Bedwetting Nocturnal Enuresis

What is bedwetting?

Bedwetting (nocturnal enuresis) means a child passes urine in the night when they are asleep. Many parents expect children aged 3 years to be dry at night. Although many children are dry at this age, it is common to need nappies at night until school age. However, even beyond this age, bedwetting is common.

A child who has never been dry at night has primary nocturnal enuresis. A child who has had at least six months of dry nights but then develops bedwetting, has secondary nocturnal enuresis. Bedwetting is more common in boys than it is in girls.

What causes bedwetting?

In most children there is no specific cause. Bedwetting is not your child's fault. It occurs because the volume of urine produced at night is more than your child's bladder can hold. The sensation of a full bladder does not seem to be strong enough to wake up your child at night. As your child develops and grows, the amount of urine produced at night gets less, and they become aware that they need to wake in the night if their bladder is full. So the problem goes away eventually in most children.

Some factors are thought to make bedwetting worse or more likely. Some of these factors are always there; others may tip the balance in some children on some nights. Risk factors include the following:

• Times of stress may start up bedwetting again after a period of dryness. For example: starting school, arrival of a new baby, illness, bullying, and maltreatment.
• Drinks and foods that contain caffeine. These include tea, coffee, cola and chocolate. Caffeine increases the amount of urine made by the kidneys (it is a diuretic).
• Constipation. Large stools (faeces) in the back passage (rectum) may press on and irritate the back of the bladder. In particular, children who have persistent (chronic) constipation are more likely to have a bedwetting problem.
• Weight. Bedwetting is more common in children who are obese.
• Family history. Children whose parents had a problem with bedwetting when they were young are more likely to have the same problem.
• Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of having a bedwetting problem.
• Children with delay in development caused by serious physical conditions such as Down's syndrome or cerebral palsy often have a delayed ability to become dry at night.

Other specific medical causes of bedwetting are rare. For example, a urine infection, pauses in breathing whilst asleep (sleep apnoea) due to an obstructed airway, diabetes and rare disorders of the bladder may cause bedwetting. A specific medical cause is more likely if daytime wetting occurs in addition to bedwetting. A doctor can usually rule out these causes by examining the child and testing a urine sample. More tests to check for rare bladder problems may be needed in children who have daytime wetting.

The following are some general tips that may help

Nappies

If you decide 'now is the time', then stop using nappies. Some older children are still put in nappies at night when trying to be dry. This gives them little motivation or need to be dry. The risk without nappies is wet beds for a while. However, in younger children, if a trial period without nappies does not work out, then go back to nappies for a while and try again at a later date. Nappies or pull-up training pants may take the pressure off you and your child if they are just not ready yet.

Patience, reassurance and love

As mentioned above, if trying without nappies fails at age 3 years, it may be wise to give up for a while and then try again a few months later. Treatments are not normally needed or advised for children under the age of 5 years. Keep trying every few months until successful. Even if your child is bedwetting when he or she starts school, there is a high chance that it will stop soon. There is a great variation in when children become naturally dry at night.

Do not punish children for bedwetting. It is not their fault. Rather, they should be praised and made a fuss of if you notice any improvement. Try to be sensitive to any family or school disruption that might be stressful to your child. If bedwetting appears after a period of dryness, it may reflect a hidden stress, or fear (such as bullying at school, etc).

Explaining to children

It needs your child's co-operation to be dry at night. As soon as your child is old enough to understand, a simple explanation will help them. If you find it hard to explain bedwetting to your child, visit the website of the Children's Bowel and Bladder Society, ERIC, together. There are age-appropriate resources to help you. A link to this is available in the Further Reading section below.

Child's responsibility

When old enough (about age 5 or 6 years), encourage your child to help change any wet sheets. It may be quicker for parents to do it, but many children respond to being given responsibility. It might also give extra motivation for them to get out of bed and go to the toilet to avoid the chore of changing the sheets. Try to make it a matter-of-fact routine with as little fuss as possible.

