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Bed-wetting - Sleeping at the Shallow End

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Bed-wetting1 is a common condition experienced by children.

Voluntary control over the bladder during daytime is a skill learned by children in their first few years. However, voluntary control at night can be an elusive skill for some and can result in episodes of bed-wetting. Unfortunately the condition is seen by many parents to be a problem that they are responsible for and must solve quickly.

Dispelling Some Myths

They Should Have Grown Out of It by Now!

Children gradually gain control of their bladder from birth until, by the age of three, about half can and do remain dry through the night. Most of the rest have gained voluntary control by the age of five, but as the following statistics show, bed-wetting is still very common.

  • One in six five-year-olds suffer with it
  • One in seven seven-year-olds
  • One in 11 nine-year-olds

For some unlucky few (about 1 in 100) the problem can persist into early adulthood, although, in these cases, there is usually a medical reason.

'You're a Failure as a Parent!'

Children learn how to control their bladder themselves. There is very little, if anything at all, that parents can do to 'teach' a child how to 'hold it'. Perhaps a brief technical description will help.

Normally the kidneys produce a continuous stream of urine, which ends up in the bladder. As the bladder fills it gradually becomes stretched and eventually signals the brain that we have a need to urinate. This feeling of urgency should be familiar to us all. In addition, during sleep, the brain produces vasopressin which reduces urine output from the kidneys, usually to a level where the bladder does not fill completely until we are awake.

If, when we are asleep, the bladder does fill and our brain fails to recognise the sense of urgency for what it is, then the bladder has no alternative but to relax the pelvic floor muscles and open the floodgates.

Is There a Cause?

Bed-wetting can be the result of any one of several unrelated problems.

In some children, the brain doesn't produce enough vasopressin. In these cases urine production from the kidneys continues unabated during sleep. This may show up as episodes shortly after falling asleep and repeated episodes during the night. The good news is that as children grow, their brains naturally increase production of vasopressin, although for some the effects might not kick in until puberty.

In others, the bladder is simply not big enough. This will tend to show up through frequent toilet use during the day.

The brain may not recognise the signal indicating a full bladder or may not be able to trigger waking. This is not because a child sleeps deeply, it is simply that the system isn't working as it should.

In some instances, the condition may be inherited. Danish researchers have identified two genes associated with bed-wetting - ENUR1 and ENUR2. The ENUR1 gene is located on the 13th chromosome and ENUR2 is found on chromosome 12. Recently, the possibility of a third bed-wetting-related gene (ENUR3) on chromosome 22 has also been examined.

The problem can also result indirectly from external factors, such as stress, bullying, disturbance at home or even just a scary bedtime story.

Strategies for Dealing with the Problem

Although they cannot physically teach their children bladder control, parents can help a child to learn for his/her self, by offering support and encouragement. Also parents should not scold or punish a child for bed-wetting as this can reinforce the problem. Finally, parents should not be deceived in to thinking that the problem can be resolved in a day, a week or even a month. The problem can resolve itself spontaneously; it's just a question of when.

First Line Approaches

It is important to make sure that a child continues to drink enough throughout the day. This is particularly important, not only for their general health, but as a means of stretching the capacity of their bladder and allowing their brains to become accustomed to the signals from a full bladder. Try to ensure that your child drinks both with meals and in between, including during the evening.

  • Encourage your child to wait to go to the toilet and try to ensure that, when they do, their bladder is full. A good starting point is to encourage them to wait about two hours between urinations. This interval can then be extended gently.

  • Keep a record of progress and provide encouragement. Some medical practitioners advise the use of an input/output chart. However, you should discuss this with your own doctor or school nurse to determine whether it will be appropriate for your child.

  • Avoid diuretic drinks2, such as tea, coffee, fizzy drinks, cocoa and chocolate.

  • Ensure that your child is happy with their sleeping arrangements and that they can find the bathroom. Maybe they are afraid of the dark and need a night light or perhaps the room is too cold.

  • Involve your child in dealing with the problem. Get them to help change themselves and their bed when wet and if you are using a chart, have them record their progress.

  • Use mattress and duvet protectors.

  • Ensure that your child is not constipated. Constipation can contribute to bed-wetting, so make sure they have a regular diet with plenty of fibre.

  • Make sure that there are no other factors involved, like a water infection3 or stress, bullying or disturbance at home.

  • Encourage showers or baths, particularly in the morning if they have an episode, to reduce the possibility of teasing at school. Teasing can only worsen the problem, not improve it.

  • Consider a reward system for improvement.

Some Things Not to Do

  • Deliberately waking a child to go to the toilet4 might seem like a good idea, but it doesn't help train their bladder. Either the bladder will only be half full, or the child will still be half asleep. Either way, the child won't learn the sensation of a full bladder.

  • Don't restrict fluid intake, particularly during the evening, as again the child won't learn the feeling of a full bladder.

  • Irregular night time routines can prolong the problem.

  • Trainer pants5 should be avoided if at all possible. These limit the discomfort felt by a child when wet, which can make it harder for them to learn control.

Second Line Treatments

Second line treatments involve either alarms or medication, but neither are particularly recommended for children under seven.

Alarms can be purchased and in some areas may be rented or borrowed. The aim of the alarm is to wake a child when they have an episode of bed-wetting. An alarm element is placed under the bed sheets and detects the first signs of wetness. This then starts an audible signal that wakes the child to go to the toilet. It can take a couple of months before the alarm is no longer needed.

Medication is usually Desmopressin6, which is prescribed to address a deficiency of vasopressin. Unfortunately, this can be counter productive as the child can see the drug as the solution to the problem. Very rarely, a drug called Oxytocin may be prescribed for a condition called bladder instability.

Further Reading

1Also known as nocturnal enuresis.2Diuretics increase urine production.3A water infection can be evidenced by the urine smelling strongly.4This practice is sometimes called lifting.5A variety of nappy or diaper worn at night time.6Desmopressin is available as either a nasal spray or in tablet form.

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