Paeds 3 Flashcards
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:
diabetes,
urinary tract infection,
constipation,
psychological problems (for example behavioural or emotional problems),
family problems (vulnerable child or family)
What are the risk factors for enuresis
FH male delay in development constipation 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
HTN
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
FBC CRP VBG U+E
AXR
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 TPN intubation or ventilation if apnoea surgery if perforation/necrotic bowel
What are the potential complications of necrotising enterocolitis
Perforation. Acquired short bowel syndrome (following surgery). DIC. 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
probiotics