Getting up

Make sure there are no hidden fears or problems about getting up at night. For example, fear of the dark or spiders, getting up from a top bunk, etc. Try leaving a night-light and the bathroom light on. In some cases, where getting to the toilet might be difficult in the night, it may be worth trying having a potty by the bed for your child to use instead.

Drinks

Restricting drinks sounds sensible but it does not help to cure bedwetting. The bladder has to get used to filling up and holding on to urine. If you limit drinks all day then the bladder cannot be trained to hold on to larger amounts of urine. A sensible plan is only to give drinks to your child if he or she is thirsty in the 2-3 hours before bedtime. Do not restrict drinks for the rest of the day. Most children should drink about 6-8 cups of fluid a day.

Also, as mentioned above, caffeine in tea, coffee, cola and chocolate may make bedwetting worse. These are therefore ideally avoided, especially in the few hours before bedtime.

Lifting

It is common practice to wake children up to take them to the toilet several hours after they go to sleep. However, this lifting is of little use and it may even prolong the problem. Your child has to get used to waking up when their bladder is full. Children often do not remember being lifted, and lifting usually does not help them to achieve their own bladder control.

However, make sure your child goes to the toilet just before bedtime. If your child does wake in the night then you should encourage him or her to go to the toilet then.

Constipation

If your child is constipated, see a doctor for advice and treatment. Treatment of constipation often cures bedwetting too.

Nights away

A common worry is that staying with friends or relatives will be embarrassing. However, there are a number of ways to handle this. If it is a school trip, speak to the teacher. It is normal for there to be more than one child on a primary school trip who is not dry at night. It may be helpful on school trips or sleepovers for some children to use pull-up pants. You can also speak to your GP about short-term medicines especially used for nights away (see the treatment options below). Bedwetting in young children is common and it shouldn't interfere with their social lives.

Practical measures

Use waterproof covers for mattress and duvet and use absorbent quilted sheets. A moisturising cream is useful to rub on to the skin that is likely to become wet, to prevent chaffing and soreness.

What are the treatment options for bedwetting?

Not using any treatment is an option, as most children will eventually stop bedwetting. However, treatments often work to achieve dryness sooner rather than later. The older a child becomes, the more likely that bedwetting will stop on its own. Treatment options include the following:

Bedwetting alarms

A device called a pad and bell or a similar alarm device is a common treatment. There is a good chance of cure, particularly for children aged 7 years and older. Alarms are effective in two thirds of children who use them. An alarm is usually needed for 3-5 months to condition the child to wake and empty their bladder when it is full. Briefly, the alarm goes off as soon as wetting starts. This wakes the child and prompts him or her to go to the toilet. In time, the child is conditioned to wake when their bladder is full before they begin to wet. Alarms can be bought, or borrowed from your local continence advisor. Your doctor can advise about this. See the separate leaflet called Bedwetting Alarms for more details.

Medicines

Desmopressin is the common medicine used for bedwetting. It works by reducing the amount of urine made at night by the kidneys. It usually works well (in about 7 in 10 cases) and straightaway. If it works, a common plan is to take it for three months and then try without it. However, when it is stopped, the bedwetting often returns. (A permanent cure following treatment is more likely with bedwetting alarms than with desmopressin.) Desmopressin can also be useful for short spells of time. For example, during holidays or for times away from home. See the separate leaflet called Bedwetting Medicine (Desmopressin) for more details.

Occasionally other medicines are used by specialists. Imipramine is one such medicine. It can have some serious side-effects, so it is only used occasionally when other treatments have not worked.

Reward systems

Briefly, you agree a reward with your child if he or she achieves a goal. Often the goal is not a complete dry night (as most children who wet the bed have no control over their wetting). An agreed goal could be: going to the toilet before going to bed, getting up and telling the parents they are wet, helping to remake the bed, etc. A goal of a dry night may be appropriate in some cases when the situation is improving. A common example of a reward system is a star chart. This is simply a calendar with a space for each day. A child places a sticky star on each day following a good night (where the goal was achieved). For a poor night (where the goal wasn't achieved), the day is left blank. You may agree a reward for a number of stars. The aim is to give the child motivation to become dry. See the separate leaflet called Bedwetting Reward Systems for more details.