BEDWETTING (nocturnal enuresis)

Written by Dr Nické Theron, Pediatrician.

“MOMMIEEEEE!” Your heart sinks when your little one calls you because he wet his bed AGAIN. The endless changing of sheets in the dark, piles of washing. Buying ANOTHER pack of pull-ups for your five-year-old. When will this all end? 

Take a deep breath, make a cup of tea and read on. You are not alone!

According to research 15-20% of 5 year olds still wet their beds. And 5% of 10 year olds. So for one in six 5 year olds, bedwetting is totally NORMAL. Bedwetting is usually not a potty-training problem, it is a developmental milestone that has to be reached. 

To stay dry at night, a few things need to happen: the brain must send out a spike of Anti-Diuretic Hormone to tell the kidneys to produce less urine at night time. The bladder needs to have a good functional capacity. The child needs to have a good bladder sensation, and the child needs to wake up when the bladder feels full. Your child should also be able to physically get out of bed, go to the potty/toilet and use it during the night.

Enuresis (urinary incontinence) is to have a loss of bladder control. In children up to the age of 5 it is still totally normal to not yet have full bladder control. According to the Mayo clinic in America it is still normal until 7 years of age. 

To be diagnosed as a problem, a child older than 5 years must wet their bed more than twice a week for more than 3 months. It has been found that children who wet their beds have family members that did the same. Children who struggle with constipation, anxiety, ADHD or who have developmental delay in other areas are also at a higher risk of enuresis at night time. Boys are also more prone to bedwetting than girls.

Some technical terms that you might hear when you speak to a doctor about your child’s bedwetting:

  • Primary Enuresis: your child has never been dry or fully potty trained
  • Secondary Enuresis: there was a period of 6 months when your child was dry or fully potty trained during the day and night, and then they start having “accidents” again
  • Nocturnal Enuresis: wetting only happens at night and dry during the day
  • Diurnal Enuresis: wetting/”accidents” happen both during the day and the night

It is not exactly clear what the cause of primary enuresis is, but there are a few contributing problems:

  • Small functional bladder (the bladder cannot hold a lot of urine as the muscles in the bladder wall is too thick/strong/over-reactive)
  • Full bladder does not wake child (the “I am full” signals sent out by the bladder does not yet register as critical in the brain)
  • Delay in developing an ADH-peak early in the evening

Secondary enuresis usually means the child has mastered his bladder developmentally, and there is something else that is contributing to the problem:

  • Constipation (large stools in the rectum pushes against the bladder and thus leaves a smaller functional capacity)
  • Urinary tract infections can cause symptoms such as frequent urination, burning urine and urgency to urinate. These symptoms can lead to diurnal enuresis.
  • Sleep apnoea (episodes during the night when your child stops breathing due to a severely blocked nose, large adenoids or obesity. Your child’s sleep is thus of a poor quality, causing them to sleep very deeply in between episodes of waking due to the apnoea, and therefore not waking up for a full bladder.)
  • Diabetes (children with uncontrolled diabetes produce large volumes of urine, leading to accidents and bedwetting)
  • Emotional / psychological issues. If your child went through a traumatic event or abrupt changes in his/her routine or if they perhaps develop a fear of the dark, it might contribute to bedwetting. An example we all lived through recently is the hard lockdown in SA: I heard from many moms whose children “regressed” from being fully potty trained to wetting their beds again. 

Now that you understand more about enuresis, let us look at a few management options to help you and your child cope with this problem.

Firstly, remember that it is usually normal and most children will outgrow the bedwetting! It is very important not to make the child feel guilty about wetting his bed, he is not doing it on purpose and it is just as embarrassing and uncomfortable for him. Involve him in the plans you make to try and reduce the frequency of the bedwetting episodes.

“Let us not become weary in doing good, for at the proper time we will reap a harvest if we do not give up.”

Galatians 6:9

Some practical tips and changes to start with:

  • Invest in a good mattress protector. You do not want to have to carry the mattress out every morning. 
  • Try to keep the items of pjs and bedding to a minimum and always have an extra set close by to prevent further night-time drama.
  • Let your child drink more fluids in the morning, tapering fluid-intake in the afternoon and stop 2 hours before bedtime.
  • Stop all high-sugar and caffeine-containing drinks.
  • Wake your child before you go to bed. You can also set an alarm for 2-3AM if that is when the bedwetting usually happens. This prevents the actual wetting episode and trains the brain to wake up at these times.
  • Keep a calendar of wet and dry nights as this can put the problem into perspective at the doctor, and show you objectively if the treatment is making a difference.
  • Ensure a normal urinating pattern during the day (4-7 times).
  • The routine use of nappies/pull-ups can make a child lazy to get up and go to the toilet, and should not be used except in special circumstances e.g. when child is sleeping elsewhere.  

Motivational therapy:

This should be the first line of therapy in 5-7year olds who do not wet their bed every night. Make use of reward charts to motivate your little one to stay dry. You can also award appropriate behaviour such as going to the toilet before bed time. Some small trials show that these interventions lead to fewer wet nights, higher cure rates and lower relapse rates than no therapy.

The moisture alarm / Enuresis alarm:

This is the most effective long-term therapy (with the lowest relapse rate and no side-effects). It works by placing a sensor in the child’s bed that activates a device to wake the child from sleep (either by sound or vibrations). It is important that the child takes some of the responsibility for the alarm by switching it off, helping to clean themselves and the bed, and to reset the alarm. 

It works by teaching the child to wake up and to inhibit bladder contraction. You must prepare yourself that this is not a quick fix, it can take weeks for the child to master this skill. Treatment can be stopped if your child has 14 consecutive dry nights. 

Medical treatment:

  • Desmopressin (DDAVP): (Slow night-time urine production) This is a synthethic hormone that mimics the work of Anti-Diuretic-Hormone. It is given orally in the late evening and then it reminds the kidneys to make more concentrated urine during the night. It can be used in children older than 5years and works the best in children with a normal bladder capacity and who has large volumes of urine at night. Total dryness is only achieved in 30% of children, and relapse rates are high when it is stopped.  Treatment should be continued for 3 months in children where signs of improvement are seen. Treatment should be gradually tapered and not stopped abruptly. Side-effects can occur if the child drinks a lot of fluid during the evening due to a low sodium concentration in the blood (more water is held back if the urine is concentrated).
  • Oxybutinine: (calm the bladder) May decrease bladder contractions and increase the functional capacity of the bladder.
  • Tricyclic anti-depressants: This medication works by decreasing the amount of time in REM sleep, stimulating the secretion of ADH and relaxing the bladder muscles. Only 20% of children using it achieve total dryness, and relapse rates are high. It should be stopped after 3 months if there is no improvement by decreasing the dose slowly. 

As you can see, there is no quick-fix for enuresis (unfortunately), but there is hope.  Behavioural changes should form the basis of the management, and if medication is required, it is important that you discuss the best option for you and your child with your health care provider. Try to keep the bigger picture in mind – they will outgrow it! Keep reassuring your child that this does not have to define him/her, there is help available. 

Stay strong and dry!

Resources:

  1. Jansson UB, Hanson M, Sillén U, Hellström AL. 2005. Voiding pattern and acquisition of bladder control from birth to age 6 years–a longitudinal study. J Urol. 2005 Jul;174(1):289-93.
  2. https://www.uptodate.com/contents/nocturnal-enuresis-in-children-management#H1
  3. https://emedicine.medscape.com/article/1014762-overview
  4. https://www.parentingscience.com/bed-wetting.html
  5. https://www.bedwettingandaccidents.com/

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