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Helping Your Child Overcome Bed-Wetting

Toilet training a child takes a lot of patience, time, and understanding. Bed-wetting is a very common problem-so common we consider it normal until at least 6 years of age. Some 40% of 3-year-olds urinate involuntarily in their sleep, as do 10% of 6-year-olds and 3% of 12-year-olds. The medical term for this is enuresis.

Age of Child % of children have achieve night time control
Under 3 years 66%
Under 4 years 75%
Under 5 years 80%
Under 6 years 85%

Most children who urinate in their sleep have bladders that are too small to hold all the urine produced in a night (this is an inherited characteristic), and don't awaken to the signal of a full bladder. Enuresis is rarely caused by a physical disorder, and your pediatrician can detect those few cases that are. Emotional problems do not cause enuresis, either, but mishandling of bed-wetting can create psychological difficulties for children.
Most children who wet the bed overcome the problem between 6 and 10 years of age. Even without treatment, all children eventually get over it. Therefore, treatments that might have harmful complications should not be used. Treatments without side effects, however, can be started as soon as your child has been toilet-trained for longer than six months.
Often, a child who has been dry at night will suddenly start bed-wetting again. When this happens it is usually due to stress in the child's life. Such stress could be due to a big change, such as a new baby in the home, moving, or a divorce. If your child wets the bed after having been dry at night in the past, your child should be evaluated by your doctor. The bed-wetting may be a sign that stress or an illness is causing the problem.

In trying to find the cause of your child's bed-wetting, your pediatrician may ask you the following questions:
1. Is there a family history of bed-wetting?
2. How often does your child urinate, and at what times of the day?
3. When does your child wet the bed? Is your child very active, upset, or under unusual stress when it happens?
4. Does your child tend to wet the bed after drinking carbonated beverages, caffeine, citrus juices, or a lot of water?
5. Is there anything unusual about how your child urinates or the way his urine looks?

Most school-age children who wet their beds have primary enuresis. This means they have never developed nighttime bladder control. Instead, they have had this condition since birth and often have a family history of the problem. Children who are older when they develop nighttime bladder control often have at least one parent who had the same problem. In most cases, these children become dry at about the same age that their parent(s) did.
If your pediatrician suspects a problem, he or she may take a urine sample from your child to check for signs of a urinary tract infection. Your pediatrician may also order tests, such as x-rays of the kidneys or bladder, if there are signs that the problem is due to more than just delayed development of bladder control.

Signs of a Problem
Some parents fear that their child's bed-wetting is due to a disease or other physical problem. Actually, only about 1% of bed-wetting cases are related to diseases or defects such as:
1. Bladder or kidney infections
2. Diabetes
3. Structural abnormalities in your child's urinary system
With any of these cases, there will often be changes in how much and how often your child urinates during the day. Your child may also have discomfort while urinating. Tell your pediatrician if you see any of the following signs at any age:
1. Unusual straining during urination, a very small or narrow stream of urine, or dribbling that is constant or happens just after urination
2. Cloudy or pink urine, or bloodstains on underpants or nightclothes
3. Daytime as well as nighttime wetting
4. Burning during urination

Parents Need To Provide Support
It is important that parents give support and encouragement to children who wet the bed. They should be sensitive to the child's feelings about bed-wetting. For instance, children may not want to spend the night at a friend's house or go to summer camp. They may be embarrassed or scared that their friends will find out they wet the bed.
Make sure your child understands that bed-wetting is not his fault and that it will get better in time. Reward him for "dry" nights, but do not punish him for "wet" ones. Remember, your child does not have control over the problem and would like it to stop, too!
Do not pressure your child to develop nighttime bladder control before her body is ready to do so. As hard as your child might try, the bed-wetting is beyond her control, and she may only get frustrated or depressed because she cannot stop it.

A No Teasing Rule
Do not let family members, especially siblings, tease a child who wets the bed. Explain to them that their brother or sister does not wet the bed on purpose. Do not make an issue of the bed-wetting every time it occurs.

