Thursday, May 12, 2016

Bed-wetting

Nocturnal enuresis, otherwise known as bed-wetting, is something that many patients and families have to deal with. More than half of the bed wetters are boys. To give you a sense of numbers and make you not feel so alone, 15% of 5 year olds still wet the bed; 5% of 10 year olds continue to have issues of staying dry at night. Most of the persistent older bed wetters will grow out of this by puberty without any intervention, but hopefully you don’t need to wait until your child is a teenager to get this resolved; that is the purpose of this post.

There is definitely a genetic tendency at work. Unless on-line dating has taken it to a new level, history of bed-wetting is typically not a subject that comes up on the first date, but now it is worth knowing if one of the parents had the same issue. For those of you washing the sheets every night for your twelve year old, please keep in mind that there is a reason that most camp forms ask about bed wetting. This is not an uncommon situation. The goodnight pull-ups come in such big sizes because there are plenty of older kids needing them

If a child had been dry at night and the bed-wetting is new, check in with the doctor to make sure there isn’t something else going on. This post is referring to patients who have never consistently been able to stay dry through the night.

This can be a really frustrating issue and there are many opinions about how to deal with it. Wetting the bed should not a punishable offense. Waking up wet and feeling loss of control is punishment enough. It is not okay to humiliate your child. Having your child begin to accept some responsibility however, is not a punishment.

The natural consequence for having a wet bed is to be part of the clean up team. Perhaps your child can be in charge of stripping the wet sheets off the bed. Let them be part of the solution rather than being the cause of the problem.
Until your child has shown that they can be dry at night, I would have them in special nighttime pull ups and make sure you have waterproof pads on the bed. Expecting dry sheets before your child has shown they are ready is just going to be aggravating for everyone.

There are some basic considerations and common sense approaches to start with.
The very first thing is to figure out if there could be any constipation issues. (click here for a link to my previous blog post)
Once the kids are out of diapers and off at daycare or school, many parents lose track of the kids bowel habits. Are they pooping daily? Do they have to sit for a while before the poop comes out. Does it come out in hard little pieces? Constipation is a huge factor and is your first step to eliminating bed-wetting issue. Often times, kids are found to be constipated even if they are pooping once or twice a day and the poops seem normal. According to Anne, the wise and wonderful nurse at the UCSF Continence Clinic, this may be because the kids don’t always take the time to get all of the poop out. When we end up sending patients to the continence clinic at UCSF to treat the enuresis, they start off by cleaning almost all of the kids out with a combo of Miralax and sometimes suppositories.

Other common sense steps include  having them better hydrate during the school day. Some kids are “camels” at school and don’t drink. Talk about what the fluid options are. Is there an accessible fountain? Do you send something to drink with their lunch?

Recommended fluid intake for children is measured by weight:

<2 year/<10 kg        30-35 ounces/day
2-5 years/<20 kg     40-50 ounces/day
6-12/<50 kg             50-60 ounces/day
Teens                      60-70 ounces

While we want to bump the fluids during the day, it is time to start  limiting fluids after dinner. Consider taking your child for a “dream pee” before the adults go to bed.
Often you can walk your sleepy child to the bathroom without having them fully wake up. If these "twilight trips' to the bathroom appear to be  disrupting their sleep cycle, see if you can adjust the timing.
If they are impossible to rouse enough to get to the bathroom without you practically carrying them, Dr. Schwanke would suggest that this is a big sign that they aren’t ready yet.

Let's give that bladder some exercise. The continence clinic does not generally recommend “kegels”  exercises for their patients, but once in awhile it is okay to have them practice starting and stopping the urine stream if they can. Another activity is to see if they can hold the pee for a couple of moments when they first realize that they need to go. Without good relaxation of the perineum, children are unable to empty their bladder completely. Try to teach your child to relax when they are peeing. One way to do this is to have them give a big sigh. Sighing is a normal relaxation trigger.

