Other considerations
The evidence found no benefit from restricting fluid intake. The consensus of the GDG was that it is important to actively raise the issue of fluid intake with children and young people and families and carers to counter any misconceptions about fluid restriction. The presence or absence of daytime symptoms may also not be apparent if children, young people or families or carers are restricting fluids. Ensuring adequate intake during the day also may prevent children and young people from needing to drink larger amounts nearer bedtime.
The GDG considered it important to provide children, young people and families and carers with a guide to desirable fluid intake. There is no single recommended figure for fluid intake in children and young people as fluid requirements are influenced by numerous factors including size, dietary intake, activity levels and ambient temperature. The human body can regulate its water content over a wide range of fluid intakes and prevent both dehydration and over hydration. Water intake comes from both drinks and food intake and both these values can vary enormously between individuals.
The GDG considered the information provided by government bodies and experts and the most comprehensive source of information on water requirements is:
Dietary reference intakes for water, potassium, sodium, chloride, and sulphate. Panel on Dietary Reference Intakes for Electrolytes and Water Standing Committee on the Scientific Evaluation of Dietary Reference Intakes Food and Nutrition Board. Institute of Medicine (U.S). 2004. 79
The reference values provided in this document describe “Adequate Intake” as the median intake of total water in different age bands documented in the U.S Third National Health & Nutrition Survey 1988–1994. These values were chosen because of data demonstrating that hydration was maintained over a wide range of fluid intakes varying from the 10 percentile to the 90th percentile of fluid intake. The document is very clear that it is not possible to provide a recommended fluid intake.
In applying these figures to children and young people with bedwetting in the UK, the GDG considered that the extremes of fluid intake were undesirable in that insufficient fluid intake may inhibit the development of normal toileting patterns and mask the symptoms of bladder disorders whilst excessive fluid intake, especially before bedtime, may provoke wetting. We have therefore given guidance on the ranges of total intake from drinks (this is easier to measure and hence influence than including fluid associated with non-drinks intake) and have taken this as the inter-quartile range of fluid intakes (rounded to nearest 100 ml). This then provides a guideline minimum and maximum fluid intake although these figures need to be considered in relation to each individual’s circumstances and health status and adapted accordingly.
The GDG noted there was no evidence about the effect of fizzy drinks. The GDG were concerned that many children and young people might be drinking caffeine containing drinks (which are diuretic) and that these might not be helpful in general or specifically for urinary symptoms and felt this was a good opportunity to reiterate these messages.
The GDG wished to give children, young people and families and carers some indication of normal toileting frequency and consensus was to use the standardized International Children’s Continence Society (ICCS) criteria. The ICCS suggest <3 times per day is abnormal and >8 itimes per day is abnormal. These figures were judged by the GDG to be extremes indicating abnormality and a midway figure of 4-7 was more reasonable range when recommending to parents and carers.
It was the experience of the GDG that children, including children and young people with behavioural or attention difficulties, may be managed by parents and carers in pull ups/nappies and that a trial without this should be considered if they are toilet trained by day.
