Bed wetting or nocturnal enuresis

Definition

Bed-wetting is also known as nighttime incontinence or nocturnal enuresis. Generally, bed-wetting before age 6 or 7 isn't cause for concern. At this age, nighttime bladder control simply may not be established.Soggy sheets and pajamas — and an embarrassed child — are a familiar scene in many homes. But don't despair. Bed-wetting isn't a sign of toilet training gone

bad. It's often just a developmental stage.

If bed-wetting continues, treat the problem with patience and und

erstanding. Bladder training, moisture alarms or medication may help reduce bed-wetting.

Symptoms

Most kids are fully toilet trained by age 4, but there's really no target date for developing complete bladder control. By age 5, bed-wetting remains a problem for o

nly about 15 percent of children. Between 8 and 11 years of age, fewer than 5 percent of youngsters are still bed-wetting.Bed-wetting is characterized by involuntary urination at night.

When to see a doctorMost children outgrow bed-wetting on their own — but some need a little help. In other cases, bed-wetting may indicate an underlying condition that needs medical attention.

Consult your child's doctor if:

• Your child still wets the bed after age 5 or 6
• Your child starts to wet the bed after a period of being dry at night
• The bed-wetting is accompanied by painful urination, unusual thirst, pink urine or snoring

Causes

A small bladder. Your child's bladder may not be developed enough to hold urine produced during the night.No one knows for sure what causes bed-wetting, but various factors may play a role.

• Inability to recognize a full bladder. If the nerves that control the bladder are slow to mature, a full bladder may not rouse your child from sleep — especially if your child is a deep sleeper.
• A hormone imbalance. During childhood, some kids don't produce enough anti-diuretic hormone (ADH) to slow nighttime urine production.
• Stress. Stressful events — such as becoming a big brother or sister, starting a new school, or sleeping away from home — may trigger bed-wetting.
• Urinary tract infection. A urinary tract infection can make it difficult for your child to control urination. Signs and symptoms may include bed-wetting, daytime accidents, frequent urination and pain during urination.
• Sleep apnea. Sometimes bed-wetting is a sign of obstructive sleep apnea, a condition in which the child's breathing is interrupted during sleep — often because of inflamed or enlarged tonsils or adenoids. Other signs and symptoms may include snoring, frequent ear and sinus infections, sore throat, and daytime drowsiness.
• Diabetes. For a child who's usually dry at night, bed-wetting may be the first sign of diabetes. Other signs and symptoms may include passing large amounts of urine at once, increased thirst, fatigue and weight loss in spite of a good appetite.
• Chronic constipation. A lack of regular bowel movements may lead to reduced bladder capacity, which can cause bed-wetting at night.
• Anatomical defect. Rarely, bed-wetting is related to a defect in the child's neurological system or urinary system.

Risk factors

Sex. Bed-wetting can affect anyone, but it's more common in boys.Several factors have been associated with an increased risk of bed-wetting, including:

• Family history. If both of a child's parents wet the bed as children, their child has an 80 percent chance of wetting the bed, too.
• Attention-deficit/hyperactivity disorder (ADHD). Bed-wetting is more common in children who have ADHD.

Complications

Rashes on the bottom and genital area may be an issue as well — especially if your child sleeps in wet underwear. To prevent a rash, help your child rinse his or her bottom and genital area every morning. It also may help to cover the affected area with a petroleum ointment at bedtime.Although frustrating, bed-wetting without a physical cause doesn't pose any health risks. The guilt and embarrassment a child feels about wetting the bed can lead to low self-esteem, however.

Preparing for your appointment

Here's some information to help you get ready for y

our appointment, and what to expect from your doctor.You're likel

y to start by seeing your family doctor or your child's pediatrician. However, he or she may refer you to a doctor who specializes in urinary disorders (pediatric urologist or nephrologist).

What you can do

• Write down any symptoms, including any that may seem unrelated. It can also be helpful to keep a voiding diary. Write down when your child goes to the toilet, as well as whether or not he or she felt a sense of urgency to urinate. Also include your child's total daily fluid intake and his or her fluid intake after the evening meal, if possible.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins and supplements that your child is taking.
• Write down questions to ask your child's doctor.

Your time with your child's doctor may be limited, so preparing a li

st of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For bed-wetting, some basic questions to ask your doctor include:

• What's causing my child to wet the bed?
• When might he or she outgrow wetting the bed?
• What treatments are available, and which do you recommend?
• Are there any side effects?
• Are there any alternatives to the primary approach that you're suggesting?
• Are there any fluid or dietary restrictions that my child needs to follow?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor

, don't hesitate to ask questions during you

r appointment at any time that you don't understand something.