If none of the above actions has made a difference, it is up to you when you want to stage an intervention. I usually wait until your child has expressed readiness to tackle this. Dr Kaplan says that in her opinion, once the kids are old enough to read, they are old enough to be dry at night. She gives her patients a little talking to and tells them that they are in charge of telling that good brain of theirs that they need to not pee at night. She claims a degree of success!

Sometimes, once they are old enough for summer camp or sleepovers, kids are more invested in a cure. If they don’t care one way or the other, you can increase their role in the clean up, but until they are an active and motivated part of the team, I would wait a bit.

Once you are ready to intervene there are several options.

Some of my families have had long lasting success with the bed-wetting alarms. There are several on the market. Here is an email that was sent to me from a mom who wanted to share her experience"

"We purchased a Chummie bed-wetting alarm (along with an extra sensor so we'd have two of those) and I read a really helpful book called "7 Steps to Nighttime Dryness" (by Renee Mercer) which I read through quickly and highly recommend.  

Some takeaways from the book:

-- kids who wet their beds after age 6 likely will benefit from an intervention (like a bed-wetting alarm, which is the most effective intervention available) WHEN both the parents and the child are ready to take the time and effort to do so and are willing to have the disruption to their sleep (which can be tough on everyone).
-- When first starting use of the alarm, parents need to respond promptly when the alarm goes off to scaffold the learning process for their child -- i.e., they'll have to help the child wake up and get to the toilet to start developing and patterning that behavioral response.  Slowly, over a period of time (12 weeks total on average), the child's body will start to learn to wake up when their bladder is full and they'll be able to get themselves to the toilet... until eventually their bladder learns to hold urine until the morning.
-- The author recommends using a chart to track progress. This helps you see and feel a sense of progress, which is helpful to everyone involved.  For example, at first our son would pee heavily twice each night (those wake-ups every four hours reminded us of our prior sleep disruption patterns when we had a baby!)... then it became lighter pees since he started to stop himself mid-stream and would get the rest into the toilet with our help... and then he would pee once per night lightly, and so on until he was dry and slept through the night without disruption.
-- Once your child consistently has dry nights for 2 weeks straight, you wean them from the alarm for another 2 weeks by using it every other night.  This weaning leads to the most effective long-term results.

Before starting the alarm intervention, I had imagined in my head that perhaps our son's bladder got full while he was sleeping, his bladder communicated its fullness to his brain, but he didn't wake up to respond properly so he simply would pee while sleeping.  The alarm helps that transmission of info work properly.

Our experience:
Our son was highly motivated to stop wetting the bed, so we decided to try this alarm approach to see if it might help him.  At bedtime, our son put on his undies, taped the sensor to the outside of his undies as instructed (so the alarm goes off when the sensor starts to feel pee), and then he wore a pull-up outside of all that (so we didn't have to change his bedding a gazillion times).  Our son's first dry night happened 3 weeks into the alarm intervention (although we had forewarned him that it would take 12 weeks so his expectations were realistic).  At 3 weeks, for a few nights he was dry every other night, and then he was miraculously dry every single night from thereafter.  We continued with the alarm for another several weeks and did the weaning process and he has been dry ever since (we first used the alarm 3/26 so it's been 2 months. Woohoo!).  We are thrilled and surprised since he is such a deep sleeper and always has peed at night.  He was a quick-results case, which we were not expecting.  It feels like the alarm kind of magically connected a synapse that wasn't there before!

We used a weekly chart to track his progress.  We used tiny reward stickers both for cooperation (in the "good determination award" cell) and for "dry night" (the latter obviously doesn't happen for a while so it's nice to feel rewarded for at least trying.)"


There is no medication that cures enuresis, but there are some medications that can address the symptoms. The most commonly used is DDAVP. This is a prescription approved for children over 6. It comes as a  tablet. It used to be available as a nose spray but that has been discontinued due to side effects.

When the drugs are stopped, the bed-wetting usually returns unless the child has naturally outgrown the condition. It is nice to know that this possibility exists for use on an intermittent basis such as an overnight or summer camp.

Please note that even when you feel like you have successfully put this behind you, it is possible for mini relapses to occur with little illnesses or increased stress.

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