Suggestions For Children Of All Ages

1. Encourage your child to get up to urinate during the night - This advice is more important than any other. Tell your child at bedtime, "Try to get up when you have to pee." Leaving a light on in the bathroom may help. Some preschoolers prefer to use a potty chair left next to the bed.
2. Encourage your child to postpone urination - If your child urinates often during the day, encourage him to go less frequently, but don't make an issue of it. Don't remind him to use the bathroom except at bedtime. Your child should start his night with an empty bladder.
3. Encourage fluids during the morning and early afternoon - The more fluids your child drinks, the more urine she will produce, and more urine leads to larger bladders.
4. Discourage drinking more than two ounces of fluids during the two hours before bedtime - Give gentle reminders about this, but don't argue about a few swallows of water.
5. Protect the bed from urine - Have your child wear extra thick underwear in addition to his pajamas. This keeps much of the urine from getting through to the sheets. By 4 years of age, your child should no longer be using diapers or plastic pants. However, special absorbent underpants (pull-ups) are helpful for camping or overnights at someone else's home. Pull ups also eliminate the frustration you and your child feel every time the sheets have to be changed. Protect the mattress with a plastic mattress cover. Odor becomes a problem if urine soaks into the mattress or blankets.
6. Establish a morning routine for wet pajamas and wet bedding - On wet mornings, your child can rinse her pajamas and underwear in the sink until the odor is gone. If she smells of urine, she will need to take a quick shower so she won't be teased at school. You can cut down on the laundry by placing a dry towel under your child's bottom each night. This can be rinsed each morning and saved until you do your wash. If a wet bed is left open to the air, the sheets are usually dry by noon. Because of odor, the sheets may need to be washed one extra time each week.
7. Respond positively to dry nights - Praise your child on mornings when he wakes up dry. A calendar with gold stars or "happy faces" for dry nights may also help.
8. Respond gently to wet nights - Your child does not like being wet. Most bed wetters feel guilty and embarrassed about this problem. They need sympathy, not blame or punishment. Punishment or pressure will delay a cure and cause secondary emotional problems. Do not allow siblings to tease a bed wetter. Do not use pull-ups as a form of punishment- use of pull-ups should be to eliminate any frustration you and your child are experiencing.

Additional Help For Children 6 Years Of Age
Follow the previous recommendations and add the measures outlined below.

Help your child learn to wake up when her bladder feels full
Children with small bladders cannot stay dry unless they get up to urinate one or more times every night. Make sure your child understands that her goal should be getting up, not holding her urine until morning. Give her a pep talk every night, before she goes to sleep. Tell her she needs to practice waking up when her bladder feels full. Tell her to:
1. Lie on your bed with your eyes closed.
2. Pretend it's the middle of the night.
3. Pretend your bladder is full.
4. Pretend it's starting to hurt.
5. Pretend it's trying to wake you up.
6. Pretend it's saying: "Get up before it's too late".
7. Then run to the bathroom and empty your bladder.
8. Remind yourself to get up like this during the night.

Encourage your child to change his own wet clothes and bedding during the night
If your child wets at night, he should try to get up and change himself.
1. First, if your child feels any urine leaking out, he should try to stop the flow of urine.
2. Second, he should hurry to the toilet to see if he has any urine left in his bladder.
3. Third, he should change himself and put a dry towel over the wet part of the bed.

This step can be made easier by keeping dry pajamas and towels on a chair near the bed. The child who shows the motivation to carry out these steps is close to being able to awaken from the sensation of a full bladder.

Find out how much your child's bladder can hold
Ask your child to hold her urine as long as possible, then urinate into a container. Do this on at least three occasions and measure the amount of urine in ounces. The largest of the three measurements can be considered your child's bladder capacity. Normal capacity is one or more ounces for each year of age. In a 6-year-old, a capacity of five ounces or less is small; six to eight ounces is normal and means that the bladder can hold a nights’ urine production until morning.

