CASE REPORT OF NOCTURNAL ENURESIS
ABSTRACT: Nocturnal enuresis (NE) is involuntary urination that occurs at night during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology. There are a number of treatment options available for NE; such as drug therapy, bladder training, positive reinforcement, and the enuresis night alarm. It requires patience, persistence and motivation. Several behavioural approaches can be used for treatment such as enuresis night alarm therapy and various skills oriented components. A thorough homoeopathic case taking and treating with an individualised homoeopathic remedy of single dose gives an assured result. Case with marked peculiar symptom can be made basis of prescription and not all cases requires repertorization.
Keywords: Nocturnal enuresis, bedwetting, enuresis, homoeopathy, single dose, peculiar symptom.
INTRODUCTION:
Nocturnal enuresis (NE) is defined as “involuntary voiding of urine that occurs while sleeping that can happen at an inappropriate and socially unacceptable time and place� and due to which its negative impact occurs on the quality of life of the affected children and their families. It is most common in boys, with a ratio of three boys for every girl until the age of 15. Enuresis should be differentiated from continuous or intermittent incontinence or dribbling. The bed is usually soaking wet in enuresis, compared to incontinence in which there is loss of urine without normal emptying of the bladder.
More than 85% children attain complete diurnal and nocturnal control of the bladder by five years of age. The remaining 15% gain continence at approximately 15% per year, such that by adolescence only 0.5-1 % children have enuresis. Up to the eleventh year, enuresis is twice as common in boys as it is in girls; thereafter, the incidence is similar or slightly higher in girls.
Enuresis is called primary when the child has never been dry and secondary when bed wetting starts after a minimum period of six months of dryness at night.
Enuresis may be comorbid with mood and emotional disorders and also has a high level of comorbidity with attention deficit hyperactivity disorder (ADHD). Part of emotional disorder such as anxiety, expression and insomnia are experienced by persons who have elimination disorders related to distress and social stigma
Classifications
Enuresis classified on the basis of the time of occurrence into the following three subtypes:
• Nocturnal Enuresis: Passing urine during sleep.
• Diurnal Enuresis: Leakage of urine during waking hours.
• Monosymptomatic or uncomplicated NE: Normal voiding at night with absence of symptoms.
• Polysymptomatic or complicated NE: Bedwetting at day time with symptoms urgency, frequency, constipation and encopresis.
• Nocturnal and diurnal Enuresis, also known as nonmono-symptomatic enuresis.
Aetiology:
- NE is hereditary, children whose parents were not enuretic have only a 15% incidence of bedwetting and when one or both parent were enuretics, the rates increases to 44% and 77% respectively
- From the difficulty in waking up when the bladder is filled.
- excessive nocturnal urine production and nocturnal bladder hyperactivity
- Can be drinking late in the evening or not passing urine before going to sleep, resulting in excessive urine volume.
- Another cause may be a low amount of antidiuretic hormone during the night which controls the production of urine.
Goals of treatment
The following are goals of management for NE
• To stay without bedwetting on particular occasions such as sleepover at night or day.
• To decrease the frequency of wet nights.
• To decrease the impact of enuresis on the child and family.
• To avoid recurrence of bedwetting.
For achieving the above goals lifestyle and behavioural changes play an important role.

Primary management of enuresis is behavioural modification and positive reinforcement and it should be start with educating the child as well as parents about the condition, which can be achieved through :
-Behavioural Management.
-Night urine alarm therapy.
-Pajama (Under wear) Device
-Mechanism of action of Night urine Alarm Device
-Waking schedule

CASE REPORT :
A female patient of age 10 years visited our A. M. Shaikh Homoeopathic Hospital on 22/07/2019 with her father who described her case in detail with the presenting complaint of Bed wetting since 5 years.

