[Obscurity still exists with regard to the policy in undescended testes: early operation versus well-underpinned wait-and-see policy]. / Nog steeds onduidelijkheden over het beleid bij niet-scrotale testis: vroeg opereren versus onderbouwd afwachten.

The frequency of orchidopexy in the Netherlands is higher than the frequency of genuine undescended testes in spite of an existing consensus guideline on the subject. Evidence that orchidopexy has a positive effect on fertility or the decrease of testicular malignancy is lacking. Clinical trials are necessary to answer the question whether orchidopexy before the age of 2 years prevents malignancy or improves fertility. It is important that research that shows no results of early orchidopexy is also published. A public health approach is necessary to prevent unnecessary surgical interventions.

[Further development of 'Enuresis nocturna' guidelines for children with persistent problems]. / Uitwerking Richtsnoer 'Enuresis nocturna' voor kinderen met hardnekkige klachten.

To achieve dryness in children who suffer from persistent bedwetting, it is important to find out which factors play a role in their bedwetting and why previous treatment has failed. The use of a micturition diary is essential. The child's problems and needs have to be identified and treated individually. The enuresis alarm, with the proper guidance, is the preferred form of initial treatment. Desmopressin is particularly suitable in cases of nocturnal polyuria or if the use of the alarm is unfeasible. If the alarm does not have any effect within two weeks or if a rapid result is important, a combination of desmopressin and the alarm is advisable. Bedwetting combined with daytime micturition problems is often indicative of a small bladder capacity and/or detrusor instability. In these children bladder training and/or treatment with an anticholinergic drug (possibly combined with desmopressin) may be effective.

[The guideline 'Detection of visual disorders at the age of 0-19' from the Dutch Association of Child Health Care]. / De standaard 'Opsporing visuele stoornissen 0-19 jaar' van de jeugdgezondheidszorg.

The child health-care guideline 'Detection of visual disorders at the age of 0-19' draws attention to the importance of early detection of visual disorders and provides guidelines to child health-care workers for detecting disorders during routine check-ups. Children under the age of 3 are examined by the 'Early detection of visual disorders' method. Picture charts may be used for children from the age 3 onwards. From the age of 3.5 charts which follow the Snellen principle such as the Landolt-C chart should be used. Screening for refraction after the age of 7 and screening for colour blindness are not necessary. Children born before 32 weeks of pregnancy, children with a family history of visual disorders and mentally disabled children have an increased risk of visual disorders.

Prevention of smoking in adolescents with lower education: a school based intervention study.

OBJECTIVE: To assess the effect of an antismoking intervention focusing on adolescents in lower education. Students with lower education smoke more often and perceive more positive norms, and social pressure to smoke, than higher educated students. An intervention based on peer group pressure and social influence may therefore be useful to prevent smoking among these students. DESIGN: Group randomised controlled trial. SETTING: 26 Dutch schools that provided junior secondary education. SUBJECTS: 1444 students in the intervention and 1118 students in the control group, all in the first grade, average age 13 years. INTERVENTION: Three lessons on knowledge, attitudes, and social influence, followed by a class agreement not to start or to stop smoking for five months and a class based competition. MAIN OUTCOME MEASURES: Comparison of smoking status before and immediately after and one year after the intervention, using multilevel analysis. RESULTS: In the intervention group, 9.6% of non-smokers started to smoke, in the control group 14.2%. This leads to an odds ratio of 0.61 (95% CI= 0.41 to 0.90) to uptake smoking in the intervention group compared with the control group. One year after the intervention, the effect was no longer significant. CONCLUSIONS: In the short-term, an intervention based on peer pressure decreases the proportion of adolescents with lower education who start smoking. Influencing social norms and peer pressure would therefore be a promising strategy in terms of preventing smoking among adolescents. The results also suggest that additional interventions in later years are needed to maintain the effect.

[Youth health care: much prevention for little money]. / Jeugdgezondheidszorg: veel preventie voor weinig geld.

