Carol Joinson

Early Childhood Risk Factors Associated with Daytime Wetting and Soiling in School-age Children

OBJECTIVEnTo examine the impact of a range of early childhood factors on the risk for daytime wetting and soiling.nnnMETHODSnThis is a longitudinal study based on a UK population of over 10,000 children from age 4 to 9 years. Parents completed questionnaires on child development (at 18 months); child temperament (24 months); maternal depression/anxiety (21 months), and parenting behaviors (24 months). The analysis examined whether these risk factors distinguish between children with normal development of daytime bladder and bowel control and those with delayed acquisition of daytime continence; persistent daytime wetting/soiling, and relapse in wetting/soiling.nnnRESULTSnDelayed development, difficult temperament, and maternal depression/anxiety were associated with an increase in the odds of experiencing problems with bladder and bowel control.nnnCONCLUSIONSnThe current findings provide evidence that risk factors in early childhood are associated with a subsequent increase in the odds of children experiencing daytime wetting and soiling at school age.

Factors Predicting Atypical Development of Nighttime Bladder Control

Objective: To derive latent classes (longitudinal “phenotypes”) of frequency of bedwetting from 4 to 9 years and to examine their association with developmental delay, parental history of bedwetting, length of gestation and birth weight. Method: The authors used data from 8,769 children from the UK Avon Longitudinal Study of Parents and Children cohort. Mothers provided repeated reports on their childs frequency of bedwetting from 4 to 9 years. The authors used longitudinal latent class analysis to derive latent classes of bedwetting and examined their association with sex, developmental level at 18 months, parental history of wetting, birth weight, and gestational length. Results: The authors identified 5 latent classes: (1) “normative”—low probability of bedwetting; (2) “infrequent delayed”—delayed attainment of nighttime bladder control with bedwetting <twice a week; (3) “frequent delayed”—delayed attainment of nighttime bladder control with bedwetting ≥ twice a week; (4) “infrequent persistent”—persistent bedwetting < twice a week; and (5) “frequent persistent”—persistent bedwetting ≥ twice a week. Male gender (odds ratio = 3.20 [95% confidence interval = 2.36–4.34]), developmental delay, for example, delayed social skills (1.33 [1.11–1.58]), and maternal history of wetting (3.91 [2.60–5.88]) were associated with an increase in the odds of bedwetting at 4 to 9 years. There was little evidence that low birth weight and shorter gestation period were associated with bedwetting. Conclusion: The authors described patterns of development of nighttime bladder control and found evidence for factors that predict continuation of bedwetting at school age. Increased knowledge of risk factors for bedwetting is needed to identify children at risk of future problems attaining and maintaining continence.

Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study

Objectives To identify different patterns (trajectories) of childhood urinary incontinence and examine which patterns are associated with bladder and bowel symptoms in adolescence. Design Prospective cohort study. Setting General community. Participants The starting sample included 8751 children (4507 men and 4244 women) with parent-reported data on frequency of bedwetting and daytime wetting for at least three of five time points (4½, 5½, 6½, 7½ and 9½ years—hereafter referred to as 4–9u2005years). Study children provided data on a range of bladder and bowel symptoms at age 14 (data available for 5899 participants). Outcome measures Self-reported bladder and bowel symptoms at 14u2005years including daytime wetting, bedwetting, nocturia, urgency, frequent urination, low voided volume, voiding postponement, passing hard stools and low stool frequency. Results We extracted 5 trajectories of urinary incontinence from 4 to 9u2005years using longitudinal latent class analysis: (1) normative development of daytime and night-time bladder control (63.0% of the sample), (2) delayed attainment of bladder control (8.6%), (3) bedwetting alone (no daytime wetting) (15.6%), (4) daytime wetting alone (no bedwetting) (5.8%) and (5) persistent wetting (bedwetting with daytime wetting to age 9) (7.0%). The persistent wetting class generally showed the strongest associations with the adolescent bladder and bowel symptoms: OR for bedwetting at 14u2005years=23.5, 95% CI (15.1 to 36.5), daytime wetting (6.98 (4.50 to 10.8)), nocturia (2.39 (1.79 to 3.20)), urgency (2.10 (1.44 to 3.07)) and passing hard stools (2.64 (1.63 to 4.27)) (reference category=normative development). The association with adolescent bedwetting was weaker for children with bedwetting alone (3.69 (2.21 to 6.17)). Conclusions Trajectories of childhood urinary incontinence are differentially associated with adolescent bladder and bowel symptoms. Children exhibiting persistent bedwetting with daytime wetting had the poorest outcomes in adolescence.

