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The remaining disorders of childhood include the eating disorders Pica, Rumination Disorder, and Feeding Disorders, and the tic disorders: Tourette's Disorder, Chronic Motor or Vocal Tic Disorder, Transient Tic Disorder.  There are also the elimination disorders of Encopresis and Enuresis. And finally a variety of others: Separation Anxiety Disorder, Selective Mutism, Reactive Attachment Disorder, and Stereotypic Movement Disorder.

Habitual Snoring Linked to Hyperactive, Inattentiveness, Tiredness, Emotionality: In 1144 children, habitual snoring (HS; snoring frequently or always) and impaired behavior were assessed using parental questionnaires. Intermittent hypoxia was determined by pulse oximetry. HS was significantly associated with hyperactive (OR: 2.4) and inattentive behavior (OR: 4.0), daytime tiredness (OR: 7.1), and sleepiness (OR: 2.6-4.8). These associations were independent of intermittent hypoxia. HS was also significantly associated with bad conduct (OR: 2.8), emotional symptoms (OR: 5.5), and peer problems (OR: 9.7). At follow-up, hyperactive and inattentive behavior but not academic success had significantly improved in children in whom HS had ceased. Habitual snoring, intermittent hypoxia, and impaired behavior in primary school children. Urschitz MS, Eitner S, et al. University Children's Hospital, Tuebingen, Germany. Pediatrics. 2004 Oct;114(4):1041-8


The standard medication treatment for bedwetting is imipramine, which is very inexpensive and very well researched with many double-blind studies since in 1960s.  Desmopressin in a nasal spray (20 micrograms) or pill form (200-800 micrograms) is also effective and has many double-blind studies supporting its use, but it is quite expensive despite being a generic.  Indomethacin and diclofenac have helped in individual double-blind studies.  Clomipramine, another noradrenergic antidepressant, is of reported benefit. The one study comparing a low dose of the anti-depressant amitriptyline (very inexpensive) to desmopressin found the anti-depressant better and no added benefit from the combination. Carbamazine, an inexpensive seizure medication, was quite effective in one study.  Behavior therapy did much better than desmopressin and the combination was of no added benefit.  Atomoxetine helped somewhat in one study and is being promoted by the manufacturer for bed wetting.  However, it is quite expensive and has no advantages unless the youth needs treatment for ADHD.  Even then, nortriptyline or desipramine may work just as well for both at a lower cost.

Behavior therapy can be very useful for bed wetting.  The use of a bed wetting alarm blanket is of some value, but without a more complete behavior therapy program, the blankets alone have had only modest success.

Amitriptyline Better than Desmopressin and Combo no Added Benefit: A PC DB study of 45 children with those under 10 receiving 25 mg/d amitriptyline and those over 10 receiving 50 mg/d. Amitriptyline resulted in a 40% improvement, desmopressin a 23% improvement and the combination a 47% improvement, not a significant improvement over amitriptyline alone.   A comparison of amitriptyline, vasopressin and amitriptyline with vasopressin in nocturnal enuresis. Burke JR, Mizusawa Y, Chan A, Webb KL. Pediatr Nephrol. 1995 Aug;9(4):438-40

Atomoxetine of Modest Value in DB: Nineteen of the 44 atomoxetine-treated and 22 of the placebo-treated had ADHD, which is a frequently occurring comorbid condition with nocturnal enuresis, with up to 30% of ADHD children also experiencing bed-wetting. At baseline, patients in the atomoxetine arm had a mean of 1.51 dry nights per week, and placebo patients a mean of 1.01. By the study's end at one week, the atomoxetine group had a mean increase of 1.5 dry nights compared with 0.6 for the placebo group. Eight subjects taking atomoxetine had seven dry nights, while none of the placebo patients had a dry week. Adverse events were reportedly minimal. Headache was the most reported effect. Dr. Kelsey told the media that he believes that the drug is at least, or more, potent that current therapies such as imipramine, and it is better-tolerated. It is not clear, however, how the drug is working in nocturnal enuresis. (Ed: Dr. Kelsey has no evidence that atomoxetine is as good as imipramine or that it is better-tolerated.  Imipramine is much less expensive and has been used for bed wetting for over 20 years.)

