Bed Wetting / Nocturnal Enuresis

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Nighttime wetting is a completely separate topic from toilet training. This is because nighttime wetting is usually out of a child’s conscious control. Every person’s body makes a hormone called anti-diuretic hormone (ADH) at night. This hormone helps the body concentrate urine – it pulls water out of the bladder so that the bladder does not become overly full while sleeping. This is why urine is darker – more concentrated – first thing in the morning. If the body is not making enough of the ADH then the bladder becomes very full very quickly, and if your child is a deep sleeper (most young children are) then s/he will not feel the bladder fullness and will wet a diaper, a pull-up or the bed. As your child gets older his/her body will make more ADH and will also become more sensitive to the stretching of the bladder walls – s/he will produce less urine at night and will become more aware of a full bladder so will get up and use the toilet when necessary.

Remember – nighttime wetting is out of your child’s control. If you become angry or frustrated, or choose to punish your child you will only cause anxiety and upset and will not have any effect on the bedwetting itself. Imagine punishing your child for falling when learning to ride a bike – this is almost equivalent. If changing sheets and bedding is tiresome and frustrating for you then talk to your child about wearing pull-ups to bed until his/her body is ready for nighttime underwear. Or consider layering the bed: waterproof mattress pad, fitted sheet, then another waterproof mattress pad with a fitted sheet – so if the fitted sheet and mattress pad are wet in the middle of the night you simply need to pull off the top layer and have your child change PJ’s in the middle of the night – quicker and easier than having to entirely make the bed up again.

When should you expect your child to stay dry through the night?

Nighttime wetting is normal under five years of age. From the ages of five to six, if your child is not feeling badly about the bedwetting, it is still considered normal. Approximately 10-15% of 5-year olds wet the bed. Approximately 2-5% of 10 years old wet the bed. This is something that time alone will cure. For most children over the age of six bedwetting can be embarrassing and there are ways to try to eradicate it more quickly.

Behavioral Techniques

  1. Talk about any plan to prevent bedwetting before beginning it, and make sure that your child is on board.
  2. Limit fluids in the two hours prior to bedtime.
  3. Have your child go to the bathroom right before bedtime.
  4. Awakening: wake your child up right before you go to bed and walk with him/her to the bathroom to use the toilet.
  5. After 5-7 days try to awaken your child with your voice only – no touch.
  6. After one week begin using a bedwetting alarm (described below).
  7. Within 4-6 months of using a bedwetting alarm 70-90% of children no longer have bedwetting.
  8. After your child has been dry for at least 3-4 weeks you can stop using the alarm to see how things go.

Bedwetting Alarms

The way the alarms work is they have a sensor that is attached to underwear. The sensor triggers the alarm as soon as a drop of moisture comes into contact with it. Your child will need to get out of bed, turn off the alarm, go to the bathroom to finish urinating, and then will need to change any wet bedding and underwear, dry and reattach the sensor, reset the alarm and go back to sleep. It is time and labor intensive so if your child is not ready to do the work then the alarm won’t work!

Medicinal Intervention

Anti-diuretic hormone is available by prescription in both pill and intranasal forms. For children who have tried behavioral techniques alone without success, or for those who have a sleepover/week at camp planned and are anxious about accidents, it can provide a layer of help and reassurance. Because part of the issue in bedwetting is the lower than expected level of ADH being produced by the body, replacing it allows the body to produce less urine and helps to prevent bedwetting.

If bedwetting alarms alone have not worked, using an alarm with ADH is often the next step. It can take 4-6 months before bed-wetting will cease, and if not used with an alarm the bedwetting often returns when ADH is stopped.

If you think that your child may be a candidate for ADH treatment you should schedule an appointment to discuss this with your Pediatrician during regular office hours.

When to see a doctor

  1. If your child has been dry at night for more than 3-6 months and then suddenly begins having nighttime wetting you should talk to your child’s Pediatrician for guidance.
  2. If your child has daytime wetting, urgency about using the bathroom, fever, pain with urination, or is using the bathroom very frequently s/he may have a urinary tract infection and testing of the urine is a good first step.

Call if you feel that something is just not right – remember no one knows your child like you do!

-Monique Araya, MD, FAAP

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