Beating the Bed-wetting Blues

WebMD Live Events Transcript

Is your children one of the 10% of all children over the age of 6 who has serious bed-wetting problems? Coping with this problem can be difficult and expensive. Pediatrician Steven Parker, MD joined us on Aug. 3, 2005 to answer your questions.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Dr. Parker. Thanks for joining us today.

PARKER:
Thank you, it's great to be here.

MODERATOR:
At what age should we become concerned about a child wetting the bed?

PARKER:
There is no set age. In this country at least, we know that by 3, about three-quarters of children are dry at night but one out of four aren't and they're perfectly normal children. Every year after that about one in five or one in six begins to achieve nighttime dryness without any treatment at all.

Usually bed-wetting is not a sign of a medical or psychological problem so there is no real time we need to be concerned. I think the question is more when we decide to try to do something about it and help the child to achieve dryness at night.

MODERATOR:
Is it more prevalent among boys or girls or does gender not matter where bed-wetting is concerned?

PARKER:
Everything is always more prevalent in boys and bed-wetting is no exception. Boys are usually two to three times more likely to not have achieved nighttime dryness compared to girls for some reason.

MODERATOR:
So if you have a child who is six years old, getting ready to start kindergarten and is still wetting the bed, what would be the first steps you should take?

PARKER:
I think in all cases where you are concerned about bed-wetting going on too long, whether it's at night or during the day, the first order of business is to make sure that there isn't a medical cause. That means that your child should see his or her pediatric provider who can do a thorough physical exam to make sure there is nothing physically wrong. Also it's always essential to obtain a urine sample and make sure there's no infection or sugar or something else that might be going on that is causing the child to continue to wet -- that can only be diagnosed through an examination of the urine.

The first order of business is to make sure there's no medical problem, which is usually the case; usually kids are perfectly healthy. In fact, we don't know why they are still wetting the bed except that probably it runs in some families and the child is just slow in maturing in the areas that allow kids to be dry at night.

"I almost never think that bed-wetting is due to 'laziness'. Almost any child is going to stay dry when they can -- it's such a sign of maturity and being a big boy or girl."

MEMBER QUESTION:
My son was dry for almost a year at age 3 but started to wet the bed after a primary care taker passed away. He is dry all night -- he pees as he is starting to wake up. Could this just be laziness or do you see him as an actual bed wetter? My son is now 7.

PARKER:
That's a really good question and makes one important point. There's a difference in children who have never been dry at night, which is called primary enuresis, and children who are dry for a long time and then begin to wet the bed again; that's called secondary enuresis.

When there's primary enuresis, which was not the case with your child, usually we don't have concerns about a medical problem or stress causing it, but rather it's a problem with immaturity of the nervous system.

On the other hand, if there is secondary enuresis and the child has been dry for a while, we know that he or she is capable of being dry and wonder what might be causing the recurrence of the wetness. In that case it's especially important to look for a medical problem. Stress can also be an inducer for the enuresis to recur.

In your child's case, since he is dry all night, it's possible that stress has something to do with it, but it's hard for me to understand why the wetting only occurs in the morning.

I almost never think that bed-wetting is due to 'laziness'. Almost any child is going to stay dry when they can -- it's such a sign of maturity and being a big boy or girl. To wet the bed voluntarily, or because one is lazy, is really rare. I think some children get a bad rap from their parents because the parents believe that the child is doing it on purpose. That's always the last on my list.

Why your little guy waits until morning to wet the bed is not clear to me. Most kids who wet the bed do so a couple of hours after they have gone to sleep at night, when they are in a very deep sleep and in the first few stages of sleep. Perhaps his bladder is filling up a lot and exceeds its capacity to hold it by the morning, but this doesn't happen earlier on in the nighttime.

I would suggest if he is wetting at a certain time every morning, that you try awakening him a half hour or hour before that time and getting him up and letting him pee and see if you can short circuit the whole thing by pre-empting the morning wetness through waking him up and having him go on his own. Good luck and let me know how it goes.

