A. von Gontard

Factors Influencing Apnea and Bradycardia of Prematurity – Implications for Neurodevelopment

Background: Apnea and bradycardia of prematurity (ABP) are possible risks towards damage of the developing brain. Objectives: To characterize the influence of neonatal factors on ABP and to determine the relationship of ABP to neurodevelopmental outcome. Methods: ABP was described in very low birth weight infants (n = 83) using the frequency and severity of ABP episodes with a clinical score considering heart rate, oxygenation, duration and interventions performed during each episode. Neonatal factors were analyzed for their relationship to ABP using regression analysis. Neurodevelopment was investigated using the Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) of the Bayley Scales of Infant Development II at a corrected age of 13 months. Power of ABP parameters to predict outcome was assessed by logistic regression analysis. Results: ABP typically started within the first week after birth. Spontaneous resolution occurred at a postmenstrual age (PMA) of 36.0 ± 2.2 (31.1–44.1) weeks. A delayed resolution (>36 weeks PMA) and a higher average daily ABP score during a defined developmental period (31–37 weeks PMA) were associated with a higher incidence of unfavorable outcome (MDI or PDI <69 or death). Conclusion: ABP is an age-specific phenomenon. However, more severe courses than expected for PMA or the resolution at a later PMA indicated an increased risk of neurodevelopmental disturbances at a corrected age of 13 months.

Association of Attention Deficit and Elimination Disorders at School Entry: A Population Based Study

PURPOSE Attention deficit/hyperactivity disorder is a common comorbid disorder in children with nocturnal enuresis, daytime urinary incontinence and fecal incontinence. We assessed the specific association of these conditions in a population based sample. We hypothesized that children with elimination disorders have a higher rate of attention deficit/hyperactivity disorder, and that children with daytime urinary incontinence are more strongly affected than those with nocturnal enuresis. MATERIALS AND METHODS All children in a defined geographic area (Saarpfalz Kreis) were examined at school entry. Mean age was 6.22 years in 734 boys and 6.18 years in 645 girls. A questionnaire regarding elimination problems and the attention problems scale of the Child Behavior Checklist were administered as an interview to parents. Participation rate was 99.1% (1,379 parents). RESULTS Of the children 71 (5.1%) had attention deficit/hyperactivity disorder problems of clinical relevance (7.1% of boys and 2.9% of girls). A total of 185 children (13.4%) were wet (nocturnal enuresis in 9.1% and daytime urinary incontinence in 4.4%) and 19 (1.4%) had fecal incontinence. Attention deficit/hyperactivity disorder symptoms were more common in children with urinary incontinence than nonwetting children (16.8% vs 3.4%). When controlled for confounding variables, only children with daytime urinary incontinence (but not nocturnal enuresis) had a significantly higher risk of attention deficit/hyperactivity disorder symptoms (OR 4.4). CONCLUSIONS Attention deficit/hyperactivity disorder symptoms were increased in children with urinary incontinence in this population based sample. Children with daytime urinary incontinence were at greater risk for attention deficit/hyperactivity disorder than those with nocturnal enuresis. Screening and referral for specialized treatment of both disorders are recommended.

The natural history of daytime urinary incontinence in children: a large British cohort

Aim:  Few studies have looked at the prevalence of daytime incontinence in a longitudinal cohort of children. This study set out to determine the prevalence of daytime incontinence and relationships between daytime incontinence and bedwetting, faecal incontinence and urgency in a large cohort of British children.

Quality of Life and Self-Esteem for Children With Urinary Urge Incontinence and Voiding Postponement

PURPOSE Urge incontinence and voiding postponement are common subtypes of daytime wetting in children. We analyzed health related quality of life for children with urge incontinence and voiding postponement, and healthy controls at 2 centers. MATERIALS AND METHODS We examined a total of 49 consecutive children 5 to 13 years old who presented with urge incontinence (22) or voiding postponement (27), and 32 controls matched for age and sex. Health related and overall quality of life were measured with generic questionnaires, and self-esteem was measured with the Piers-Harris questionnaire. RESULTS Health related quality of life was significantly reduced in parent rating but not in child rating in the incontinent vs control group (total mean parent score 73 vs 78, child 76 vs 76). Children with voiding postponement have the lowest health related quality of life. Overall quality of life was significantly reduced in children with incontinence, while self-esteem did not differ. Children with externalizing disorders generally have the lowest health related and overall quality of life. CONCLUSIONS Health related and overall quality of life are useful constructs, and are reduced in children with daytime incontinence by parental rating. In comparison, children rate their quality of life as being higher. Quality of life is lowest with externalizing behavioral disorders, as in children with voiding postponement. Due to comorbid behavioral disturbances, children with voiding postponement often need additional assessment, counseling and treatment.

