Bed-wetting: Is this a problem?

Bed-wetting is something I discuss often in my office.  I think one thing a child needs to hear is that it is COMMON!  Many kids internalize this problem as something that is wrong with them or something that they should be ashamed of.  However, for most kids, this is a normal, everyday occurrence that, in most cases, will go away on its own.

Night-time bed wetting (or in medical terms Nocturnal Enuresis) is defined as involuntary wetting that occurs at night or during sleep beyond the age of anticipated bladder control.  The good news is that less than 5% of cases have a definable medical cause.  Although there is a high rate of spontaneous remission (15% per year), enuresis can result in social and emotional stigma, considerable stress, and inconvenience to the child and his/her family.

Nighttime enuresis, or bed-wetting, can be broken down into Primary and Secondary.  Primary Enuresis describes a child who has never been dry during the night (has not gone longer than 6 months without wetting the bed) and accounts for 75-80% of cases. Secondary enuresis describes a child who develops bed-wetting after having been dry for at least 6 months. Although this is still likely not due to a medical cause, there is an increased possibility there is one here.

Daytime accidents or wetting (Diurnal enuresis)  is a whole topic in itself and is something that should prompt a visit to the doctor.

We are going to focus this discussion on Primary Enuresis.  If your child falls under the Secondary or Diurnal variants, then please make an appointment with your pediatrician.

For those of you like me who like statistics and reassurance as to how normal things are, these numbers may help. Nighttime bed-wetting affects 40% of 3 year old, 25% of 4 year old, 15% of 5 year olds, 10% of 6 year olds, and 5% of 10 year olds (yes, 5 out of 100 10 year olds have this).  Spontaneous remission rate is 15% per year of age. There is also a slight male predominance (60% males vs 40% females).

There have been many studies and postulations as to what causes this problem. Most hoping that if we find an exact cause we can find a quick and easy fix. Although there is no one single factor that has emerged to fully explain enuresis, below are the most common theories:

1) Genetic Factors:

 Since their seems to be a strong association between parents and their children both having a history of bed-wetting, many believe there is a strong genetic component. In families where both parents had a history of bed-wetting, there is a 77% chance of the children also having difficulties with bed wetting. For those families where one parent had history, there is a 44% chance. This is compared to families where no parent has a history where there is a 15% chance. In most studies, the father was affected more than the mother, which is not surprising given the overall male predominance.  What is interesting is that the parents age at dryness can be a predictor for the child's most likely age to reach dryness.

2) Maturational Delay:

Another possible cause is immaturity or delay in neurological development.  It is proposed that a delay in maturation of the central nervous system can  reduce the ability to inhibit bladder contractions at night and thus can contribute to a decrease in the sensation of a full bladder. The fact that bed-wetting spontaneously resolves supports this theory.  The other support for this theory is the fact that bed-wetting is seen in more children whom have delayed attainment of language and/or motor milestones

3) Pattern and Fluid intake:

 Drinking a lot of fluids before bed  is the one theory that most of us grew up thinking was the main cause of bed-wetting. Studies have shown that children who do not wet the bed tend to take a normal fluid amount consistently throughout the day.  In contrast, children who wet the bed tend to drink less overall fluids and when they do drink will take most of the liquids after 5pm. Restricting evening fluids may not be desirable if your child drinks little thought the day as it may lead to dehydration. An alternative is to have the child drink more throughout the day and divide it 40% in the morning, 40% in the afternoon, and 20% in the evening.

4) Disordered Sleep Patterns

Another commonly blamed cause is heavy sleeping.  Parents, me included,  often report that their child is a very deep sleeper and is difficult to awaken.  Although this is a widely believed cause of bed-wetting, extensive studies in the past have confirmed that nighttime bed-wetting is independent of sleep stage (ie: they wet the bed even in the light stages of sleep). Due to these studies, it is believed that heavy sleeping does not contribute to bed-wetting.

5) Lack of nighttime anti-diuretic hormone(ADH) Surge(big words - read on for info)

 ADH is a hormone the body uses to restrict urine formation. The body mainly uses ADH in times of dehydration to keep us from expelling all of our precious fluids.  Recent studies have demonstrated that a wide range of children (25-100% depending on the study) who wet the bed lack an increase in ADH at nighttime. This leads to more urine production and thus bed-wetting.  It also led to one of the possible therapies (see below)

So what do you do?