What to expect from your doctorYour doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• Is there a family history of bed-wetting?
• Has your child always wet the bed, or did it begin recently?
• How often does your child wet the bed?
• Does the bed-wetting seem to be triggered by certain foods, drinks or activities?
• Is your child dry during the day?
• Is your child facing any major life changes or other stresses?
• Does your child complain of pain or other symptoms when urinating?
• If you're divorced, does your child live in each parent's home and does the bed-wetting occur in both homes?

What you can do in the meantimeTry to be patient and understanding with your child. Bed-wetting is a source of anxiety and frustration for your child. He or she is not wetting the bed on purpose. While you're waiting to see the doctor, try limiting the amount of fluid your child drinks in the evening.

Tests and diagnosis

Your child will need a physical exam. Depending on the circumstances, urine tests may be done to check for signs of an infection or diabetes. If the doctor suspects an anatomical abnormality or other problem, your child may need X-rays or other imaging studies of the kidneys or bladder

Treatments and drugs

Generally, your child will be your doctor's guide to the level of necessary treatment. If your child isn't especially bothered or embarrassed by an occasional wet night, less aggressive treatments may be all that's needed. However, if your grade schooler is terrified about wetting the bed on a sleepover, he or she may be more motivated to try additional treatments.Mos

t children outgrow bed-wetting on their own. If there's a family history of bed-wetting, your child will probably stop bed-wetting around the age the parent stopped bed-wetting.

Moisture alarmsThese small, battery-operated devices — available without a

prescript

ion at most pharmacies — connect to a moisture-sensitive pad on your child's pajamas or bedding. When the pad senses wetness, the alarm goes off. Ideally, the moisture alarm sounds just as your child begins to urinate — in time to help your child wake, stop the urine stream and get to the toilet. If your child is a heavy sleeper, another person may need to listen for the alarm.

If you try a moisture alarm, give it plenty of time. It ofte

n takes at least two weeks to see any type of response and up to 12 weeks to enjoy dry nights. Moisture alarms are highly effective, carry a low risk of relapse or side effects, and may provide a better long-term solution than medication does.

MedicationIf all else fails, your child's doctor may prescribe medication to stop bed-wetting. Various types of medication can:

• Slow nighttime urine production. The drug desmopressin acetate (DDAVP) boosts levels of a natural hormone (anti-diuretic hormone, or ADH) that forces the body to make less urine at night. The medication is available as a pill or nasal spray. However, the nasal spray isn't recommended for the treatment of bed-wetting because this form of the medication stays active for much longer, which can increase the risk of serious side effects. Although DDAVP has few side effects, the most serious is a seizure. This can happen if the medication is accompanied by too many fluids. For this reason, don't use this medication on nights when your child has had a lot of fluids. Additionally, don't give your child this medication if he or she has a headache, has vomited or feels nauseous.
• Calm the bladder. If your child has a small bladder, an anticholinergic drug such as oxybutynin (Ditropan) or hyoscyamine (Levsin) may help reduce bladder contractions and increase bladder capacity. Side effects may include dry mouth and facial flushing.
• Change a child's sleeping and waking pattern. The antidepressant imipramine (Tofranil) may provide bed-wetting relief by changing a child's sleeping and waking pattern. The medication may also increase the amount of time a child can hold urine or reduce the amount of urine produced. Imipramine has been associated with mood changes and sleep problems. Caution is essential when using this medication, because an overdose could be fatal. Because of the serious nature of these side effects, this medication is generally recommended only when other treatments have failed.

Sometimes a combination of medications is most effective. There are no guarantees, however, and medication doesn't cure the problem. Bed-wetting typically resumes when the medication is stopped.

Lifestyle and home remedies

Limit fluid intake in the evening. Limit your child's fluid intake during the evening. Around 8 ounces (about a quarter of a liter) or so in the evening is generally enough, but check with your doctor to find out what's right for your child. There's no need to limit your child's fluid intake,

but some experts feel a good rule of thumb is for children to have 40 percent of their liquids between 7 a.m. and noon, another 40 percent between noon and 5 p.m. and just 20 percent of their daily fluids after 5 p.m. However, don't limit fluids if your child is participating in sports practice or games in the evenings.Here are changes you can make at home that may help:

• Avoid beverages and foods with caffeine in the evening.Caffeine may increase the need to urinate, so don't give your child drinks, such as cola, or snacks that have caffeine, such as chocolate, in the evening.
• Encourage double voiding before bed. Double voiding is urinating at the beginning of the bedtime routine and then again just before falling asleep. Remind your child that it's OK to use the toilet during the night if needed. Use small night lights so that your child can easily find the way between the bedroom and bathroom.
• Encourage regular urination throughout the day. During the day and evening, suggest that your child urinate once every two hours, or at least enough to avoid a feeling of urgency.
• Treat constipation. If constipation is a problem for your child, your doctor may recommend an over-the-counter stool softener.

