Diaper removal and difficulties in acquiring continence

LETTERS TO THE EDITOR

Diaper removal and difficulties in acquiring continence

Dear Editor,

I congratulate the authors and Jornal de Pediatria for the publication of the article "Sphincter training: methods, parents' expectations and associated morbidities”,¹ which approaches an important issue that has little visibility in Brazilian journals. When reading that review, the statement in the first paragraph of the introduction, about sphincter control, drew our attention: "All children will acquire that control, but the difficulty in acquiring it is a major concern for parents (...).” Although most children will naturally achieve continence, there is a group that, due to functional or structural reasons, will not achieve that ability, being exposed to the risk of a series of consequences ranging from psychological and social problems to renal failure.² Pediatricians should not only calm parents down and advise about diaper removal, but also acknowledge that children need diagnostic investigation and treatment, providing early intervention and avoiding complications inherent to voiding disorders. The idea that all children will eventually, with age, acquire sphincter control can contribute to decreasing the importance of this issue.

Another important aspect to be stressed is that, by describing the factors that can affect acquisition of sphincter control, the anatomical changes and inferior urinary tract dysfunction are not mentioned. Despite bladder dysfunction in many cases being a result of inadequate attempts to remove the diaper, it can precede this stage and be the cause of the difficulty in achieving continence. That dysfunction is not always originated from unsuccessful sphincter training. In case of children with difficulty achieving continence, the hypothesis of inferior urinary tract dysfunction, either of a neurological origin or not, should always be considered.² Recurrent urinary tract infection and constipation, when present before the sphincter training process starts, also point to that possibility. Pediatricians should, through anamnesis and physical examination, search for indications of structural or inferior urinary tract dysfunction anomalies to adopt necessary conducts.^2,3 Besides minimizing psychological and social consequences, early diagnosis of bladder dysfunction also prevents renal damage. Diagnosis of occult dysraphism and consequent urinary tract dysfunction as the cause of urinary incontinence is often performed in adolescence, despite the neurocutaneous stigmas at the lumbosacral region present since birth. Similarly, many children with continuous urinary loss due to ectopic ureter have their diagnosis performed at school age, after much unnecessary suffering caused by incontinence.

Parents' concern should always be valued, and the child should be screened for signs indicating possible changes responsible for the difficulty in acquiring continence to repair them or, in their absence, provide a positive feedback to parents. The lack of information on urinary tract disorders for pediatricians has been pointed as one of the main obstacles against their acknowledgment.⁴ Thus, we consider that discussions on difficulties in sphincter training should not omit inferior urinary tract dysfunction and structural anomalies as possible causes and also the main data for their diagnosis. The publication of that article in Jornal de Pediatria, a major means of information for pediatricians, will certainly be an important contribution to disseminating such knowledge.

No conflicts of interest declared concerning the publication of this letter.

Eliane Maria Garcez O. Fonseca

Doutora, Instituto Fernandes Figueira, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil. Professora, Faculdade de Medicina Souza Marques, Rio de Janeiro, RJ, Brazil. Chefe, Setor de Urodinâmica, Serviço de Pediatria, Hospital dos Servidores do Estado, Rio de Janeiro, RJ, Brazil

Authors's reply

Dear Editor,

We thank the comments on our article, which made us happy, since it shows that both the text and the theme are arising interest. One of the main objectives of our article was to draw physicians' attention, and especially pediatricians, to an issue that represents the first "crisis” for most children. Despite its importance, we demonstrated that physicians have a limited interest on this issue. Hence, we do not believe that a single sentence can decrease the value of that theme by indicating that children will eventually acquire sphincter control. In the article, we stressed the importance of that process and possible consequences of an improper treatment.¹ Since the text is essentially based on the process of toilet training in healthy children, the statement that all children will achieve sphincter control cannot be considered wrong.

On the other hand, we can only agree with the letter's author when she claims that pediatricians should advise parents in the process of diaper removal and detect changes that may be manifested during that period. Sphincter control has been postponed in most countries, coinciding with increase in prevalence of bladder dysfunction, which has multifactorial etiology. Failures in the process of toilet training can contribute to that problem, which is a matter of concern for us. In fact, bladder dysfunction² was one of the reasons that led us to study toilet training in our birth cohort. Along with disclosure of available training methods,³ we emphasized the need for investigating urinary and intestinal habits during routine visits to the child's pediatrician.⁴ By reminding pediatricians of this development milestone, we draw their attention to the need of being familiar with the theme and to involve themselves in the process. We also want to encourage researchers to investigate this issue, especially to evaluate existing strategies and adapt them to our reality, or even propose new methods.

We are still performing the follow-up of children in the 2004 cohort, in Pelotas (Brazil), so that it will be possible to assess age of sphincter control acquisition for the whole group and also to detect bladder and intestinal dysfunctions, as well as other urinary tract diseases. Children with history of urinary infection in the first 2 years of life are being assessed and investigated, and will be dealt with in a further article.

No conflicts of interest declared concerning the publication of this letter.

Denise Marques Mota^I; Aluísio J. D. Barros^II

^IMestre. Nefrologista pediátrica, Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil

^IIDoutor. Professor associado, Programa de Pós-graduação em Epidemiologia, UFPel, Pelotas, RS, Brazil

Referências (cartas ao editor) / References (letters to the editor)

Referências (Resposta dos autores) / References (authors' reply)

• 1. Mota DM, Barros AJ. Toilet training: methods, parental expectations and associated dysfunctions. J Pediatr (Rio J). 2008;84:9-17.
• 2. Bauer SB, Koff SA, Jayanthi VR. Voiding dysfunction in children: neurogenic e non-neurogenic. In: Walsh PC, Retik AB, editors. Campbell's urology. Pennsylvania: Elsevier; 2002. p. 2231-83.
• 3. Fonseca EM, Costa Monteiro LM. Diagnóstico clínico de disfunção miccional em crianças e adolescentes enuréticos. J Pediatr (Rio J). 2004;80:147-53.
• 4. Lima MG. O reconhecimento da disfunção miccional pelo pediatra [dissertação ]. Rio de Janeiro (RJ): Instituto Fernandes Figueira/ FIOCRUZ; 2003.
• 1. Mota DM, Barros AJ. Toilet training: methods, parental expectations and associated dysfunctions. J Pediatr (Rio J). 2008;84:9-17.
• 2. Bakker E, Wyndaele JJ. Changes in the toilet training of children during the last 60 years: the cause of an increase in lower urinary tract dysfunction? BJU Int. 2000;86:248-52.
• 3. American Academy of Pediatrics. Toilet training: guidelines for parents. Elk Grove Village, IL: AAP; 1998.
• 4. Mota DM, Victora CG, Hallal PC. Investigação de disfunção miccional em uma amostra populacional de crianças de 3 a 9 anos. J Pediatr (Rio J). 2005;81:225-32.

Publication Dates

• Publication in this collection
  24 June 2008
• Date of issue
  June 2008