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 three to be dry at night. Although many children are dry at this age, it is common to need nappies at night until school age. But even beyond this age, bedwetting is common. About 1 in 7 children aged five, and 1 in 20 children aged ten, are bedwetters. A child who has never been dry at night has 'primary nocturnal enuresis'. A child who has had a good period of dry nights, but then develops bedwetting has 'secondary nocturnal enuresis'. Bedwetting is twice as common in boys than girls.

What causes bedwetting?

In most children there is no specific cause. Factors that may contribute in some children include:

• Parents may have unrealistic expectations. Some children just develop later in the bladder area than others. This is normal and is not related to intelligence, or to other developmental problems. Although it is convenient to be dry at age three, the bladder may not be ready for another few years.
• A small bladder capacity is one theory. Some children with bedwetting go to the toilet more often than average during the day. They tend not to be able to 'hold on', and have more 'overactive' bladders. If this is a cause, it usually improves as the child gets older.
• A slight hormone imbalance is another theory. Children with a bedwetting problem may not make as much hormone called ADH (antidiuretic hormone) at night as non-bedwetting children. This hormone reduces the amount of urine that you make. With less ADH, you tend to make more urine. If this is a factor, it tends to improve as the child gets older.
• Bladder awareness at night. A child with a bedwetting problem may also be less aware of a full bladder, and not wake up so easily to go to the toilet when their bladder is full. Again, if this is a factor, it tends to improve as the child gets older.
• Genetic factors. Bedwetting often runs in families. About 1 in 7 children who are late in being dry have a parent, brother, or sister who also had this problem in childhood.

Some things are thought to make bedwetting worse or more likely. They may 'tip the balance' in some children on some nights. These 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, moving house, bullying, abuse, etc.
• 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 rectum may press on and irritate the back of the bladder. In particular, children who have chronic (persistent) constipation are more likely to have a bedwetting problem. One study found that 1 in 3 children with chronic constipation had a bedwetting problem.
• Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of having a bedwetting problem.

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.

Patience, reassurance and love

As mentioned above, if trying without nappies fails at age three, 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 five years. Keep trying every few months until successful. Even if your child is bedwetting when they start 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 a child's co-operation to be dry at night. As soon as your child is old enough to understand, a simple explanation on the following lines can be helpful. "The body makes water (wee) all the time and stores it in the bladder. The bladder is like a balloon which fills up with water. We open the 'tap' when the bladder gets full. The bladder fills up at night when we are asleep. However, the bladder tap should not go to sleep, and should wake us up when the bladder is full."

Child's responsibility

When old enough (about age five or six), encourage your child to help change the 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. Try leaving the bathroom light on.

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 'train itself up'. A sensible plan is to give drinks to your child if he or she is thirsty in the 2-3 hours before bedtime, but not to have extra drinks for pleasure such as cans of lemonade. 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. So these are best avoided 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 may even prolong the problem. The child has to get used to waking up when their bladder is full. Children often do not remember being lifted, and it usually does not help to achieve their own bladder control. However, make sure your child goes to the toilet just before bedtime.

Constipation

If your child is constipated, see a doctor for advice and treatment. Treatment of constipation often cures bedwetting too. In one study, about 1 in 3 children with persistent constipation had a problem with bedwetting. Treatment of the constipation also cured the bedwetting in 2 out of 3 of those who had a problem with bedwetting.

Nights away

A common worry is that staying at friends or relatives will be embarrassing. However, it is not uncommon to find the bedwetting stops for the nights away in a strange bed. A few days away with an understanding relative or friend may result in dry nights. This may be a very positive experience and encouraging for your child.

Practical measures

Use waterproof covers for mattress and duvet, and use absorbent quilted sheets. A moisturiser cream is useful to rub on 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. The older a child becomes, the more likely bedwetting will stop. However, treatments often work to achieve dryness sooner. Treatment options include the following:

Bedwetting alarms

A 'pad and bell' or similar device is a common treatment. There is a good chance of cure for children aged seven and older (up to 8 in 10 children are 'cured'). 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 borrowed from your local continence advisor. Your doctor can advise about this. See 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 straight away. 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. For example, during holidays or for times away from home. See separate leaflet called 'Medicines to Treat Bedwetting' for more details.

Reward systems

Briefly, you agree a reward with your child if they achieve 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) and left blank for a poor night. You may agree a 'reward' for a number of stars. The aim is to give the child motivation to become dry. See separate leaflet called 'Reward Systems for Bedwetting' for more details.

Further information and help

ERIC - Education and Resources for Improving Childhood Continence

34 Old School House, Britannia Road, Kingswood, Bristol, BS15 8DB
Tel (helpline): 0845 370 8008 Tel (admin): 0117 960 3060 Web: www.eric.org.uk
Provides support and information (including booklets, CD-ROM, DVD, and video), and sells a range of products including alarms, mattress and bedding covers, waterproof duvets, etc.