What is Bedwetting
Bedwetting also called primary nocturnal enuresis is a common problem faced by Millions of families each night. Bedwetting can be frustrating and embarrassing for families as they try to determine the cause and treatment of bedwetting. For children, bedwetting can be stressful and can be emotional. Let’s face it, bedwetting is common but not easy to deal with.easy to deal with.
And whilst there are many products commercially offered as a good solution to bedwetting, the reality is that often many of them are not permanent solutions.
Bed-wetting isn’t caused by a psychological problem. A significant life change such as a divorce, a death, or a move can trigger it, according to Dr. Howard Bennett, author of Max Archer, Kid Detective: The Case of the Wet Bed.
The National Institutes of Health states that nocturnal enuresis or nighttime incontinence (the medical terms for bedwetting) is involuntary urination after age 5 or 6, and that more than 5 million children experience it. According to the Mayo Clinic, 15 percent of children still wet the bed by age 5, but less than 5 percent of kids do so by ages 8 to 11. Bedwetting tends to run in families and is more common among boys than girls; experts estimate the ratio as roughly 2 boys to 1 girl. Although most children eventually outgrow this phase, here are eight steps you can take to help your child keep dry through the night.
There are several reasons why a child might be a bed-wetter. For starters, it could be genetic since “about three out of four children who are wet at night have a first degree relative that had the same problem,” said Bennett, who blogs at howardjbennett.com.
Bed-wetting might also be caused by a lack of communication between the bladder and the brain. When your kid is toilet trained, he or she learns to inhibit the contractions and hold the urine back. Yet even if your child is able to do it during the day, he or she may still wet at night because “whatever learning goes on between the part of your brain that is responsible for having your bladder empty or holding your urine in, is still immature,” Bennett said.
Another culprit might be that the bladder simply doesn’t have enough room. And those children often have problems holding their urine during the day as well, according to Dr. Hubert Swana, a pediatric urologist who practices at Nemours Children’s Hospital in Orlando, Fl.
If your child is a bed-wetter, here’s what you can do:
Bedwetting is very common among children. Many families believe that their child will simply outgrow bedwetting over time, but this isn’t necessarily true. Unfortunately, families start looking for bedwetting solutions when they have exhausted most needs and they are ready to try new methods.
How to Stop Bedwetting
- Shift times for drinking. Increase fluid intake earlier in the day and reduce it later in the day.
- Schedule bathroom breaks. Get your child on a regular urination schedule (every two to three hours) and right before bedtime.
- Be encouraging. Make your child feel good about progress by consistently rewarding successes.
- Eliminate bladder irritants. At night, start by eliminating caffeine (such as chocolate milk and cocoa) and if this doesn’t work, cut citrus juices, artificial flavorings, dyes (especially red) and sweeteners. Many parents don’t realize these can all irritate a child’s bladder.
- Avoid thirst overload. If schools allow, give your child a water bottle so they can drink steadily all day. This avoids excessive thirst after school.
- Consider if constipation is a factor. Because the rectum is right behind the bladder, difficulties with constipation can present themselves as a bladder problem, especially at night. This affects about one third of children who wet the bed, though children are unlikely to identify or share information about constipation.
- Don’t wake children up to urinate. Randomly waking up a child at night and asking him or her to urinate on demand isn’t the answer, either – and will only lead to more sleeplessness and frustration.
- Don’t resort to punishment. Getting angry at your child doesn’t help him learn. The process doesn’t need to involve conflict.
Medications: not usually recommended
Although there are medications, including a synthetic form of a hormone, that can address bedwetting, Dr. Rhee doesn’t prescribe them unless a child is already on the medication.
“There are side effects,” she says. “Plus it’s a temporary fix, a Band-Aid remedy, when what we want is an overall solution.”
See the pediatrician
If your child suddenly starts to wet the bed and never did before, he or she might have a urinary tract infection or a more rare condition like diabetes or a neurological problem. Sleep apnea could be the culprit too. Be sure to talk to your child’s pediatrician who can identify a cause, rule out other health problems, and provide solutions.
