Bedwetting

Nocturnal enuresis, or wetting the bed at night, is defined as involuntary urination during sleep at age 6 or older.

Children who've never been dry are considered to have primary enuresis. Children who were dry for a time but later begin to wet the bed are considered to have secondary enuresis.


Causes/associated factors
Generally, bedwetting before age 6 or 7 isn't cause for concern. At this age, nighttime bladder control simply may not be established. Bladder control will come later, as children grow and develop. But some children continue to experience nighttime bedwetting.
At age 3, about 40 percent of children wet the bed. By age 5, only about 20 percent wet the bed, and by age 6 the figure drops to about 10 percent. By age 12, only 2 to 3 percent of children continue to wet the bed.

Bedwetting can affect both boys and girls, but it's more common in boys.

In most cases, what causes bedwetting is unknown. A combination of factors may be at play, including:

genetics (A child has about an 80 percent chance of being a bedwetter if both parents were bedwetters.)
slower physical development
a smaller bladder
an inability to recognize that the bladder is full when sleeping
an overproduction of urine at night
drinking beverages with caffeine or drinking too much fluid before bedtime
anxiety due to increased stress, such as beginning school or other major life changes
Bedwetting may also be a symptom of:

a sleep disorder
an underlying illness, such as diabetes
an anatomical disorder of the urinary tract
a urinary tract infection
an anatomical disorder of the urinary tract or one affecting the adenoids or tonsils
a physical problem with the nervous system, such as a spinal cord compression

Signs/symptoms
Most children begin to stay dry at night between ages 2 and 4 or after toilet training. Consult your child's doctor if your child:
experiences bedwetting after age 6 or 7 (Physical problems may need to be identified or ruled out.)
used to be dry at night but has recently begun to wet the bed
Also tell the doctor if your child:

has developmental problems
wets his or her pants or dribbles urine during the day
drinks fluids excessively
is frequently constipated

Diagnosis
Diagnosis is based on the child's health history and a physical exam. Routine urine and blood tests may be done to rule out diabetes or a urinary tract infection. If other symptoms are present or the doctor suspects an anatomical abnormality of the urinary system, your child may need an ultrasound (using sound waves to create images of internal body parts) or other imaging studies.

Treatment
Many children stop bedwetting without treatment as they grow older. In fact, many doctors don't recommend medical treatment before age 7 or 8.
At any age, successful treatment requires a motivated child and a supportive family who provides positive reinforcement. Treatment often takes time. Consult a doctor or mental health professional if your child is upset about wetting the bed or you have trouble managing the situation or your frustration with the bedwetting.

At-home tips for bedwetting at any age
Avoid focusing your child's attention on nighttime bedwetting -- this may only make matters worse.

Consider the importance of positive reinforcement. When your child stays dry at night, offer praise. Remember that children are often embarrassed by bedwetting. Punishment or teasing will only add to the problem.

Without making an issue of it, encourage your child to delay daytime urination. This simple "stretching exercise" may help the bladder hold more urine at night. If your child's bladder isn't completely full, the urge to urinate will often fade within a few minutes. With practice, most children can learn to hold their urine for longer periods of time. Only prompt your child to use the bathroom at bedtime.

Limit your child's fluid intake to just a couple of ounces during the last two hours before bedtime. Some children may need to stop drinking fluids completely after dinner. It's also helpful to avoid caffeine late at night because it stimulates the bladder to contract. Remember, caffeine is also found in chocolate, not just beverages.

Have your child urinate before going to bed, then wake him or her to go again when you go to bed yourself.

Use a plastic mattress cover to prevent urine from saturating your child's mattress. Because diapers or plastic pants aren't recommended after age 4, you may want to try thick underwear at night to help contain the urine.

When appropriate, enlist your child's help in rinsing his or her own pajamas or underwear or placing these items in a specific container for washing. This may help your child feel in control and responsible for his or her own actions. Make sure your child views this activity as a responsibility, not a punishment.
Alarms
If your child is a heavy sleeper or doesn't wake up when his or her bladder is full, you may want to set the alarm to wake your child during the night. Or, try a small battery-operated alarm that's connected to a moisture-sensitive pad worn in your child's pajamas. The device will sound when your child begins to urinate. After a while, your child may learn to wake up automatically when his or her bladder is full.

According to recent studies, the combined cure rate of various minialarms ranges from 40 to 70 percent. The risk of bedwetting recurring once the alarm is no longer used is lower than that of medication treatments. Your child must be motivated to use the alarm, however, and you must be willing to take time to give the treatment a chance. Often, results aren't apparent for two to three months.

Medication
Desmopressin acetate (brand name DDAVP, for example) treats a deficiency in the secretion of antidiuretic hormone (ADH) from the body's pituitary gland during sleep. This hormone causes the body to produce less urine. Given orally or in the form of an odorless, tasteless nasal spray, the medication is typically used for a few months after age 6, then tapered off to see if the child can stay dry without it. This medication is successful 60 to 70 percent of the time. Bedwetting may recur when the medication is stopped.

Imipramine (Tofranil, for example) is a medication that increases bladder capacity when taken one hour before bedtime. The U.S. Food and Drug Administration recommends the medication as a temporary treatment for reducing bedwetting in children older than age 6. It shouldn't be used for long-term treatment, and bedwetting may recur when the medication is stopped. It may provide some relief from bedwetting for more than 50 percent of children. Imipramine is less commonly used now than DDAVP and must be given under close medical supervision. Be careful to keep this and all medications out of children's reach.

If you're considering medication for bedwetting, be sure to discuss the risks and benefits with your child's doctor. Some doctors prefer not to use medications since bedwetting usually improves with age and medications may be unsuccessful or have unwanted side effects.

Alternative therapies
Researchers have studied hypnosis, acupuncture and biofeedback for bedwetting. Further research is needed before they can be proven effective.

Counseling
Counseling may be helpful if distress, guilt, embarrassment or diminishing self-esteem are contributing to the bedwetting. Individual or family therapy may be helpful if your child's bedwetting is related to family stress of some sort (such as the birth of a new sibling, a divorce, illness or financial problems).


Complications
Bedwetting may lead to anxiety or low self-esteem for your child. Consult your child's doctor or a mental health care professional if this is a concern.