MODERATOR:
Could we talk a minute about parents' attitudes? You touched a bit on that in your answer. Parents can do a lot of harm or a lot of good to their child who is having problems with bed-wetting by their attitude.

PARKER:
Absolutely. In fact, I think the one thing I worry most about with bed-wetting is the parents' attitude and therefore the child's self esteem when he or she has a bed-wetting problem. This, as I mentioned, is almost always something the child can't help and occurs during sleep. But it's also somewhat humiliating and a sign of "a baby."

If the parents are not positive but also negative about it -- they call the child lazy, ask why the child is such a baby, why can't he or she stay dry, what's going on, and if they are very angry about the whole thing (which many parents understandably are) that can really have a devastating effect on the child's self-esteem. This can continue long after the bed-wetting stops -- the child still thinks of himself or herself as not an adequate child and having these major problems.

So, I think the parental attitude is in fact the most important aspect of all of this because the odds are 98% that no matter what you do your child is going to stop wetting the bed at night. The key more is the process you go through and how your relationship is changed by dealing with this issue in those early years. That's why I think punishment has no place in the treatment of bed-wetting because one, it does not work, and two, it just makes the child feel terrible.

MODERATOR:
One of the methods that is talked about to stop bed-wetting involves the opposite of punishment -- it's a rewards system with a chart with stars. How would that work?

PARKER:
Let me say that punishment does not work, and frankly, rewards don't work that well either.

Think about it: If I offered you a million dollars to stop snoring at night, it wouldn't work -- you're asleep, you can't help it. If I offered you a million dollars to not sleep with your mouth open, you couldn't do it. The reason is, of course, when you're asleep, you're not responsive to rewards or punishments and neither is your child. So rewards are an adjunct.

You can use sticker charts and rewards to reinforce your child, help them and motivate them through the bed-wetting blues, but it's not going to have nearly as big a result as many parents would like to think. There are much more effective techniques which I'm sure we'll talk about later, than rewards and punishment. So sure, keep your sticker charts, encourage your child with rewards for success, but don't expect that rewards are going to do the trick either.

"It's really a parents' choice and child's choice about when and if to deal with nighttime bed-wetting."

MEMBER QUESTION:
My daughter is 7 years old and would like to go to sleepovers but is embarrassed by her bed-wetting. Is it all right to use those pull-ups or do they simply allow her to continue to bed wet? I'd like to make her feel better about having sleepovers.

PARKER:
I think for sleepovers, you have a number of options. One is that you can try to use the medications that are sometimes effective for nighttime bed-wetting. These medications, such as desmopressin or DDAVP can work quite well. The problem is that once you stop the medications the bed-wetting resumes. For that reason, they can be quite helpful for children who are going for overnights with friends or to camp for a summer -- it gets you through the time and avoids the child's being embarrassed by bed-wetting during the time when it would be most difficult for them to bed-wet. The problem is that once you stop the medication, and I don't recommend children staying on these medications for a long time, then the bed-wetting will come back. So you certainly could try one of those medications when your daughter goes for an overnight, and only use them at those times.

But you also asked whether pull-ups would be promoting the bed-wetting later on. I think you might guess, as I mentioned before, since this is involuntary, I don't think it would have a negative or positive effect. If your daughter is not embarrassed to wear them on an overnight, by all means, go ahead and save her the difficulties of not wearing them. I don't think it's going to make a difference in the long run. But many parents find the medications a more effective way to deal with overnights than using pull-ups.

Try either and let me know how it goes.

MODERATOR:
What solutions do you suggest when parents come to you with a child who is bed-wetting at age six or seven?

PARKER:
I think the most important thing, again, is for parents to understand that this is almost certainly not a sign of a problem, either medical or psychological. They need to understand that it's not their child's fault -- their child isn't being lazy or willful. What it is, we think, is just an immaturity of the brain. When our bladder, in the middle of the night, says it wants to urinate, our brains are able to turn the bladder off even though we're asleep. But children with primary bed-wetting are unable to do that for some reason until the connections are made from the brain to the bladder. The most important thing to understand is that this is not a medical problem or a psychological problem. It's certainly inconvenient and no fun for anybody at times but as I mentioned, the child's self-esteem is more important than dealing with it in a way that would be negative for the child.