Encourage bladder stretching exercises
These exercises gradually enlarge the size of the bladder so that it can hold more urine at night. Introduce the exercises only if your child wants to try them. For some children, that won't happen until age 8.
To stretch the bladder, encourage your child to hold his urine as long as possible during the daytime. Waiting ten to 15 minutes after he feels the urge to urinate during the day can help your child's bladder wait at night until he wakes from a deep sleep.
Learning to resist the first urge to urinate is especially important. Whenever your child feels the urge to go, he can try to distract himself for the ten seconds or so it takes for the bladder spasms to stop. At least once a day, have your child urinate into a measuring cup to see if he has maintained or even beaten his previous record (in ounces). Mark the highest volume achieved with a piece of masking tape on the cup.

Help your child assume responsibility
Your child should feel responsible for solving the bed-wetting problem. The bladder exercises, self-awakening program, control of fluid intake, and record keeping all need her involvement and commitment. Do not routinely awaken your child at night to urinate unless you are temporarily helping her learn to respond to an enuresis alarm.
As long as you are waking up your child, she is less likely to do it for herself. Your child should look upon you and her pediatrician as people who can provide suggestions and support but who do not take responsibility for the bed-wetting.

Bed-Wetting Alarms
Alarms are used to teach a child to awaken when he needs to urinate during the night. They have the highest cure rate (about 70%) of any available approach. They are the treatment of choice for any child with a small bladder who can't otherwise train himself to awaken at night. The new transistorized alarms are small, lightweight, sensitive to a few drops of urine, not too expensive (about $40 to S60), and easy for a child to set up by himself. Some children as young as 5 years want to use them. Children using alarms still need to work on the self-awakening program.

How To Use A Bed-Wetting Alarm
Almost all children who wet the bed need to get up during the night to urinate. A bed-wetting (enuresis) alarm, which is activated by moisture, can help your child learn to awaken in time to go to the bathroom. The new models are lightweight and easy for the child to operate. Enuresis alarms can be used on any child from age 5 onward who wants to try one. On the other hand, they should never be imposed on a child at any age, even 12, if he or she doesn't want to use one.

What To Tell Your Child About a Bed Wetting Alarm
Give your child the following instructions:
1. This is your alarm. It can help you wake up if you use it correctly. Remember, the alarm won't help you unless you listen for it carefully and respond to it quickly.
2. Hook up the alarm system by yourself. Trigger the buzzer a few times by touching the sensors with a wet finger and practice going to the bathroom as you will do if it goes off during the night.
3. Turn on your nightlight before you go to sleep or keep a flashlight near your bed so you can see what you are doing when the alarm sounds.
4. Try to beat the buzzer. Wake up when your bladder feels full, but before any urine leaks out and sets off the alarm. If the buzzer does go off, try to wake up and stop urinating as soon as you think you hear it (even if you think you are hearing it in a dream).
5. As soon as you hear the alarm, jump out of bed and stand up. Once you are standing and awake, turn off the buzzer by removing the metal strip from the little pocket in your underwear (if you have a Wet-Stop) or disconnect the clips (if you have a Nytone Training System) and dry them off.
6. Hurry to the bathroom. Empty your bladder to see how much urine you were able to hold back.
7. Put on dry underwear and pajamas, and reconnect the alarm. Put a dry towel over the wet spot on your bed. Remind yourself to get up before the alarm buzzes next time and review your plan.
8. In the morning, write on your calendar DRY (no alarm), WET SPOT (you got up after the alarm went off), or WET (you didn't get up).
9. Use the alarm every night until you go three or four weeks without bed-wetting. This program usually takes two to three months, so try to be patient.
10. While your child is using the bed-wetting alarm, it's very important that he also practice a self-awakening program at bedtime.