Stressful Events in Early Childhood and Developmental Trajectories of Bedwetting at School Age

Objective To examine whether early stressful events are associated with developmental trajectories of bedwetting.u2003Methodsu2003This is a prospective cohort study comprising 8,761 participants from the Avon Longitudinal Study of Parents and Children. Stressful events were measured using a maternal questionnaire completed at 3 time points before their child was 4 years old. The association between stressful events and trajectories of bedwetting from 4 to 9 years was examined using multinomial regression.u2003Resultsu2003The association with stressful events was strongest for the frequent persistent bedwetting trajectory (wetting at least twice a week up to age 9). A 1 standard deviation increase in the stressful events score was associated with a 29% (13–47%) increase in the odds of experiencing frequent persistent bedwetting compared with normal attainment of nighttime bladder control.u2003Conclusionsu2003Clinicians and parents should be aware that continence is a developmental outcome that is associated with high levels of stress in the family.

Effects of urinary incontinence on psychosocial outcomes in adolescence

To examine whether daytime wetting and bedwetting urinary incontinence (UI) in childhood and adolescence are associated with psychosocial problems in adolescence. We used data from the Avon Longitudinal Study of Parents and Children to examine the association between trajectories of UI from 4 to 9xa0years and self-reported psychosocial problems in adolescence (13–14xa0years) including depressive symptoms, peer victimisation, poor self-image and school experiences (negative perception of school and teachers, problems with peer relationships). Sample sizes ranged from 5162 (perception of teachers) to 5887 (self-image). We also examined associations between self-reported UI at 14xa0years and psychosocial problems. Relative to normative development, adolescents who experienced delayed development of bladder control had poorer self-image [standardised mean differencexa0=xa00.18 (95% CI 0.04, 0.32)], more negative perceptions of school [0.18 (0.02, 0.34)] and more problems with peer relationships at school [0.25 (0.10, 0.40)]. Persistent wetting (bedwetting with daytime wetting) in childhood was associated with increased problems with peer relationships in adolescence [0.19 (0.03, 0.34)]. The strongest associations between adolescent UI and psychosocial problems were found for daytime wetting (referencexa0=xa0no UI at 14xa0years): depressive symptoms [ORxa0=xa03.04 (95% CI 1.91–4.84)], peer victimisation [2.14 (1.48–3.10)], poor self-image (txa0=xa0−8.49, pxa0<xa00.001) and problems with peer relationships (txa0=xa0−4.69, pxa0<xa00.001). Children with delayed development of bladder control and persistent wetting have increased psychosocial problems in adolescence. Adolescents with UI reported a range of psychosocial problems and clinicians should be aware that they might require support from psychological services.

Early childhood risk factors for constipation and soiling at school age: an observational cohort study.

Objective Constipation and soiling are common in childhood. This study examines the comorbidity between childhood constipation and soiling and early childhood risk factors for these problems. Design The sample comprised 8435 participants from the Avon Longitudinal Study of Parents and Children with maternally reported measures of constipation (six time points between 4 and 10u2009years) and soiling (five time points between 4 and 9u2009years). We used latent class analysis to extract longitudinal patterns of constipation and soiling. We examined whether the latent classes are differentially associated with maternally reported risk factors in early childhood (stool consistency, breast feeding, socioeconomic background, gestation, birth weight, developmental level and age at initiation of toilet training) using multinomial logistic regression models. Results We extracted four latent classes: ‘normative’ (74.5%: very low probability of constipation or soiling), ‘constipation alone’ (13.2%), ‘soiling alone’ (7.5%) and ‘constipation with soiling’ (4.8%). Hard stools at 2½ years were associated with increased odds of constipation alone. Developmental delay at 18 months was associated soiling alone and constipation with soiling, but not constipation alone. We found limited evidence of associations with socioeconomic background and no evidence of associations with age at initiation of toilet training, breast feeding, gestational age or birth weight. Conclusion Constipation alone was the most prevalent pattern in this cohort. Treatment for hard stools in early childhood is needed to prevent chronic constipation at school age. Constipation with soiling was less common than soiling alone. Further research is needed into the causes of non-retentive soiling.

