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Night diapers use and sleep in children with enuresis
Sleep Medicine, volume 10, issue 14, pages 1013 - 1016
We aimed to assess the association between night diapers use and sleep quality of school-aged children with enuresis.
The sleep patterns of 72 school-aged children (ages 6–9 y) with enuresis referred to a clinic specializing in bladder disorders and 63 healthy control children were assessed. Sleep measures were derived from four to five monitoring nights of actigraphy and daily logs.
In comparison to controls, children with enuresis who did not wear night diapers had poorer sleep quality as reflected by both actigraphic measures (more activity during sleep and shorter periods of continuous sleep) and one reported measure (lower sleep quality). However, no differences were found on any of the sleep measures between children with enuresis wearing night diapers and controls. The reported sleep quality of all children with enuresis with and without night diapers was lower than controls.
Our results suggest that sleep patterns of school-aged children with enuresis who do not wear night diapers are impaired, and the sleep quality of children using night diapers is similar to those of healthy children. Thus, clinicians and healthcare providers should consider recommending sleeping with night diapers for untreated children with enuresis, based on its positive impact on sleep.
Keywords: Enuresis, Sleep, Night diapers, Actigraphy, Children, Parental Behaviors.
Enuresis is one of the most widespread and chronic childhood disorders , , , , and  and may have a remarkably negative impact on the child , , , and . Most parents typically are concerned with the social and emotional impact of enuresis on their child  . Clinical experience and review of the literature suggests that many parents adopt methods associated with waking the child during the night or taking him or her to the toilets during sleep to void in attempt to cope or manage enuresis  .
Another coping method in an attempt to manage enuresis implications is wearing night diapers or napkins. However, there are clinical claims that this method can have an adverse impact on the child’s motivation to develop nocturnal bladder control as well as on the child’s self-esteem. To date we failed to find evidence-based studies evaluating or supporting these claims.
The link between enuresis, sleep, and sleep disorders has been demonstrated in previous studies , , , and . However, the literature on the relation between night diaper wearing and sleep is scarce. Interestingly, in 2007 Zotter et al.  explored whether or not bladder voiding induced arousals in sleeping infants. The authors simulated voiding by administering water into diapers. This procedure did not cause an awakening or induced body movements in sleeping infants, and polygraphic measures were not significantly affected. Another study did not reveal an association between the type of diaper babies wore and the frequency of night awakenings in 3-month-old infants  .
In a previous study, we found that naturalistic sleep of children with enuresis was significantly more fragmented than sleep of control children. A key finding was that this phenomenon was associated with the occurrence of bedwetting episodes and attempts to keep the child dry during the night  . Thus given the high prevalence of enuresis in childhood, its adverse effects on the child’s sleep and the link to the mentioned parental coping strategies, our study aimed to explore if night diaper use among children with enuresis was associated with the child’s sleep quality. Based on our previous findings linking fragmented sleep of children with enuresis to parental coping behaviors, we hypothesized that the sleep quality of children with enuresis who used night diapers would be more protected and have more resemblance to those of controls. To the best of our knowledge, our study is the first actigraphy study assessing the association of night diaper wearing with sleep among school-aged children with enuresis compared to controls.
The study was approved by the department ethical committee. There were 72 school-aged children with enuresis (ages 6–9 y) referred to a clinic specializing in bladder disorders who participated in our study (43 boys, 29 girls) (mean age, 7.31 ± 0.87 y). The control group was based on children participating in an earlier study on the sleep patterns of normal children  and consisted of 63 healthy control children (32 boys, 31 girls) (mean age, 7.5 ± 0.82 y). All parents signed informed consent; children also signed to express their willingness to participate in the study. Exclusion criteria included reported active medical problems, use of medication, underlying known urologic or other medical causes for enuresis, and sleep apnea. Enuresis was diagnosed by a licensed clinical psychologist at the initial interview in the clinic according to International Children’s Continence Society criteria definition  .
Actigraphy is based on a miniature wristwatch-like device which is attached to the wrist of the child and continuously records movement for an extended period. Actigraphy has been established as a reliable and valid method for sleep assessment in infants, children, and adults , , , and . The device enables continuous recording for extended periods (more than a week) with no interference with the child’s natural sleep environment. The actigraph used in our study was the miniature actigraph (Ambulatory Monitoring Inc., Ardsley, NY), preset to the standard mode for sleep-wake scoring algorithm with amplifier setting 18 and 1-minute epoch interval  . The parents were asked to attach the actigraphs to their child’s nondominant wrist from the time they went to bed at night until his or her morning rise time. Sleep assessment was performed for five continuous nights. Sleep measures were derived from the raw data using the Actigraphic Scoring Analysis program for an IBM-compatible PC. These sleep measures have been validated against polysomnography with agreement rates for minute-by-minute sleep-wake identification higher than 90% in children and adults , , and .