History of presenting complaint
Patient came with the complaint of bed wetting at night and daytime as well; there is no single dry night since 5 years.At times she passes urine 2-3 times at night and once during her day/evening sleep.
No H/O Night terrors or Nightmare.
Treatment history:
Has consulted an allopathic paediatrician for the above mentioned complaint and was on treatment for 3years with no desirable improvement, so wilfully seeking homoeopathic treatment.
Past history: No H/O any major illness or any remarkable events occurred since birth.
Family history: Nothing significant. No family history of enuresis.
Milestones:
Neck holding - 4th month
Monosyllable speech – 7th month
Crawling – 9th month.
Sitting without support by 10th month.
Walking without support – 14th month.
Normal speech with meaningful words – after18 months.
Personal History:
Diet : Vegetarian,
Appetite :Not adequate, hardly eats a roti at times.
Thirst : 1 – 1.5 ltrs / day,
Micturition : D/N : 3-4/2-3,
Stools : Once/day, Regular, Soft.
Desires : Spicy food.
Life Space Investigation :
ï‚— Birth history : Full term normal hospital delivery. Mother had absolutely healthy pregnancy throughout the term. Mother was not a known case of Hypertension, Diabetes Mellitus, Hypothyroidism. No H/O any insult (injury) at birth.
 Post delivery – till date. : Patient is born and brought up in Kadoli, Belagavi. No remarkable events since birth.
ï‚— She is good in studies, mingles with people easily. She gives debate and speaks freely without fear in-front of people and she has won in almost all the debate she has participated yet she is timid. She cannot takes / tolerates the pain when other people are quarrelling (reaction sympathetic). She is that sensitive she cannot even tolerate the fight in movies and serials. If she sees any beggar on road she tends to lend her tiffin.
General Physical Examination :
Patient is moderately built and moderately nourished, No pallor, cyanosis, icterus, clubbing, oedema, lymphadenopathy, Temperature : 98.6º F. (Afebrile), Thermals : Hot, Height :129cms, Weight :26kgs, Birth Weight : 2.75kgs, Pulse rate :84 bpm, Respiratory cycle : 18cpm.
Clinical diagnosis :Primary enerusis.
Totality of symptoms :
ï‚— Bedwetting at night and daytime.
ï‚— Desires spicy food.
ï‚— She cannot tolerate when other people are quarrelling (reaction - sympathetic), She is that sensitive she cannot even tolerate the fight in movies and serials. If she sees any beggar on road she tends to lend her tiffin
ï‚— Hot patient.
Analysis of symptoms :
Common symptoms Uncommon symptoms
Bed wetting. She cannot tolerate when other people are quarrelling.
Timid but speaks in public.
Desires spicy food

Prescription: Causticum200 HS 1dose
Basis of prescription : This case has been prescribed without repertorization as we found the substantial / peculiar symptom ( sensitive to emotional disturbances) for prescription while case taking.
Follow up’s : (written as it is expressed by father)
ï‚— 29/07/2019
Father said patient has passed urine only twice during her sleep since last week.
Complaints are better by 50%.
Prescribed Placebo BD for 15 days.
ï‚— 19/08/2019
Patient has passed urine during day sleep only once since past 10days.
No bedwetting at night since 10 days.
Appetite has improved, father said she herself asks and have food.
Patient is better by 75%.
Prescribed Placebo BD for 15 days.
ï‚— 03/09/2019
Bedwetting only once at day sleep and no bedwetting at night since 1 month.
Feeling generally better.
No fresh complaints.
Prescribed Placebo BD for 15 day.
Conclusion : Enuresis can be successfully treated with detailed homoeopathic case taking with individualised homoeopathic medicine along with encouragement, a positive attitude and motivation are important components of treatment to become dry. Punishment and criticism has no role to play in care. Children with enuresis get always benefit from a caring attitude of parents. A positive approach by the physician and care taker is also important role to play for putting confidence and to increase compliance.
References :
1. Ghai. O. P, BaggaArvind, Pual. V.K; Ghai essential paediatrics; 8th edition revised and enlarged; CBS Publications and distributors Pvt. Ltd.; NewDelhi; 2013, P-504.
2. Kliegman, M. Robert, Stanton, F. Bonita. Geme, St. Schor; Nelson Textbook of Paediatrics; 20th edition; ELSEVIER; Philadelphia; 2016;
3. http://dx.doi.org/10.5350/Sleep.Hypn.2019.21.0168. Sleep and hypnosis : a Journal of Clinical Neurosciences and Physiopathology.
From :
Dr Shashank H S
Dept of Paediatrics
PG Part 1
A M Shaikh Homoeopathic Medical College , PG Research Centre & Hospital, Belagavi.

Under the guidance of :
Dr Nahida M Mulla. M.D (HOM); MACH
Prof. and HOD Paediatrics
A M Shaikh Homoeopathic Medical College , PG Research Centre & Hospital, Belagavi.