How To Order An Alarm
Alarms and parent information flyers can be ordered from:
1. Potty Pager: 800-497-6573 www.pottypager.com
2. SleepDry Alarm: 800-346-7283 www.sleepdryalarm.com
3. Palco Wet-Stop Alarm: 877-768-8963 www.wetstop.com
4. Nytone Enuretic Alarm: 801-973-4090 www.nytone,com

Alarm Clock
If your child can't awaken herself at night and you don't want to use a bed-wetting alarm, teach her to use an alarm clock or clock radio. Set it for three or four hours after your child goes to bed. Put it beyond arm's reach. Encourage your child to practice responding to the alarm during the day while lying on the bed with eyes closed. Have her set the alarm each night. Praise her for getting up at night, even if she isn't dry in the morning.

Medications
Most children who have trouble staying dry at night need extra help for slumber parties, camping trips, vacations, or other overnights. Some take an alarm clock with them and stay dry by awakening once at night. Some are helped by temporarily taking medication at bedtime.
The drawback of these medications is that bed-wetting usually returns when your child stops taking them. They do not cure bed-wetting. Therefore, children who take medication for enuresis should also be using an alarm and learning to wake themselves up at night.

DDAVP is a drug to treat children with bed-wetting. Although DDAVP does not cure the condition, it does help treat the symptoms while the child is on the drug. DDAVP is a man-made copy of a normal body chemical that controls urine production. The benefit of DDAVP might be due to a reduction in the overnight production of urine or possibly to an effect on arousal.
DDAVP can be taken as a nasal spray or tablet. However, the tablet has several advantages. If your child has no problems swallowing pills, the tablet is more discreet for sleepovers and other special occasions. Additionally, the tablet has reported a better response rate. The nasal spray can be affected by a stuffy nose from colds or allergy.
DDAVP has few side effects. The most common side effects with the nasal spray are nasal discomfort, nosebleeds, tummy pain, and headache.
The only serious side effect (very rare) noted in children treated with DDAVP is seizures due to water intoxication (drinking too much water). This serious problem is preventable with care not to overdo fluids on any evening that DDAVP is taken. Children should take only one eight once cup of fluid at supper, no more than 8 ounces between supper and bedtime, and nothing to drink in the two hours before bedtime. Early symptoms of water intoxication include headache, nausea, and vomiting. If these symptoms occur, the medication should be stopped and the child should be seen by a doctor immediately.
Another drug, Imipramine, comes as a tablet. It is safe at the correct dosage, but dangerous if too much is taken or a younger sibling gets into it. Imipramine generally is not used to treat bed-wetting in children younger than 6 to 7 years of age. Success rates have been found to be higher in older children. Even though Imipramine is a type of antidepressant, there is no reason to suggest that depression plays a role in the cause of bed-wetting.
This drug is thought to work one of several ways:
1. by changing the child's sleep and wakening pattern
2. by affecting the time a child can hold urine in the bladder
3. by reducing the amount of urine produced.

If you do use either medication, be very careful about the amount you use and where you store it-and be sure to keep the safety cap on the bottle.

The Parent's Role
If your child doesn't awaken immediately to the sound of the buzzer on the bed-wetting alarm, she needs your help. You may need to be involved every night for the first two to three weeks. Here's what to do:
1. Go to your child's room as soon as you hear the buzzer. Turn on the light and say loudly, "Get out of bed and stand up.'
2. If that doesn't work, sit her up in bed and run a cold washcloth over her face to bring her out of deep sleep.
3. When she is on her feet, remind her to turn off the alarm. Don't do it for her. Your child must learn to carry out this step herself.
4. Make sure the child is wide awake and walks into the bathroom before you leave her. If necessary, ask her questions to help her wake up.
5. Your goal is to help your child awaken immediately and get out of bed when the buzzer goes off. Phase yourself out of the alarm program as soon as possible. Making sure your child goes to bed at a reasonable hour, with the radio off and a night light on, can help her respond faster to the alarm.

Adapted from Schmitt BD: Your Child's Health and The American Academy of Pediatrics Handout on Bed-Wetting



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