Bedwetting

Bedwetting, or enuresis, occurs when a child who has developed bladder control during the day continues to wet the bed at night. For very young children, this is normal. Bedwetting is typically not considered a problem until the child reaches a certain age or unless the bedwetting causes significant distress in the child’s life. The age that bedwetting becomes a concern is not entirely agreed upon, but most pediatricians agree that it falls between the ages of 5 and 7 years.

The kidneys produce urine, which is stored in the bladder. The walls of the bladder stretch when it fills and send a message to the brain that it needs to be emptied. Then, the bladder walls contract and the muscle that keeps the bladder closed (sphincter) opens. This pushes the urine through the urethra and out of the body.

In infancy, the kidneys continue to produce urine at all times, both day and night, and the bladder empties whenever it is full. The bladder is small at first and cannot hold much urine, but it increases in capacity every year. As the child grows and develops, several changes take place. A hormone (antidiuretic hormone) is secreted that reduces the amount of urine produced at night. As a child ages, his or her growing bladder can hold more urine. As the central nervous system develops, the child’s brain becomes capable of recognizing a full bladder and keeping it from emptying until the child finds an appropriate time and place to urinate. Eventually, the central nervous system develops to the point that it can wake a sleeping child when the bladder is full.

Children generally gain daytime bladder and bowel control between the ages of 2 and 4 years. They learn to tell their parents or other caregivers when diapers need to be changed and eventually to use the toilet themselves. This is called toilet training. However, daytime bladder control occurs before nighttime control. Children who remain dry during the day may still wet the bed for some time. This may continue for many years, but it becomes less common as the child ages. According to the American Academy of Pediatrics (AAP), about 40 percent of children still wet the bed at age 3. The rate drops dramatically in the fourth year, with about 15 percent continuing to wet the bed, according to the American Academy of Child and Adolescent Psychiatry (AACAP). However, bedwetting typically stops well before puberty.

Nearly all children wet the bed on occasion. Wetting the bed is not typically considered diagnosable enuresis unless it occurs at least twice a week for at least three consecutive months. However, if the bedwetting is less common than this and causes significant distress to the child, a pediatrician may still consider it problematic enuresis.

Although bedwetting can be very embarrassing and stressful for both the child and the parents, it generally causes no physical problems. However, a rash can sometimes develop on the buttocks and genital area. This is particularly true if the child continues to sleep in wet underwear. To prevent a rash, parents can help the child rinse the area each morning. Covering the area with a petroleum ointment before bed may help some children.

In most cases, enuresis is not caused by an illness or physical problem. It is not usually associated with emotional problems. Because girls develop a bit faster than boys, girls tend to develop nocturnal bladder control at an earlier age. According to the American Academy of Family Physicians, more than twice as many boys as girls continue to wet the bed after age 5.

Bedwetting (enuresis) that occurs in childhood is usually primary enuresis. These children never developed nocturnal (nighttime) bladder control and have wet the bed since infancy. Most have at least one parent who also wet the bed as a child. In most cases, the child will stop wetting the bed at around the same age that the parent developed nocturnal bladder control.

Bedwetting becomes increasingly less common with age. The American Academy of Pediatrics (AAP) reports that bedwetting occurs in 20 percent of 5-year-olds, 10 percent of 6-year-olds and 3 percent of 12-year-olds.

School-aged children are often very embarrassed by their bedwetting. They may avoid sleepovers with friends and may not want to attend a summer camp. They do not want their friends to find out about their problem. However, these childhood outings can still be enjoyed with proper preparation. Parents can speak privately with camp counselors about their child’s enuresis. Most counselors understand the problem and can provide needed support and assistance. Trying to stay awake all night does not help and can be bad for the child’s health. It is important to bring extra clothes and underpants in case an accident occurs. In addition, new commercial products are available that resemble underpants and are absorbent and disposable.

The vast majority of adolescents no longer wet the bed. According to the National Kidney Foundation, only 1 to 2 percent of adolescents age 15 or older still have problems with bedwetting. The AAP reports than only 1 percent of the population continues to wet the bed into adulthood.

Most cases of bedwetting (enuresis) are caused by slower than normal development of the central nervous system, bladder muscles and bladder capacity. There may be a delay in the production of antidiuretic hormone, which reduces the amount of urine produced at night. However, normal childhood development covers a wide range and slower development does not mean that anything is wrong with the child. These children are still physically and emotionally healthy and normal and they will eventually have control over their bladders at night.

Secondary enuresis (bedwetting after a period of remaining dry at night) is typically the result of stress, fears or insecurities, such as the birth of a sibling, moving, the divorce of parents, a hospitalization, the death of a loved one or abuse. These factors can also prolong primary enuresis (bedwetting that has occurred since infancy).

According to the American Academy of Pediatrics, only around 1 percent of enuresis cases are related to diseases or other physical problems.

Bedwetting runs in families. Most children who have a problem with wetting their beds have a close relative who had a similar problem as a child. Typically, one or both parents wet their beds during childhood. Scientists have even located certain genes that influence bedwetting.

In most cases, bedwetting (enuresis) is not accompanied by other symptoms. Children may wet their beds every night, or only on some nights. The number of dry nights tends to increase as the child gets older. Sometimes, enuresis is accompanied by vivid dreams – even of getting up to use the bathroom. Many parents report that children with enuresis are deep sleepers and can be quite difficult to awaken.