Talk about it
Studies show that kids who wet the bed have low self-esteem, probably because they feel that it’s something they should be able to control. It can help to talk about how common it is and if a family member had the same problem, share that too. “Children often feel bad about it, and it helps to know that somebody else in the same family had the same problem,” Bennett said.
Kids don’t wet the bed on purpose, so discipline won’t stop it.
Pay attention to poop
Constipation can put pressure on the bladder, making it difficult to hold in urine and causing an urge to go. If your kid doesn’t have soft, easy and regular bowel movements, talk to the pediatrician.
Get an alarm
The bed-wetting alarm is the best solution for bed-wetting. It’s about 75 percent effective, when used properly and when both parents and child are motivated. Swana says a process should be followed: Once your child wets the bed, you must wake him or her up and then instruct your child to change the sheets, take a shower and return to bed. When children realize they have to do this each time “eventually they learn to wake up by themselves,” he said.
Desmopressin acetate is the most common medication to control bed-wetting and it’s effective in about 50 to 75 percent of children. Ask your pediatrician if it’s right for your child.
Mark the calendar
Keeping track of both wet and dry nights can help motivate your child to end his or her bed-wetting.
Drink and pee
Encourage your child to drink more fluids throughout the day and urinate as soon as there is an urge to go. “If you don’t pay attention to your bladder in the daytime, it’s hard to pay attention to it at night,” Bennett said.
Cut the caffeine
Drinking after dinner is okay, but avoid soda and sports energy drinks, because caffeine can trigger bed-wetting.
Here’s how it works: Before you go to bed, either pick your child up out of bed or wake him or her up to use the bathroom. This will serve as a reminder for what it feels like when your child’s bladder is full so he or she can pay attention to it at bedtime. “It does help them stay dry until they either outgrow the problem, or if it doesn’t work, they’re more motivated to do something like the alarm,” Bennett said.
Bedwetting Treatments (Enuresis Treatment)
Finding effective bedwetting treatments is not hard. Bedwetting is a medical condition with a treatment which is possible.
The treatment for your child depends on a number of things, such as:
- how often they're wetting the bed
- the impact that bedwetting is having, both on your child and on you, your partner and other members of your family
- your child’s sleeping arrangements, such as whether they sleep alone or share a room with other children
- whether there's a short-term need to control your child’s bedwetting – for example, if they're going away on a school trip
- how your child feels about specific treatments
- Disposable absorbent underpants
- Reusable absorbent underpants
- Sleeping bag liners
- Moisture alarms that go off when the child begins to wet the bed
- Establishing a regular bedtime routine that includes going to the bathroom
- Waking your child during the night before he/she typically wets the bed and taking him/her to the bathroom
- Developing a reward system to encourage your child, such as stickers for dry nights
- Talking to your child about the advantages of potty-training, such as not having to wear diapers and becoming a "big kid"
- Limiting beverages in the evening - even those last minute water requests
- Using a "bell-and-pad" which incorporates an alarm that goes off whenever your child's pajamas or bed become wet during an accident. These systems teach your child to eventually wake up before the bedwetting occurs
Controlling fluid intake
Drinking too much or too little can contribute to bedwetting. Ensuring your child gets the right amount of fluid each day is often recommended.
Although the amount of fluid your child needs can vary depending on things like how physically active they are and their diet, there are some general recommendations for daily fluid intake. These are:
- boys and girls 4 to 8 years old – 1,000 to 1,400ml (1.7 to 2.4 pints)
- girls 9 to 13 years old – 1,200 to 2,100ml (2.1 to 3.7 pints)
- boys 9 to 13 years old – 1,400 to 2,300ml (2.4 to 4 pints)
- girls 14 to 18 years old – 1,400 to 2,500ml (2.4 to 4.4 pints)
- boys 14 to 18 years old – 2,100 to 3,200ml (3.7 to 5.6 pints)
However, it’s important to remember that these are just guidelines and many children don't drink this much.