If a child is 6, we know that still about 10% or so of them are not dry at night normally. The question is if you should do anything about it. Since it's not a medical or psychological problem you don't really have to unless you want to. Why would you want to? If the child is embarrassed and is looking for help with it -- and most 6-year-olds frankly are not that motivated yet -- or if it's interrupting the family routine or causing bad relationships within the family to such an extent that you want to see if you can get rid of it so everybody can sleep better at night -- those are the reasons to treat it.

On the other hand, if you don't mind it that much and you've come to terms with it and your child is OK with it -- it's perfectly acceptable just to let it go and wait for it to go away on its own. If it doesn't in the next year or two and things change and you want to try some of the treatments then, you can.

It's really a parents' choice and child's choice about when and if to deal with nighttime bed-wetting.

MODERATOR:
Having said that, if you have decided and your child has decided that you'd like to deal with it, are there some behavioral approaches that you can take? Understanding that it's not the child's fault, that it's nothing conscious they are doing -- are there things you can do short of medication, like withholding liquids or restricting certain types of liquids, that would help with the issue?

PARKER:
Sure and parents do it all the time. Not having the child drink much after dinner, waking them up to pee before you go to bed or a half hour before they usually wet the bed, not having too much stimulation like a television on in the room after they go to sleep -- these are common interventions parents try. The problem is they are not all that effective and rarely do the job -- but it might and it's certainly worth a try.

If you look at the research that has been done on bed-wetting, there's no question that the most effective treatments are the alarms -- they are effective in about three-quarters of children. The major advantage is that once a child is somehow trained by the alarm, the recurrence of bed-wetting is much lower than any other technique. If you stop the alarm, the odds are good that the child will not relapse and will continue to stay dry.

So, the nighttime alarm is probably the best way to go if you really want to attack nighttime bed-wetting in a successful way, but it does require your child's cooperation. I should also say your child should know the alarm is not a punishment but a reminder to wake him or her up at night to help him or her to be dry. It also requires some family intervention initially of everybody getting up with the child when the alarm first goes off and taking the child to the bathroom. It requires some work and may take even months to be successful in the three-quarters of cases that it works but it is by far the best treatment for nighttime bed-wetting that we have.

MODERATOR:
The alarm system that you're talking about -- is this with a sensor for wetness or will it work with just an alarm to wake the child up?

PARKER:
These are enuresis alarms which have a sensor for wetness that then transmits a signal to either a beeper or a buzzer that makes noise or a vibrating beeper that vibrates, or for children who just can't wake up to save their lives, both making a noise and vibrating to wake them up. When the sensor senses wetness the alarm goes off and hopefully the child wakes up or the parent wakes the child up, then they go to the bathroom and finish the job.

We don't really understand why they work. Somehow they seem to train the sleeping brain to be more aroused, awake and alert, and to avoid urinating when the urge exists. When they work, some children are then able to sleep through the night completely without even waking up and staying dry. Others wake up when they feel the urge to pee and go to the bathroom.

As I said though, in about a quarter of the cases, the alarms may not work so well. In those cases if you're really stuck and your child is getting older, sometimes a combination of the alarm and DDAVP will work more effectively than either one alone.

MODERATOR:
Could you explain the kinds of medications that may be tried? I do want to emphasize again your point that the medications are not as effective as the alarms and they don't continue to be effective once you stop taking the medications but if the child has short-term needs to be dry for sleepover camp for instance, what would those medications be and what are some of the potential side effects of those medications?

"If you look at the research that has been done on bed-wetting, there's no question that the most effective treatments are the alarms -- they are effective in about three-quarters of children."