As part of government policy, the 'Youth healthcare' prevention programme is offered free of charge to all children aged 0 to 19 years who are resident in the Netherlands. It consists of a programme of primary prevention (including vaccinations, information and advice) and secondary prevention (screening, surveillance, early diagnosis) and individual prevention and care. Many elements from the programme package have been shown to have a favourable cost-effectiveness relationship, in terms of health benefits and financially. Other elements have a social priority. The present government expenditure for the total youth healthcare package is about 380 million euros per year, that is 1900 euros per child. In terms of conditions prevented or years of life gained, this is cheaper than accepted prevention programmes for adults. The present approach can only be maintained and strengthened, if the expenditure is increased so that new programme elements can be investigated and--if found effective--implemented.

Effect of dry bed training on behavioural problems in enuretic children.

UNLABELLED: Children with nocturnal enuresis (n = 91) selected by school doctors in The Netherlands from 1991 to 1994 were included in a study to assess the course of behavioural problems especially when the children became dry after the Dry Bed Training (DBT) programme. The Child Behaviour Checklist (CBCL) questionnaire was completed by 88 parents (96%) prior to DBT (T1) and by 83 parents (91%) 6 mo after DBT (T2). The mean CBCL total problem score at T1: 24.0 (range 2-91, SD 16) was significantly higher than that of a Dutch norm group: 20.45, (p=0.025). Compared to T1, the mean CBCL total problem score at T2 was 16.8 (range 0-73; SD 14.7; p < 0.0001). Of the children with CBCL total problem scores at T1 in the borderline or clinical range, 92% became dry and 58% improved to the normal range. At T2, the children seemed to have less internal distress, fewer problems with other people, and were less anxious and/or depressed. CONCLUSION: Children with behavioural/emotional problems who wet their beds need not first be treated for their behavioural/emotional problems. Bedwetting can be treated successfully with DBT when other treatments such as normal alarm treatment have failed, and alarm treatment/DBT can have a positive influence on behavioural/emotional problems.

[Non-scrotal testes; first line of management]. / Niet-scrotale testes; beleid voor de eerste lijn.

For non-scrotal testes a distinction can be made between retractile testes (completely descended and normally developed but sometimes situated subcutaneously in the groin area), retained testes (testes cannot be brought into the scrotum or this can only be achieved using light manual pressure) and ectopic testes (lying outside of the descent trajectory). It is estimated that 0.7-0.8% of all boys have as yet undescended testes. The first few days after the birth are the most suitable for testing and registration, as then the cremaster reflex is absent. Registration should take place in both the youth healthcare file and in the 'growth book' for the parents. Retractile testes do not require treatment. There is no consensus concerning the treatment of (possible) acquired nonscrotal testes. For undescended testes the management depends on previous testes localisations. For ectopic testes and testes that have never been scrotal, a referral for surgical treatment should be made prior to the second birthday. Orchidopexy (a better description is orchidofuniculolysis followed by orchidopexy) is only justified in the case of testes which have never descended. In the case of a clear indication, the general practitioner should make a prompt referral (before the second birthday) and in other cases assurance should be provided and an expectant policy adopted until puberty.

[Youth Health Care Services guideline 'Early screening for hearing impairment, 0-19 years']. / De standaard 'Vroegtijdige opsporing van gehoorstoornissen 0-19 jaar' van de Jeugdgezondheidszorg.

The Youth Health Care guideline 'Early screening for hearing impairment, ages 0-19 years' draws the attention of all parties involved to the case finding of, notably, perceptive hearing loss; it helps workers in the Youth Health Care argue their referrals and improve the next steps in the process. Referrals always aim at ruling out perceptive hearing impairment. It is essential to diagnose and subsequently treat children with perceptive hearing impairment. It is important to keep track of the process after the referral. Screening methods are the Ewing test, the 'Compacte Amsterdamse paedo-audiometrische screener' (CAPAS) test and audiograms. Each age category has groups at risk for hearing impairment. Problems in neonates are a low specificity of the Ewing/CAPAS tests, treatment of middle ear disease without ruling out perceptive hearing impairment and absence of interdisciplinary agreements regarding the steps to be taken and the necessary feedback. Children with perceptive hearing loss should be diagnosed before 18 months of age. In the near future neonatal screening may detect congenital perceptive hearing impairment, but hearing impairment may still develop after the screening. Alertness with respect to hearing impairment will remain necessary in every consultation of a child.

