The Bedwetting Blues

Last Editorial Review: 1/30/2005

Don't Get Mad, Get Help

WebMD Feature

Nov. 6, 2000 -- Michelle Taylor (not her real name) is no stranger to soggy sheets and training pants. This Idaho mother of four has washed more than her share over the years. Her two oldest children, Amy (age 8) and Tania (almost 7) both wet the bed nightly until they were over 6 years old. And Michelle, who says bed-wetting seems to run in her family, is wondering if her two other children (aged 3 and 8 months) will follow the pattern.

Michelle's girls are not alone. An estimated 5 to 7 million American children over the age of 6 regularly wet the bed at night, according to recent statistics from the National Kidney Foundation (NKF). It's so common and so misunderstood that the NKF began running public service advertisements this year featuring baseball star Mark McGwire -- a former bed wetter -- to raise awareness of the issue. They want parents to understand that bed-wetting is a developmental or medical problem that can be treated, rather than a form of stubborn or disobedient behavior on the part of a child. But in order to get help, parents and their children need to break through some of the mythology that has surrounded bed-wetting for so long.

A Source of Shame

Bed-wetting (or primary nocturnal enuresis, as it's called by doctors) is often a source of shame to children. "Kids who wet their beds are often too embarrassed to go away to camp or to sleepovers with their friends, and the experience can lower their self-esteem," says Lynne Brownell, RN, a pediatric nurse practitioner in Clovis, Calif., with a special interest in the topic.

Dealing with the lost sleep and extra laundry involved with bed-wetting can create stress for parents, too. Bed wetters often wake up in the middle of the night asking for help with soggy sheets. And if mattresses are ruined, it can be financially stressful as well.

To make matters worse, some parents still believe that bed-wetting is the child's fault. The NKF estimates that 35% of bed wetters are punished by their parents for wetting the bed -- the worst possible response, says Brownell. She says parents need to understand that bed-wetting is a physical condition and that children who wet the bed need support and understanding from their parents, not disapproval and discipline.

Understanding the Cause

While a small number of bed-wetting cases are due to medical conditions such as a kidney infection or other urological problems, Alan Greene, MD, a San Francisco Bay Area pediatrician, says enuresis is most often a developmental issue. Children who wet the bed simply don't "shut off" urine production at night. This ability normally occurs around the age of 5, when bed-wetting will stop on it's own for 90% of kids, according to the American Academy of Pediatrics.

While babies produce urine around the clock, toddlers start to go to the bathroom on a daytime and nighttime schedule once their bodies start to produce a substance called 'anti-diuretic hormone' (ADH) that inhibits urine production. In addition, as kids mature they become more sensitive to the feeling (produced by stretching of the bladder walls) that they need to urinate.

Children who continue to wet the bed beyond the age of 6 may not be producing enough ADH hormone at appropriate times, or may not yet be attuned to their bodies' signals, or both, says Greene. Parents should start looking into formal treatment sometime between the ages of 6 and 7, according to the National Enuresis Society -- or sooner if the child seems troubled by the bed-wetting.

The first step is to work with the child's doctor to rule out any illness and to develop a safe and effective treatment plan. The two main approaches are behavioral modification and medications that inhibit urine production. "Almost all kids can be dry within about 12 weeks, with treatment," says Greene.

Sensors, Alarms, and Buzzers

One of the simplest methods to cut down on wettings is to limit a child's fluid intake -- especially milk and caffeinated or carbonated drinks -- in the last hour or so before bedtime. Then make sure the child goes to the bathroom before bed. While this will limit the amount of urine in the body and reduce the odds of wetting the bed, it still doesn't shut off the urination switch during sleep.

The most common method to address that issue involves placing a moisture-sensitive sensor on the bed or under the child's pajamas. The system sets off a loud alarm in the presence of fluid. Most bed-wetters urinate while deeply asleep and sleep right through the alarm, sometimes even switching it off without waking up. Because of this, parents also need to get up, wake the child, and take him or her to the bathroom.

After several weeks of this, the child's brain should learn to avoid the unpleasant circumstance of being awakened in the middle of the night by not urinating during sleep. This method has a nearly 95% success rate, says Greene, but requires commitment on the part of both parents and children who will need to wake up frequently until the child can stay dry.

A variation of this approach (that doesn't require a sensor) is to set an alarm clock for a few hours after bedtime (and subsequent times during the night) so the child can wake up, go to the bathroom, and then go back to sleep. Again, parents also need to wake up to make sure the child doesn't just shut off the alarm but actually gets up. Over a few weeks, the child will stay dryer longer and the amount of time between alarms can be increased. "Eventually, the body gets to a point where it is conditioned to hold its urine all night long," says Brownell.

Pills and Potions

When these behavioral approaches don't work, medication can be considered. The two most commonly used to treat bed-wetting are imipramine and Desmopressin.

Imipramine is an older antidepressant whose basic effect is to keep kids from reaching deep sleep. It's usually used in combination with the behavioral therapy methods above. In theory, children on this medicine will be more likely to awaken when they need to go to the bathroom. However, it has many troublesome side effects including nervousness, intestinal problems, and excessive tiredness during the day. And as with many medications, an overdose can be fatal.

The newer drug treatment, Desmopressin is a hormone that is chemically similar to ADH and works by inhibiting urine production. Taken before bedtime, it can help children make it through the night without wetting. It is available in nose drops, nasal spray, and tablet forms. Headaches, nausea, upset stomach, and nasal irritation (from the drop and spray forms) are the most common side effects. In some cases, depression, agitation, dizziness, and a reduction in the ability to produce tears can occur.

While using medications may sound easier than getting up every few hours, parents should be aware that they only have a success rate of around 50% and don't train the child's body to hold its urine on its own, says Greene. Therefore, many kids revert to bed-wetting after they stop taking the drugs. Still, these medicines can be a good option when a child faces an overnight trip away from home, at camp or a sleepover, for example.

The Taylors Stay Dry

The Taylor family never made a big issue when their kids wet the bed. Michelle and her husband felt it was important not to belittle them, to pressure them into stopping, or to compare them to peers who had already stopped. Instead, they had the girls wear training pants to bed and focused on praising them when they got through the night dry. "We really emphasized the positive, and never pushed the negative."

Michelle Taylor's oldest daughter stopped wetting the bed on her own shortly after her 6th birthday. The transition began with a few dry nights in a row, then a week, then a month, and finally the bed-wetting stopped altogether.

When younger daughter Tania didn't stop by age 6 1/2, Michelle started to look into sensor therapy. But before she could get the equipment, Tania's bed-wetting also stopped spontaneously.

"We felt that the better we could make the girls feel about the situation, the more likely it would clear up on its own," says Michelle. "And it did."

Will Wade, a San Francisco-based writer, was the co-founder of a monthly parenting magazine. His work has appeared in POV magazine, The San Francisco Examiner, and Salon. He is the father of a 5-year-old daughter.

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