Bed wetting

 

What is bed-wetting?

Very young children pass water without control day and night, so wet beds are normal in the first few years of life when a youngster isn't wearing a nappy. Most children can control their bladders in the day-time by the age of three, and through the night too by the age of four. However over 10% of children regularly wet the bed at the age of five and over 5% still do at the age of 10.

The medical term for bed-wetting is nocturnal enuresis. Doctors sometimes use the expression primary enuresis when a child has never been dry, and secondary enuresis when a child has been dry but then starts to wet again. Although one needn't use technical terms, it's still helpful to distinguish between youngsters who've never achieved bladder control, and those who have lost it.

When should something be done?

The age at which bed-wetting is a problem varies from family to family. Some parents are very upset by wet beds at the age of four - though the child himself may be unconcerned until he's older and starts school. Most experts reckon bed-wetting is normal up to five, especially in boys, who tend to mature later. So it's rarely necessary to do anything till the age of five, especially if the child has always been wet (primary enuresis).

 

Why does it occur?

Most youngsters who bed-wet are completely normal, and just seem to be less mature in their bladder development. They're usually dry by day, and, given time, they become dry at night. Late development of bladder control can run in families, so the doctor may ask about the age at which a child's siblings and parents were toilet-trained.

Having been dry, children may bed-wet again when they're upset or feel insecure at home or at school. The arrival of a new baby in the family often causes a toddler to wet, especially if he has only recently abandoned nappies.

Research shows that most bed-wetters (and their families) aren't neurotic or disturbed. However, a small number have serious stresses or difficulties, and some have even been abused. Such children can have other behaviour problems too, and the doctor may ask various searching questions. However personal these are, parents should try not to be offended. It's vital to spot at an early stage the few who need psychological help.

One theory is that youngsters who wet don't produce enough ADH (anti-diuretic hormone) to concentrate the urine. Research doesn't really confirm this, although some studies suggest bed-wetters may have more dilute urine. A tiny number of children who wet the bed have some abnormality of their anatomy, either the bladder itself or another part of the urinary system, but these children tend to be wet all the time, not just at night. Urine infections can also cause bed-wetting.

 

What are the consequences of bed-wetting?

At school a child who wets may get teased or bullied, while at home his siblings and parents may ridicule him, or worse. It's difficult to cope with wet beds, but families should try hard to be patient. Waking up cold and wet is unpleasant enough without having to face angry parents. Parental outbursts usually stress the child further and are counter-productive.

What are the tests?

As well as a physical examination, urine is usually tested for blood, protein, and sugar, to rule out diabetes and infections. The urine concentration (specific gravity) may also be measured. This is usually all a child needs, though in some older children video studies may be suggested.

 

What is the treatment?

Obviously any physical or psychological cause for bed-wetting needs treating in its own right. Otherwise the range of treatments includes:

Doing nothing

Since many youngsters gain bladder control later than others, it may be enough to wait and let time be the doctor, especially if the child is five years old or younger. This works best when the parents can be relaxed about it, and don't scold the child or discuss their "problem" in front of them. Machine-washable bedding helps parents take it in their stride. Lighting the way to the toilet at night and covering up any cold lino may encourage a youngster to get out of bed. Restricting fluids is usually unnecessary, but it helps to cut down on fizzy drinks and fruit juices because these are acidic and stimulate the bladder.

Many parents find it helps to get their sleeping child up to use the toilet or potty in the night, usually just before they themselves go to bed. When lifting or "potting" it's important to wake the child thoroughly, as otherwise the youngster is still passing water in his sleep, albeit not in the bed.

Behavioural treatment

Children over five often respond well to organised encouragement, such as the use of "star charts" as an incentive scheme. One dry night merits sticking a star on a chart, while 5 or 10 stars, say, results in a small reward. It's vital to aim for a target the child can achieve. If there are no dry nights in a whole fortnight, 10 stars are going to be a very long way off. When encouragement alone fails to do the job, an enuresis alarm can help.

Alarms

Enuresis alarms come in two main types, those with a sensor mat or pad under the child, and smaller ones which are worn on the body. Both set off a loud but harmless buzzer if the child begins to pass water. The idea is for the child to beat the buzzer and quickly get up to turn it off when it sounds.

Initially there are often problems - the alarm may wake the whole household except for the child. At first the child will still wet, but with time the patches become smaller.

Alarms are generally used for the over-sevens, though a bright six-year old can often cope. Children can take eight weeks to become dry, and may need to continue with the alarm for another few weeks or months, but the long-term success rate is about 80% when alarms are used correctly and with professional support.

Drug treatment

Several drugs can be used, for instance imipramine and other so-called tricyclic drugs. Since these are actually antidepressants, it's not clear how they relieve bed-wetting. They take several weeks to have an effect, and unfortunately only work while the child is on them. In overdose tricyclics can be fatal, so they're not used much for bed-wetting, though they benefit some children.

DDAVP (desmopressin)

This is a hormone which concentrates the urine and can help a child go through the night without wetting. It works like anti-diuretic hormone which normally makes urine stronger at night. Given by nasal spray, DDAVP works quickly and is very helpful for a bed-wetter who desperately needs to be dry for, say, a weekend away with the Cub Scout pack. It can even work when enuresis alarms have failed, but long-term results are better with alarms than with drugs.

 

Are there other treatments?

Complementary therapy

Acupuncture has been used, but most paediatricians disapprove since bed-wetting is basically a behavioural problem rather than a painful condition, and acupuncture is unlikely to be successful.

Surgery

Over the years various surgical treatments have been tried, such as circumcision and dilatation of the urethra (urinary tract opening). Except for the few children with an anatomical problem, operations have nothing to offer bed-wetters and their families.

Since alarms and behavioural treatment do work, putting a child through any painful or unproven treatment for bed-wetting (whether it's surgery or a form of complementary therapy) may be unethical as well as unhelpful.

 

Where can I get further information?

Apart from contacting your GP, the following organisation may be able to offer further help:


ERIC (Education and Resources for Improving Childhood Continence)
36 Old School House, Britannia Road
Kingswood,
Bristol
BS15 8DB
Telephone:0845 370 8008 (Monday –Friday 10:00-16:00)
Email: info@eric.org.uk
Web page: www.eric.org.uk