Talk to your doctor.  I know this sounds like I am trying to drum up business, but this is something that is worth discussing with your provider.  This does not necessarily warrant a special "sick visit", however, it is a great topic to discuss at the annual physical or well child check.  Although I will discuss therapy options below, it is important that your child have an exam to rule out other causes.

So, you have discussed this with your pediatrician and now want to figure out a plan. (Or you want to know your options before you go to the pediatrician - also valid!!)

First, it is important to remember that this process can be very frustrating. If you are like me, sometimes frustration can cause you to interact with your child in a manner you wished you had handled differently.  Just remember, this is a problem that may resolve on its own and that your child should not be blamed or punished for wetting the bed.

1) Motivational Therapy:

 Motivational Therapy is probably a good first line for younger children.  This form of therapy should involve the child as an active participant and can be used for more than just bed-wetting.  To start, use a voiding diary or star chart for dry days and nights. Have your child decorate it and make it their own.   Make sure they empty their bladder completely before going to bed and have him/her participate in morning cleanup of the linens without punishment.  Resolution with this therapy has been shown to be as high as 25 %.  Even for those kids who don't have complete resolution, up to 70% of children have a decreased number of wet nights

2) Parent Awakening

To start, your child should be awakend at your bedtime each night until the he/she is able to be awoken quickly by sound for 7 consecutive nights. Once your child is awake, you must allow him/her to locate the bathroom on their own.  You can try a hierarchy of prompts ranging from turning on the light, saying his name etc.  It has shown that it is counterproductive if you carry or lead the child to the toilet. If your child is very hard to arouse or is confused, try again in 20 minutes. If he becomes angry or yells, the parent should stop and talk to the child in the morning.

3) Dry Bed training

This is the most more labor intensive behavior therapy technique. On the first night, awaken your child once every hour until 1am. Make sure that he is awake enough to walk and talk coherently. If he is dry, praise him or her and ask "Do you need to go to the bathroom or can it wait an hour?" Your child must walk to the toilet alone. If the he is wet, encourage him or her to change pajamas and bedding.  At the 1am awakening, tell your child to try voiding even is he or she is dry. For the next 5 nights, wake your child once. The first nigth, wake him 3 hours after falling asleep. The next night, wake him 2.5 hours after falling asleep. Keep diminishing the interval, so that on the fifth night, he is awakened 1 hour after falling asleep.  On the 6th night, tell him to wake himself up if he needs to go. If your child relapses, repeat the six nights of awakening. In one study of 51 children, the cure rate was 92% (other studies have shown high cure rates but not this high)  The average length of time to achieve a cure, defined as 14 consecutive nights(in the study), was 4 weeks.  The relapse rate was 20% but all children who relapse respond to a second course of training.

4)Bed-Wetting Alarms

 Bed Wetting Alarms has one of the highest overall cure rates of any intervention. They work by alerting and waking the child once they detect moisture. The cure rate is close to 70% with a relapse rate of 20-30%. Of those who relapse, 75% will respond to a second treatment   These alarms are less likely to help if the child is under 8 years old or has developmental delay.  Treatment should continue  until 4 dry weeks are achieved which may take up to 2-6 months. Brands, like the one above, can be researched at bedwettingstore.com
Many types of alarms exist but studies have shown that there were fewer wet nights when using an alarm that woke the child immediately versus a time delay.  It was also found that a body worn alarm was just as effective as a standard bed alarm. Since each one is a little different, it is best to read about each one before purchasing them.

5) Medicine

 There a a few options in terms of medication, none of which are a quick fix. One of the most common and popularly used medications is called DDAVP which is a man-made version of ADH (see above).
DDAVP will help the child attain night time dryness, and in some cases may even cure night time bed-wetting.  However, there is a very high relapse rate.  It is also important to note that there are side effects of this medicine (including, in some cases, seizures) so it is imporant to discuss the medication in detail with your doctor before using it on a daily basis.  Usually, the best use of this medicine is for nights when your child is away from home and bed-wetting could cause social stigmas or low self-esteem

Take Home Points:

1) Night Time Bed-wetting is very common
2) There are a wide variety of theories as to what causes it, but it usually resolves on its own
3) Treatments, especially in older children who are affected emotionally by the problem, may be helpful
4) This is an important problem to discuss with your child's pediatrician!