PARKER:
There are really two medications that are used and probably DDAVP is the one most commonly used now, especially since you can take a pill instead of the spray into the nose that we had to do previously. DDAVP is a naturally occurring hormone that makes us make less urine. Some people think one of the causes of nighttime bed-wetting may be that children make more urine at night and don't have more of this hormone being naturally created during the nighttime so the DDAVP slows down urine production and the child can get through the night.

Side effects with DDAVP are very rare and have really only been seen in children who have way too much to drink before they go to sleep. That can cause "water intoxication" because they are not making very much urine and the water stays in the body and can cause problems with the mineral concentration in the body. But that's pretty rare and with sensible precautions, it's very unlikely. As far as I know, no other problems with DDAVP have been found.

The other medication, which I used to use much more before DDAVP came around, is called imipramine. It is kind of an antidepressant but works very well in keeping children dry. Again, it's relatively safe because you're only giving one dose at night and a low dose at that. The concern about imipramine however, is that an overdose of imipramine is horrific. If there's a chance of a toddler getting into it or anyone taking many of the pills for some reason, it's not a good idea to even have around. But it is fairly safe and a good alternative to DDAVP if you want to get through a night without wetting.

MEMBER QUESTION:
My 13-year-old nephew still wets the bed at night and his urine has a really strong smell to it. What can I do to help?

PARKER:
Well, as I said before, the first order of business will be to make sure that strong- smelling urine is normal. That means to be sure that he has been seen by his pediatric provider and the urine has been tested to make sure there's no evidence of infection or other problems that might continue the nighttime bed-wetting.

Let's assume that's not the case and he is perfectly healthy. Then it's likely he is still one of the few percent of children who continue to have bed-wetting into their teens. This is again probably due to genetics and often runs in families.

If he is motivated at this point, the urine alarm is probably, again, the best way to go, to help him to achieve nighttime continence. If he is not motivated to do that, you're not going to get very far. Certainly a 13-year-old needs to participate in his own treatment. It helps to do that by explaining what's going on, about how the brain is too asleep and how the alarm will help to wake him up. If he has not tried an alarm, I would certainly go that route first, and then if that didn't work, add DDAVP onto the alarm and see if you can achieve some success.

If that doesn't work, send me a message on my message board in a few months and we'll go to plan C. Good luck.

MODERATOR:
Dr. Parker has a message board right here on WebMD and you can always post questions to him on his message board.

MEMBER QUESTION:
Is there a brand of alarm system that is better than another?

PARKER:
I don't think so, they're all pretty good at this point and I never like to recommend one brand vs. another. You can talk to your pediatric provider and you can look online. They all work by pretty much the same principle and are, as far as I can tell, pretty equivalent in terms of their ability to help the child.

MEMBER QUESTION:
Is it just that the children sleep so soundly?

PARKER:
That's a really good question and still hotly debated. It probably has, in some children, a little bit to do with the lack of their waking up to the stimulation of the urge to pee, but this observation of some parents is suspect. Parents have always told us that when they try to wake their child up at night to go to the bathroom, he or she remains really sleepy and hard to wake up. Of course, they don't wake up any of their other children at night, who might be equally hard to wake up, who aren't wetting the bed.

We also used to think that bed-wetting occurred just at one certain stage of sleep but now it seems to occur at all stages of sleep. So the returns aren't in. Maybe the children are a little bit of a deeper sleep and sleep a little deeper but it's not clear if this is a cause or just a contributor to children who don't wet the bed or who do wet the bed.

"I do want to mention one cause of daytime wetness in girls many of you should be aware of because I have seen it quite commonly. It's called vaginal reflux. This occurs often in chubby girls who have wet panties throughout the day."

MEMBER QUESTION:
What's the best route to take if they have a problem in the day and the night?

PARKER:
I'm glad you asked because just as I said there are two kinds of nighttime bed-wetting -- primary when the child has been wetting his or whole life and secondary, which occurs after a period of dryness -- there's also what's called diurnal enuresis, when children are wetting during the day and/or at night. As you might imagine, this is a very different story. The child is awake when he or she wets, and so the issues and the cause are likely quite different than that in primary nighttime bed-wetting.