Children experience feelings of nervousness, fear, or worry from time to time; these feelings are part of a normal response to a stressful situation, but when they occur to such an extent that they interfere with normal life, children anxiety disorder may be the underlying cause.
Children anxiety disorder may be manifested by symptoms such as extreme nervousness, inability to concentrate, poor school performance, and physical symptoms like nausea, heart palpitations, headache, shortness of breath, and sweating. Children anxiety disorder can be the result of a recent traumatic or high-stress event such as a move to a new home and school, divorce of the parents, death of a pet or a loved one, or it can have no obvious environmental or emotional basis at all.
Anxiety disorder in children is treated most successfully the earlier treatment begins; treating anxiety may include a combination of talk therapy, positive reinforcement, and in some cases medications.
Symptoms of children anxiety disorder:
Anxiety disorder can be difficult to recognize, because symptoms are often attributed to other factors (like Social anxiety). Signs of extreme nervousness and restlessness, an inability to concentrate, poor school performance, difficulty relating to peers, irritability, and physical complaints such as nausea, upset stomach and frequent headaches may indicate an anxiety disorder.
Causes of children anxiety disorder:
Medical researchers have not yet fully uncovered the causes behind anxiety disorder. There is some suggestion of a hereditary link, as anxiety and other mental disorders tend to run in families, and studies have located small differences in areas of the brain that influence anxiety.
How to diagnose children anxiety disorder?
Anxiety diagnosis is based mainly on the observations by the doctor and parents of a child's behavior. While there are no laboratory tests that can pinpoint anxiety disorder, certain tests may be conducted to rule out another underlying medical cause for the symptoms.
Common categories of children anxiety disorder:
Some of the most common types of childhood anxiety disorders include obsessive-compulsive disorder, phobias (irrational and overwhelming fears), separation anxiety disorder, post traumatic stress disorder, and panic disorder,. These conditions usually affect children between the ages of 6 and 11.
Treatment: Treatment of anxiety in children is more effective the sooner it is addressed after the appearance of symptoms. The most common form of treatment for children anxiety disorder is psychotherapy and teaching positive reinforcement techniques; medicines may also be prescribed for children with anxiety.

A Case of separation anxiety:
Master Rahul, aged 9 yrs, studies in 3rd standard.
The child was apparently normal before he was brought for the consultation. He started developing the following symptoms when the school reopened after vacations.
Fear of being alone.
Difficulty in sleeping & he gets up frightened from sleep after which he is unable to sleep.
Frequently complaints of headache & stomach ache.
He refuses to go to school without the mother. Earlier he used to go in an auto with his friends.
Throws tantrum when mother returns home after dropping him at school.
Complaints of loose stools & attacks of breathlessness accompanied by anxiety.
Moves anxiously from place to place. Restless.
A recent traumatic event had occurred in the family where mother was hospitalized for a week.
The following line of treatment was adopted:
• Psychotherapy: This helped the child learn to understand his feelings and tolerate the separation to a more natural degree.
• Cognitive Behavioral Therapy: This taught the child to change the way he thinks about separation, allowing him to respond more appropriately to natural separation from the mother.
• Medication: Homoeopathic medicine (Ars Alb 200) was given. He recovered well with treatment. There were some brief recurrences of the anxiety, but the coping skills learned through treatment were effective at dealing with the problem when it came up the next time, making each instance shorter and more manageable until the anxiety disappeared completely. Child’s self esteem was strengthened through positive reinforcement. The whole family supported and helped the child as he is undergoing treatment.
Dr. Nahida M.Mulla.M.D (Hom) MACH
PRINCIPAL.
Professor of Repertory & PG Guide.
HOD Paediatric OPD.
Child Counsellor.
A.M.Shaikh Homoeopathic Medical College, Hospital & PG Research Centre, Nehru Nagar, Belgaum - 590010
E-Mail: drnahida_mulla@yahoo.com
Mobile: 09448814660.

EFFECTS OF NUTRITION ON BEHAVIOR AND MENTAL PERORMANCE

Nutrition can affect behavior and emotional adjustment. However, to demonstrate a clear-cut relationship between nutrition on the one hand and behavior and emotional adjustment on the other is extremely difficult since nutrition is only one of a number of factors affecting the expression of interaction of the individual and his environment. Nevertheless, the effects of under-nutrition or malnutrition be discernible in situations which are complicated by poor physical environment and emotional stresses and strains. Periods of severe under-feeding provide evidence.