Alternative medicine

Hypnosis. Small trials of hypnosis coupled with suggestions of waking up in a dry bed or visiting the toilet in the night found that this therapy may help some children stay dry throughout the night.Many people are interested in trying alternative therapies to treat bed-wetting, and several therapies, such as hypnosis and acupuncture, appear to be somewhat effective. However, other therapies currently don't have evidence to support their use.

• Acupuncture. This treatment involves the insertion of fine needles in specific parts of the body. Results of multiple studies have found that acupuncture is effective for some children.
• Diet. Some people believe that certain foods adversely affect bladder function and that removing these foods from the diet could help decrease bed-wetting. Limited research has not involved many subjects, and more study is needed.
• Chiropractic. The idea behind chiropractic therapy is that if the spine is out of alignment, normal bodily functions will be affected. However, convincing evidence is lacking regarding the use of chiropractic for the treatment of bed-wetting.
• Homeopathy and herbs. Although some people are interested in homeopathic remedies and herbal products, none of these has been proven effective in clinical trials. If you decide to try such a product, check with your child's doctor before giving it to your child, as some of these products may contain harmful ingredients or may interact with other medications your child is taking.

Things that are cool to talk about with friends:

• your new computer games
• going to the movies
• what to do this weekend

Things that you probably don't talk about with friends:

• how you cry when you watch the movie Bambi
• the day you accidentally wore your underwear inside out
• how you wet the bed when you sleep

You Are Not Alone

Millions of kids and teenagers from every part of the world wet the bed every single night. It's so common that there are probably other kids in your class who do it. Most kids don't tell their friends, so it's easy to feel kind of alone, like you might be the only one on the whole planet who wets the bed. But you are not alone.

The fancy name for bedwetting, or sleep wetting, is nocturnal (nighttime) enuresis (say: en-yoo-ree-sus). Enuresis runs in families. This means that if you urinate, or pee, while you are asleep, there's a good chance that a close relative also did it when he or she was a kid. Just like you may have inherited your mom's blue eyes or your uncle's long legs, you probably inherited bedwetting, too.

The most important thing to remember is that no one wets the bed on purpose. It doesn't mean that you're lazy or a slob. It's something you can't help doing. For some reason, kids who wet the bed are not able to feel that their bladders are full and don't wake up to pee in the toilet. Sometimes a kid who wets the bed will have a realistic dream that he or she is in the bathroom peeing - only to wake up later and discover he or she is all wet.

Many kids who wet the bed are very deep sleepers. Do your parents complain that it's hard to wake you up? Could you sleep through a marching band parading outside your bedroom door? Or a pack of dogs howling at the moon? Trying to wake up someone who wets the bed is often like trying to wake a log - they just stay asleep.

Some kids who wet the bed do it every single

night. Others wet some nights and are dry on others. A lot of kids say that they seem to be drier when they sleep at a friend's or a relative's house. That's because kids who are anxious about wetting the bed may not sleep much or only very lightly. So the brain may be thinking, "Hey, you! Don't wet someone else's bed!" This can help you stay dry even if you're not aware of it.

Good News

The good news is that almost all kids who wet the bed eventually stop. So if you wet every night, don't be discouraged. And don't worry that you're not normal, either physically or emotionally. Sleep wetting is not usually caused by a problem with your body or your feelings

.

It's likely that bedwetting will go away on its own. In fact, 15 out of 100 kids who wet the bed will stop every year without any treatment at all. But if you have this problem it's still a good idea for you and your parents to talk to your doctor about it.

Your doctor will ask you some questions, and it's important to answer them truthfully and not feel embarrassed. Remember, bedwetting is so common that your doctor probably treats a lot of kids who do it. The doctor will examine you and probably ask for a urine sample to test. Some kids who have other problems, like constipation (when you aren't pooping regularly), daytime wetting, or urinary infections, may need some extra tests.

More Good News

If you wet the bed, there are some things you can do to stay dry. Try not to drink anything after dinner and remember to go to the bathroom before going to bed. If you do wet the bed, help with the cleanup by pulling off the sheets and putting them in the laundry.

A lot of doctors think that the best treatment for enuresis is a

program that retrains your brain to do one of two things:

1. wake you up so you can go to the bathroom
2. stay asleep and hold it until morning

This program includes doing bladder exercises, such as waiting a little longer to pee during the day, reading about and imagining staying dry, or even using a tiny alarm. The alarm is connected to a pad placed in your underwear at night. If you start to urinate, the pad senses the moisture and sets off the alarm. Different alarms buzz, vibrate, or do both, but they're all easy to use and can help wake even the deepest sleeper.

There are medicines for kids who wet the bed. They might help you temporarily, but they don't cure bedwetting. These medicines work best when combined with the alarm or other training programs.

It may take some practice to retrain your brain, and you'll need to be patient. But eventually, you will stop wetting the bed.