What are some of the reasons that a child might wet his pants during the day? Certainly again, you want to rule out the possibility of a medical problem causing it. Assuming that's not true, there are a number of possible causes. One is the child's attention span -- some children are very easily distracted and do not pay attention to the sensation of a full bladder. They continue to play and then finally when they have the urge to go, it's too late to hold it in because they didn't respond when the initial feelings occurred.

Other children may have what's called a small functional capacity -- this means that the bladder is a normal size but for some reason when they get a certain amount of urine in it, they get an incredible urge to pee, much more than another child might have. This doesn't give them the time to make it to the bathroom and avoid wetting their pants.

There can be other causes which are less common such as constipation, when the bowels are so full this pushes on the bladder and causes the child not to be able to hold in his or her urine.

There are much rarer causes with problems where the anatomy of the urinary system is "off" and the urine goes directly to the vagina or penis rather than into the bladder, but those are rare.

I do want to mention one cause of daytime wetness in girls many of you should be aware of because I have seen it quite commonly. It's called vaginal reflux. This occurs often in chubby girls who have wet panties throughout the day. They have no idea they are going and the urine just seems to be dribbling out. What's happening in this case is that when they are sitting on the toilet and peeing, the urine bounces off their thighs and back into the vagina without their knowing. Then during the day the urine simply dribbles out of the vagina slowly and they have no sense of having to go. This is actually a fairly common and easily controlled cause of daytime wetting in some girls. The treatment is quite simple -- it's to make sure that the little girl understands what's going on. Sometimes facing backwards on the toilet so her legs remain spread and she watches the pee go into the toilet, assures that the vaginal reflux does not occur. If you have a little girl with this problem of daytime wetting, think about vaginal reflux also.

MEMBER QUESTION:
My 9-year-old son is diagnosed with ADHD. Part of the evaluation asked if there was any bed-wetting, and yes, he used to wet the bed. Talking with other parents whose children have ADHD, I have found that many of them also wet the bed. Is there a connection between bed-wetting and ADHD?

PARKER:
Not that I know of. Many children with ADHD, as I mentioned, can have a daytime problem because they don't pay attention to the sensation of having to pee and have that problem. But I'm not aware of any evidence that shows children with ADHD are more or less likely to have bed-wetting at night.

MODERATOR:
Dr. Parker, do you have any other tips to share to help us with the bed-wetting blues?

PARKER:
There's a tip that I've learned through the years that can be helpful. As I mentioned before, bed-wetting is no fun for the family who has to get up at night and is understandably angry at the child for disrupting everybody's sleep. I like to recommend what I call the double-bubble technique to diffuse family tensions and to allow the child to take care of his or her own wet pajamas and sheets at night without involving the rest of the family so everybody can get a good night's sleep.

"Know just that this too will pass, and your child will stop wetting the bed at some point."

The double bubble involves putting the sheets and blanket on the bed covered by a plastic liner, covered again by a new set of sheets and blanket. The child gets into the top set of sheets and blanket and has an extra spare pair of pajamas at the bedside. You teach him or her that if he wets the bed at night and wants to change, he can take care of it himself by pulling off the top layer of the sheets and plastic liner, putting on a new pajamas, and cozying into the new nice warm dry sheets underneath. This way the child can take care of the issue, the parents don't have to get up, everybody gets a good night's sleep, and family relations are restored. Think of the double-bubble technique if this has been an issue for you.

MODERATOR:
Dr. Parker, we're about out of time for today. Do you have any final words for us?

PARKER:
Know just that this too will pass, and your child will stop wetting the bed at some point. As I said before, the important thing is how you deal with it and how it affects your relationship with your child over time. I have hopefully given you some strategies that will help and may even cure the bed-wetting, but they may not. It may be something that you will have to learn to live with until it mysteriously fades on its own.

I hope I have given you some hope and reason to think that there are things to do and some perspective about when and when not to treat this really common occurrence.

MODERATOR:
Thank you Dr. Parker.



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