Lloyds Pharmacy and Ferring
Lloyds pharmacy is a leading community pharmacy and healthcare provider with over 1,650 pharmacies across the UK, mainly in community and health centre locations. We employ around 17,000 staff and dispense over 150 million prescription items every year. Lloyds pharmacy is committed to ‘healthcare for life’ and our vision is to be a great healthcare brand.
Lloyds pharmacy is working in partnership with Ferring to raise awareness of night-time bedwetting, a condition known medically as Nocturnal Enuresis. As 500,000 children aged between 5 and 16 in the UK regularly wet the bed, we wish to support parents to inform them that they are not alone and that treatment options are available. Our overall aim is to support parents in getting their children out of nappies by the time they start secondary school.
Ferring and Lloyds have worked together to achieve this by producing in store materials such as leaflets and flyers to offer parents and patients support and advice. To accompany this Lloyds pharmacists have received training to raise their individual awareness of the condition and to increase their understanding of the differences and benefits of various treatment options.
What is bedwetting (nocturnal enuresis) and how you can help
What is bedwetting?
Bedwetting or nocturnal enuresis is defined as intermittent incontinence while sleeping. It is a widespread and distressing condition that can have a deep impact on a child or young person’s behaviour, emotional wellbeing and social life. It is also very stressful for the parents or carers. However, successful treatment improves the mental health of the child and brings practical relief to the family. Read more...
In the UK approximately half a million children between the ages of 5 and 16 wet the bed, the likelihood decreases as the child gets older, however, it is estimated that about:*
- 1 in 12 children wet the bed regularly at four and a half years old (regularly is defined as at least twice a week)
- 1 in 40 children wet the bed regularly at 7 and a half years old
- 1 in 65 children wet the bed regularly at 9 and a half years old
- About 1 in 100 people continue to wet the bed into adulthood.
The causes of bedwetting are not fully understood. Bedwetting can be considered to be a symptom that may result from a combination of different predisposing factors such as bladder problems, excessive urine production, difficulties waking up during the night, underlying health conditions and emotional problems.
Some children affected by bedwetting have what’s known as overactive bladder syndrome. This is where the muscles that control the bladder go into spasm, leading to the involuntary passing of urine.
Excessive urine production
If a child drinks lots of fluids during the evening, it could result in them wetting the bed during the night, particularly if they have a small bladder capacity. Drinks that contain caffeine, such as cola, tea and coffee can also stimulate an increase in the production of urine.
In some cases of bedwetting, it may be that the child’s body doesn’t produce enough of a hormone that regulates urine production, called vasopressin. This means their kidneys produce too much urine for their bladder to cope with.
Difficulties waking up during the night
Once the amount of urine in the bladder reaches a certain amount, the bladder should send signals to the brain, which would cause most people to wake up. However, some younger children are particularly deep sleepers, and their brain doesn’t respond to the signals being sent from their bladder, so they don’t wake up.
Alternatively, in some children the nerves attached to the bladder may not yet be fully developed, so they don’t generate a strong enough signal to send to the brain.
Underlying health conditions
Bedwetting can also be caused by conditions such as constipation, Type 1 diabetes and urinary tract infections.
In some cases, bedwetting can be a sign that a child is upset or worried for reasons such as starting a new school, being bullied or the arrival of a new baby in the family.
If a child starts to wet the bed after previously being dry for a period of 6 months or more, emotional problems such as stress and anxiety may be responsible.
Management of Bedwetting
The type of treatment is dependent on the age of the child or young person, the frequency of bedwetting and the motivation and needs of the child or young person and their family.
The GP or Nurse will assess the needs of the patient and recommend a bedwetting alarm and/or drug treatment such as desmopressin. A combination of an alarm and desmopressin can be used in some cases (please refer to the NICE pathway on pages 6 and 7 of the downloadable PDF).
What is desmopressin
Desmopressin is a synthetic form of the naturally occurring hormone that regulates the production of urine, called vasopressin. It helps to reduce the amount of urine produced by the kidneys.
Ferring desmopressin for PNE is available in 2 forms:
The GP will determine whether the patient is suitable for the melt formulation or a tablet. Melts do not require water and dissolve under the tongue instantly where as a tablet will require a minimum of 60ml to be taken. Read more...
DesmoMelt is indicated for the treatment of primary nocturnal enuresis.
Precautions for use
Care should be taken with patients who have reduced renal function and/or cardiovascular disease or cystic fibrosis. In chronic renal disease the antidiuretic effect of DesmoMelt would be less than normal.
When DesmoMelt is used for the treatment of enuresis, fluid intake must be limited from 1 hour before until 8 hours after administration.
