Saturday, 2 May 2015

Why simple strategies are not enough for bedwetting

Waking in the middle of the night to change your child’s sheets after a bedwetting episode is practically a rite of passage for parents. And it is more common than you think. Scientists have said that there is no one single cause of bed-wetting, but if you want an easy target, look no farther than your own DNA. Reasons for bedwetting are not totally understood, but experts think it may be associated with the time it takes children to develop control over the bladder, a complex milestone. The timing varies from child to child. From five to seven million children wet the bed some or most nights – with twice as many boys wetting their bed as girls. After age five, about 15 per cent of children continue to wet the bed, and by age 10, 95 per cent of children are dry at night.

While techniques such as fluid restriction can help some children who have problems with bedwetting, alarms and medications are more effective, a new study finds. “Simple behavioural therapies such as rewarding the child for dry nights or taking the child to the toilet during the night can sometimes help with bedwetting, and is better than doing nothing,” said study leader Dr. Patrina Caldwell, a pediatrician at the Children’s Hospital at Westmead and senior lecturer at the University of Sydney, in Australia. 

“However, there are more effective treatments such as bedwetting alarm training or medications,” she said. But alarm training is more difficult, she noted. Bedwetting affects about five million children in the United States, with up to 20 per cent of five-year-olds having the problem. Most kids outgrow the problem, known medically as nocturnal enuresis, and only two per cent of adults are affected. However, bedwetting can be frustrating, stressful and traumatic. Remedies and treatments abound, but with much debate about which are best. 

In the United States, two medications are approved for childhood bedwetting – desmopressin (DDAVP) and imipramine (Tofranil) – although others are also used off-label. Dr. Trevor Resnick, chief of neurology at Miami Children’s Hospital, said he only prescribes medication on an as-needed basis, such as to spare children embarrassment on a sleepover. The new report was published recently in The Cochrane Library. For the review, Caldwell’s team reviewed 16 published studies involving more than 1,600 children, with about half trying simple interventions. Among them were fluid retention, rewards for dry nights (such as stars on chart), and lifting children and taking them to the bathroom after they have been asleep. No one simple strategy worked better than another, the researchers found. When they compared alarm training with the simple strategies, the alarm training was more effective. And treatment with medication alone was better than the simple interventions.

However, the researcher noted that “the findings from this review should be interpreted cautiously due to the poor quality and small sizes of the trials.” The findings suggest that parents may want to start with simple treatments, Caldwell said, “then move to alarm training or medication if simple treatments do not work after trying for six months.” “Younger children generally take longer to respond to treatment,” she said. “Don’t get annoyed with the child, because bedwetting is usually out of their control.” While the alarm system, which sounds an alarm when drops of urine are detected, is effective, it is difficult to do, Caldwell said. Another downside she has sometimes seen is when children become dry on alarm training then develop sleepwalking or night terrors. “Bedwetting and night terrors and sleepwalking are all parasomnias (sleep disorders) and are known to be associated,” she said.

The new findings mirror what U.S. expert Resnick has seen in his patients. “I’d say behavioural therapies work about 50 percent of the time,” said Resnick, who was not involved in the study. If simple treatments do not work, Resnick said he may consider medications, but he only prescribes them on an as-needed basis, since the medications have side effects.

To be continued next week

This story was published in Newswatch Times on May 2,  2015.

Without increased funding, Nigeria may not be rid of malaria

While some health watchers are busy celebrating the expected malaria vaccine that will prevent millions of young children from catching the disease, some experts have raised doubts over the ability of Nigeria to provide required funding to rid the vector.

The new vaccine would be available in October after trial results found that it reduces number of cases by half. But, experts have said that Nigeria’s programme on malaria may be far from achieving the desired result of eliminating malaria unless there is further cheering news about the trial vaccines currently going on in seven African countries. Although the promising trial vaccine which has been tested on 16,000 children from seven African countries excluding Nigeria found that booster doses were of limited use and vaccines in young babies were not effective, experts have warned that unless more funding is made available, Nigeria may never be rid of the malaria vector.  Scientists gathering at the Nigerian Institute of Medical Research (NIMR), Lagos on Tuesday, at a symposium to mark the World Malaria Day submitted that the various efforts at combating the endemic disease in the country “have been complex and contradictory, hence near futility”.

