If your child has begun wetting the bed, you're not alone in your concern. Primary nocturnal enuresis (PNE) or bedwetting affects an estimated 5 to 7 million American children 6 years of age or older. PNE occurs in children who are older than five years, have never achieved a six-month period of dryness at night, and wet the bed at least three times a week. Studies show that enuresis is more common in boys than girls. In a recent survey of enuretic children, bedwetting was ranked as the third most stressful life event after divorce and parental disagreements. Not only is PNE a problem in itself - interrupting the family's sleep, soiling pajamas, sheets and blankets - it also carries a stigma that makes everyone feel ashamed. Children may even feel there's something wrong with them, and parents may think they're doing a bad job. Bedwetting can become a deep, dark family secret. The fear of having that secret revealed can negatively affect a child's quality of life and may result in low self-esteem and/or behavioral problems. The good news is that most children will eventually outgrow PNE. But until that happens, it can interfere with children's social and emotional development, including a general reluctance to engage in typical childhood activities such as camps, sleepovers and family/friend visits.
What causes bedwetting? Bedwetting is not the child's or the family's fault. While no one knows the exact cause, most healthcare professionals believe it results from the interplay of multiple factors related to waking up when it's time to urinate - factors like maturational delay of the central nervous system. (Due to decreased arousal, the child does not perceive the feeling of a full bladder); functional (small) bladder capacity, which may result in frequent bedwetting episodes, as the bladder cannot hold the amount of urine produced; and abnormal sleep patterns - possible abnormal, deep sleep patterns in which children are unsuccessful in awakening to the sensation of a full or contracting bladder. Investigations into the hereditary nature of PNE suggest that a strong familial history is a significant determinant for this condition. In fact if one or both parents wet the bed as children, the incidence of bedwetting increases dramatically. More specifically, research suggests that if both parents have a history of bedwetting, the child has a 77 percent likelihood of wetting the bed and a 44 percent chance if only one parent wet the bed. Researchers recently identified a gene marker on chromosome 13, which is associated with this disorder. Another factor is that some children who wet the bed seem to have lower evening levels of anti-diuretic hormone (ADH), which is responsible for increasing urine concentration and reducing nighttime urine production.
How can a family manage bedwetting? There are treatment options available, including enuresis alarms, behavior modification, and medications. Since PNE management is usually individualized to the specific child and family, it is important to consider all available options. The age of the child and the family situation (i.e., degree of motivation, family stress/intolerance of bedwetting episodes, etc.) may help determine what therapy is best for each child.
Alarms: Alarms work by attaching a sensor to the lining of the child's underwear and that sounds as soon as moisture is detected. This method is thought to teach a child to sense a full bladder and awaken as a result. Parents should be aware that the alarm is not appropriate for every family situation. It usually takes 4-6 weeks to achieve dryness with the alarm. While alarms produce good results, they require a time commitment from parents who will have to awaken and help arouse the child. Alarms may not be appropriate for children who share a bedroom, or in cases where the child's bedroom is far from the parents.
Medication; Many families prefer to use a medication called DDAVP to control wetting. DDAVP (desmopressin), a synthetic version of the anti-diuretic hormone (ADH) vasopressin, safely and effectively reduces nighttime urine production and can be taken on a short- or long-term basis. DDAVP works quickly with few side effects; some children experience nausea or headache. This treatment option is also useful for families whose situations are inappropriate for the alarm. I often recommend this option to patients seeking a prompt solution. For example, DDAVP can be used for an upcoming trip, such as camp. However, it is not a cure, but rather a bridge until the time the child becomes dry on his/her own.
Therapy: Motivational therapy usually helps most families by boosting the child's self-confidence and self-esteem. It is equally important for the child to remain an active participant in the treatment plan and to receive continuous parental reassurance and support that bedwetting is not the child's fault. Motivational therapy can be an asset to the medication or alarm program.
Other Options: Other options include a modification of certain habits, including restrictions in caffeine, chocolate and other diuretics that can increase urine production. Also, patients should urinate regularly during the day, and especially before bedtime. Limiting fluids prior to bedtime can help as well. The first thing to do if you think your child has PNE is to see your pediatrician or family physician. Your health care provider can discuss both short- and long-term treatment options, and help you decide what is right for your child.
- Don't - Let the stigma surrounding bedwetting keep you from seeking appropriate and timely treatment for your child - Don't - Belittle or reprimand your child for wetting the bed; while bedwetting can be equally frustrating for the family as it is for the child, punishment only functions to further erode his/her self-esteem - Don't - Be ashamed to talk to your child's pediatrician; encourage dialogue about the condition as part of developmental/health assessments during annual visits, until the child achieves consistent dryness - Don't - Believe myths - enuresis is neither a behavioral nor emotional abnormality - Don't - Assume that your child can control/overcome wetting the bed if he/she would 'just try harder'
DR. MICHAEL PACKER is a pediatric urologist with Urology for Children, LLC in Voorhees, NJ; he is also associate professor of urology at Temple Children's Hospital in Philadelphia.