Association Of Disposable Diaper Dependence And Child's Bladder Bowel Control Function Development

Background Bladder and bowel control is a milestone in child growth.In recent decades,the age of toilet training for infants and children has been delayed all over the world,especially in developed countries in Europe and America.The age of bladder and bowel control has risen from 24 months in the 1950's to 36?48 months at the beginning of the 21^stcentury.At the same time,Bladder&Bowel Dysfunction(BBD)including daytime urinary incontinence and enuresis has become the Top 1 disease in the outpatient department of pediatric urology,and the prevalence rate has shown a significant rise in the trend,which seriously affects children's self-esteem and self-confidence,leads to psychological problems such as inattention,anxiety,inferiority and loneliness,and becomes the third biggest psychological trauma event of children.It is found that children's nocturnal enuresis is very common in western countries and is almost regarded as a social phenomenon.15%-30% of 5-year-old children and 10%of7-year-old children have frequent enuresis.However,the pathogenesis and pathophysiological changes of nocturnal enuresis have not yet been fully clarified,which need more deeply to explore and more medical arguments.Whether delayed training will have a negative impact on the development of bladder and blower control ability in children,resulting in BBD,daytime urinary incontinence and enuresis has not yet been systematically studied.When to initiate toilet training and whether this training is consistent with the age of children's urinary continence has been controversial topics,few if any studies have evaluated the risks and benefits of parenting AITT/EC practice and the child's bladder control function development.Through a national epidemiological investigation,case-control study,prospective cohort study,systematic review and meta-analysis,this research investigates the effects of early assisted infant toilet training(AITT),early introduction of Elimination Communication(EC)on bladder and bowel function development,and the effects of disposable diapers dependence on elimination dysfunction.Part?The influence of parenting AITT/EC practice,timing of disposable diaper use cessation on child's bladder control acquisition and prevalence of LUTS:a cross-sectional studyObjectives:This study aims to explore the related factors influence on child's bladder bower control function.Methods:A cross sectional study of child's bladder bowel control developments and prevalence of LUTS was performed by using the Infant and Children Continence Questionnaire to investigate 19500 parents in five provinces of mainland China from July 2017 to October 2017;Meanwhile,in southwest Fujian province,a stratified cluster sampling survey was conducted focus parenting AITT/EC practice and current situation of disposable diaper use on 2,550 parents of children aged 3?7 years in 8kindergartens.The questionnaires included sociodemographic data,family caregivers'information,attitude and practice of AITT/EC,and details about the disposable diapers(DD)usage,timing of bladder and bowel control acquisition,lower urinary tract symptoms(LUTS),and family history of PNE in children.The 2017 PNE prevalence was compared with that of 2006 in Mainland China.Results:The total response rate was 97.04%(18631 of 19500)and 92.39%(18016of 19500)qualified for statistical analysis.The effective questionnaires were 2,300(response rate of 90.2%)in Fujian group.There were 782(34%)parents support the method of AITT/EC,1,077(46.8%)parents were against AITT/EC practice,and 441(19.2%)parents unknown.The median age of daytime bladder control attainment in children was 24(21,30)months(21,30),which was 6-month delay compared with the standard of daytime bladder control for children(18-month-old in the scale of assessment of Chinese Children's Psychological Behavior Development Scale)but earlier than western countries.The median age of nocturnal urinary continence was 30(24,36)months.The prevalence of Enuresis(NE)was 16.6%in the 5-year-old group,12.3%in the 6-year-old group and 10.5%in the 7-year-old group.Compared with the2006 survey,the overall incidence was increased,among them,the incidence of the5-year-old group was increased which was close to the western level.There was a significant positive correlation between the age of daytime disposable diaper use cessation and the age of day dry and nocturnal bladder control(P<0.001).The multivariate linear regression model suggested that the daytime bladder control was associated with the age of disposable diaper use cessation and the age of potty training,and the two independent variables could explain 60.8% of the variation of the result variables.In the multivariate linear regression model with nocturnal bladder control as the outcome variable,the standardized partial regression coefficient of age of disposable diaper use cessation was 0.388(P<0.001).Conclusion:The current age of bladder control in children was delayed compared with that in 1990's,the prevalence of primary enuresis(PNE)was significantly higher than that in 2006,and the prevalence of PNE and DUI was close to that in western countries.The later the age of toilet training and the age of disposable diaper use cessation is,the later the bladder control is obtained.The age of toilet training over 24 months or the use of disposable diapers over the age of 24 months was associated with the delay of children's bladder control acquisition and increase the prevalence of children's daytime urinary incontinence and primary nocturnal enuresis.Part? Disposable diaper dependence is associated with childhood enuresis:a case-control studyObjective:This research investigated the association between prolonged disposable diaper(DD)wearing in infancy and childhood primary enuresis(PNE).Methods:As a case-control study,we collected data from 376 children with enuresis and 379 healthy children who were sex-and age-matched at three tertiary care institutions in mainland China from August 2017 to July 2018.The patients with PNE ?