WHAT PARENTS NEED TO KNOW ABOUT BEDWETTING

Every night across America, 5 to 7 million children are turning off the lights, going to sleep, and wetting their beds.

The medical name for bedwetting is enuresis - "the involuntary voiding of urine beyond the age of anticipated control" - and it's a common condition in children and adolescents. It is also very stressful for both parents and children. For the child wetting the bed, it's often a major embarrassment. For parents, there may be a mixture of annoyance and sometimes a little anger. They wonder if bedwetting is done on purpose or because of laziness.

Who's affected?

Enuresis affects 15% to 20% of 5- to 6-year-old children and about 1% of adolescents. Most children with enuresis are physically and emotionally normal. While some may have small bladders, this should not keep them from achieving dryness.

Simple sleep-wetting in children under age 6 is so common that it doesn't warrant a special treatment program. The average age of children treated at the Enuresis Clinic at the Alfred I. duPont Hospital for Children is 10.

Enuresis often runs in families - 85% of the children seen at duPont's clinic have a relative with enuresis, and 57% have a parent or sibling with enuresis.

Types of Enuresis

Most children have "primary" enuresis, meaning that they have wet their beds since toddlerhood. Enuresis has nothing to do with how a child was taught to use the toilet.

Parents should not feel guilty or think they did something wrong.

Some children have "secondary" enuresis, meaning they were dry for at least a few months and then became wet. While some medical problems, such as urinary tract infections or diabetes, and some family stresses, such as divorce or school problems, may play a role in secondary enuresis, often no specific reason is identified.

Most children with enuresis have nocturnal (or night-time) enuresis. They wet while asleep. Occasionally some children wet during the day while awake (diurnal enuresis). They may have an unstable bladder, which is associated with frequent urination and urinary tract infections. These children may also be seen by paediatric urologists and occasionally use medication for a few months to relax the bladder muscle.

Constipation is associated with enuresis, sometimes with underwear soiling (encopresis) in severe cases. Usually, simple dietary changes can cure mild constipation, but in severe cases constipation may require aggressive treatment before the enuresis can be addressed.

Primary enuresis can also be associated with other disorders such as attention deficit hyperactivity disorder and sickle cell anemia/trait. Enuresis is responsive to the nonpharmacologic approach used in the clinic.

Causes and treatments

No one knows exactly why children wet the bed - there may be many reasons. Almost all children seen at the duPont clinic, for example, are very deep sleepers. While other children wake up when they sense that their bladders are full, these children may simply have difficulty arousing.

Some children are drier when sleeping at a friend's or relative's home, but always wet in their own bed. Perhaps when sleeping in a strange bed away from home, they do not sleep quite as deeply. This is especially frustrating for the child and parents. However, this is an excellent sign that the child should be able to be cured. These children may be consciously or subconsciously thinking about staying dry through the night when they are away from home. This kind of mental imagery can help.

"Most parents have tried waking their children up during the night to urinate (not an easy task), but often they are still wet in the morning, and everyone is exhausted," says Sandra Hassink, M.D. of the duPont Hospital for Children. "Most also try fluid restriction (sometimes to extremes), and their children still are wet the next morning - and thirsty all night. We do not stress these types of techniques. We want children to sleep through the night or awaken on their own. We do stress common sense with the amount of fluids at night, plus avoiding caffeine."

According to Dr. Hassink, enuresis almost always resolves on its own and is not the child's fault. "Success in enuresis treatment depends on a motivated child. Though they might not know 'how' to change their sleep behaviour, dry nights can be achieved. We stress that almost no one wets the bed on purpose. After all, it's often embarrassing and uncomfortable. Punishments have no place in the treatment of sleep-wetting, and can make the problem worse. If there is to be success, family support and positive reinforcement are vital."

"Most of the children seen in our clinic wet 7 nights per week," Dr. Hassink says. "Some wet multiple times per night. Still, they can become successful at staying dry. Understandably, most children think that they are the only ones in their class who sleep-wet. We emphasise to them that others also sleep-wet, but since most children aren't likely to discuss sleep-wetting with their friends, it may feel as though they are the only ones with the problem." It is helpful to let a child know about other family members who used to be wet but are now dry.

Parents should discuss sleep-wetting with their child's doctor. A history, physical exam, and urinalysis screening are important first steps - and usually show completely normal results. Many hospitals have established clinics to help treat the problem.

As children increase in age, the percentage who have primary nocturnal enuresis usually decreases. A child who sleep-wets is likely to stop eventually. The purpose of a treatment program is to make this happen sooner. Success can come as early as 1 or 2 months after treatment has begun.

Most successful treatment programs are multifaceted, using several techniques simultaneously to achieve the greatest effect with the fewest office visits (usually one or two).

The duPont enuresis clinic

"We treat hundreds of boys and girls each year in our clinic at duPont," Dr. Hassink says. "Our approach stresses changes in behaviour, not use of medications. Some programs use the anti-diuretic hormone DDAVP that can be sprayed up the nostrils before bed. Most of our patients have already tried these medications unsuccessfully by the time they see us. The 1-year cure rate for the medications isn't as good as you would hope. In fact, it's less than half of that of the behavioural methods. And medications often are expensive. On the other hand, your child's doctor may be comfortable with this approach initially. For some it does work."

Dr. Hassink encourages having the children take responsibility by helping with the wet sheets. This is not a punishment! Rather, children will often feel better by helping with the clean-up process. "We suggest that the children stop using pull-up pants for 1 to 2 months while they are on a program, and do bladder stretching exercises once a day. We also have the kids read a picture book about enuresis each night to reinforce staying dry.

A buzzer alarm (either auditory or vibratory) is a big part of our program. One quarter of our patients have previously tried buzzer alarms without success. But when they use it in combination with other techniques, they do well. We also go over how the children can practice waking up with the buzzer with Mom or Dad there (before going to sleep). Finally, we stress that it takes weeks to months to respond to these techniques and that everyone must be patient. The most common mistake is to do a program for 1 to 2 weeks and then give up."

It's important for parents to be supportive of a child with enuresis and to remember that the long-term outlook is excellent. In almost all cases, dry days are just ahead.