Bedwetting is one of the most common paediatric health issues. It occurs in 15-20% of five-year-olds, 6-8% of eight-year-olds and declines to 1-2% by fifteen years of age and over. However, a child shouldn’t be considered a bed wetter, unless he or she wets the bed more than twice a week after the age of five.
Studies indicate that around 15% of bedwetting children will outgrow the problem each year. However, because bedwetting does cause considerable unhappiness and stress, a safe treatment regime with minimal side effects is highly recommended. If a child is ready and wants to cure his or her bedwetting then parents should discuss the options with them.
In a minority of cases bedwetting is caused by anatomic, urological or neurological defects. If there are any concerns it always pays to check with a doctor.
Nocturnal enuresis is usually the result of a developmental delay in the bladder reflex, sometimes coupled with the under-production at night time of ADH (anti-diuretic hormone). As a result some children produce too much urine in their sleep and their bladder doesn’t send a signal to the brain to wake up when the bladder is full and needs to be emptied. So, when the bladder fills beyond a certain level the bladder reflex causes the bladder to empty automatically. The child is not being lazy, they are simply not getting the signal to wake.
Genetics are definitely implicated in bedwetting, for example, if one parent wet the bed when young then the child has a 40% chance of being a bedwetter. If both parents were bedwetters then the child’s chances of being a bedwetter increase to 70%. However, genes can skip generations so even though the parents may not have been bedwetters this is no guarantee that their children will not be bedwetters, if there is bedwetting in the extended family.
Deep sleep occurs in both bedwetters and non-bedwetters. It is not, therefore, the cause of bedwetting but it can make treatment of bedwetting more challenging if the child has an arousal dysfunction whereby there is an inability to awaken to normal stimuli such as being cold or uncomfortable or hearing loud noises, particularly smoke detectors. Children who exhibit behaviours such as sleep walking, night terrors, teeth grinding, head banging or sleep apnoea may suffer from arousal dysfunction. There are, however, a variety of priming and other strategies that can be used with an alarm to help train the brain of a deep sleeper to wake with the sound of the alarm and eventually the feeling of a full bladder. These are discussed in our other blog postings.
Research indicates that enuresis is prevalent in 7-20% of boys and 3% of girls in the age range 5-7 years old. Boys often toilet-train later than girls so they may also be later to stay dry at night. At age 10, the prevalence is 3% in boys and 2% in girls. So, even though boys are more prone to bedwetting, girls are certainly not immune to the condition.
While it is true that drinking within the two hours of going to bed can aggravate bedwetting it is not the cause of the bedwetting. We would recommend that children who wet the bed limit evening beverages, and all children should avoid sugary or energy drinks before bed, however, this alone will not alleviate the problem. If a child’s bladder is deemed to be small then a programme of drinking water during the day and asking the child to hold off going to the toilet when they get the urge, for several minutes to start with and building up to 15-30 minutes over a period of a week can help ‘stretch’ the bladder to increase its capacity. Again this will not cure the night time bedwetting but may help with wetting frequency if the bladder is able to hold more fluid before voiding.
Punishing a child for wetting the bed when they have no control over it is hurtful and humiliating. It can lead to low self-esteem and lead to other behavioural problems. However, teaching a child to take responsibility for the consequences of his or her bedwetting, e.g., getting them to help strip and re-make the bed and making sure that soiled clothing goes into the laundry, gives them a degree of control over the situation and lets them feel like they are contributing rather than being a problem.
Drug treatment is relatively expensive and runs the risk of uncommon but severe side effects. In the case of Desmopressin (Minirin) it needs to be used with great caution in children who have problems with fluid balance or cystic fibrosis because excessive fluid intake can affect the fluid balance in the brain leading to confusion or even convulsions. Also, it tends to be ineffective with children with viral or symptomatic allergic rhinitis. Imipramine (Tofranil) can lead to emotional irritability in children and there is the possibility of accidental overdose which can lead to convulsions and coma. Drugs do not cure bedwetting long term. Once a child stops taking them the symptoms usually return.
However, studies indicate that only around 15% of bedwetting children will outgrow the problem each year. Bedwetting can cause considerable unhappiness and stress during this time. It can lead to self-esteem issues, disrupt family routines and increase the amount of housework required to keep a child dry and clean. A safe treatment regime with minimal side effects is highly recommended when a child is ready and wants to cure his or her bedwetting.
‘Lifting’ or waking a child in the middle of sleep to toilet can lead to frustration and conflict, especially if the child does not feel he or she wants to go to the toilet. Any attempt to force a child to go to the toilet before bed or during sleep will not bring any improvement in bladder control unless, fortuitously, it coincides with the sensation of a full bladder and the child is aware of this.