6-year-old
children who presented at children out-patient clinic of Federal
Teaching Hospital Abakaliki, Ebonyi state in South-eastern Nigeria for
non-chronic ailments. Those with chronic medical conditions, or taking
some form of medication for enuresis were excluded. Minimum sample size
of 234 was obtained using 23.2% prevalence obtained in a previous study
and the total outpatient attendance of 1652 with the degree of accuracy
set as 0.05 [8]. Subjects kept a diary for enuresis. Caregivers were
subsequently interviewed in a confidential and non-threatening
environment. School report and Teachers’ Rutter score were obtained on
follow-up visits. Socioeconomic classification was done using Oyedeji’s
criteria [9]. Rutter’s behavioural Scale (B2) [10] for children
(Teachers scale) as validated for Nigerian Children by Iloeje [11] was
used to asses presence of behavioural disorder. BEARS criteria [12] and
a consistent reported abnormality of >1/week in the past 6 months was
considered indicative of poor sleep hygiene.
Institutional Ethics Committee approved the study.
Informed consent was obtained from all participanting families. SPSS
version 20 was used for data analysis using the Chi-square and results
presented as frequencies. Significant variables were subjected to
logistic regression. Level of significance was accepted as P<0.05.
Results
Of the 216 children assessed, 80 (37%) had enuresis.
Of these, 53 (66.2%) of caregivers had made attempts at stopping
enuresis; frequent night waking 51 (96.2%), denial of fluids 40 (75.5%),
and punishments 25 (47.2%). Only 17.5% (n=14) had sought orthodox
help. Majority of caregivers were unconcerned (60.6%, n=66).
Abnormal behavior was observed in 50 (23.1%) participants while 26
(12.4%) had poor academic performance.
More males had enuresis 54 (67.5%, P=0.028),
and frequency of enuresis decreased with increasing age (P<0.001).
There was a significant association between enuresis and behavioral
disorders (P=0.026) as well as with sleep hygiene. Ingestion of a
heavy meal just before sleep was significantly associated with enuresis
(Table I). There was no statistically significant
relationship between academic performance of participants and enuresis (P=0.057).
TABLE I Association of Enuresis with Sleep Hygeine
Variable |
Odd Ratio (95% CI) |
Bedtime problem |
0.41 (0.38, 0.46) |
Excesive daytime sleepiness |
0.59 (0.52, 0.67) |
Night awakenings |
0.97 (0. 73, 1.22) |
Ingestion of a heavy meal just before sleep |
2.54 (1.92, 3.17) |
Discussion
There was a high prevalence rate of enuresis in our
study population. Majority of caregivers do not seek orthodox help
rather, they make poor attempts which may reinforce negative feelings in
the child. Behavioral disorders and poor sleep hygiene were more common
amongst enuretic children. There was; however, no association between
enuresis and school performance in current study.
Parental report used in the study suggests that
under-reporting is unlikely. The cross-sectional nature of the study was
a limitation. A longitudinal study of a cohort of children may have
revealed other comorbidities which may contribute to the occurrence of
enuresis and behavioral disorders.
A common practice of not seeking orthodox help for
enuresis was found in the present study which was also reported by Etuk,
et al. [15]. This finding shows the enormity of poor
health-seeking behavior, which is a determinant of child health in
Nigeria and other resource-poor countries. Most caregivers made poor
attempts at curbing enuresis. Such attempts have been shown to reinforce
negative feelings in the child without any positive effects in reducing
the frequency of enuresis. Frequent night-wakening may impair good sleep
resulting in day time sleepiness of a child, also punishment for a child
with enuresis may worsen the psychological state of the emotionally ill
child. It therefore shows the need for increased education of the
community on proper care of enuretic children.
The finding of a significant association between
enuresis and behavior is in contrast to a report from Istanbul where no
significant differences were found [6].
1. Neil WB, Richard D. Enuresis (Bed-wetting). In:
Berhrman RE, Kliegman RM, Jenson HB, editors. Nelson textbook of
Pediatrics. 17th ed. Philadelphia: W.B Sanders Company; 2003.
p.74-5.
2. Ozkan KU, Garipardic M, Toktamis A, Karabiber H,
Sahinkanat T. Enuresis- prevalence and accompanying factors in school
children: A questionnaire study from Southeast Anatolia. Urol Int.
2004;73:149-55.
3. De Sousa A, Kapoor H, Jagtap J, Sen M. Prevalence
and factors affecting enuresis amongst primary school children. Indian J
Urol. 2007;2132:354-7.
4. Mbibu NH, Ameh EA, Shehu AU, Wammanda RD. The
prevalence of enuresis among primary school children in Zaria, Nigeria.
Niger J Surg Res. 2005;7:182-6.
5. Hashem M, Morteza A, Mohammad K, Ahmad-Ali N.
Prevalence of nocturnal enuresis in school aged children. Iran J Pediatr.
2013;23:1-11
6. Ozkan S, Durukan E, Elvan Iseri, Serhat Gürocak,
Iºil Maral, Bumin MA. Prevalence and risk factors of monosymptomatic
nocturnal enuresis in Turkish children. Indian J Urol. 2010;26:200-5.
7. Desta M, Hagglof B, Kebede D, Alem A.
Socio-demographic and psychopathologic correlates of enuresis in urban
Ethiopian children. Acta Pediatr. 2007;96:556-60.
8. Araoye MO. Research Methodology With Statistics
for Health and Social Sciences, 1st ed. Ilorin: Nathadex
Publishers.; 2003.
9. Oyedeji GA. Socioeconomic and cultural background
of hospitalized children in Ilesa. Niger J Paediatr. 1985;12:111-7.
10. Rutter MA. Children’s behavior questionnaire for
completion by teachers, preliminary findings. J Child Psychol.
1967;8:1-11.
11. Iloeje SO, Meme J. Rutter’s behavior Scale (B2)
for children (Teacher’s scale): Validation and standardization for use
as Nigerian children. J Trop Pediatr. 1992;38:235-9.
12. Owens JA. Dalzell V. Use of the ‘BEARS’ sleep
screening tool in a pediatric residents’ continuity clinic: a pilot
study. Sleep Med. 2005;6:63-9.
13. Senbanjo OI, Oshikoya KA, Njokanma OF.
Micturitional dryness and attitude of parents towards enuresis in
children attending outpatient unit of a tertiary hospital in Abeokuta,
Southwest Nigeria. Afr Health Sci. 2011;11:244-51.
14. Paul NI, Alikor EAD, Anochie IC. Prevalence of
enuresis among primary school children in Port Harcourt. Niger J
Paediatr. 2012;39:18-21.
15. Etuk IS, Ikpeme O, Essiet GA. Nocturnal enuresis
and its treatment amongst primary school children in Calabar-Nigeria. J
Nephrol Therap. 2012;2:2.