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BEDWETTING
10 Bedwetting Facts Parents Should Know 1. The medical term for bedwetting is "enuresis," which refers to
bedwetting that is not due to an abnormality of any portion of the urinary
tract. Primary enuresis means the child has never been dry, whereas secondary
enuresis is the term used for a child who has previously been dry but then
starts wetting his bed. Bedwetting is sometimes referred to as "nocturnal
enuresis" or "nightwetting." Sometimes it's called "sleep wetting," since some
children may also "nap wet." Bedwetting really should be called "sleep wetting"
because it occurs during sleep.
2. Fifteen percent of five-year-olds or around three to four children in a
first grade class, are not dry every night Eighty-five percent of children
eventually outgrow bedwetting without treatment. In the teenage years, only two
to five percent of children, or one child per class, continue to wet their bed.
Bedwetting boys outnumber girls by a ratio of 4 to 1.
3. Bedwetting is not an emotional or psychological problem, nor does
it reflect a dysfunctional family. It is a problem of sleeping too deeply to be
aware of bladder function.
4. The genetics of bedwetting are similar to that of obesity If both
parents were bedwetters, the child has a seventy- percent chance of being a
bedwetter. If only one parent was wet at night, the child will have a forty-
percent chance of following his parent's nocturnal habit.
5. It helps to first understand how children usually achieve bladder
control In early infancy, bladder-emptying occurs mostly by the bladder-
emptying reflex. When the bladder reaches a certain fullness and the muscle has
stretched to a certain point, these muscles automatically squeeze to empty the
bladder. Sometime between 18 months and 2½ years, most children have an
awareness of bladder fullness, the first step toward bladder control. Next, the
child becomes aware that he can consciously inhibit the bladder-emptying reflex
and hold in his urine. As a result of his urine-holding efforts, his bladder
stretches and its capacity increases. When the child can consciously inhibit the
bladder-emptying reflex, he achieves daytime bladder control. Nighttime control
occurs when the child can unconsciously inhibit the bladder-emptying reflex.
6. Think of bedwetting as a communication problem: the bladder and the
brain don't communicate during sleep The bedwetting child literally sleeps
through his bladder signals. Delay in bladder control can occur if there is a
delay in awareness of bladder fullness, a small bladder, or the bladder-emptying
reflex continues to be strong well into later childhood.
These components of bladder maturity occur at different ages in different children. Bedwetting is simply a developmental lag in the mastering of a bodily skill. There are late walkers, late talkers, and late dry-nighters. 7. Bedwetting is a sleep problem New insights into the cause of
bedwetting validate what observant parents have long noted: "He sleeps so
deeply, he doesn't even know he's wetting the bed." These deep sleepers are not
aware of their bladder sensation at night, let alone how to control it. In
addition to bedwetters sleeping differently, the hormonal control of urination
may act differently in some children.
8. Some bedwetters may have a deficiency of ADH (anti-diuretic
hormone), the hormone that is released
during sleep and concentrates the urine so that the kidneys produce less of it
during sleep and the bladder doesn't overfill.
9. Normally, bladder fullness works like supply and demand The
bladder fills with just enough urine at night so that it does not overfill and
demand to be emptied. Bedwetters may overfill their bladder so the supply
outweighs the demand, but because they are sleeping so soundly they just don't
tune into their bladder fullness.
10. A small number of children have small bladders that are more easily
overfilled.
Bedwetting is not a psychological problem It does not mean that your
child is too lazy to get up, is using bedwetting as a control issue, or is
manipulating the family. Misunderstandings about bedwetting have kept it from
being viewed as a legitimate medical problem. If the lungs malfunction, the
child is medically and sympathetically treated for, say asthma. If the bladder
malfunctions, the child is thought to be lazy, stubborn, and immature. You would
certainly be sympathetic to an asthmatic child who wheezes at night because his
lungs aren't filling with enough air. Think of bedwetting as any other medical
concern in which an organ of the body is malfunctioning. Bedwetting is a
malfunction of the bladder-brain communication system. The child sleeps so
deeply that bladder-overfilling and spilling occurs. It's a myth that children
don't care. Really, what child would want to wake up in a wet, smelly bed every
morning, and start each morning stripping the bed and carrying wet sheets to the
washer?
