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Bedwetting (or nocturnal enuresis or sleepwetting) is involuntary urination while asleep. It is the normal state of affairs in infancy, but can be a source of embarrassment when it persists into school age or the teen years.
Primary enuresis is when the child has never been dry at night or would not sleep dry without being taken to the toilet by another person or has some dry nights but continues to average at least two wet nights a week with no long periods of dryness. Secondary enuresis occurs when a child goes through an extended period of dryness and begins to experience night-time wetting again. Secondary enuresis is often (though by no means always) caused by emotional stress.
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Regulation in the organism
Children usually achieve nighttime dryness by developing one or both of two abilities. There appear to be some hereditary factors in how and when these develop.
One is a hormone cycle in which a minute burst of antidiuretic hormone happens daily at about sunset reducing kidney output of urine well into the night so the bladder doesn't get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six, others between six and the end of puberty, and some not at all.
The other is the ability to awaken before sleepwetting. For some children this is a natural extension of learning to be aware of and control their bladders while awake. For others, a variety of factors suppress or disrupt this awareness when asleep, and they are unlikely to develop it. Taking children to use the toilet while not fully awake can prolong dependence on that by encouraging them to urinate while nearly asleep.
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Prevalence
Figures commonly cited suggest that enough children sleepwet at age six (perhaps one in three) so that it is within normal expectations and supportive management is appropriate until a child is seven or eight or has the maturity and desire to take an active role in planning and implementing specific treatment. Also, even with no active treatment, about 15% (one in seven) of children who do sleepwet will stop each year through natural development. Some sources indicate that 5-10% of teenage children experience occasional sleepwetting.
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Treatment
Tricyclic antidepressant prescription drugs with anti-muscarinic properties (i.e. Amitriptyline, Imipramine or Nortriptyline) may be used to treat bedwetting with much success for periods up to 3 months.
Another medication, Desmopressin, is a synthetic replacement for the missing burst of antidiuretic hormone. Desmopressin is usually used in the form of Desmopressin acetate, DDAVP. Whether used daily or occasionally, DDAVP simply replaces the hormone for that night with no cumulative effect.
Some psychologists and experts recommend the use of night-time training devices such as a bedwetting alarm to help condition the child first to wake up at the sensation of moisture and then at the sensation of a full bladder. Success with alarms is increased and relapses reduced when combined in programs which may include bladder muscle exercises, dietary changes, mental imagery, stress reduction, and other supportive activities.
Using absorbent products such as diapers or padded night-time pants usually helps bedwetting children feel less embarrassed about their accidents. Although these products will not treat or cure bedwetting, they make it easier for children and their families to deal with the issue.
The use of diapers or disposable training pants without any other treatment is not considered unusual until about 6 to 10 years of age. After that point, other treatments may be used with or without absorbent products, such as the aforementioned medication or alarm systems. Occasional bedwetting such as once a month to once a year is normal for a child between 4 and 16 and nothing to get alarmed at.
There is however, a growing number of voices against the use of such products, because some parents feel that they can hinder, rather than help the process of assisting with bedwetting; since some children appear to treat them and indeed use them, as a substitute diaper.
Experts generally agree that parents' understanding that sleepwetting is not the child’s fault strongly increases the child's willingness to help deal with it. Although historically, physical punishment such as spanking was the normal method of incentivizing older children to stop sleep wetting, anti-spanking advocates have discouraged any corporal punishment for this purpose. Punishments including restrictions, teasing, or shaming, whether actual or threatened, are counterproductive. Encouragement of self reliance allows for the child's own natural and native development to acquire the ability to sleep dry on his or her own terms.
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Myths and Common Misconceptions about Bedwetting
You have to wait for your child to outgrow bedwetting.
Although 15 percent of bedwetting children stop wetting on their own each year, that means 85 percent will still be wetting this time next year. Because we now have safe, effective techniques to help your child eliminate bedwetting, there is no reason that you have to wait for years for bedwetting to stop spontaneously. When your family has become frustrated with laundry and begins making excuses for sleepovers, it is time for intervention. Your child should be around 6 before you start.