Representative of Director General, Nigerian Institute of Medical Research (NIMR), Dr. Odunukwe Nkiruka (left); Chairman of the occasion, Prof. Olubunmi Otubanjo; Lagos State Commissioner for Health, Dr. Jide Idris; and Category Manager, Pest Care, Health Care, and Air Care, RB West Africa, Qaiser Rashid, during a symposium in commemoration of World Malaria Day 2015 in Lagos, Tuesday.
Addressing the audience, Director General, Professor Innocent Ujah, represented by Director of Research, Nkiruka Odunukwe, noted; “Although the 2014 World malaria reports testifies to the fact that the malaria target under the MDG 6 had been met with 55 countries on track to reduce the malaria burden by 75 per cent by the end of 2015, the situation in Nigeria is complex and contradictory. “Whereas, malaria had accounted for over 60 per cent of hospital out-patient visits, 25 per cent infant deaths, 30 per cent of all under-five and 11 per cent of maternal mortality annually, all the efforts to improve on these figures through the National Malaria Elimination Programme has not significantly changed the trend”, observed the DG. Ujah lamented that the economic loss to the Nigerian nation as a result of man-hour loss per annum from absenteeism from work due to malaria fever is enormous and runs into billions of Naira. In his keynote address on the theme: ‘Invest in the future, Defeat Malaria’, Lagos State commissioner for health, Dr Jide Idris observed that though NIMR has been involved in a lot of research works on malaria, the effect would only be meaningful if sufficient support is given for scaling up of findings by all stakeholders with federal government taking the lead.

According to Idris, “A lot of the research funding for NIMR comes from external bodies; there is need for concerted effort to invest more seriously in our public health institutions especially in the area of research”.
The Commissioner stated that no country can make any progress especially in the health sector without research because that is the only place where new things are discovered and new things are modified.
“Findings are made and these help in making decisions and guidelines for policies which are very essential”, said Idris. The Lagos Ministry of Health boss challenged the in-coming administration of the General Muhammadu Buhari to revisit some of the moribund health facilities and revitalize same. According to Idris, there is very strong awareness now in the country and we know there is need to address our decaying infrastructure, the moribund vaccine factory is definitely part of the infrastructure which has to be refurbished and staffed and equipped so that we can encourage our scientists.

“Our best scientists and experts are outside this country and what we need is to create the best environment for them to do better back home”, Idris charged. He noted that the state government deliberately set up a research fund as a way to stimulate research saying, “In most countries abroad, it is not government as such that funds research; this is driven mostly by the private sector with government only creating avenue for it.”
Dr Samson Awolowo, Head of Malaria Research Group of the Institute attributed the high rate of death due to malaria to the widespread of fake medicines and parasite resistance to malaria drugs. Awolola said that mosquitoes resistance to insecticides and lack of fund for malaria research also contributed to the high cases of the ailment in Nigeria. “We need more funding into malaria research if we want to totally address these challenges and reduce deaths due to malaria,” he added.

Also speaking, Prof. Olubunmi Otubanjo, a Professor of Parasitology at the University of Ibadan said that malaria prevention and control should not be left out in the era of change as Nigeria begins a new dispensation. Otubanjo said that Nigeria contributed to one-quarter of all malaria cases in Africa and the incoming government should place high priority on prevention and control of the malaria. “Malaria should not be left out in this era of change with more funding to healthcare, effective partnership, and sustained political will to ensure a malaria-free nation, “ she said.

Dr Tolu Arowolo, a representative of the World Health Organisation (WHO) said there was the need to generate public awareness about the dangers of poor quality malaria drugs. Arowolo said that education campaigns would also help the public make more informed choices about preventive measures like insecticide-treated bed nets and residual indoor spraying. The President, Malaria Society of Nigeria, Dr John Puddicombe, said controlling and preventing malaria required a collaborative effort from all sectors of the society. He said that everyone could help a great deal in advocacy, social mobilisation campaigns as no single person or unit could do it alone. “Just as the government at all levels has the responsibility to strengthen the health system, individually and as a group, the citizens also have a big stake. “We have the responsibility of protecting ourselves and our children from malaria by using insecticide-treated nets, draining of stagnant water and keeping our environment clean,” he said.

Meanwhile, the Niger Government has said that the state is losing more than N5.2 billion on the prevention, control, treatment cost and loss of man hours. The state Commissioner for Health and Hospital Services, Hajiya Hadiza Abdullahi, disclosed during this year’s World Malaria Day in Minna. Abdullahi said that this informed government priority to fight the scourge among the infants and adults in the state. “Historically, Niger state has remained the leading state in the central zone of the country in malaria elimination programme.
“In the last three years, the state has maintained its position within the top three states in the country,” she said. Abdullahi, represented by the ministry’s Permanent Secretary, Dr Ibrahim Tifi, added that malaria accounts for 30 per cent of under-five year’s mortality and 11 per cent maternal deaths. Similarly, the Support to National Malaria Programme (SUNMAP) revealed that it covered 95 per cent of the state in distribution of Long Lasting Insecticidal Nets (LLIN) last year.

Dr Olatunde Olotu, SUNMAP Niger Technical Malaria Manager, said that the residents have embraced the LLIN. “Over the years, we have ensured the vast embracing of treated mosquito nets across the state. “So, whatever intervention will come in malaria control, the net serves as first point of referral,” he said. The event was attended by top government functionaries and development partners from WHO and UNICEF.

This story was published in Newswatch Times on May 2,  2015.

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