Each night in the United States at least five million school-age children wet their bed. Bedwetting is more of a problem than just running a load of wet sheets to the washer before rushing off to work. It is an annoyance for the whole family. Yet, with new insights and approaches children no longer have to suffer the embarrassment of wet nights and parents no longer have to endure years of laundry while waiting for their child to "grow out of it." Here's the step-by-step method of helping the nightwetter keep dry that I have used during my thirty years in pediatric practice, a time-tested approach that enables at least seventy percent of children to wake up in a dry bed. Step 1: Keep a diary Beginning between four to five years of age
record the patterns of your child's nightwetting for one week. Identify the
triggers, what is different about your child's day on the nights he is wet or
dry? Is there a relationship to food, drinks, life's events, family events,
school situations, daytime bowel and bladder patterns, or family dynamics? Try
to put your finger on the triggers that lessen the number of sheets you have to
change.
DON'T RESTRICT FLUIDS
In my experience, withholding liquids is not helpful and may be harmful.
Children need to drink a lot for proper bodily function, especially during hot
months. Restricting fluids may cause dehydration and constipation, which can
aggravate bedwetting.
Step 2: Do a medical evaluation Your doctor will want to know the
results of your diary, the correlation you have noticed and the changes you have
made. Your doctor will do a complete physical examination to detect if there are
any neurological problems that may affect the urinary tract, such as spinal cord
abnormalities that may affect nerve supply to the bladder. Abnormalities in the
external genitalia, such as a misplaced urethral opening, may give a clue to
deformities inside. Your doctor may watch your child urinate and examine the
force of the flow. A "stuttering stream" rather than a smooth flow may be a clue
that there is a structural abnormality in the child's plumbing. A urinalysis and
urine culture may be performed as a screening test for kidney function and to
exclude a urinary tract infection. To gauge your child's bladder capacity, the
doctor may also ask you to measure your child's volume each time he urinates
over a three day period to see if he has a functionally small bladder. The usual
bladder capacity is a child's age plus two ounces. So, a six-year-old should be
able to hold eight ounces of urine.
Finally, if an abnormality of the urinary tract is suspected, your doctor may refer you to a urologist to perform studies such as an ultrasound VCUG (an x-ray picture of how the kidneys and bladder function) to reveal possible abnormalities that could prevent your child from keeping dry all night. The good news is that over ninety-five percent of children have no urinary tract abnormalities causing the bedwetting. Once you've excluded a medical problem, you're ready to begin a night- training program. In order to achieve success, your child must cooperate with the program and take responsibility for his nighttime dryness. Consider this a team approach: the doctor, the parents, and the child. After all, your child has to learn to control his bladder. You can't control it for him you can only help. In fact, your job is to understand bedwetting, work out a night-training program, be consistent with it, and the rest is up to the child. Step 3: Draw a diagram With the use of a picture book, such as Dry
All Night by Allison Mack (Little Brown, 1989),
explain to your child how his kidneys make urine and fill the bladder. Here's
how I explain it to six-year-olds: "Your bladder is like a balloon the size of a
baseball, and inside the balloon are tiny nerves, like feelers, that tell you
when your bladder is full. When you're awake, you feel this pressure, but you
can hold it because there is big, doughnut-shaped muscle at the end of your
bladder that you squeeze shut to keep your pee inside. So, if you're in the
middle of a game and don't want to go to the bathroom, you're able to hold it.
When your bladder gets full, these nerves tell your brain that it is full, and
you go potty. But at night your brain is sleeping so deeply that it says to the
bladder, 'Don't bother me, I'm sleeping.' But the bladder says, 'I'm too full,
I've got to go,' so out comes the pee onto the sheets. We're going to work out
some fun games that help your bladder and your brain listen to each other at
night, so your brain knows that your bladder is full and says to the bladder,
'Squeeze down and hold it' or 'Wake Billy up to go to the bathroom'."
Step 4: Teach triple voiding Many
children, tired and in a hurry, go to bed with a half-full bladder. Just before
your child goes to bed, do some bladder-emptying techniques. Encourage him to
"go three times" or "grunt, grunt, grunt" while urinating, to "squeeze your
baseball-size bladder to push all the pee out."
