FCPS Paediatrics TOACS · Interactive Station

✅ Candidate's answer:
• Diagnosis: Primary monosymptomatic nocturnal enuresis (PMNE).
• Primary vs secondary:
- Primary: Child has never been dry at night for a sustained period (≥6 months). This patient has never had a dry period longer than 2 weeks – primary.
- Secondary: Child was dry for ≥6 months and then started wetting again (often associated with stress, UTI, diabetes).
• Monosymptomatic vs non-monosymptomatic:
- Monosymptomatic: Only nocturnal enuresis, no daytime symptoms (no daytime wetting, no urgency, no dysuria). This patient has no daytime symptoms.
- Non-monosymptomatic: Daytime symptoms present (suggests bladder dysfunction).
• Age: Enuresis is considered a disorder if the child is ≥5 years old (or developmentally equivalent). This patient is 8 years old.
• This is a classic case of PMNE.

✅ Candidate's answer:
• Prevalence:
- 5 years: 15-20% of children.
- 7 years: 7-10% of children.
- 10 years: 5% of children.
- 15 years: 1-2%.
- Adults: 0.5-1%.
• Spontaneous resolution rate: Approximately 15% per year (most children outgrow it by adolescence).
• Male predominance: More common in boys (2:1).
• Family history: If one parent had enuresis, risk ~40%; if both parents, risk ~70%.
• This patient (8 years old, 4-5 nights/week) may not outgrow it quickly and may benefit from active treatment to avoid social embarrassment and anxiety.

✅ Candidate's answer:
• Pathophysiology (three main factors):
1️⃣ Nocturnal polyuria – lack of normal nocturnal increase in antidiuretic hormone (ADH) → excessive urine production at night.
2️⃣ Reduced bladder capacity – functional bladder capacity may be smaller than expected for age.
3️⃣ Failure to arouse from sleep – the child does not wake up in response to a full bladder (not laziness – a neurologic/arousal disorder).
• Why a star chart works (behavioral mechanism):
- The star chart uses positive reinforcement – a token economy where the child earns a star for each dry night.
- Stars are exchanged for a reward (e.g., small toy, extra screen time).
- This increases motivation to wake up or hold urine.
- It reduces anxiety (child feels empowered).
- It works best in children who are motivated and have some ability to control wetting (i.e., mild to moderate severity).
- Does NOT treat the underlying pathophysiology but can be effective in up to 50-70% of motivated children, especially those with anxiety (who respond well to structure and rewards).

✅ Candidate's answer:
• Implementation of star chart:
1️⃣ Explain to the child: "This is not punishment. You are working toward a goal, and we will reward you when you succeed."
2️⃣ Create a chart (calendar or paper) with spaces for each night.
3️⃣ Target behavior: Dry night (no wetting).
4️⃣ Reward: Star sticker placed on the chart for each dry night.
5️⃣ Backup reward: After a certain number of stars (e.g., 7 stars), the child earns a small prize (e.g., small toy, extra 30 minutes of screen time, special outing).
6️⃣ Involve the child: Let them place the star on the chart.
7️⃣ Do NOT punish wet nights – ignore them, or say "better luck tonight." Punishment increases anxiety and reduces effectiveness.
8️⃣ Review weekly: Celebrate successes, adjust reward if needed.
• Key principles of positive reinforcement (behavioral psychology):
- Reinforcement must be immediate (star placed in the morning).
- Reinforcement must be contingent (only given when target behavior occurs).
- Reinforcement should be meaningful to the child (the child values the star and reward).
- Intermittent reinforcement after initial success (to maintain behavior).
- Star chart is a form of token economy (stars are tokens exchanged for backup reinforcers).

✅ Candidate's answer:
• Good candidate for star chart (positive reinforcement):
1️⃣ Age 8 years – old enough to understand and cooperate.
2️⃣ Mild anxiety – children with anxiety often respond well to structured, predictable interventions with clear rewards; star chart reduces anxiety by giving the child a sense of control.
3️⃣ Motivated to stop – likely embarrassed, wants to be dry (especially for sleepovers, camps).
4️⃣ No severe behavioral problems (no oppositional defiant disorder, conduct disorder).
5️⃣ Parents are engaged (they are seeking help).
6️⃣ Mild to moderate severity (4-5 wet nights per week; not every night).
• Star chart is non-invasive, inexpensive, has no side effects, and can be done at home.
• If star chart fails after 3-6 months, then escalate to enuresis alarm or desmopressin.
• For this child, star chart is an excellent first step.