As well as the quantity, timing is also important. Most of the recommended fluid intake should be consumed during the day, with only about a fifth during the evening.
Also, encourage your child to avoid drinks that contain caffeine, such as cola, tea, coffee or hot chocolate, because these increase the need to urinate during the night.
Encourage your child to go to the toilet regularly during the day. Most healthy children urinate between four and seven times a day. You should also make sure your child urinates before going to bed and has easy access to a toilet.
Many parents find reward schemes helpful in managing bedwetting. This is because motivating your child can help bedwetting treatments be more effective.
However, it's important to emphasise that these are only effective when they promote positive behaviour rather than punishing negative behaviour.
Bedwetting is something your child can't control, so rewards shouldn't be based on whether they wet the bed or not. Instead, you may want to give rewards for:
- sticking to their recommended fluid intake
- remembering to go to the toilet before going to bed
It's important not to punish your child or withdraw previously agreed treats if they wet the bed. Punishing a child is often counterproductive as it places them under greater stress and anxiety, which could contribute to bedwetting.
If you have tried using a reward scheme to improve your child’s bedwetting and it hasn't been effective, there's little point continuing it as it's unlikely to be helpful.
If the above measures don't help, a bedwetting alarm is usually the next step.
A bedwetting alarm consists of a small sensor and an alarm. The sensor is attached to your child’s underwear and the alarm is worn on the pyjamas. If the sensor starts to get wet, it sets off the alarm. Vibrating alarms are also available for children who have impaired hearing.
Bedwetting alarms are not prescribed on the NHS, but you may be able to borrow one from your local clinical commissioning group (CCG). Otherwise, they're available to buy. For example, an organisation called Education and Resources for Improving Childhood Continence (ERIC) sells alarms for around £40 to £140, depending on the type of alarm.
Over time, the alarm should help your child to recognise when they need to pee and wake up to go to the toilet.
Reward systems to promote good behaviour may help, such as getting up when the alarm sounds and remembering to reset the alarm. It also helps to make it as easy as possible for your child to go to the toilet during the night, such as using night lights.
The alarm will usually be used for at least four weeks. If there are signs of improvement by this point, the treatment will continue. If there's no sign of improvement, treatment is usually withdrawn as it's unlikely to work for your child.
The aim of the alarm is achieve at least two weeks of uninterrupted dry nights. If there's some improvement after three months, but no sign of this goal being achievable, alternative treatments are usually recommended (see below).
When bedwetting alarms are unsuitable
Bedwetting alarms require commitment from both children and parents. There may be some situations where they're not suitable. For example, if:
- more immediate treatment is required, for example because you're finding it emotionally difficult to cope with your child’s bedwetting
- there are practical considerations that make using an alarm problematic, such as if your child shares a room or the alarm disturbs sleep
Some children and their parents may also not like the idea of using an alarm to signify when the child has wet the bed.
If a bedwetting alarm doesn't help or isn't suitable, treatment with medication is usually recommended. The three main medicines used are described below.
Desmopressin is a synthetic (man-made) version of the hormone that regulates the production of urine, called vasopressin. It helps to reduce the amount of urine produced by the kidneys.
Desmopressin can be used:
- to provide short-term relief from bedwetting in certain situations – for example, if you're going on holiday or if your child is going on a trip with friends
- as a long-term alternative treatment in situations where a bedwetting alarm is ineffective, unsuitable or unwanted
Desmopressin should be taken just before your child goes to bed.
The medication reduces the amount of urine your child produces and makes it harder for their body to deal with excess fluid. Therefore, it's important they don't drink from an hour before taking desmopressin, until eight hours after. If your child drinks too much fluid during this time, it could cause a fluid overload, leading to unpleasant symptoms such as headache and sickness.
If your child isn't completely dry after one to two weeks of taking desmopressin, inform your GP because the dosage may need to be increased.