Psychosocial risks for constipation and soiling in primary school children

To examine prospective associations between psychosocial problems and childhood constipation and soiling. We used latent classes of constipation and soiling (‘constipation alone’, ‘soiling alone’, ‘constipation with soiling’) extracted from longitudinal maternally reported data on constipation (4–10xa0years) and soiling (4–9xa0years) from 8435 children (4353 males, 4082 females) from the ALSPAC cohort. We examined the association between maternally reported psychosocial problems at 2–3xa0years (difficult temperament, behaviour/emotional problems, temper tantrums, behavioural sleep problems and stressful events) and the latent classes using multinomial logistic regression adjusted for a range of confounders relating to the child and family (reference categoryu2009=u2009normative latent class with very low probability of constipation/soiling). Difficult temperament and emotional/behaviour problems were associated with increased odds of constipation and soiling. Associations were generally strongest for ‘constipation with soiling’, e.g. difficult mood: 1.42 (1.23–1.64); behaviour problems: 1.48 (1.28–1.71); temper tantrums: 1.89 (1.34–2.65); lack of a regular sleep routine 2.09 (1.35–3.25). Stressful life events were associated with constipation alone [1.23 (1.12–1.36)] and constipation with soiling [1.32 (1.14–1.52)], but not soiling alone. Additional comparisons of the non-normative latent classes provided evidence for differential associations with the risk factors, e.g. frequent temper tantrums were associated with a greater than twofold increase in the odds of constipation with soiling versus constipation alone. Psychosocial problems in early childhood are risk factors for constipation and soiling at school age. An increased understanding of early risk factors for constipation and soiling could aid the identification of children who require treatment.

A prospective cohort study of biopsychosocial factors associated with childhood urinary incontinence

The objective of the study was to examine the association between biopsychosocial factors and developmental trajectories of childhood urinary incontinence (UI). We used developmental trajectories (latent classes) of childhood UI from 4–9xa0years including bedwetting alone, daytime wetting alone, delayed (daytime and nighttime) bladder control, and persistent (day and night) wetting (nu2009=u20098751, 4507 boys, 4244 girls). We examined whether biopsychosocial factors (developmental level, gestational age, birth weight, parental UI, temperament, behaviour/emotional problems, stressful events, maternal depression, age at initiation of toilet training, constipation) are associated with the trajectories using multinomial logistic regression (reference categoryu2009=u2009normative development of bladder control). Maternal history of bedwetting was associated with almost a fourfold increase in odds of persistent wetting [odds ratio and 95% confidence interval: 3.60 (1.75–7.40)]. In general, difficult temperament and behaviour/emotional problems were most strongly associated with combined (day and night) wetting, e.g. children with behavioural difficulties had increased odds of delayed (daytime and nighttime) bladder control [1.80 (1.59–2.03)]. Maternal postnatal depression was associated with persistent (day and night) wetting [2.09 (1.48–2.95)] and daytime wetting alone [2.38 (1.46–3.88)]. Developmental delay, stressful events, and later initiation of toilet training were not associated with bedwetting alone, but were associated with the other UI trajectories. Constipation was only associated with delayed bladder control. We find evidence that different trajectories of childhood UI are differentially associated with biopsychosocial factors. Increased understanding of factors associated with different trajectories of childhood UI could help clinicians to identify children at risk of persistent incontinence.

Examining the effectiveness of parental strategies to overcome bedwetting: an observational cohort study

Objective To examine whether a range of common strategies used by parents to overcome bedwetting in 7½-year-old children (including lifting, restricting drinks before bedtime, regular daytime toilet trips, rewards, showing displeasure and using protection pants) are effective in reducing the risk of bedwetting at 9½ years. Design Prospective cohort study. Setting General community. Participants The starting sample included 1258 children (66.7% boys and 33.2% girls) who were still bedwetting at 7½ years. Outcome measure Risk of bedwetting at 9½ years. Results Using propensity score-based methods, we found that two of the parental strategies used at 7½ years were associated with an increased risk of bedwetting at 9½ years, after adjusting the model for child and family variables and other parental strategies: lifting (risk difference=0.106 (95% CI 0.009 to 0.202), ie, there is a 10.6% (0.9% to 20.2%) increase in risk of bedwetting at 9½ years among children whose parents used lifting compared with children whose parents did not use this strategy) and restricting drinks before bedtime (0.123 (0.021 to 0.226)). The effect of using the other parental strategies was in either direction (an increase or decrease in the risk of bedwetting at 9½ years), for example, showing displeasure (−0.052 (−0.214 to 0.110)). When we re-analysed the data using multivariable regression analysis, the results were mostly consistent with the propensity score-based methods. Conclusion These findings provide evidence that common strategies used to overcome bedwetting in 7½-year-olds are not effective in reducing the risk of bedwetting at 9½ years. Parents should be encouraged to seek professional advice for their child’s bedwetting rather than persisting with strategies that may be ineffective.