✅ Candidate's answer:
• Enuresis alarm: A device with a moisture sensor placed in the child's underwear or on a pad. When the sensor detects moisture (urine), it triggers an audible or vibrating alarm to wake the child. Over time, the child learns to wake up before wetting (classical conditioning).
• When to recommend:
- After failure of star chart (3-6 months of consistent use).
- As first-line for children with more severe enuresis (every night).
- For children who are motivated and able to tolerate the alarm (some children sleep too deeply to wake to the alarm).
- If the family is willing to be consistent (may take 2-4 months).
• Effectiveness: Enuresis alarm is the most effective treatment for nocturnal enuresis with long-term cure rates of 50-70%. However, it requires high motivation from the child and family.
• Disadvantages: Can disrupt sleep of entire family, may take weeks to show benefit, not suitable for all children.
• For this child (mild anxiety, moderate severity), start with star chart first; if fails, then alarm.

✅ Candidate's answer:
• Desmopressin (DDAVP): A synthetic analog of antidiuretic hormone (ADH). It reduces urine production at night by increasing water reabsorption in the kidneys.
• Indications:
- Short-term or situational use (e.g., sleepovers, summer camp, travel).
- Children who fail behavioral therapy (star chart) and enuresis alarm.
- Children who cannot tolerate the alarm.
- As an adjunct to alarm (not usually first-line).
• Dose: Oral tablet 0.2-0.6 mg or sublingual melt, given at bedtime.
• Effectiveness: Reduces wet nights by 50-70% while taking it, but high relapse rate after stopping.
• Risks:
- Hyponatremia (low sodium) and water intoxication – if the child drinks excessive fluids before bed. Patients must restrict fluids 1 hour before and 8 hours after taking DDAVP.
- Headache, nausea, abdominal pain.
- Rare: seizures (secondary to hyponatremia).
• This patient should try star chart first; DDAVP reserved for special occasions or after behavioral failure.

✅ Candidate's answer:
• Secondary causes (rule out before labeling as primary enuresis):
1️⃣ Urinary tract infection (UTI) – would have daytime symptoms (dysuria, frequency, urgency). This patient has no such symptoms.
2️⃣ Diabetes mellitus (type 1 or 2) – polyuria, polydipsia, weight loss. Not present here.
3️⃣ Diabetes insipidus – excessive thirst and large volume of dilute urine. Not present.
4️⃣ Chronic constipation – can compress the bladder, leading to enuresis. Assess bowel habits. This patient had no mention of constipation.
5️⃣ Obstructive sleep apnea (OSA) – enuresis can be a symptom of OSA in children (due to increased intra-abdominal pressure and disrupted sleep). Snoring, restless sleep, daytime sleepiness would be present. Not mentioned here.
6️⃣ Neurogenic bladder – history of spinal dysraphism, myelomeningocele, abnormal voiding pattern. Not present.
7️⃣ Behavioral/psychiatric causes – secondary enuresis may occur after stress (divorce, bullying, abuse). No history of major stress.
• This patient has no red flags – appropriate for primary enuresis diagnosis.

✅ Candidate's answer:
• Treating enuresis is likely to REDUCE anxiety, not worsen it.
- Enuresis is a significant source of embarrassment and anxiety for children (fear of sleepovers, camps, being discovered).
- Successful treatment leads to improved self-esteem and reduced social anxiety.
• How to address anxiety in the management plan:
1️⃣ Reassure the child and parents: "This is not your fault. It is a medical condition, not laziness."
2️⃣ Use positive reinforcement (star chart) – reduces anxiety by giving the child a sense of control and predictable rewards.
3️⃣ Do NOT punish wet nights – punishment increases anxiety and is counterproductive.
4️⃣ If anxiety is significant (beyond mild), consider screening for generalized anxiety disorder – but this child has only mild anxiety related to school tests.
5️⃣ If anxiety persists despite enuresis treatment, refer to mental health for CBT.
- This child's mild anxiety is not severe enough to require separate treatment; focus on enuresis treatment.