Your child’s treatment should be reviewed after four weeks. If the bedwetting has improved, it's usually recommended that treatment continues for another three months, although your doctor may advise taking desmopressin earlier each night (1-2 hours before bedtime). If there is continuing improvement during this time, the course may continue.
If bedwetting stops while taking desmopressin, the medication is reduced gradually to see if your child can stay dry without taking it.
If desmopressin or a bedwetting alarm doesn't work, you will be referred to a specialist.
Another option is to use a combination of desmopressin and an additional medication known as an anticholinergic. An anticholinergic called oxybutynin can be used to treat bedwetting.
Oxybutynin works by relaxing the muscles of the bladder, which can help improve its capacity and reduce the urge to pass urine during the night.
Side effects of oxybutynin include feeling sick, dry mouth, headache,constipation or diarrhoea. These should improve after a few days once your child’s body gets used to the medication. If they persist or get worse, contact the doctor in charge of your child’s care for advice.
If the above treatments don't work, a prescribed medication calledimipramine may be recommended.
Imipramine also relaxes the muscles of the bladder, increasing its capacity and reducing the urge to urinate.
Side effects of imipramine include dizziness, dry mouth, headache, and increased appetite. These should improve once your child’s body gets used to the medication. It's important that your child doesn't suddenly stop taking imipramine because it can lead to withdrawal symptoms such as feeling and being sick, anxiety and difficulties sleeping (insomnia).
Treatment should be reviewed after three months. Once it's felt your child no longer needs to take imipramine, the dosage can be gradually reduced before the medication is stopped completely.
Advice for parents
It can be easy for experts to advise parents to remain calm and supportive if their child is bedwetting, but in reality it can be a difficult condition to live with.
While it's important never to blame or punish your child, it's also perfectly normal to feel frustrated.
You should tell your GP if you feel you need support, particularly if you're finding it difficult to cope.
You may also find it useful to talk to other parents who have been affected by bedwetting. Education and Resources for Improving Childhood Continence (ERIC) has a message board for parents.
The advice below may help you and your child cope better with bedwetting:
- Make sure your child has easy access to the toilet at night. For example, if they have a bunk bed they should sleep on the bottom. You could also leave a light on in the bathroom and put a child’s seat on the toilet.
- Use waterproof covers on your child’s mattress and duvet. After a bedwetting, use cold water or mild bleach to rinse your child’s bedding and nightclothes before washing them as usual.
- Avoid waking your child in the night or carrying them to the toilet, as these are unlikely to help them in the long-term.
- Following a bedwetting, older children may want to change their bedding at night to minimise disruption and embarrassment, so having clean bedding and nightclothes available for them can help.
- You can try taking off pull-ups at night, but this should be considered a trial rather than a treatment. If the child continues to bedwet, wearing pull-ups is often nicer for them and easier for the family to manage.
Commonly used bedwetting solutions include bedwetting alarms, diapers, waterproof bedding and prescription medications. There is no right or wrong. While diapers and waterproof bedding’s aim at controlling urine from spreading on the bed, prescription medications absorb water from the kidney and limit the urge to go to the bathroom. Bedwetting alrms ont he other hand are clinically proven solutions that can stop bedwetting permanently.
When used correctly, these enuresis alarms have a high success rate with low relapse.
When your kid wakes up with wet sheets, it can leave him feeling embarrassed and uncomfortable, and leave you sleepless, stressed and buried in laundry. Many parents try restricting water or waking their kids during the night, but the problem only persists and the whole family becomes more sleep-deprived. We called in the experts to teach us their simple but not-so-obvious strategies to eliminate bedwetting.
Keep them hydrated
Your first instinct might be to cut back on your child’s fluid intake, but Lane Robson, a paediatric nephrologist at The Children’s Clinic in Calgary, says this can lead to dehydration, which can actually exacerbate the problem. He sees many parents withhold water only to find their kids are still excreting just as much urine at night, because the body, which needs water for proper functioning, learns to draw it out of other sources like the intestines. This leaves kids constipated, and the buildup in the bowels presses on the bladder, restricting its capacity. Robson recommends encouraging your child to drink plenty of water in the morning (aim for 40 percent of what he needs in a day), some water or a “treat drink” (like iced tea or chocolate milk) at lunch, and then water after school, at dinner and in the evening to keep him consistently hydrated.