Actigraphic measures included: (1) true sleep time (sleep time excluding all periods of wakefulness, (2) number of night awakenings (lasting at least 5 min), (3) activity level (detected activity during sleep), (4) longest sleep period (the longest period of continuous sleep without any arousal) and (5) sleep efficiency (percent of actual sleep time from total sleep duration, excluding wake time after sleep onset). Sleep measures were averaged over all the nights during the assessment period.
2.2.2. Sleep diary
The diary included items to be completed by the child and the parents. The evening items assessed sleep latency. The morning items assessed the number of night awakenings and the quality of sleep  .
2.2.3. Family Background Information Questionnaire
The Family Background Information Questionnaire included 25 questions covering demographic and developmental data.
2.2.4. The Child Behavior Checklist
The Child Behavior Checklist (CBCL) was used to assess behavior problems as perceived by parents  . The CBCL is widely used for the assessment of behavior problems in children with well-established psychometric properties. The CBCL has been translated into Hebrew and validated in Israel  .
All children and their parents signed informed consent and completed screening questionnaires and the CBCL. Children completed four to five monitoring days. During the monitoring period, parents were asked not to change their children’s sleep habits or enuresis management strategies. In addition, children and their parents were asked to follow the sleep assessment instructions, including actigraph attachment (see actigraphy description above) and sleep diary completion.
2.4. Data analysis
Analysis of covariance was used to compare the clinical and control group on both actigraphic and sleep diary measures ( Table 2 ). The independent variable was group (children with enuresis vs controls). Age and gender were entered as covariates to control for any potential gender or age effects. The total CBCL score also was entered as covariates to control for any potential effects for other behavior problems that may account for group differences in sleep patterns. Analysis of covariance also was used to compare the sleep measures of two subgroups of children with enuresis: those sleeping with and those without night diapers compared to control children. The Bonferroni test was used for post hoc analysis.
No significant differences were found between the enuresis and control groups for any of the demographic variables ( Table 1 ).
|All children with enuresis n = 72||Enuresis without diapers n = 43||Enuresis with diapers n = 19||Controls n = 63|
|Child’s age (mo)||7.31 ± 0.87||7.29 ± 0.86||7.15 ± 0.95||7.5 ± 0.82|
|Child’s gender (boys/girls)||43/29||26/17||13/6||32/31|
|Mother’s education (y)||15.23 ± 2.57||15.41 ± 2.31||15.47 ± 2.82||14.78 ± 2.59|
|Father’s education (y)||14.58 ± 2.24||15.08 ± 2.10||14.06 ± 2.08||14.52 ± 2.41|
Abbreviations: mo, months; y, years.
3.1. Comparison between the total group of children with enuresis and controls
Overall, children with enuresis reported significantly lower sleep quality in comparison to controls (F[1,128] = 10.30; P < .002). No other group differences were found on the actigraphy and sleep diary measures ( Table 2 ).
|All children with enuresis
n = 68
|Enuresis without diapers
n = 43
|Enuresis with diapers
n = 19
n = 63
|True sleep time (min)||502.87 ± 40.54||499.42 ± 41.35||499.94 ± 38.93||515.19 ± 37.00||n.s|
|No. of night awakenings||2.22 ± 1.20||2.48 ± 1.18||2.12 ± 1.26||2.22 ± 1.23||n.s|
|Activity level||10.55 ± 3.61||11.32 ± 3.95||10.12 ± 2.93||9.43 ± 2.97||3.39|
|Longest sleep period (min)||166.93 ± 63.96||155.43 ± 58.46||180.60 ± 65.14||191.38 ± 71.03||3.26|
|Sleep percent||91.85 ± 4.47||91.03 ± 4.67||92.11 ± 4.32||92.68 ± 3.85||n.s|
|Sleep diary Measures|
|No. of night awakenings||0.52 ± 0.52||0.56 ± 0.56||0.39 ± 0.46||0.38 ± 0.50||n.s|
|Sleep quality b||1.46 ± 0.38 c||1.48 ± 0.38||1.35 ± 0.39||1.18 ± 0.73||5.41|
a The significance levels refer to comparisons between the enuresis group with night diapers, the enuresis group without night diapers, and controls.
b 1 = very good, 2 = good, 3 = not so good, and 4 = bad.
c Reported sleep quality for all children with enuresis was lower compared to controls (P < .01).
P < 0.05.
P < 0.01.
P < 0.0001.
