could also have an emotional cause best treated by a flower remedy practitioner. In the meantime try aloe vera juice, and vitamins E and C.

Omega-3 sources: try Arctic Sea with omega-3 and -6, or Perilla oil, while a natural source is purslane, which can be added to salads or cooked.

Bedwetting: pumpkin seeds may help, as they are high in zinc. Reflexology, Bach flower remedies or chiropractic may all offer help. Try Virtual Scanning, says our man at the Virtual Scanning centre. One boy was cured with the help of an aura therapist, one reader relates.

White spots: they’re a sign of dehydration and an inability to break down fats. If it is caused by high cholesterol, it’s called xanthelasma, says one reader helpfully.

Itchy scalp: a scalp massage with 3 drops teatree oil, 2 drops rosemary oil to 30 ml jojoba oil, left in the hair overnight might help matters.

And so to other issues. . .one reader wonders if the ‘interview’ last week between WDDTY and a Department of Health official was a spoof. Well, we know our sense of humour can be subtle, but we didn’t realize it had become invisible! But yes, it was a spoof. . .

a homoeopath takes us to task for suggesting that ‘homoeopathic remedy x can cure disease y’. It doesn’t work like that, she says. Point taken, but these suggestions come from other homoeopaths. . .another homoeopath takes us to task for a different reason. We don’t give enough references to back up all the statements we make. For that, you’d have to read our monthly newsletter What Doctors Don’t Tell You, which is packed with references. E-news doesn’t seem to be an appropriate platform for this. So if you want the references, you have to subscribe. Sorry!. . .

we hear of a doctor called Dr John Reckless who wants to add a statin, the cholesterol-lowering drug featured last week, into the public water supply. So you’d have fluoride in the water to protect your teeth, and statins to protect your heart. Marvellous stuff. No wonder he’s called Reckless. . .

a few American readers say we’re attacking their country’s foreign policy, an accusation based on our tongue-in-cheek headline ‘There are weapons of mass destruction in Iraq’. We thought we were taking a swipe at the UK’s foreign policy, but never mind. One gentleman says that Lynne McTaggart (WDDTY editor) doesn’t understand because she’s not American. Well, we think Lynne does understand, and she is an American.

But to spoil our argument, Lynne doesn’t write E-news. Damn.

Try EFT (Emotional Freedom Technique), says one reader, which can solve problems like bedwetting in one session. Or try an hypnotherapist, suggests another.

Walnut oil can do the trick too. Just two dessert spoonfuls a day (one in the morning and evening) for two days should be enough. A homoeopath, meanwhile, would suggest low-potency Equisetum (horsetail), says one reader, while another (a homoeopath) says to try Tuberculinum and Equis. The New Era B tissue salts might help, suggests one reader.

Or try the DDAT programme (Dyslexia, Dyspraxia and Attention Deficit Treatment Centre). More information can be found on the website, http://www.ddat.co.uk.

A feng shui expert resolved one bedwetting problem when she told the parent to remove any items stored under the bed. The mother removed all the toy boxes, and the son never wet the bed again! Or try visualization.

Induce deep relaxation in the child and allow him to explore the root cause of the complaint. It’s worked for others, and it can work for you.

Many of the E numbers on processed foods can be a cause as they can relax the muscles, resulting in involuntary wetting. Try and remove all chemicals and preservatives from the diet and use chemical-free toiletries. Fluoride in toothpaste could be a major cause.

One reader took her daughter to a chiropractor, who cleared up the bedwetting after three sessions. If the problem is linked to the alignment of the spine, a visit to the chiropractor could be the answer.

One reader cured her son’s bedwetting by cutting out apple juice from his diet, and also by encouraging him to get up if she saw he was restless in his sleep.

In a review of several types of bedwetting treatments, Jonathan Evans, of the Children and Young People’s Kidney Unit in Nottingham, found that drugs such as the antidiuretic desmopressin or the antidepressant imipramine can improve symptoms, but there is no evidence of long-term benefit.

Imipramine, in particular, also has a high frequency of serious adverse effects involving the central nervous system and should therefore be used with caution.

Enuresis alarms, which wake the child at the first sign of wetting, can be effective as behavioural conditioning. But, he notes, they require several months of continuous use, and many parents find them arduous and impractical. Furthermore, like the drug treatments, a large number of children relapse once the alarm use is stopped (BMJ, 2001; 323: 1167-9).

Equisetaceae

Names: Shavegrass.

Habitat: Common on wet ground and waste places.

Collection: Take care to ensure the plants being picked are E.arvense or other common species, as some other specices are rare butlocally abundant. Collect in early summer. Cut the plant just above the ground, hang in bundles and dry in an
airy place.

Part Used: Dried aerial stems.


Constituents:

• Alkaloids, including nicotine, palustrine andpalustrinine

• Flavonoids such as isoquercitrin and equicetrin

• Sterols including cholesterol, isofucosterol, campesterol.

• Silicic acid.

• Misc: a saponin equisitonin, dimethylsulphone, thiaminase & aconitic acid.
  

Indications: Horsetail is an excellent astringent for the genito-urinary system, reducing hemorrhage and healing wounds thanks to the high silica content. Whilst it acts as a mild diuretic, its toning and astringent actions make it invaluable in the treatment of incontinence and bed wetting in children. It is considered a specific in cases of inflammation or benign enlargement of the prostate gland. Externally it is a vulnerary. In some cases it
has been found to ease the pain of rheumatism and stimulate the healing of chilblains.

Ellingwood suggest the following uses: dropsy, lithaemia, haematuria, gonorrhea, gleet, irritable bladder, enuresis in children, prostatitis, and the ashes for acid dyspepsia.

Combinations: Horsetail is often combined with Hydrangea in the treatment of prostate troubles.

Preparations & Dosage: Infusion: pour a cup
of boiling water onto 2 teaspoonfuls of the dried plant and let infuse for l5-20 minutes.. This should be drunk three times a day. Bath: a useful bath can be made to help in rheumatic pain and chilblains. Allow l00 grams (3 l/2 ounces of the herb to steep in hot water for an hour. Add this to the bath. Tincture: take 2-4 ml of the tincture three times a day.