Robson sees many young patients who have hard, pasty poops, which affects their bladder. Even if your child doesn’t complain of constipation, taking steps to improve her bowel health can reduce bedwetting. In addition to plenty of water, your kid needs fibre—ideally, some in every meal or snack—to promote bowel regularity. Focus on a healthy diet filled with veggies and complex carbs, and try a stool softener to improve your little one’s bowel functioning. Robson also stresses the importance of giving kids time to relieve themselves in the morning—they should have bowel movements on a daily basis—in order to ease pressure from the intestines and allow the bladder to expand.
Avoid problem foods
Certain foods can impact a child’s sleep and bladder function. The Canadian Paediatric Society recommends cutting out caffeine-containing foods (think chocolate or pop), because they’re diuretics. Peter Grise, a bedwetting therapist who coaches families in southern Ontario, suggests avoiding milk before bed, because it’s a protein, which is hard to digest, and because underlying dairy sensitivities can lead to sleep problems. Citrus foods or drinks, like orange juice, which can irritate the bladder, are also on his not-before-bed list. Meanwhile, Robson looks at the sodium content in the diet of his patients if they’re obese or adolescents. “Salt intake drives pee production because the kidneys are meant to regulate salt balance,” he explains. If your child is eating a lot of processed foods, chances are his diet is high in sodium.
Practice going pee
In addition to helping prevent constipation, getting kids into the habit of regularly drinking water and emptying their bladders throughout the day can help them build the muscle awareness and control needed to stay dry through the night. “Get your kids to go to the bathroom—whether they need to go or not—every two hours and then have them drink a cup of water,” recommends Grise. He explains that “holding it” is a bad habit for kids to get into, because it can thicken the muscular bladder walls, reducing their sensitivity to bladder fullness. He also suggests using a practice exercise to train young kids (ages three to five) to get up from bed to go to the washroom. First, give them a big glass of water an hour before bedtime. Then, have them get in bed, pretend to fall asleep and get up to go pee. They should do this exercise at least twice a night to “build muscle memory,” says Grise.
Reward proactive habits
Use a bedwetting alarm
A bedwetting alarm, which is worn by the child and emits a loud sound at the first sign of moisture, is a slightly more complicated but effective approach that can work for older kids (ages seven and older). Because many kids who wet the bed are deep sleepers, the alarm may not wake your kid up at first, so you might need to get your kid up. But, with time, your kid should begin to wake up in the first moments of the alarm sounding, so he can get to the washroom. Eventually, his body will learn to wake up when the bladder is full, so he can get to the bathroom in time. Both Grise and Robson are advocates of bedwetting alarms and, according to the Canadian Paediatric Society, though it may take a few months, almost half of kids in studies stopped bedwetting after using an alarm. “It’s about recognizing the feeling of having to go,” says Grise, who explains that the alarm conditions kids to wake up when they notice that feeling. Once kids have learned to wake up, he takes it a step further and tells kids to stay in bed and focus on the sensation, then go back to sleep. That way, they can learn to control their bladder while they sleep.
Skip the drugs
There are some pharmaceutical options used to help deal with enuresis (the medical term for bedwetting), but neither Grise nor Robson recommend going that route. The most common one, desmopressin acetate (DDAVP), imitates the natural water-conserving hormone in the body that tells the kidneys to stop producing urine. Grise says if it’s used inappropriately, it could upset the water balance in your body, and it’s not a long-term solution. “It doesn’t work to stop bedwetting; it stops your kidneys.” He suggests that, by using a bedwetting alarm, your kid can actually train his body to use his own naturally occurring hormones instead of relying on a drug to have the same effect.