✅ Candidate's answer:
• “That is a very common question, and many parents think the same thing. The answer is: No, he is not being lazy. Bedwetting is not a willful behavior. It is a medical condition.”
• “Your son's brain does not wake him up when his bladder is full at night. That is a neurological issue, not a lack of effort. Also, he may produce too much urine at night because his body does not make enough of a natural hormone called ADH.”
• “If he could stop by trying harder, he would have done so already. Punishing him or shaming him will only make him feel bad and will not stop the wetting.”
• “The star chart we are using is a positive way to encourage him. It gives him a goal and a reward. This is much more effective than punishment.”
• “With patience and the right treatment, most children eventually outgrow this. We are here to help you, not to blame him.”
• “I also recommend that you never let siblings tease him about bedwetting – that can cause lasting psychological harm.”

✅ Candidate's answer:
• Lifestyle modifications (adjunctive, not curative):
1️⃣ Fluid restriction in the evening – avoid fluids for 1-2 hours before bedtime. Do NOT restrict during the day (risk of dehydration).
2️⃣ Avoid caffeine and sugary drinks in the evening – caffeine is a diuretic.
3️⃣ Double voiding – void at the beginning of the bedtime routine, then again just before sleep.
4️⃣ Regular bowel movements – treat constipation if present (constipation can worsen enuresis).
5️⃣ Use a waterproof mattress cover – reduces stress for parents.
6️⃣ Involve the child in morning cleanup – have the child help change sheets (not as punishment, but as responsibility).
7️⃣ Encourage the child to void as soon as they wake up (even if dry).
8️⃣ Avoid lifting (waking the child to void) – this can disrupt sleep architecture and is not effective long-term. Only useful for special occasions.
• Star chart should be used alongside these modifications.

✅ Candidate's answer:
• Duration of star chart trial: 3-6 months of consistent use before considering escalation.
- If the child shows improvement (reduction in wet nights from 4-5/week to 1-2/week), continue star chart.
- If no improvement after 3 months, consider next step.
• Next step after star chart failure:
1️⃣ Enuresis alarm – most effective long-term treatment. Requires motivated child and family. Success rate 50-70% with low relapse.
2️⃣ Desmopressin (DDAVP) – can be used as short-term or situational treatment (e.g., sleepovers) or as adjunct to alarm.
3️⃣ Combination therapy (alarm + DDAVP) – for resistant cases.
4️⃣ Referral to pediatric urology or nephrology – if alarm and DDAVP fail, or if daytime symptoms develop, or if suspicion of bladder dysfunction.
• This patient (moderate severity, mild anxiety) is a good candidate for star chart; if no improvement, offer enuresis alarm.

✅ Candidate's answer:
• Success rate of star chart alone: Approximately 50-70% of motivated children show significant improvement (≥50% reduction in wet nights) within 2-4 months.
- Complete dryness (100%) occurs in 20-30%.
• Time to improvement:
- Some improvement may be seen within 2-4 weeks.
- Maximal benefit by 3-6 months.
• Factors that improve success:
- Child's motivation (wants to be dry).
- Consistent parental involvement.
- Appropriate rewards (meaningful to the child).
- Absence of punishment.
• Relapse after stopping star chart: Common (30-50%). Can restart star chart or transition to enuresis alarm for long-term cure.
• For this child, a 3-month trial of star chart is reasonable; if partial response, continue; if no response, escalate.

✅ Candidate's answer:
• No, this child does not need formal psychotherapy for mild anxiety.
- His anxiety is mild, limited to school tests, and not causing significant functional impairment.
- Treating the enuresis is likely to reduce his anxiety (enuresis is a major source of worry).
- The star chart itself provides structure and reduces anxiety by giving him a sense of control.
• Role of the pediatrician:
1️⃣ Reassurance and normalization – explain that mild anxiety is common and usually does not require treatment.
2️⃣ Teach basic coping skills – deep breathing, positive self-talk before tests.
3️⃣ Monitor for worsening – if anxiety increases, consider screening (SCARED, PHQ-9).
4️⃣ Refer to mental health if anxiety becomes moderate-severe – e.g., school refusal, panic attacks, significant distress.
• This child does not need referral at this time. Focus on enuresis treatment. Reassess anxiety at follow-up.