Abbreviations: min, minutes; No., number; n.s., not significant.
3.2. Comparison between children with enuresis sleeping with or without night diapers and controls
We compared objective and subjective sleep measures of three groups: two subgroups of children with enuresis, those sleeping with night diapers (n = 19), and those without night diapers (n = 43) compared to control children.
3.3. Objective measures
Significant overall differences of actigraphic sleep measures of longest sleep duration (F[2,121] = 3.39; P < .04) and activity during sleep (F[2,121] = 3.39; P < .04) were found between children with enuresis sleeping with or without night diapers and control subjects. Further analysis indicated that children with enuresis who did not sleep with night diapers had shorter periods of continuous sleep (P < .04) and were more active during sleep (P < .03) in comparison to controls. No other differences were found ( Table 2 ).
3.4. Objective measures
A significant overall difference of reported sleep quality (F[2,120] = 5.41; P < .006) between children with enuresis sleeping with or without night diapers and controls was found. Further analysis indicated that children with enuresis who did not sleep with night diapers had lower reported sleep quality (P < .004) in comparison to controls. No other differences were found ( Table 2 ).
Our study was aimed at assessing the link between using night diapers and sleep quality of children with enuresis. To the best of our knowledge, our study is the first study that assessed this question in children with enuresis in their natural environment using objective measures. First, contrary to our expectations we found no objective actigraphy evidence for impaired sleep of children with enuresis as a total group compared with healthy controls. Of all reported actigraphy measures, only sleep quality suggested that sleep of children with enuresis was impaired compared to healthy children. This finding contrasts with the results from our previous study using actigraphy measures  in which sleep of children with enuresis was more impaired than in control children. Other studies also reported compromised sleep quality in children with enuresis  and .
However, when comparing control children with the subgroup of children with enuresis who did not sleep with night diapers, we found significant group differences on both actigraphic and sleep diary measures. In comparison to control children, children with enuresis who did not sleep with night diapers had poorer sleep quality as indicated by both actigraphic measures (more activity during sleep and shorter periods of continuous sleep) as well as on one reported measure (lower sleep quality). These results were obtained after controlling for all important covariates such as the child’s age and gender. In contrast, we did not detect any significant group differences on any of the actigraphic and sleep diary measures between children with enuresis who slept with night diapers compared to controls.
Because wearing night diapers is supervised by parents, these results lend more support to our previous findings which showed that the sleep quality of children with enuresis may be mediated by parental enuresis coping strategies. Our previous results indicated that parental attempts to keep their children dry during the night (e.g., awakening them to void) was linked to impaired sleep and higher morning and evening sleepiness in children with enuresis  .
Based on our study results, no conclusions regarding the specific mechanisms of the protective role of night diapers use on children’s sleep can be drawn. However, one possible explanation is that sleeping with night diapers may reduce the implementation of the mentioned adverse parental coping strategies and maintain children’s consolidated sleep. Another possible explanation is that night diapers prevent discomfort or awakenings related to wetting itself. This hypothesis should be further explored by detailed and nightly monitoring of specific wet and dry nights and parental coping strategies.
The results of our study may serve as evidence countering various possible claims suggesting that sleeping with night diapers at older ages may have negative impact on children with enuresis and may perpetuate night wetting. It also is possible that using such strategies will contribute to the reduction of parental stress and children’s feelings of shame, due to being blamed by their parents for the burden of daily cleaning and washing of bedclothes related to enuresis. It also may lower the negative impact of enuresis on the child’s well-being and psychologic functioning , , and .
Our results suggest that sleep patterns of children with enuresis who do not sleep with night diapers are impaired. In contrast, the sleep patterns of children with enuresis who sleep with night diapers resemble those of healthy children. Possible explanations for this phenomenon are that sleeping with night diapers may reduce or prevent the implementation of other common parental coping strategies such as parent-initiated night awakenings or may prevent discomfort or awakenings that can have potential adverse effects on sleep. Thus, it is suggested that clinicians and healthcare providers consider recommending sleeping with night diapers for untreated children with enuresis, based on its positive impact on sleep quality.
The authors are Thankful to Ornit Arbel for coordinating and managing the study. The study was supported by Helene and Woolf Marmot and also by the Israel Foundations Trustees (Doctoral grant number 28). This project was based on the Phd Project of the second author, Vered Cohen-Zrubavel.
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a The Dr. Kushnir Enuresis and Encopresis Clinics, Israel
b School of Psychological Sciences, Tel Aviv University, Israel
c The Child Psychiatry Unit, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
Corresponding author. Address: The Child Psychiatry Unit, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan 52621, Israel. Tel.: +972 526160044; fax: +972 39305843.
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