In treating a child for primary nocturnal enuresis, which approach should be used if the child is older than 5 and has been bedwetting multiple times a week?

For a child older than 5 years who has been experiencing primary nocturnal enuresis multiple times a week, the most effective approach is to use an enuresis alarm. This method is recognized in pediatric practice as one of the first-line treatments for bedwetting in older children.

Enuresis alarms work by detecting moisture and waking the child when bedwetting occurs, promoting conditioning and teaching the child to respond to the sensation of a full bladder during sleep. This approach helps to reinforce bladder control and increases the child's awareness of the need to void at night.

While reward systems and fluid restriction may have their roles in treatment, they do not address the physiological aspect of the child’s inability to recognize a full bladder. Reward systems can be motivating, but they are more effective when used alongside other treatments rather than as standalone solutions. Fluid restriction might also be short-sighted as it doesn’t support the child in developing normal bladder control. Therefore, the enuresis alarm is the most comprehensive strategy aimed at correcting the underlying issue of bedwetting in this age group.