[Alarm training also successful in 5 to 7 year olds with nocturnal enuresis]. / Plaswekker ook succesvol bij 5-7-jarigen met enuresis nocturna.

OBJECTIVE: To determine how many bed-wetting children aged 5-7 years unlearn the habit using the alarm treatment. DESIGN: Descriptive. SETTING: TNO Prevention and Health, Leiden, the Netherlands. METHODS: The population consisted of all children aged 5 to 7 with nocturnal enuresis (defined as > or = 2 wettings per week) who ordered an Elther alarm set (Elther BV, Tilburg) in May or June 1996 (n = III). The parents and the child were asked to keep notes during the treatment of whether the child had remained dry and of whether the alarm had sounded. When at the time of cessation of the alarm training the results were insufficient, the parents were asked about the reason to stop. When the child had remained dry for 14 nights in succession (the definition of 'success'), a questionnaire was sent 6 months later to inquire if the child was still dry or had relapsed. RESULTS: The totals of success for children aged 5, 6 and 7 years were 70% (n = 7/10), 73% (n = 29/40) and 90% (n = 55/61), respectively. Seven-year-olds were significantly more successful than the children aged 5 or 6 (p = 0.02). No significant correlations were found between results of treatment and sex, the nature of the enuresis (purely functional or not), familial occurrence and frequency of bed-wetting at the start of the treatment. The average times until success were 53 days for the 5-year-olds (range: 31-78), 65 days for the 6-year-olds (26-154) and 59 for the 7-year-olds (17-141). The proportions of relapse after 6 months were 0%, 14% and 9%, respectively. CONCLUSION: Alarm training with pad and buzzer appears to be a suitable method of treatment even for children younger than 8 years.

Bedwetting and behavioural and/or emotional problems.

OBJECTIVE: To assess the link between enuresis nocturna and the severity of behavioural and/or emotional problems in Dutch children and the course of these problems. SETTING: West-Mine Region in the Netherlands. SUBJECTS AND METHODS: Prospective cohort study involving 66 of the 80 bedwetting children from all 1652 children born in 1983 in this region. After 1 y, contact was still possible with 64 of the enuretics. We used the Dutch version of the Child Behaviour Checklist (CBCL) and a questionnaire about bedwetting. RESULTS: The mean T-score for Total Problems (CBCL score) in 1992 (M1; mean age 8.6) was 52.1, and 1 y later was 49.2 (M2). There was no significant difference in the CBCL scores for M1, M2 and a matching group from the Dutch CBCL norm population, either in the group who remained wet or in the group who became dry. There were no differences between the sexes. There was no link between the severity of behavioural and emotional problems and the frequency of bedwetting. However, more children with bedwetting than expected were in the clinical range. CONCLUSION: There was no difference in behavioural and/or emotional problems between the first and the second measurement and the matching group from the CBCL norm group. There were no differences in behavioural and/or emotional problems between primary and secondary bedwetters, nor were there any consequences related to the frequency of bedwetting.

Enuresis nocturna in adults.

To assess the prevalence and characteristics of enuresis nocturna in adults, the treatment they received and the perceived impact, a random sample of 13081 non-institutionalized adults (18-64 years old) were asked to participate in the study in January-March 1996. The response rate was 87%. A personal computer questionnaire included 23 questions on frequency of bedwetting, daytime wetting, treatment and perceived impact. Any respondent reporting bedwetting at least once during the previous 4 weeks was considered to have enuresis nocturna. The overall prevalence of enuresis nocturna was 0.5%. Differences between age groups and sexes were not significant. Fifty percent of men and 19% of women reporting enuresis nocturna had primary enuresis nocturna, of those with enuresis nocturna, 12% of men and 29% of women had always daytime incontinence. Fifty percent of the men and 35% of the women had never consulted a care provider for their bedwetting and 38% of the men and 26% of the women had done nothing to become dry. Only 30% believed that bedwetting was treatable. Bedwetting was associated with several psychosocial problems. Enuresis nocturna in adults is common and may lead to embarrassment and discomfort. It may affect careers, social life and personal relationships. Adults should be more aware that bedwetting is a treatable problem. More information should be given on this issue.