Bed-wetting

After your child is toilet trained (usually between ages two and four), it is not uncommon for children to wet the bed at night. This may happen as often as two to three times per week early in this period, and gradually become less and less until it is completely gone at around age five.

The exact cause of this incontinence (wetting) is not known. The best way to approach it is to consider it to be something natural and unimportant, and not to scold or punish your child. Some children continue to wet at night past the age of five. When wetting occurs only during sleep, it is called nocturnal (nighttime) enuresis, or bed-wetting. It affects one out of every four children at age five, one in five at age seven years, and about one in twenty at age ten years. Boys make up two-thirds of this group, and often there is a family history of bedwetting(usually in the father). Although the reasons for bed-wetting are not fully understood, it may be related to the time it takes different children to develop control over the nervous, muscular, and nighttime full bladder sensation that needs to be subconsciously suppressed.

Bed-wetting generally is not associated with other physical or emotional problems. A much smaller number of children over age five have daytime wetting problems, and an even smaller group is unable to hold their urine both day and night. When incontinence does occur during both the day and night, it may signal a more complicated problem with the bladder or the kidneys. If your child wets at night, here are some possible causes:

• Slow development to awaken when the bladder is full
• Constipation, which can cause extra pressure on the bladder from the rectum
• An early sign of diabetes mellitus, a urinary tract infection, or emotional distress caused by an upsetting event or unusual stress—but only if wetting began suddenly after an extended dry period.

Signs of a Problem

When your child is starting toilet training, he is sure to have “accidents.” Therefore, you shouldn’t be concerned about wetting until at least  six months to a year after the training is successful. Even then, it is still normal for him to have some accidents, but they should decrease in number, so that by age six he should have only occasional accidents during the day, with perhaps a few more at night. If your child continues to wet frequently, or if you notice any of the following signals, talk with your pediatrician:

• Wet underpants, nightclothes, and bed linens, even when the child regularly uses the toilet
• Unusual straining during urination, a very small or narrow stream of urine, or dribbling after urination
• Cloudy or pink urine, or bloodstains on underpants or nightclothes
• Redness or rash in the genital area
• Hiding underwear to conceal wetting
• Daytime as well as nighttime wetting

Treatment

Up to about the age of five years old, it is perfectly normal for your child to have occasional nighttime wetting or daytime accidents when she is laughing, engaged in physical activity, or just too busy playing; in these cases, you should not be concerned. Although annoying to you and perhaps embarrassing for your child, these episodes should stop on their own. There probably is no need for a medical investigation. However, your pediatrician will want to know the answers to the following questions.

• Is there a family history of wetting?
• How often does your child urinate, and at what times of the day?
• When do the accidents occur?
• Do accidents happen when your child is very active or upset, or when she’s under unusual stress?
• Does your child tend to have accidents after drinking a lot of fluids or eating a lot of salty foods?
• Is there anything unusual about your child’s urination or the way her urine looks?

If your pediatrician suspects a problem, he may check a urine sample for signs of a urinary tract infection If there is an infection, the doctor will treat it with antibiotics, and this may cure the wetting problems. Usually, however, an infection is not the cause. If there are other indications that wetting is due to more than just slow development of being able to respond to a full bladder, and the wetting persists well beyond age five, your pediatrician may request additional tests, such as X-rays of the bladder (voiding cystourethrography or VCUG) or an ultrasound examination of the kidneys. If an abnormality is found, the doctor may recommend that you consult a pediatric urologist. If no physical cause can be found  in a child who wets and is over five years of age, and the wetting is causing significant family disruption, your pediatrician may recommend a home treatment program. The program will vary, depending on whether your child wets during the day or the night.

Treatment for Daytime Wetting After Toilet Training

1. Prevent skin irritation in the genital area by avoiding harsh detergents or underclothing, as well as bubblemaking products in the bathwater. Also, choose mild soaps for bathing, and apply petroleum jelly to protect the affected areas from further irritation from the water and urine.
2. Prevent constipation or treat it if it occurs.
3. Try using a timed voiding program, reminding your child to empty his bladder every few hours rather than waiting until he “has to go”—which by then may be too late.

Home Treatment for Nightime Bed-Wetting Over the Age of Five

The following plan usually is helpful, but you should discuss it with your pediatrician before beginning.

1. Explain the problem to your child, emphasizing that you understand and know it’s not his fault.
2. Discourage him from drinking fluids during the two hours before bedtime.
3. Reward dry nights, but don’t punish wet ones. This is very important, since this is an emotional issue for both of you.

If your child is still wetting after one to three months on this plan, your pediatrician may recommend using a bed-wetting alarm device or some medications. This alarm will awaken your child automatically as soon as he begins to wet, so he can get up and complete his urination in the toilet. When used consistently and according to your pediatrician’s guidelines, this bladder-conditioning method is successful for half of the children who try it. It is important to follow your pediatrician’s directions carefully in order to give this device the best chance to work.

Another option may be oral medications. These work in about half of the children who use them and side effects are rare. It is important to limit water drinking before bedtime when on this medicine, and to follow your doctor’s directions.

If None of the Treatments Work

A small number of children with bedwetting simply do not respond to any treatment. Almost all will outgrow the problem by adolescence, however. Only one in a hundred adults is  troubled by persistent bed-wetting. Until your child does outgrow his wetting problem, he may need some emotional support from the family, and he also may benefit from speaking with his pediatrician about this condition, or receiving counseling with a child mental health professional. Because bed-wetting is such a common problem, you may see advertisements for many mail-order treatment programs. You should be wary of them, however, as many false claims and promises are made. Your pediatrician is still your most reliable source for advice, and you should ask him for it before enrolling in or paying for any treatment program.