Incontinence in children with autism spectrum disorder

INTRODUCTION Autism spectrum disorder (ASD) and incontinence (nocturnal enuresis (NE), daytime urinary incontinence (DUI), fecal incontinence (FI)) are relevant disorders in childhood. In general, children with special needs such as intellectual disability (ID) or ASD are more often affected by incontinence than typically developing children. OBJECTIVE In the few studies conducted on children with ASD, gastrointestinal (GI) symptoms have received more attention than NE, DUI and lower urinary tract symptoms (LUTS). The aim of the present study was to assess the prevalence of incontinence, LUTS and psychological symptoms/disorders in children with ASD compared to controls. STUDY DESIGN Forty children with ASD (12 children with infantile or childhood autism, 15 with atypical autism and 13 with Aspergers syndrome) (mean age 11.3 years) and 43 age-matched control children (mean age 10.7 years) were assessed. A questionnaire referring to incontinence and the International Consultation on Incontinence Questionnaire-Pediatric LUTS (ICIQ-CLUTS) were administered. Child psychopathology was assessed with the Child Behavior Checklist (CBCL/4-18). Child psychiatric ICD-10 diagnoses were based on a structured psychiatric interview (Kinder-DIPS). RESULTS Children with ASD showed increased rates of NE (30.0% vs 0%) and DUI (25.0% vs 4.7%) compared to controls. Among children with ASD, daytime bladder control (≥5 years of age: 20.5% vs 0%) and bowel control (≥4 years of age: 42.5% vs 7.5%) were delayed compared to controls. Children with ASD had a higher LUTS score. Additionally, children with ASD were more often affected by psychological symptoms and disorders. Rates of clinically relevant externalizing symptoms (32.5% vs 0%), internalizing symptoms (67.5% vs 9.3%) and total problem score (70.0% vs 2.1%) were higher in children with ASD than the controls (see table). Children with ASD had more ICD-10 diagnoses than the controls (47.5% vs 4.7%). DISCUSSION The present study showed that children with ASD are more at risk of DUI and NE than healthy controls. In addition, children with ASD had more LUTS, especially urgency and postponement, and they needed a longer time to become dry and continent. Additionally, according to the parental CBCL questionnaire, children with ASD showed higher rates of clinically relevant psychological symptoms (externalizing and internalizing symptoms), and according to the psychiatric interview, they had higher rates of comorbid psychological disorders. CONCLUSION Autism spectrum disorder is an incapacitating disorder with significant impairment in social functioning. In most cases, psychological symptoms and disorders co-occur. Additionally, children with ASD are at a greater risk of being affected by different forms of incontinence and LUTS. Therefore, screening for incontinence and, if indicated, treatment of these disorders is recommended.

Central nervous system processing of emotions in children with faecal incontinence

Aim:  Faecal incontinence (FI) is a common disorder involving both the enteric (ENS) and central nervous systems (CNS). The aim of the study is to analyze neurophysiologically the central processing of emotions in children with FI, healthy controls and children with Attention‐deficit hyperactivity disorder (ADHD).

Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society

BACKGROUND Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found - these children suffer from functional nonretentive fecal incontinence (FNRFI). OBJECTIVE To summarize the evidence-based recommendations of the International Childrens Continence Society for the evaluation and management of children with FNRFI. RECOMMENDATIONS Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.

Incontinence in children with treated attention-deficit/hyperactivity disorder.

INTRODUCTION Attention-deficit/hyperactivity disorder (ADHD) and incontinence (nocturnal enuresis, daytime urinary incontinence and fecal incontinence) are common disorders in childhood. Both disorders are strongly associated with each other. OBJECTIVE ADHD can affect compliance to incontinence therapy in a negative way; it can also affect outcome. The aim of the present study was to assess the prevalence of incontinence, age of bladder and bowel control, and psychological symptoms in children having treatment for ADHD compared to a control group. STUDY DESIGN Forty children having treatment for ADHD (75% boys, mean age 11.4 years) and 43 matched controls (60.5% boys, mean age 10.7 years) were assessed. Their parents filled out questionnaires to assess: child psychopathology (Child Behavior Checklist), incontinence (Parental Questionnaire: Enuresis/Urinary Incontinence; Encopresis Questionnaire - Screening Version) and symptoms of the lower urinary tract (International-Consultation-on-Incontinence-Questionnaire - Pediatric Lower Urinary Tract Symptoms). The ICD-10 diagnoses and childrens IQ were measured by standardized instruments (Kinder-DIPS, Coloured Progressive Matrices/Standard Progressive Matrices). RESULTS Rates of incontinence in the ADHD group (5% nocturnal enuresis, 5% daytime urinary incontinence, 2.5% fecal incontinence) did not differ significantly from incontinence rates in the control group (4.7% daytime urinary incontinence). More children in the ADHD group had Child Behavior Checklist scores in the clinical range. Further ICD-10 disorders were present in eight children with ADHD and in one control child. More children with ADHD had delayed daytime and nighttime bladder control, as well as delayed bowel control, than the controls. DISCUSSION The present study showed that if children are treated for their ADHD, according to standard practice guidelines, incontinence rates are similar to those without ADHD. More children with ADHD reached continence at a later age than the controls, which could be an indicator of maturational deficits in the central nervous system. Additionally, children with ADHD showed higher rates of clinically relevant psychological symptoms. CONCLUSION This study provides further information of the association between ADHD and incontinence. Treatment of ADHD may be associated with positive effects on incontinence outcomes. Therefore, children with ADHD should always be screened for incontinence problems and children with incontinence problems should also be screened for ADHD if symptoms of hyperactivity, inattention and/or impulsivity are also present.

