Dry spells: managing bedwetting

Bedwetting is more common than most parents realise. In a school class of 30 children:

• at age five, there will be five or more children in the class who wet the bed at least twice a week
• at age seven, there will be about two in the class still wetting the bed at least twice a week
• at age 10 there will be one or two
• in the first year of high school there will be one
• in Year 10 (15 year olds) there will be one in every two classes

The Continence Foundation of Australia knows a lot about the lengths that parents will go to find a solution because bedwetting does not just mean wet sheets in the morning – more importantly it has an impact on your child’s self-esteem. The Dry Night, a resource booklet for parents can be downloaded from their website, contains reassuring information and tips on managing this common problem

The first thing to realise about bedwetting is when does it become a problem? In the under five population, the Foundation says that most children aren’t reliably dry during the day until they’re between three and four, and not dry on most nights until age four. Essentially staying dry at night is a developmental skill, and like all developmental skills children acquire them on their timeline, not yours; but be assured, almost all children will achieve staying dry at night over time.

Bedwetting is strongly linked to whether parents themselves were bedwetters: 77 percent of children whose parents both wet the bed as youngsters will do the same. Forty-three percent of children of one bedwetting parent will follow suit, and only 15 percent of children whose parents had no trouble staying dry at night will wet the bed. Grandma is your best reference here in deciding when to regard those wet sheets as a problem that is not going to go away without help.

Bedwetters fall into two categories; those who have never really been dry at night, and the child who has been dry at night for some time, then starts wetting the bed again. Of those that have never been dry, there may be a physical cause:

• A bladder which is too small, or growing too slowly
• Some children can sleep through smoke alarms going off – the remote control (the brain) telling them that their bladder is full is on ‘mute’.
• Some children do not have sufficient of a hormone called ADH (anti diuretic hormone). This message from the brain tells the kidneys to slow down urine production.
• Medical conditions such as diabetes will also impact on night dryness.

Dr Janet Hall, author of How You can be Boss of the Bladder, says children may have either ‘get up’ or ‘shut up’ bladders.

‘Get ups’ can learn the skill of waking if their bladder is full and go to the toilet. Children with ‘shut up’ bladders seem able to process the message from brain to bladder to ‘stretch’ so they don’t have to wake. 

However her clinical experience in testing children is that bladder size, dryness and sleeping all night are not logically connected. Some children with a small capacity of 150mls can be ‘shut ups’ whilst others with double the capacity are ‘get ups’.

Reversal of night time dryness may be due to

• they never learnt correct toileting
• stress such as a new baby or moving house
• changes in diet eg cola drinks are high in caffeine
• an underlying medical condition

It’s always a good idea to check with your doctor to rule out any medical causes of bedwetting. Bedwetting affects not only the bedwetter, but what you might call the ‘bed wettee’ ie whoever has to get up! With the wet sheets comes disrupted sleep, short tempers and frustration. It’s really important that you diffuse the emotions as much as possible – no child deliberately wets the bed.

Talk to your child about their feelings and realise that for some children wetting their bed is not a cause for anxiety! Eliminate external fears, such as fear of the dark, and lay out their bedroom so that there’s a clear path to the toilet, with a dim light source lighting the way. 

Problems are always best solved with everyone taking responsibility and through co-operation. Successful programs to solve bedwetting all agree – parents can’t impose solutions, instead they must be the cheer leaders for their children’s efforts and achievements.

Water in – wee out?

The verdict is in – restricting fluids at night doesn’t work! Although it might make sense, it can actually make the problem worse by reducing the bladder’s ability to expand and hold larger volumes of urine. What urine there is in the bladder will be concentrated, smellier and may irritate the bladder walls.

Water is always the best fluid after dinner, since fizzy drinks may irritate the bladder or produce extra urine. Children should also drink lots of fluid during the day – the general rule of thumb is 6-8 glasses, and this fluid intake should be spread fairly evenly across the day.

Waking for a wee

The Continence Foundation recommends that children are not ‘lifted’ from their beds each night in order to do a wee. This routine lifting may certainly reduce the number of wet sheets you have to wash, but ‘sleep walking’ a child to the loo doesn’t fit into the definition of independently managing the problem!

No wee punishments

Although part of the management plan of bedwetting is that children should manage their own wet sheets (depending on age and ability), don’t make the process of cleaning up a punishment for your child. 

Experts are also ambivalent about using reward charts. It all depends on how the chart is set up and rarely works in isolation. Set the bar too high and it will inevitable lead to failure. Rather than rewarding for dryness, reward for very small incremental improvements. It is far more likely to work if your child is keen to try this method (and so owns it) but remember, the Xbox payoff should held for major victory!

Things kids can do for themselves 

• drink more water during the day and wait longer to go to the toilet – this helps expand and train the bladder
• Let them choose what sheets are going to work best, eg plastic undersheet, or consider wearing protective undies (but stress that it is not going back into nappies!)
• Practice changing their sheets in the daytime so that they become expert at doing at night with least disruption to the rest of the household – this is best for older children.
• Keep a chart or diary to work out what time of night they are most likely to wet, then set an alarm clock for them to get up to go to the toilet.
• Watch what they eat, and make a special effort to eat more fruit and vegetables.
• Have a shower each morning – being called names because they smell is one cause of embarrassment easily eliminated.
• Realise that most people do eventually grow out of it.

Alarms

When kids get to the age of seven or eight with no sign of dryness in sight, and all other efforts have not worked, a bedwetting alarm system is the next step. Alarms are used under the guidance of a continence consultant and the aim is for your child to learn to be the person responsible for use of it.

A simple bell and pad alarm works by activating an alarm when the child starts to wet the bed. This prompts the child to wake up, go the toilet and empty their bladder fully. As this is a retraining program it’s important to reset the alarm after each episode so that each near miss is caught in time.

Bedwetting alarms have a good success rate, but only if they’re used consistently and correctly with well-motivated children.

Medication

A nasal delivery spray of the synthetic hormone Desmopressin can be prescribed – it acts to reduce the amount of urine produced at night. Generally medication is considered in cases where alarms have not worked or they are not suitable for the particular child. Hypnotherapy is also worth considering.

Typically, children who wet the bed more than once a night will start to outgrow bedwetting by beginning to wet fewer times each night. Then they move on to wetting fewer nights each week, with fluctuations back and forth, until they eventually outgrow bedwetting altogether.  Parental patience is essential as the entire process can take more than a couple of years!

The development of bladder control in childhood

1-2 years – becomes aware of a full bladder
3 years – is able to hold urine for longer and longer periods (this increases the bladder’s ability hold larger volumes of urine)
3-4 years – is able to empty bladder into a toilet when the bladder is full. The majority of children will achieve daytime dryness during this year
4 years – can stop passing urine when child wishes – the majority of children will be dry on most nights
6 years – can pass urine regardless of whether the bladder is full (the age at which it’s realistic to say, ‘I want you to do a wee before we get into the car’)

Sources

Child and Youth Health Services, SA. It also has an excellent section on bedwetting written for children.

National Continence Helpline 1800 33 00 66

National Continence Foundation of Australia. Down load copies of The Dry Night (for parents), Sleepover (a story for children), and Watertight (information for older children and adolescents).

Dr Janet Hall has run the successful Boss of the Bladder Program for over 20 years.

Drynites - commercial website with useful tips

This article was first published in Australian Family Magazine, May 2006. Updated July 2009.