² were seen at Pediatric and Child Behavior Development Outpatients,while control group were seen at Child Health Care Outpatient.A questionnaire containing 33questions was answered by the mothers during the hospital stay.We recorded the patient's medical records at the same time.Early initiation of toilet training(TT)was considered to be before 18 months.The data of daytime disposable diaper removal age was classified into three categories:?17 months,18-24 months and?25 months.Odds ratios(ORs)and a 95%confidence of PNE were calculated.Generalized additive model(GAM)was used to identify the non-linear relationship.Result:The median age of daytime disposable diaper removal was significantly delayed in children with enuresis[26(18,32)months versus controls:20(18,25)months,P<0.001];The character of daytime assistant infant toilet training practice was significantly less in children with enuresis(157,41.8%)versus the control group(297,78.4%,P<0.001).Nocturnal training was instituted significantly later in children with enuresis[36(26,48)months versus controls:24(19,36)months,P<0.001];Positive family history,age of daytime disposable diaper removal?25 months,age of night training initiation>30 months were associated risk factors of PNE,while assistant infant toilet training practice was protective factor.Furthermore,odds ratio(95%confidence interval)of PNE across the categories of age disposable dipper removal at daytime were as follows:D0(?17months):1.00(reference),D1(18-24months):1.67(0.95,2.94),P=0.076,and D2(?25months):3.13(1.66,5.91),P<0.001.A non-linear relationship was detected,whose point was 21 months(the effect sizes and the 95%CI on the left and right sides of inflection point were 1.04(0.99-1.10),P=0.131 and 1.25(1.18-1.31),P<0.001).Conclusions:In conclusion,the children diagnosed with primary enuresis after age5 stopped using disposable diapers at daytime later than the control group.Association between duration of DD exposure and the risk of childhood enuresis is modified by AITT/EC practice.Timely cessation use of disposable diaper and practice AITT/EC may shorten the time to nocturnal continence,and the prospective cohort studies are needed to verify the discoveries.Part? Effect of parenting elimination communication practice vs disposable diaper use alone in children on the development of bladder function-a population base prospective studyObjectives:Based on the theory of the Ecology of Human Development,from children's ecological environmental perspective,to dynamically observe the“sensitive period”of toilet training in infant and children,investigate the association of AITT/EC and disposable diaper usage with children's bladder bowel control function development.Methods:Participants who volunteered for study were recruited from prenatal schools in tertiary maternal and child health care hospitals.Inclusion criteria:live newborns between March 2015 and March 2017.Exclusion criteria:newborns with birth defects or congenital diseases.In the study,no matter whether the disposable diapers were used,the children trained with AITT before the age of 18 months from parents'voluntary selection were divided as the observation group(AITT group),and the children with diaper alone were divided as control group(DD group).A total of 365participants were recruited in the study.At the age of 6 months,12 months and 18 months,the bladder control observational records and physical examination records were evaluated in observation group.The evaluation indexes were as follows:when to initiate AITT,AITT method,how many times practice AITT per day and infant responses.The control group was followed up only for general physical examination.Both groups of children were observed for 4 hours urination at the age of 24 months.Post-void residual urine was checked by B-ultrasound,and Child Behavior Checklist(CBCL)was evaluated.Parents fill in the Urinary Continence Questionnaire,including:when to initiate daytime toilet training,the age can show the need to urination and defecation,the age of remove disposable diaper during the daytime,the potty usage age,when to start training at night,the age of dry at night;For the children who did not reach continence,continue to observe until the bladder control achievement.Result:Finally,a total of 352 children were followed up,including the AITT group(n=132)and the diaper alone group(n=220).The Kaplan-Meier survival curves in the AITT group and the diapers alone group showed that the median age of daytime urinary continence(95%CI)was 22.0(21.0,23.0)months and 28.0(27.3,28.7)months,respectively,and the median age of nocturnal urinary continence was 28.0(26.8,29.2)months and 36(34.1,37.9)months,respectively.The Log-Rank test showed that?²=126.57,P<0.001 at day time and?²=87.44,P<0.001 at night time.During the 4-hour urination observation,the post-void residual urine(PVR)by B-ultrasound detection found that at AITT group,PVR volume was 3(0,5.7ml),which basically required no repeated measurement;while 64%at DD group had to be repeated,with 12(7,15.75)ml PVR volume,P<0.001.Constipation and stool toilet refusal were higher in DD group than in the AITT group,and there was a statistical difference between the two groups.CBCL parents'questionnaires evaluation show no significant statistic difference between the two groups in the dimensions of withdrawal,depressive,sleep problems,somatic symptoms,aggression symptoms and destructive behavior.Adjusted for mother's education,AITT attitude,breast feeding duration and constipation,by the Cox proportional hazards model,it was confirmed that AITT(HR1.78,95%CI1.139-2.784)P=0.011),and the time of diaper removal(HR=0.222,95%CI0.145-0.339 P=0.001)were the independent factors affecting bladder bowel control in children.Non-linear relationship was detected between daytime and night bladder control acquisition and age of daytime disposable diaper removal.Subgroup analysis showed in participants with AITT,the age of inflection point for daytime bladder control acquisition was 17 months,those diaper alone group,was 27 months.The same direction had been detected at nighttime bladder control acquisition too,and the P for interaction was less than 0.05.Conclusions:AITT practice can achieve seamless natural transition from assisted urination to social independent toilet training and can reach the daytime urinary continence and the nocturnal urinary continence earlier than the diaper alone,which is beneficial to the social independence development and the physical and mental health of children.