When enuresis is caused by an illness or other physical problem, it is usually accompanied by other signs and symptoms. In some cases, there may be blood on underpants or nightclothes. A loss of bladder control during the day as well as the night in a child who has been toilet trained is also a sign of a physical problem. Other signs and symptoms that may indicate an underlying condition include:

• Changes in the frequency of urination or amount of urine during the day. The child may urinate more or less often and may expel more or less urine when urinating.
• Discomfort or pain during urination. The child may have to strain while urinating and urination may hurt or burn.
• An unusual urine stream. The urine stream may be very small or narrow. It may angle too much in one direction. There may be constant dribbling or dribbling after urination.
• Unusual urine. The urine may be cloudy or discolored. It may even have a pink coloration.

Bedwetting (enuresis) is not typically a concern for children under the age of 5 years. In most of these cases, the child will eventually outgrow wetting the bed. However, if the child continues to wet the bed after reaching school age, or if the enuresis causes the child significant distress, parents may be encouraged to take the child to a pediatrician for an evaluation.

The diagnosis of enuresis generally begins with a physical examination and a thorough medical history. The physician will usually ask about any bedwetting patterns in the child’s family history. The frequency and times of urination during the day and anything unusual about the child’s urination or urine will be discussed. The physician may also ask about how the child acts during the day (e.g., stressed, tired) and what the child typically eats or drinks before bedtime. If a problem is suspected, the physician will probably order a urinalysis. This requires a sample of the child’s urine to check for any signs of illness. In some cases, x-rays of the child’s kidneys or bladder may be used to determine if there is a more serious problem.

Treatment for bedwetting (enuresis) before the age of 5 years is typically not recommended. A child of this age will usually outgrow enuresis quickly and treatment can make the child more self-conscious and embarrassed. Some children do not respond to any treatment and must simply outgrow bedwetting on their own. Children develop nocturnal (nighttime) bladder control on their own time. They must not be rushed before they are ready.

If stress, an emotional problem, illness or another physical problem is causing enuresis, it needs to be treated. The child will generally stop wetting the bed once these issues are resolved. Emotional problems may require the assistance of a child and adolescent psychiatrist or other mental health professional.

Support and encouragement are very important for a child who wets the bed. Parents, caretakers and other individuals need to be sensitive to the child’s feelings. The child may be very frustrated, upset or even depressed about the problem. Bedwetting is not the child’s fault and he or she should never be punished for wetting the bed. The child is not bad or naughty and needs to understand this. It may help the child to hear about other family members who had the same problem in childhood. It is important for parents to talk to other family members, especially siblings, about bedwetting and to prohibit teasing of any sort. Parents should not overreact every time the child wets the bed.

To help prevent wetting the bed, children should empty their bladder just before bedtime. For some children, going to bed a little earlier (e.g., 30 minutes) helps. It often helps to restrict beverages in the hours before bedtime. However, this does not mean that the child should be denied a drink. Children should not be sent to bed thirsty. Small amounts of water (e.g., 8 ounces) are typically fine.

Certain foods and beverages are best avoided in the hours before bedtime. Sources of caffeine (e.g., chocolate, sodas or other carbonated beverages) can irritate the bladder and encourage urination. Dairy foods (e.g., milk, cheese) can be problematic in some children, but not all.

Some physicians recommend waking the child up at night to use the toilet. Children can use an alarm clock or the parents can wake them up. However, this may not prevent bedwetting for all children.

It is important to make preparations for easy cleanup. A rubber or plastic bedcover between the sheets and the mattress makes cleanup easier and protects the mattress from urine. Extra bed sheets and pajamas kept near the bed allow children to return to bed more quickly if they wake up at night and find that they have wet the bed.

The most effective treatment for enuresis is a moisture alarm. This is a device that detects wetness and sets off an alarm to wake the child. Many models are available without a prescription in most pharmacies. Depending on the model, wetness may be detected by a pad or clip-on sensor in the child’s pajamas or on the bed sheets. At the first sign of wetness, these sensors set off an alarm that may ring, buzz or vibrate to wake the child. Then the child can go to the toilet and finish urinating.

A moisture alarm can be extremely effective when used by a motivated child. This device is most effective when the child already demonstrates some degree of nighttime bladder control by having both dry and wet nights. It must be used exactly as directed and a noticeable response typically takes several weeks. It may take three months or more before bedwetting stops. Some children begin wetting the bed again after the device is discontinued.

Some pediatricians recommend bladder stretching exercises. In this technique, the child waits a few minutes to go to the toilet after feeling the urge to urinate during the day. This may help to increase bladder capacity.

There are also other techniques that may help. Positive imagery helps some children with enuresis. Here, the child imagines waking up when he or she needs to urinate. The child also imagines waking up in the morning dry. Massage, acupuncture and hypnosis may help some children, but these have not been proven effective and require more research.

Parents are encouraged to avoid treatments that promise a miracle cure. A pediatrician is the best source of information regarding which treatments may actually work for any particular child.

Children aged 7 years or older may also be treated with medications that either suppress the amount of urine produced at night or affect the bladder muscles and capacity. However, this tends to be a last-resort treatment and is usually only attempted when other treatments have not worked. These medications are available in pill form or as a nasal spray. They have side effects, which can range from flushing of the face to seizures, and some can be dangerous, particularly in cases of overdose. They are not recommended for long-term use, but may be beneficial for special occasions, such as sleepovers or during summer camp. They may not work for all children. When they do work, the effects are temporary. Children typically begin to wet the bed again when the medications are stopped.

Keeping a calendar or diary of wet and dry nights helps children to monitor their bedwetting. It is frequently recommended that parents encourage the child to help with the cleanup. However, this must not be presented as a punishment. Parents should give praise for dry nights to encourage the child and make them feel better.