Most children with bedwetting have mental or physical problems.
Only three in 100 children with primary nocturnal enuresis have a physical or urologic cause for it. Psychological problems as a cause of primary bedwetting are not common. Even children with emotional challenges can respond to treatment for bedwetting.
If a child is a sound sleeper, a bedwetting alarm won't work for her.
It is true that children with bedwetting may have a higher threshold for loud noise than other children. Initially the alarm is for the parents-so they can help wake the child and accompany her to the bathroom. Over time, the child begins to associate the noise with stopping the flow of urine and going to the toilet. Gradually, she will learn to control her muscles in response to a full bladder instead of relaxing them as she has done in the past.
If the child doesn't tell her parents she is bothered by her bedwetting, she probably doesn't care if she is wet.
No child wants to wake up in a wet bed. As children reach school age and realize their peers don't wear disposable pants or worry about waking to a wet bed, their self-esteem and social independence are affected. By middle school, their age-appropriate activities are sharply curtailed. All children would rather be dry, and if given ways to control this, are very cooperative with treatments and the use of bedwetting alarms.
Bedwetting is nothing more than a pesky problem that will eventually go away.
Perhaps, but with effective treatment available, why wait until your child outgrows it? Financially, enuresis impacts families. One or two extra loads of laundry each day can cost as much as $700 each year. Disposable pants can easily add up to $300 a year. Medications for bedwetting can cost $4 per tablet, and even $25 prescription drug co-pays add up over time.
Emotionally, enuresis impacts families. Overnight arrangements are cumbersome-taking along waterproof sheets, disposable pants, extra clothing, etc. Hiding enuresis from other family members and friends is painful. Peers and siblings can be cruel, teasing or humiliating the affected child. Parents must make every effort to prevent teasing from siblings. Remind siblings that they may have challenges in certain aspects of their lives, too. Bedwetting is not done on purpose. Your family works together to overcome challenges.
My child is alone in having this problem.
If a parent, grandparent, aunt or uncle with a history of bedwetting can share their memories with your child, it will help her see that she is not so different. Learning that an adult she respects and admires was similarly affected may help. Also remind your child that, in a class of 25 8-year-olds, at least one or two other children wet the bed.
Bedwetting occurred because I left him in disposable pants too long. Most children are day toilet trained between ages 2 and 4. There are generally three types of children when it comes to nighttime dryness:
Those who become spontaneously dry at night.
Those who begin with an occasional dry night, progress to more dry nights than wet ones and achieve complete dryness without intervention, usually by 6. Parents of these children should assist them in removing their disposable pants immediately after wakening in the morning and urinating in the toilet. Disposable pants can be discontinued as dry nights prevail.
Those who have had very few, if any, dry nights in their lives. These children may wet no matter where they are, how much their fluids are restricted or even if their parents take them to the toilet during the night. Using disposable pants in this group can decrease parent frustration until a treatment program is in place.
Parents should restrict privileges or punish their children so they will become dry quicker.
Remember, your child does not consciously control her bedwetting. Punishing your child for an activity that she has no control over is counterproductive. Dealing with the wetting in a supportive manner, such as having your child help make her bed or carry her bedding to and from the washer should be viewed as sharing in household tasks, not as punishment.
Puberty will end bedwetting.
It's true that the number of children with bedwetting decreases with age, but even 1 percent of 18-year-olds continue to have bedwetting. Puberty does not cure bedwetting, and there is no reason that you should wait until your child approaches this age before you attempt treatment.
Medication is a sure cure for bedwetting.
Although medications such as DDAVP (desmopressin) or Ditropan (oxybutynin) work well as an adjunct to therapy and in instances where a child has to be dry (camps or overnight visits), use of medication alone rarely helps a child permanently overcome bedwetting. When the medication is stopped, the wetting returns in 80 to 90 percent of those treated. Medication can help to buy time in some families who are not ready to use a bedwetting alarm. Children who use alarms are nine times more likely to become dry and stay dry than those who use medication alone.(36)
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See also
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