Behavior Therapy Better than Desmopressin and Combo No Better: A very large Tel Aviv Univ. PC DB study of 226 children with bed-wetting found 49% improvement with both behavior therapy plus desmopressin, 45% with behavior therapy and placebo, and 19% with desmopressin alone. Those on desmopressin alone were more likely to relapse after stopping therapy. A controlled trial of desmopressin and behavioral therapy for nocturnal enuresis. Kahan E, Morel D, Amir J, Zelcer C. Medicine (Baltimore). 1998 Nov;77(6):384-8

Carbamazepine, Indomethacin Helped Bed Wetting: A PC DB crossover study of 26 severe enuretic children 7-15 years old were given carbamazepine 200 mg at bedtime for 30 night or placebo then crossover after a 7 day washout.  Placebo patients averaged 4 dry nights vs. 19 with carbamazepine. Those not responding to carbamazepine were given indomethacin 100 mg suppositories which were often successful with the child sleeping until the morning. Carbamazepine to treat primary nocturnal enuresis: double-blind study. Al-Waili NS. Eur J Med Res. 2000 Jan 26;5(1):40-4

Desmopressin Helps in Small DB: A PC DB crossover study of 22 children with severe enuresis found a 60% decrease in bedwetting with 55% of patients experiencing marked improvement with no improvement at all with the placebo. After one month, 7 were totally dry. Desmopressin in the management of nocturnal enuresis in children: a double-blind study. Birkasova M, Birkas O, Flynn MJ, Cort JH. Pediatrics. 1978 Dec;62(6):970-4

Desmopressin Helped in DB: A PC DB of 30 enuretic children found a 67% decrease in wet nights during the first 30 days from 18 to 6.  Of 15 on desmopressin, 40% were completely dry, 40% had satisfactory improvement, and 20% did not benefit. Desmopressin in nocturnal enuresis. Aladjem M, Wohl R, Boichis H, Orda S, Lotan D, Freedman S.  Arch Dis Child. 1982 Feb;57(2):137-40

Anti-cholinergic Medication Helped Desmopressin Failures: A Swedish PC DB crossover study of 33 children found 800 micrograms of desmopressin better than 400. Five were totally dry with 800 micrograms.  The others were then given an anti-cholinergic medication and 20 of 28 did well. Desmopressin resistant enuresis: pathogenetic and therapeutic considerations. Neveus T, Lackgren G, Tuvemo T, Olsson U, Stenberg A. J Urol. 1999 Dec;162(6):2136-40

Imipramine Better than Mianserin or Placebo: 80 children 5-13 years old in PC DB study found 72% helped by imipramine 25 mg at bedtime.  Mianserin, another anti-depressant, was only slightly better than the placebo. Nocturnal enuresis: a placebo controlled trial of two antidepressant drugs. Smellie JM, McGrigor VS, Meadow SR, Rose SJ, Douglas MF. Arch Dis Child. 1996 Jul;75(1):62-6

Imipramine Helped Quickly in Small DB: Using only 10-20 mg/d, in a PC DB study of 14 children, 11 reported benefit. The mechanism of imipramine in enuresis nocturna. Korczyn AD, Kish I. Clin Exp Pharmacol Physiol. 1979 Jan-Feb;6(1):31-5

Imipramine and Desipramine Equally Effective and Superior to Methscopolamine: A PC DB of 40 enuretic children found the benefit was independent of any impact on psychiatric difficulties.  A few children were non-responders and a few developed tolerance to the medication and had a relapse. Childhood enuresis. II. Psychopathology, tricyclic concentration in plasma, and antienuretic effect. Rapoport JL, Mikkelsen EJ, Zavadil A, Nee L, Gruenau C, Mendelson W, Gillin JC. Arch Gen Psychiatry. 1980 Oct;37(10):1146-52