Step 5: Do the shake and wake Since most children wet their bed
within a few hours of falling asleep, a perfect time for a second bladder-
emptying session is just before you retire. Awaken your child completely. Your
child must be awake enough to walk to the bathroom with assistance in order to
be awake enough to sense what's going on in his bladder. Carrying a sleeping
child to the bathroom isn't going to accomplish a complete bladder-emptying. As
you approach the bathroom, let him splash water on his face or use a cool wash
cloth to wake himself up and then go through the "grunt three times to push the
pee out" bladder-emptying drill. If your child still wets his bed despite waking
him up, do the timed nightwaking technique. The next few nights set the alarm
and wake him up two to three hours later. Gradually adjust the timing of the
nightwaking as the number of dry night's increase. Once your child has a few dry
nights, he will become motivated to better cooperate with these drills. Some
parents in our practice achieved less disturbed sleep if they taught their
seven-year-old to awaken and respond to their own alarm clocks rather than the
parents taking the responsibility for waking the child.
Step 6: Do bladder-training drills Just before your child goes to bed
or right after the first time you wake him up and put him back to bed, talk him
through how the brain and bladder can talk to each other at night, so that he
goes to bed programmed to get up when his bladder is too full. Give him phrases
that imprint the actions to take: "I'm going to feel my bladder get big," "I
will get up and go to the bathroom when I feel my bladder get big," "I will
splash water on my face and grunt, grunt, grunt to push the pee out." Try these
dialogues in a fun way, so that the child is excited about getting control of
his body. Have your child repeat after you many times "I will get up to go to
the bathroom when my bladder is full." He may actually drift off to sleep
repeating this encouraging phrase.
Do bladder-conditioning exercises during the day. These increase bladder capacity, neuro- muscular control, and awareness of bladder fullness during the day, which hopefully will carry over into the night, try these exercises:
Step 7: Try a bladder-conditioning device If the prior steps fail to produce night dryness, this is the next
step. These devices consist of a moisture-sensitive pad that the child wears
inside his underwear. When one or two drops of urine strike the pad, a buzzer or
vibrator awakens the child so that he can complete his urination in the toilet.
I have used these devices for many years in pediatric practice and they are so
successful that I rarely prescribe bedwetting-controlling drugs. My experience,
and that of others, is that they are effective around seventy to eighty percent
of the time if used correctly. Bladder-conditioning devices do just that –
condition the child to listen to his bladder signals—which implies not just
putting the alarm on the child and going to bed, but rehearsing drills with the
child as to what to do when the alarm sounds. This technique operates on the
principle of conditioned response. The child associates the sound or vibration
with a full bladder and gets up to urinate. In time, the child subconsciously
pays attention to his bladder rather than the buzzer, senses its fullness, and
automatically contracts the "doughnut muscle," "beats the buzzer," and gets up
to urinate.
REHEARSING BLADDER-CONDITIONING DRILLS
For these devices to be effective go through these steps:
As part of the drill, tell your child that the aim of the game is to "beat the buzzer," that is, sense when his bladder is full and get up and urinate before the buzzer goes off. In our office, we actually pretend that the examining room nearest the bathroom is the child's bedroom and I go through this drill with the parents and child, in addition to instructing them how to use the device. Initially, some parents report, "the alarm wakes up everyone else but the child." If this family-sleep disruption continues, try an alarm that vibrates rather than sounds. You may need to camp out in his bedroom or near his bedroom a few nights, sleep in the room closest to the bathroom, or use an intercom. Also, be sure there's an unobstructed path to the bathroom that's clearly lit with a nightlight, otherwise you're likely to have a wet rug in addition to a wet bed. It may take several weeks to begin noticing the number of dry nights increasing. Relapses are common after a few months, so you may need to go through another round of the device and the drills. Some insurance companies will cover the price of the alarm, providing your doctor gives you a prescription for it. Some doctors will bill the cost of the alarm into the fee for the overall office consultation, which insurance may completely cover. Parents sometimes report that the alarm they ordered out of a catalogue didn't work. That's because they didn't do the drills, which are a vital part of the whole bladder-conditioning package. Step 8: Drugs for dry nights Drugs do not cure bedwetting; they
simply control it until the child grows out of it. Your doctor may suggest DDAVP
(desmopressin), which diminishes the production of urine at
night, similar to the natural action of the child's own anti-diuretic hormone.
