For at least five million children in the United States, bed-wetting is a fact of life. It creates more of a problem than the need to wash a load of sheets before rushing off to work -- it can disrupt the whole family. Fortunately, thanks to new insights regarding nighttime accidents, and approaches to preventing them, most kids can be spared the embarrassment (and their parents the inconvenience) of wet nights.
Bed-wetting, or "enuresis," is rarely an emotional or psychological problem. It doesn't mean that your child is too lazy to get up or is trying to control you, or that she's stubborn or immature. Usually bed-wetting is simply a developmental lag -- and one that you may have experienced yourself: If both her parents were bed-wetters after the age of 6, a child has about an 80 percent chance of being one; if only one parent was wet at night, the child has a 40 percent chance of having accidents. There are late walkers, late talkers -- and late dry-nighters. In addition, some children have small bladders that are more easily overfilled, and some studies suggest others don't produce enough antidiuretic hormone (ADH), which is released by the pituitary gland during sleep and causes the kidneys to manufacture less urine so that the bladder doesn't fill beyond capacity. In any case, it's unreasonable to expect a child under the age of 4 or 5 to always wake up dry.
In fact, a child who wets the bed usually can't control it any more than one with asthma can help wheezing. So take heart knowing that most bed-wetters outgrow the problem without treatment; if your youngster isn't bothered by it there's no reason to intervene -- but if she is, there are effective tactics to try.
Why Kids Wet the Bed
It helps to understand how children achieve bladder control. Infants urinate in response to the bladder-emptying reflex: When the bladder has stretched to a certain point, it automatically releases the urine. Sometime between 2 and 3 years of age, most children become aware of bladder fullness, and learn that they can consciously inhibit the bladder-emptying reflex and hold in their urine. At this point they achieve daytime bladder control.
Nighttime control occurs when a child can unconsciously inhibit the bladder-emptying reflex. So think of bed-wetting as a communication problem: The bladder and the brain don't "speak" during sleep. The child who urinates in his sleep literally sleeps through his bladder's signals and fails to wake up to go to the bathroom.
7 Steps to Dry Nights
As a 5-year-old, Ben rarely had dry nights. His mom didn't worry much about it, but when he turned 6 she became concerned and brought him in to see me. Bed-wetting isn't at all unusual for a boy under the age of 6 (in fact, boys with the problem outnumber girls two to one), but by this age Ben was tired of waking up wet and his mom was tired of all the laundry. Besides, Ben was eager to be able to spend the night at friends' houses and didn't want to be embarrassed by an accident.
I suggested that Ben's mom follow the method I've recommended for 25 years. It's a time-tested approach that I estimate works for at least 70 percent of my patients. While it often takes all seven steps, the problem may be solved even sooner and most children begin to experience dry nights within about a month.
Before you start, however, make sure your child's bed-wetting isn't caused by a medical condition or by stress from a life event that may need to be dealt with (see "Hidden Causes to Consider").
Once you've ruled out an emotional or serious physical cause, you'll also want to be sure that the problem truly needs to be addressed at this point. Ask yourself these questions:
- Is your child 6 or older? (If not, it's best to wait for him to outgrow the bed-wetting.)
- Is your child bothered by his repeated bed-wetting? Does he really seem to want to stop?
- Are you so tired of coping with the problem that it's worth the effort to make your child stop bed-wetting?
If the answer to any one of these questions is yes, you'll have a much better chance of success.
EDUCATE YOUR CHILD Describe for her how her bladder becomes filled with urine and signals that it needs to be emptied. Here's how I explain it: "Your bladder is like a balloon the size of a baseball. Inside the balloon are tiny nerves, like feelers, that tell you when your bladder is full of urine. When you're awake you can feel this pressure, but you can hold it because there's a big doughnut-shaped muscle at the end of your bladder that you squeeze shut to keep your pee inside. So if you're in the middle of playing a game and don't want to go to the bathroom, you're able to hold it. But at night your brain is sleeping so deeply that it says to the bladder, 'Don't bother me, I'm sleeping.' The bladder may say, 'I'm too full, I've got to go,' so out onto the sheets comes the pee." You might want to supplement this discussion with a picture book, such as Dry All Night, by Alison Mack.