Spies et al described a child whom they had observed from 5-12 years of age. He was a white boy, the fourth child in a family of ten that had lived on a diet consisting chiefly of corn bread, biscuits, fat pork, sugar, occasionally turnip greens, corn, tomatoes and berries in season. Rarely did this child have any milk, eggs, meat, fish or cheese. At 5 years of age he was retarded in growth and showed clinical evidence of deficiencies in thiamine, riboflavin and niacin. His mother reported that he had “cracks” (symptom of riboflavin deficiency) at the corner of his mouth most of his life and frequently his tongue was red and sore (symptom of niacin deficiency). During the following three years his mother complained that he was fractious, and his teacher stated that he did not concentrate on his school work and poor grades and was quarrelsome. At 8 years and 9 months he was given a skimmed milk supplement which increased his intake of protein, calcium, thiamine, riboflavin and niacin. No other changes were made in his life. During the first year, there was little change in his lip and tongue condition and disposition of his school grades. Following that year gradual improvement in lip and tongue symptoms was noted. His mother reported great improvement in his disposition. His teacher said that, he could concentrate better on his studies, his school grades had improved and his behavior was excellent. This relatively small improvement in his diet had contributed slowly to somewhat better living for this child even though it was insufficient to improve his growth rate in height and weight.

Children with Kwashiorkar, a severe type of protein malnutrition, have a characteristic behavior. These children are dull, apathetic, and miserable. They sit without moving, indifferent to their surroundings. They rarely cry or scream, just whimper. When they are cured, the behavioral change from “peevish mental apathy” to “impish humor and vitality” is striking.
Observations during real life situations of under-nutrition have been corroborated by the changes in behavior of the subjects of the Minnesota Study on Starvation. The progressive anatomic and bio-chemical changes which produced sensations, drives and limitations to physical functions rendered the man increasingly ineffective in their daily life. During the period of semi-starvation men who had been energetic, even-tempered, humorous, patient, tolerant, enthusiastic, ambitious and emotionally stable became tired, apathetic, irritable, lacking in self-discipline and self-control. They lost much of their ambition and former self-initiated spontaneous physical and mental activity. They moved cautiously, climbed stairs one step at a time and tended to be awkward, tripping over curbstones and bumping into objects. They lost interest in their appearance. They dressed carelessly and often neglected to shave, brush teeth and comb their hair. They became more concerned with themselves and less with others. It required too much effort to be sociable. Their interests narrowed. The educational program, which was to prepare them for foreign rehabilitation work, collapsed. Humor and high spirits were replaced by soberness and seriousness. Any residual humor was of a sarcastic nature. They had periods of depression and became discouraged in part because of their inability to sustain mental and physical effort. They were frustrated because of the difference between what they wished to do and what they could do. They found themselves buying things which were not useful at the time. They stopped having “dates.” All sex feelings and expression virtually disappeared. All the time they were being distracted by hunger. Sensations and showing great concern about and interest in food. When their food was increased during the rehabilitation period, their psychological recovery was somewhat faster than their physical improvement, although many months of unlimited diet passed before recovery was complete. Emotional stability and sociability were regained more rapidly than strength, endurance and sexual drive.

The sudden feeling of improvement however was temporary. Morale became low because many anticipated quick, complete recovery. As energy increased, they no longer were willing to accept conditions unquestionably and showed annoyance at restrictions. Many grew argumentative and negativistic. Humor, enthusiasm and sociability reappeared; irritability and nervousness diminished. The feeling of well-being increases the range of interest. The sense of group identity which had become strong during the semi-starvation period was dissipated as men began looking forward to making plans for their future. An interest in activity and sex increased. Their concern about food decreased after a period of insatiable appetite when they were first permitted to eat all they desired.

Intelligence: It has been shown that under-nutrition or malnutrition can affect mental activities or the way an individual uses his mental abilities. In the Minnesota study, according to both clinical judgment and quantitative tests, the men’s mental capacity did not change appreciably during either semi-starvation or rehabilitation. The subjective estimates of loss of intellectual ability may be attributed to physical disability and emotional factors.

Studies of the effect of thiamine supplements upon learning ability have given no assurance that adding thiamine to the diet of schoolage children will be followed by increased ability to learn. Evidence has been cited that underfeeding has a real effect upon the well-being of an individual, and is reflected in his behavior. It would be wise, therefore, to keep in mind the nutritional needs of children and to meet them wherever possible.

Dr. Nahida M.Mulla M.D.MACH
Principal,
A M Shaikh Homoeopathic Medical College, Nehru Nagar, BELGAUM