Bedwetting is an issue many parents deal with, yet few discuss. They may fear violating their child’s privacy or feel that others will criticize their parenting; or maybe they wrestle with their own feelings of concern and frustration. It can be isolating.
The American Academy of Pediatrics says that 5 million children older than 6 continue to cope with nocturnal enuresis, or bedwetting. About two out of three of these are boys, and most have a parent who struggled with bedwetting as a child. The AAP also says that enuresis can often go away on its own in a certain number of affected children each year. But what is a parent to do when a child doesn’t “grow out of it?”
Marlo Eldridge, a nurse practitioner, is director of the Pediatric Voiding Improvement Program at Johns Hopkins Hospital’s Brady Urological Institute. Eldridge understands the strain that bedwetting can put on family functioning, and she helped shed light on this nighttime challenge.
Involuntary Action
Let’s start with a key fact: “There is nothing tied between intelligence and continence,” Eldridge says with great emphasis. Primary nocturnal enuresis is involuntary urination during sleep, after an age when bladder control generally occurs. The Type A parent in all of us may find it hard to ignore the parents who boast about little Jane who potty trained at age 1 and kept dry all night at 2. Stop comparing.
Ordinary Development
Bedwetting often resolves by about age 4 but is still not uncommon even between ages 8 and 10, according to Eldridge. Most often, development will resolve the issue over time. By age 10, about 95 percent of children are dry at night. But as many as 2 percent still present at age 18—mostly due to unresolved or missed diagnostic opportunities. “It is not considered out of the ordinary until the seventh birthday,” Eldridge says. “When it persists beyond age 7, there are factors to investigate.”
Tank Size
I wondered if continence was more a factor of age or body size. Eldridge reminded me that it varies by child, as she’s seen some bedwetting 9-year-olds weighing 50 pounds and others 100 pounds, so there’s no magic number. “Instead, think about tank size,” she says, “and what could be limiting capacity.” An undersized bladder, or incomplete emptying of the bladder, may be a root cause. Find baselines of functional bladder capacity by measuring urine output. “A 7-year-old’s max urine output is about 270 cc (cubic centimeters),” Eldridge relates for perspective. “If he or she is only voiding 120 cc, think about that. That’s four ounces (about a juice box). Some kids may need to urinate after only 60 cc. What is limiting that tank capacity?” Talk to your pediatric primary-care provider about your concerns. You may want to discuss imaging studies, such as an abdominal X-ray and renal/bladder ultrasound, with your child’s provider. These can sometimes be done before seeing an urologist and help expedite proper diagnosis.
Other Issues
Functional elimination syndrome refers to bladder issues with bowel involvement (constipation). Eldridge says that, in her experience, 95 percent of the time the answer is that a stool is causing the wetting. “Think of it like a brick on top of the bladder,” she says. “Many kids poop daily and show no signs of constipation, yet a scan may reveal blockages.” That stool is taking up space and putting pressure on the bladder, causing it to feel full before normal capacity. In some cases, a one-day cleanout followed by a regimen of MiraLAX resolves the issue.
Regulatory Hormones
Another possible cause of bedwetting is deficiency of arginine vasopressin— an anti-diuretic hormone that tells the body to slow down kidney production overnight and prevent the bladder from filling up during sleep. Some bedwetting is resolved by supplementation with desmopressin acetate (DDAVP). It’s not dosed by weight, so providers may begin with a .2 milligram oral tablet at bedtime and adjust from there. “If desmopressin deficiency is the culprit, you would know within the first three days if it works,” Eldridge says.
Super Deep Sleep
“Sleep quality can definitely be another factor,” she says. “About 90 percent of the parents we see say, ‘Oh, you could drive a truck through the room and he/she wouldn’t wake up,’ which implies very deep sleep, and that means trouble rousing for bladder signals.” Deep sleep may be due to chronic fatigue. Ensuring healthy sleep habits, eliminating caffeine, restricting fluid consumption in the evening and waking a child to urinate partway through the night are some of the many ways you can help heavy sleepers. Obstructive sleep apnea from oversized tonsils causes poor airflow while sleeping and leads to chronic fatigue. Although this would not be a reason for a tonsillectomy, the elimination of bedwetting is sometimes a bonus outcome.
Some children can benefit from bedwetting alarms, which detect moisture and trigger a loud noise to rouse the child and condition them to wake at the sensation of a full bladder. However, kids may desensitize to the alarm over time. Also, the use of absorbent nighttime underpants would render an alarm ineffective.
Pull-ups and Pads
Today there are abundant commercial products for bedwetting, particularly those geared toward children over preschool age. Eldridge says it does not mean that the problem has become more common, rather that we are doing a better job with information. “More products mean more kids are better able to socialize and participate in things and function normally, and that is a huge step,” she says.
A common question is whether pull-ups hinder progress. “The answer is no,” Eldridge says. “Think of it this way: Waking up in wet sheets does not set the stage for a positive day.” Children feel ashamed and guilty for something that wasn’t even in their control. Parents find it hard to respond with understanding to running yet another load of laundry and scrubbing a mattress. “It is worthwhile to use products that allow the child to wake up dry, as the issues are resolved,” she says. What’s more, those absorbent underpants for bigger kids help unlock potential to go to sleepovers with less fear of embarrassment.
Risks for Older Kids
What happens when children don’t outgrow bedwetting? The biggest issue is self-esteem, particularly as they get older. Some pediatric urology offices have a behavioral psychologist on staff to help children and families with compliance, to address self-image and to guide families in developing healthy habits. “Pressure, shaming or punishment for a condition they cannot control is psychologically damaging to children,” Eldridge says. “Check all underlying factors. Get them motivated. Treat them fully and holistically. Prepare the body to be successful.”
Who Can Help?
If your child is past the seventh birthday and still not staying dry at night, ask your pediatrician or pediatric nurse practitioner for help in finding the root cause. If you need to see a specialist, Eldridge advises, “Seek out a fellowship-trained pediatric urologist. Any urologist can hang a shingle that says they’ll treat peds, but they cannot have the depth of knowledge that a pediatric specialist will have. I don’t try to treat prostate cancer, but I know all about pediatric elimination issues.”
Rest assured, better days (and nights) are within reach.
