BED WETTING

Bed wetting, or nocturnal enuresis, is a common issue among children and young adolescents, characterized by involuntary urination during sleep. If it persists beyond the age of 5, it can affect a child’s self-esteem and emotional well-being.

Many children experience a delay in achieving nighttime bladder control. Statistics show that by age 5, about 85% of children have dry nights, and this increases to 90-95% by age 10. Therefore, bed wetting is quite common in the early years.

Primary nocturnal enuresis refers to a condition where a child aged five or older involuntarily urinates during sleep, having never consistently achieved nighttime dryness. When one or both parents have a history of prolonged bed wetting, there is increased risk of their children will also have these symptoms. If both parents experienced bed wetting as children, their offspring have around a 70% chance of encountering the issue. If only one parent was affected, the likelihood is approximately 40%. Bed wetting is twice as common in boys as girls.

Urinating during sleep is normal in young infants and children and represents a natural part of development. In the early years of a child’s life, before age 5, bladder control mechanisms and the nervous system are still maturing. As children grow, they gradually gain bladder control during wakeful times. Over time, their bodies learn to communicate bladder fullness effectively, which even carries over during sleep.

Children’s sleep patterns begin to mature, eventually helping them achieve consistent nighttime bladder control. Sleep and bladder control are interconnected. During sleep, children (and adults) naturally experience an increase in the production of the antidiuretic hormone (ADH), which helps concentrate urine and reduce urine production overnight. This process is why children and adults generally do not need to urinate as frequently during the night.

Antidiuretic hormone, also known as vasopressin, is produced in the hypothalamus and stored in the posterior pituitary gland. It manages water balance by regulating how much water the kidneys reabsorb. Higher levels of ADH result in water retention, while lower levels lead to more urine production. Thus, ADH works by retaining water in the body, thus reducing urine volume and concentrating the urine. Its short half-life of about 15 to 20 minutes allows for quick metabolism and precise regulation, adapting efficiently to the body’s hydration needs.

Research investigating the connection between antidiuretic hormone (ADH) levels and sleep patterns in children with nocturnal enuresis have shown that many enuretic children have abnormalities in the secretion of ADH at night during sleep. Instead of the expected elevated levels of ADH during sleep that reduce urine production, many enuretic children have lower or less consistent ADH levels, which leads to increased urine production and contributes to bedwetting.

Regarding sleep architecture, research has also indicated that enuretic children often experience differences in their sleep patterns, including prolonged deeper stages of sleep. These children may spend more time in the stages of deep sleep (stage 3 NonREM sleep). This deep sleep phase may make it more challenging for the child to respond to bladder signals during the night, rendering them less likely to wake up as their bladder fills. The prolonged stages of deep sleep may also affect ADH levels, lowering them, thus resulting in larger volumes of urine being produced: a recipe for a wet bed. This research shows that both hormonal regulation and sleep patterns may play a role in the occurrence of nocturnal enuresis. This interplay contributes to the complexity of the treatment of this condition.

Work up of a child with enuresis

We recommend an office evaluation with one of our physicians if bed wetting persists at six to seven years of age, occurs more than twice a week, is considered a “problem” for the family and if the child and parents are motivated to comply with treatment options. A urinalysis should be obtained to rule out underlying medical conditions such as an urinary tract infection or diabetes. Treatment options depend on the needs, preferences and commitment levels of the child and parents.

Treatment of bedwetting in children under 7 years of age:

Management of bed wetting under the age of seven years should include: education, motivational therapy (such as rewards or sticker charts), and reassurance. Bed wetting in young children typically resolves on its own without treatment.

Measures that can help reduce and manage bed wetting include:

1. Making sure the child voids regularly during the day and right before bedtime.
2. Fluid intake should be concentrated early in the day and limited in the evening.
3. Avoidance of high sugar and caffeinated drinks especially in the evening. 
4. Placing waterproof mattress covers and absorbent pads make cleanup easier, reducing discomfort for both child and parents.
5. Establish routines for using the toilet before bed.

When addressing bed wetting, it is crucial for parents to adopt a compassionate, patient and gentle approach. Shaming or punishing a child for bed wetting can lead to increased stress in the child and make the problem even worse. Encouragement, positive reinforcement on dry nights, and being supportive foster confidence and good self-esteem in bed wetting kids. Do not shame a child who wets the bed! Relational damage is likely in this circumstance. Resentment towards a shaming parent or caregiver can last a lifetime. Guard your words!

Treatment of Primary Nocturnal Enuresis in children over 6-7 years of age: 

1. Enuresis Alarms: Enuresis alarms are designed to condition children to recognize a full bladder. They detect moisture and alert the child as soon as bed wetting begins, training them over time to wake before urination. The alarm may also work by limiting the time that children remain in deep sleep, because of the disruption to sleep cycles that the alarm going off causes. Consistent daily use is often key to their success.
2. Desmopressin Acetate (DDAVP) Tablets: This medication mimics the actions of ADH, reducing the production of urine at night. DDAVP tablets are effective but it is generally recommended for short-term use, such as overnight stays or before special events such a sleepovers. The half-life of DDAVP tablets in the blood is about 3 hours, making it much longer lasting than natural ADH. DDAVP nasal spray is no longer recommended for primary nocturnal enuresis due to some children rarely developing hyponatremia (low blood sodium levels) due to its use.
3. All five measures mentioned above for younger children with bedwetting.

While nocturnal enuresis can be challenging, most children naturally outgrow it eventually. By understanding the underlying causes, applying effective treatments, and offering emotional support, parents can help their child navigate this developmental phase with minimal impact on their child’s confidence and well-being.

Secondary enuresis

Secondary enuresis, the recurrence of daytime or nighttime wetting after a period of dryness lasting at least six months in older children, can arise from various causes which require careful assessment. This condition may be caused by psychosocial factors, such as stress or anxiety from events like starting school, family changes (for example, a new baby, a new marriage, divorce or bereavement) or from bullying. Emotional trauma or other significant life transitions can also contribute to the condition.

Medically, secondary enuresis can result from several conditions. Urinary tract infections (UTIs) can irritate the bladder, while conditions such as diabetes mellitus or diabetes insipidus often increase urine production patterns. Sleep disorders, particularly sleep apnea, constipation (where stool impacts bladder pressure), and neurological disorders affecting bladder tone and control also need to be considered.

Genetic predispositions— suggested by a family history of enuresis—can play a role, as can hormonal factors, such as inadequate production of antidiuretic hormone (ADH) described previously, which normally reduces urine output at night.

Other considerations include high fluid intake in the evening, caffeine consumption, which is a diuretic, and potential bladder dysfunctions like overactive bladder or new structural abnormalities. Obviously, secondary enuresis is a complex matter. An office visit is warranted for any child with secondary enuresis.