Bedwetting (Nocturnal Enuresis)

Bedwetting

by T. Berry Brazelton, M.D., author of Toilet Training: The Brazelton Way

Of all the toilet training steps, staying dry at night is the most difficult. Don't expect it to come until well after your child learns to use the toilet during the day. For a child to hold onto urine all night demands a number of accomplishments, including:

• The child's bladder, sphincters (the muscles that keep the bladder shut), and the rest of his urinary tract must be sufficiently mature, as well as the hormones that influence the production of urine;
• Sleep cycles also need to be developed enough so that the sensation of a full bladder can rouse him from deep sleep to a wakeful state.

For many children who still wet the bed, these have not yet matured. Their pace needs to be respected.

When to Worry: According to the Children's Hospital Boston Guide, 12-20 percent of 5-year-olds and 8 percent of 6-year-olds aren't able to stay dry all night. By 6 years of age it is certainly worth bringing this to the attention of your pediatrician. He or she will first check to be sure that there are no medical causes or major stresses related to the bedwetting. Be sure to get help at the earliest sign that a child's self-image might be in jeopardy—or before. When a child begins to restrict his activities, refusing to sleep at a friend's house, or appears evasive or ashamed about his bed's damp sheets, it is surely time to look for help.

Bedwetting in a Previously Dry Child: It is helpful to distinguish between bedwetting that starts up in a child who has been dry for at least 6 months from that of a child who has not yet stayed dry at night. If a child has been dry for at least 6 months and then begins to wet again repeatedly (often enough for it to be a nuisance), it is important to consider several possible reasons. Most of the time there has been a change, a disruption, or stress—sometimes mild, for example, a family trip, a minor illness, a parent out of town for work, a change in routine, or an exciting new event, sometimes major (a move, or a new baby in the family), sometimes more serious. Bedwetting can also occur when a child is about to take a new developmental step ahead, a time when you can expect a temporary step backward in another area—a touchpoint.

Only a minority of children who wet their beds after age 5 (roughly 10 percent) will have a medical explanation for their renewed bedwetting. Be sure the doctor tests your child's urine. Does the child have a burning sensation on urinating? Children who have urinary tract infections (more likely in girls) may also be urinating more than usual. Girls this age with urinary tract infections may need to be reminded to wipe themselves from front to back so that they do not introduce bacteria that can cause infection from their feces into their urinary tract. Juvenile diabetes is another cause. The first symptoms may be frequent urination, increased drinking and eating, without weight gain, and then weight loss. Very rare causes of new, repeated bedwetting include neurological disorders.

Bedwetting in a child who has been dry can also be triggered by distressing events in the child's life: for example, the death or serious illness of a close family member, severe strain in the parents' relationship, or a divorce. Sexual molestation is an uncommon cause of bedwetting in a child who had previously been dry, but also needs to be considered when repeated bedwetting suddenly emerges—as if out of the blue. If this is a concern, your pediatrician should refer you to mental health professionals experienced in making this assessment. If confirmed, psychological help is of course needed.

If the child's pediatrician can find no medical cause, try to identify a stress that may have precipitated this symptom. Share it with the child, so he can understand the reason for his setback or "failure" (as he will see it). Of course you may feel disappointed and he's likely to sense it—and he will be disappointed in himself. If you do get angry or exasperated, apologize to him. Try saying, "I know you don't like it either. We'll work on it together. If I can help you, I will, but I want you to tell me to lay off when it feels like I'm pushing you."

Persistent Bedwetting—Possible Causes: When a 6-year-old has never been consistently dry at night, his pediatrician will probably want to look for some of the causes described above. But when it has remained a problem until this age, it is even more likely that the bedwetting is the result of an immature urinary system or sleep pattern. Here are some examples of the usual temporary delays that are thought to cause persistent bedwetting:

• A small bladder, or a normal-sized one that can't hold onto urine when full.
• Decreased antidiuretic hormone (ADH), a chemical the body makes to control urine production. Sometimes, a synthetic form of this hormone (DDAVP) can be prescribed by his pediatrician, though usually this is best saved for short-term use—like sleepovers and summer camp.
• Difficulty in arousing from deep sleep at night—an immature sleep pattern in which sleep cycles don't rouse him to urinate. Insufficient sleep may make this worse.

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