Available in a nasal spray, or tablet, it's taken before bedtime for two or
three months, and then tapered off. Many children have a relapse and need
another course of the medication. DDAVP works for 80 to 90 percent of children
who don't respond to other treatments. It can be especially helpful before a
child heads off to camp or begins sleeping over at friends' houses. DDAVP is
safe, effective, and has minimal side effects, such as an occasional nosebleed
and burning of the nasal passages. It is also expensive. (A 30-day dose costs
around $100.00.)
One of the oldest medications, and one which I personally do not recommend, is imipramine (Tofranil), which is basically an antidepressant. It has side effects such as blood pressure changes, irregular heartbeat, anxiety, insomnia, dry mouth, blurred vision, nausea, vomiting, diarrhea, dizziness, drowsiness, and headaches. Overdose can cause convulsions. Also, bedwetting often resumes when the treatment stops. To help these bladder-training techniques work, give reinforcements. Place a reward chart (sticker charts are packaged with the bladder-conditioning devices, or let the child pick favorite stickers) near his bed and let him chart "D" for dry nights and "W" for wet nights. After so many D's, he gets an agreed-upon prize. (Better than a "thing" reward; try a social reward, such as a special outing at a place of his choice.) Soon you can phase out the rewards as the waking up dry and the feeling of mastery over his bladder becomes its own reward. As further motivation to listen to his bladder signals, encourage your child to spend overnights at the homes of friends and to go to camp—where he is more than likely to sleep in a cabin with at least one other bedwetter. He will soon learn that there are other members of the nighttime wet set and he is not the only one in the world who wets his bed. Parents, you are a valuable part of the controlling bedwetting team. These do-it-yourself steps are the basis of commercial programs that charge $1,000 to $1,500 to keep your child dry. Consider these steps toward dry nights as an opportunity to reconnect to your child and help him gain control over his bladder. Parenting the child through the developmental stage from wet to dry nights is another demand on your time and energy, yet the memories of your patience and understanding last a lifetime. Here are some causes of bedwetting that are frequently overlooked: Red flags of underlying medical conditions causing bedwetting are:
Here are some causes of bedwetting that are frequently overlooked: 1. Food sensitivities It's interesting that parents often report
their child wets the bed a night after a birthday party. In our experience, the
most commonly reported foods that increase the chance of bedwetting are:
carbonated, citrus, and caffeinated juices; cola or chocolate, red dyes, and
artificially colored candy. Try eliminating each of these from your child's diet
one by one and see if the bedwetting stops.
2. Constipation Little bladders
leak a lot, especially when pressed on by full bowels. Getting your child to
have regular bowel habits will increase the likelihood of more regular bladder
habits. Don't forget to tell your doctor about your child's bowel habits:
Constipation can contribute to bedwetting, as there's not enough room for a full
bowel and a full bladder in the same small pelvis.
3. Stress Anything that interferes
with a child's quality of sleep is likely to interfere with bladder control.
Stress is a likely cause in secondary enuresis, bedwetting that occurs in a
previously night-dry child. Secondary enuresis is common following major upsets,
such as a divorce, death, arrival of a sibling, new school, or loss of a
friendship.
4. Airway obstruction Children with large tonsils and adenoids are especially prone to bedwetting because of a
condition called sleep apnea , which is periodic airway
obstruction interfering with normal breathing patterns during sleep. Parents of
bedwetters will often be ecstatic about the child becoming dry immediately after
the tonsils and adenoids are removed.
5. Attention Deficit Disorder Children with ADD (attention deficit
disorder) seem to have more problems with bladder control during the day and
night. Just as they don't pay attention to parents and teachers during the day,
they don't pay attention to their bladder at night. These kids get so distracted
during the day that they are unaware of their bodily functions, such as bladder
sensation, and they don't have the persistence or attention span to sit on the
toilet long enough to completely empty their bladder.
The above causes are more the exception than the rule, since the majority of bedwetters simply sleep too deeply to respond to their bladder signals. Potty Pager, 1-800-497-6573, website: www.pottypager.com (has the advantage of a pulsed vibrator, rather than a noisy alarm). The vibrating alarm is more useful for the child who doesn't awaken to the buzzer that wakes up the whole family. Nite-Train'r, 1-800-544-4240; website: www.nitetrain-r.com |
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