BRING ON THE REINFORCEMENT Place a chart near your child's bed with squares for each day of the week. Have her jot down a D for dry nights and W for wet nights, or use stickers -- one type to depict dry nights, one for wet ones. After so many dry nights, she gets an agreed-upon prize. (Try a social reward, such as a special outing at a place of her choice.) Soon you'll be able to phase out the prizes as the dry bed and the feeling of mastery over her bladder become its own reward. This is successful in 80 to 85 percent of cases.
As a further incentive, I ask the child to call me with a weekly progress report. This takes pressure off the parents and helps the child take more responsibility for her body.
TEACH TRIPLE VOIDING Many children go to bed with a half-full bladder. Just before bedtime, encourage your youngster to "go three times" or to "grunt, grunt, grunt" while urinating to push the urine out.
GET THE BLADDER AND BRAIN TO TALK Just before bedtime, remind your child how his brain and bladder communicate at night, so that he dozes off "programmed" to get up when his bladder is too full. Have him repeat phrases that imprint on his brain the actions to take -- "I will get up and go to the bathroom when I feel my bladder get big," "I will splash water on my face and go three times."
DO THE SHAKE-AND-WAKE Since most children wet their bed within a few hours of falling asleep, around the time you go to bed, the perfect opportunity for a second trip to the toilet is just before you retire. Awaken your child completely, so that she's able to walk to the bathroom and is aware of what's going on. If necessary, use a cool wash rag on her face to wake her up. Then go through the "grunt three times to push the pee out" drill. Remind her to repeat the phrases she learned in Step Four when she gets back into bed.
DO BLADDER-TRAINING DRILLS These exercises increase bladder capacity, neuromuscular control, and awareness of daytime bladder fullness -- and hopefully will carry over into the night. (But be sure to check with your pediatrician first -- especially before having your daughter practice the drills: Little girls who have a history of urinary tract infections may run the risk of developing one by holding their urine):
- During the day encourage your child to drink large amounts of fluid and voluntarily hold his urine for increasingly longer times, even though he has the urge to void. In time, his bladder will stretch, much like a balloon that's repeatedly inflated, and should be able to hold more without having to empty it so often. The usual bladder capacity is a child's age plus two ounces -- so a 6-year-old should be able to hold eight ounces of urine.
- Have your child start and stop his stream several times during urination. That way he learns that he can actually control his bladder.
GO HIGH-TECH If the prior six steps have failed to stem the flow -- and you and your child are still committed to ending bed-wetting episodes -- you can try using a bladder-conditioning device. This is a moisture-sensitive pad, worn inside the underwear or built into the sheet, and a buzzer, which goes off when a drop or two of urine strikes the pad, alerting a parent to wake up the child and get her to go to the toilet. It operates on the principle of conditioned response. In time, the child subconsciously pays attention to her bladder rather than be rudely awakened. These devices are available from stores and catalogs that sell childcare products and cost about $50 -- a small price for some worried parents to pay if bed-wetting is causing their child serious distress.
This technique can be effective 90 percent of the time if used correctly. For best results:
- Have your child empty her bladder completely with the triple voiding technique just before going to bed.
- Explain to her that the buzzer will help her bladder and brain listen to one another at night while she's sleeping. Tell her what to expect: "Imagine waking up and taking a trip to the toilet. Pretend your bladder is full and starting to stretch and it's time to get up."
- Practice: As she's lying in bed, set off the alarm manually, and have your child hop out of bed as soon as she hears it. Then walk her to the bathroom, remind her how to wake herself up by splashing water on her face or holding a wet washcloth against it, and have her urinate three times. Explain that the aim of the game is to "beat the buzzer" and for her to sense when her bladder is full before the alarm goes off.
Run through the procedure several times, until she's used to the sound of the alarm and won't be frightened by it in the night. Then hook up the device according to the manufacturer's instructions. So you can hear the alarm, you may need to camp out in or near her bedroom or turn on an intercom in her room and yours.
It can take a lot of work, but when you and your child really want to end his bed-wetting, it will happen -- and can be worth the effort. As one patient of mine said, "Being dry makes me feel so happy. Now I can stay overnight at my friend's house without feeling embarrassed."