Interventionsprogramme für Eltern von Frühgeborenen Kritische Übersicht

ZusammenfassungNach einleitenden Anmerkungen über den Einfluß von psychosozialen Risikofaktoren auf die Entwicklung von Frühgeborenen werden die verschiedenen Ansätze von Interventionsprogrammen dargestellt. Durch Interventionen können unterschiedliche positive Effekte erzielt werden. Sie verbessern die kognitive Entwicklung der Kinder, verändern die elterliche Wahrnehmung kindlicher Bedürfnisse und gestalten die häusliche Umgebung. Es bleibt fraglich, ob diese Ergebnisse auch für die Entwicklung der sehr kleinen Frühgeborenen Gültigkeit haben und ob die Effekte auch langfristig nachgewiesen werden können. Speziell Eltern-zentrierte Interventionsansätze können zusätzlich die Eltern-Kind-Interaktion verbessern. Aus diesem Grunde sollten zukünftige Interventionen auch Eltern- oder Eltern-Kind-zentrierte Ansätze integrieren. Methodische Probleme von Interventionsstudien und Forschungsperspektiven von Eltern-zentrierten Interventionen werden diskutiert.SummaryAfter some introductory remarks on the influence of psychosocial risk factors on the developmental outcome of premature infants this review summarizes the current knowledge about intervention programs for prematures and their parents with a special focus on parent-centered programs. Positive effects of intervention programs are found in an improvement of cognitive development, parental sensitivity and the home environment. Only parent-centered interventions enhanced the quality of parent-infant interaction. It is questioned if those effects are also reliable for very premature infants and are found in the long term. Further programs should focus on parent- and parent-infant centered interventions. Methodological problems of intervention studies and further research perspectives on parent-centered interventions are discussed.

G322 The association between trajectories of bedwetting and daytime wetting in childhood and incontinence and lower urinary tract symptoms in adolescence

Aims This is the first prospective cohort study to examine the association between developmental trajectories of childhood incontinence and adolescent incontinence and lower urinary tract symptoms (LUTS). Methods We used longitudinal latent class analysis to identify developmental trajectories of bladder control using maternal reports of their child’s incontinence from 4–9 years in 8,751 participants from the Avon Longitudinal Study of Parents and Children. We then used logistic regression to examine the association between the trajectories and self-reported bedwetting, daytime wetting, nocturia, urgency, high voiding frequency and voiding postponement at 14 years. Results We identified five trajectories: (i) Normative development of daytime and nighttime bladder control (63.1% of the sample), (ii) Delayed attainment of bladder control (8.6%), (iii) Bedwetting alone (no daytime wetting) (15.6%), (iv) Daytime wetting alone (no bedwetting) (5.8%), (v) Persistent wetting (bedwetting with daytime wetting to age 9) (7.0%). There were increased odds of bedwetting at 14 years among those with persistent wetting in childhood (odds ratio=23.5, 95% confidence interval=15.1–36.4) and bedwetting alone (3.69 [2.21–6.17]) (reference category: normative development). Odds of daytime wetting at 14 years were increased among those with daytime wetting alone (odds ratio=10.1 [6.70–15.3]) and persistent wetting (6.98 [4.50–10.8]). There were increased odds of nocturia (2.39 [1.79–3.20]) and urgency (2.10 [1.44–3.07]) in adolescence among those with persistent wetting in childhood and increased odds of voiding postponement (1.94 [1.48–2.54]) in those with daytime wetting alone. Conclusions We find evidence that trajectories of incontinence in childhood are differentially associated with adolescent incontinence. Bedwetting in adolescence was more likely in those who experienced persistent wetting in childhood compared with bedwetting alone. Daytime wetting in adolescence was associated with childhood daytime wetting and persistent wetting. LUTS were more common among adolescents who experienced childhood incontinence than those who had normal development of continence. The awareness of particular patterns of incontinence is important in clinical practice because children exhibiting incontinence trajectories associated with poor outcomes in adolescence should be prioritised for investigations and treatment.