Patients being treated for primary nocturnal enuresis should be warned to avoid ingesting water while swimming and to discontinue DesmoMelt during an episode of vomiting and/or diarrhoea until their fluid balance is once again normal.
Precautions to prevent fluid overload must be taken in:
- conditions characterised by fluid and/or electrolyte imbalance
- patients at risk for increased intracranial pressure
DesmoMelt is contraindicated in cases of cardiac insufficiency and other conditions requiring treatment with diuretic agents.
DesmoMelt should only be used in patients with normal blood pressure.
Before prescribing DesmoMelt, the diagnoses of psychogenic polydipsia and alcohol abuse should be excluded.
Desmopressin should not be prescribed to patients over the age of 65 for the treatment of primary nocturnal enuresis.
Desmotabs vs. DesmoMelts
- DesmoMelts provides superior and longer duration of action 4-8 hours after dosing compared to tablets
- DesmoMelt reaches maximal antidiuresis in a shorter time than tablets
- DesmoMelt is associated with higher compliance of 94.5% versus tablets
- The water required to swallow a solid tablet at bedtime may make the difference between a dry and a wet night
- DesmoMelts does not require intake of fluid as it dissolves sublingually
- Swallowing 60ml of fluid with a tablet is equivalent to about a quarter of the expected bladder capacity of a 7 year old
Bedwetting alarms work by helping the child recognise the sensation of a full bladder during sleep and wake up to go to the toilet or learn to hold on. There are 2 types of alarms:
- Bedside alarm – a noise-box which is placed next to the bed and has a sensor bed mat which is placed beneath the lower bed sheet. The noise box sounds when the child’s wee touches the bed mat causing the child to wake up or hold on to the sensation of a full bladder.
- Body worn alarm – a small noise box which is attached to the child’s pyjamas. The noise box sounds when the child’s wee touches the sensor causing the child to wake up or hold on to the sensation of a full bladder.
Benefits of alarms are:
- To help teach/encourage the child or young person to wake up to go to the toilet before wetting the bed
- To wake parents or carers to get child up to go to the toilet
- Non medicated option for parents unwilling to give their child medicine
How can you help?
The treatment of bedwetting has a positive effect on the self-esteem of children and young people. When having conversations with parents and/or children and young people it is important to inform them that it is not the child or young person’s fault. The first steps are to maintain a positive attitude ensuring parents and their child know that dry nights can be achieved and encourage parents to help motivate their child to continue with whatever intervention is offered.
Pharmacists can inform parents of the 2 different treatment options an alarm or drug treatment and should recommend different treatments and treatment combinations if the first-choice treatment is not successful.
- 2 on shelf tear off pads
- A5 prescription bag leaflet
Display the on shelf tear off pad which contains information for parents or carers who have a child or young person who is affected by bedwetting and has not started any form of treatment. This may prompt customers to start a conversation about their child’s condition.
Attach the A5 leaflet to prescription bags containing desmopressin. Again, this may encourage parents or carers to discuss their child’s bedwetting problem and give you an opportunity to discuss treatment options.
Questions to ask parents or carers:
- Has the child or young person previously been dry at night without assistance for 6 months? If yes, discuss potential causes such as medical, emotional or physical triggers
- How many nights a week does the bedwetting occur?
- How many times a night does the bedwetting occur?
- At what time(s) of the night does the bedwetting occur?
- Does the child or young person wake up after bedwetting?
- Does the child or young person have a presence of daytime symptoms, such as: – Daytime frequency (passing urine more than 7 times a day)
- Approximately, what is the child or young person’s fluid intake throughout the day? Discuss whether parents or carers are restricting fluids
– Daytime urgency
– Daytime wetting
– Passing urine infrequently (fewer than 4 times a day)
– Abdominal straining or poor urinary stream
– Pain when passing urine
Advice for parents or carers:
- The child or young person should be given 6 to 8 water based drinks spread out evenly during the day and they should go to the toilet regularly
- Reassure them that bedwetting is a common childhood problem and that it is not the child or young person’s fault
- Reassure them that help and support is available, but progress may take some time
- If the child has been dry during the day for 6 months, suggest a trial without nappies
- If the child or young person sleeps in a bunk bed, suggest they sleep on the bottom bunk
- Suggest leaving a light on in the corridor or a night light in the child or young person’s bedroom – they may be too afraid to get up and go to the toilet
- Suggest leaving the bedroom and bathroom doors open for easy access
*Signs of a response to desmopressin may include smaller wet patches, fewer wetting episodes per night and fewer wet nights
Lloyds Pharmacist Guide
Lloyds GP Poster
Lloyds Patient Leaflet
Apart from the discomfort and distress of waking up to a wet bed, a recent review of the impact of bedwetting included one study which showed 70.3% of children aged 5-11 years could clearly indicate that wetting is a disadvantage.3