Correspondence Address:
Prof. Mahmood Dhahir Al-Mendalawi
Department of Pediatrics, Al-Kindy College of Medicine, Baghdad University, Baghdad
Iraq

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To the Editor,

With reference to the interesting study by Aljefri et al, [1] the recently published Interna­tional Children's Continence Society guide­lines on diagnostic evaluation and therapy for children with nocturnal enuresis (NE) involve a careful medical history, including bladder diary, physical examination, urinalysis and ultra-sonography of the urinary tract system. How­ever, urodynamic, radiological and endoscopic evaluations are not necessary unless additional daytime voiding problems are present. [2] Apart from the four limitations addressed by Aljefri et al [1] in their study, I presume that the fol­lowing two methodological limitations might render the reported prevalence of NE (28.6%) among their studied cohort overestimated:

The methodology employed by Aljefri et al [1] on primary school children was a cross-sectional study primarily involving pre­recorded questionnaires, which were com­pleted by the help of parents of children with NE. Because illiteracy prevails among the Yemeni population (47%), [3] it is expec­ted that the educational level of parents could markedly affect their optimum res­ponses to the studies involving question­naires. This is obvious from the notion that 54.7% of fathers and 84.6% of mothers included in Aljefri et al's study [1] had informal/basic educational level (Table 3).Aljefri et al [1] did not include exclusion cri­teria in their methodology, among which urinary tract infection represents a critical one as it was reported in 36.8% of Yemeni children. [4]

I realize that the limited resources and tech­nical difficulties possibly impeded the appli­cation of the aforementioned diagnostic work-up [2] to confirm the diagnosis of NE and ex­clude other differential diagnosis in their stu­died pediatric population. Despite all addressed limitations, NE remains an important health problem warranting proper evaluation and treatment to curtail its adverse psychosocial outcomes on Yemeni children and their parents.

Conflict of Interest: None

Authors Reply

Dr. Hasan Mohamed Aljefri 1 , Dr. Omer Abdullah Basurreh 1 , Dr. Faisel Yunus 2 , Dr. Amen Ahmed Bawazir 2,3

1 College of Medicine, Hadhramout University for Science and Technology, Hadhramout, Yemen,

2 College of Public Health and Health Informatics, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia,

3 College of Medicine, Aden University, Aden, Yemen

E-mail: bawazir56@hotmail.com

To the Editor,

We are grateful to Prof. Al-Mendalawi for his interest and thoughtful comments in refe­rence to our article on Nocturnal Enuresis among Primary School Children, 1 and we appreciate the opportunity to respond.

With respect to the first comment, i.e., the impact of educational level on parents' opti-mum responses to our study questionnaires, we agree that this is an important issue and the educational level does affect the degree of understanding. However, we would like to point out, as has been mentioned in our study, that 54.7% of fathers and 84.6% of mothers in our study had informal/basic education. Hence, they were not completely illiterate as opposed to what Prof. Al-Mendalawi was trying to highlight. We understand that illiteracy pre­vails among the Yemeni population, but that was not the case in our study cohort. Further­more, the research team did encourage the students, who were part of the study in all sites, to help their parents in completing the questionnaires. We note that Prof. Al-Mendalawi is of the opinion that, given the higher proportion of parents with informal/ basic education in our study cohort, our study may be overestimating the prevalence of noc­turnal enuresis (NE). We are of the view that better educational level can, of course, improve the suitability of responses and hence can even further increase the prevalence of NE from the one that we have reported in our study. Therefore, it would be difficult to confirm a priori that better educational level would have led to a reduced prevalence of the condition in our study, as was suggested by Prof. Al-Mendalawi.

We completely agree with Prof. Al-Mendalawi's other comment on urinary tract infection (UTI). We did not have the technical resources to clinically diagnose and evaluate the children for NE in line with the Interna­tional Children's Continence Society guide-lines. 2 Therefore, we did not exclude the chil­dren with UTIs as it would have been difficult to ascertain the exact clinical features on self-administered questionnaires. Hence, the non-exclusion of children with UTIs may have resulted in a higher prevalence of NE in our study cohort. As cross-sectional observational studies are prone to confounding, 3 we have, for that reason, stressed the need for longi­tudinal studies to evaluate the causal asso­ciations between NE and various risk factors.

Conflicts of Interest: None.

References

Aljefri HM, Basurreh OA, Yunus F, Bawazir AA. Nocturnal enuresis among primary school children. Saudi J Kidney Dis Transpl 2013; 24:1233-41.Franco I, von Gontard A, De Gennaro M; International Childrens's Continence Society. Evaluation and treatment of nonmonosymptomatic nocturnal enuresis: A standardization document from the International Children's Continence Society. J Pediatr Urol 2013;9: 234-43.Jepsen P, Johnsen SP, Gillman MW, Sørensen HT. Interpretation of observational studies. Heart 2004;90:956-60.

References