Originally published in The Ottawa Citizen March 6 , 2004

Original Title: Nighttime waterworks

Bedwetting or nocturnal enuresis affects more than 200,000 Canadians between the ages of five and 19. It occurs three times more often in boys than in girls. This problem causes great parental angst and distress. Children often feel humiliated and ashamed when it happens. They fear sleepover parties and the cruel teasing that inevitably arises should their secret be revealed.

The International Children’s Continence Society’s specific definition of nocturnal enuresis is “the involuntary loss of urine that occurs only at night. It is normal voiding that happens at an inappropriate and socially unacceptable time and place.”

Bedwetting is not the child’s fault. The brain’s pituitary gland produces a hormone called vasopressin. Vasopressin reduces the rate of urine production by the kidneys. When we sleep, vasopressin levels increase. Indeed, children under the age of five who wet the bed are not exhibiting nocturnal enuresis. Some have not yet ramped up nightly vasopressin production. By the time they are five years old, most children will be producing enough to prevent their urinary bladders from filling while they sleep.

Children with cognitive disabilities should reach a mental age of four years before considering this diagnosis.

About 15 per cent of five-year-olds continue to wet the bed. This drops to eight per cent for 12-year-old boys, four per cent for 12-year-old girls and one per cent at age 15. Family history helps keep this condition in perspective. Fifty per cent of children will wet the bed if one of their parents had the same problem during their childhood, and 80 per cent if both parents did. Bedwetting eventually stops in most children.

Nocturnal enuresis is thought to be due to a group of conditions with different causes. It is not usually a sign of kidney problems unless the child is having problems during the day as well. Some children may have urinary bladders that are too small. They will have difficulty holding in their urine. Psychological stressors stemming from family crises, loss of friends and moving, among others, are other factors. However, the majority of children are healthy.

As with any condition, a thorough medical history, physical exam and urine test are the first steps in the evaluation process. To make this diagnosis, the five- or six-year-old child should have two or more bed-wettings per month and children over the age of six at least once or more per month. They should not be having any problems during the day.

Contrary to popular perception, sleep studies demonstrate that bedwetters do not sleep any more deeply than children who do not wet the bed. They are not lazy or acting out in defiance. Punishing children for this problem will not change their behaviour. They are unable to control this problem by conscious effort.

Treatment options include behavioural conditioning methods and medication, if required. Medication should never be prescribed for children under five.

The best cure rate is seen using a bedwetting alarm that the child wears at night. As soon as he or she begins to wet the bed, the alarm sounds. The child wakes up and gets up to go to the bathroom or holds in the urine until later. This training may take about three to four months to succeed.

Desmopressin (DDAVP) is a well-tolerated medication that is similar to vasopressin and comes in pill and nasal spray format. Some studies indicate it works best in children at least nine years of age or older and in children who had few wet nights. The generally mild side-effects include nose irritation, nosebleeds and headache. The medication acts quickly to resolve nocturnal enuresis and is used for about six months. However, children may relapse after it is discontinued.

The combination of an alarm and medication is another strategy to help train the child.

What can you do to help your child?

* Your child needs your support and reassurance that you will help them overcome this problem.

* Have a positive outlook and avoid punishing your child for a condition that is not their fault.

* Do not allow your child to drink milk, juice, water or sodas within a few hours of their bedtime.

* If they do wet the bed, ask your young child to take the sheets off the bed. Your older child should be responsible for doing their laundry.

* Get into the habit of waking your child to go to the bathroom before you go to bed.

* A sticker reward system for dry nights works well for younger children. A prize is given once they reach a certain number of dry nights.

* Consult your doctor sooner rather than later if you suspect your child may have nocturnal enuresis.

© Dr. Barry Dworkin 2004