Nocturnal Enuresis

Dear Lisa,

I have a 5 1/2 year old daughter who still wets the bed every night. She never really had a long span of time that she woke up dry, a day here and there. Before she started kindergarten this past year I really wanted her night trained. I have tried to stay kind and gentle, reminders that she needs to stay dry, waking her before I went to bed and then again during the night, then upon waking telling her to use the toilet. I did the waking her up once or twice during the night for a month before I got frustrated. She would actually go the bathroom with me, but would argue that she didn't need to go. After a minute or two sitting on the toilet I would say ok and send her back to bed. Then 30 minutes give or take later she would be waking me with a wet sheet. She even got to the point that she would just change the pad herself and not wake me. But, she couldn't do it. So, I gave her the goodnight pull ups back and we are still there. She is a sound sleeper.

The Pediatrician group we see says not to worry that it's common and no further testing is required until she's six. She is a healthy growing girl, active and vivacious. She is bright and easy going. This is my only concern about her. I am not 100% certain but my feeling is that she just doesn't mind being wet, may be even enjoys the sensation. She every now and then will have an accident soon after going to bed when I think she is still awake, and in the morning likes to lay in bed awake for a while. I have talked to her many times and she does not like to talk about it, so I don't press it. I have tried one of those hypnosis CD's for kids that still wet their beds, she listened to it once and was uncomfortable with it. So, I gave up on that. I tried bribes, didn't work. What has made this even more frustrating is that my 2 year old son has self potty trained and stays dry at night for months now. I'm not comparing and I'm not sure she even has noticed. But, for some reason I am losing my patience and don't want to wait until she is six.

“Looking forward to dry nights"

Dear “Looking forward to dry nights”,

Nocturnal Enuresis or “Bedwetting” is the involuntary passage of urine at night in a child over three years old. A child who never obtains night time dryness is considered to have Primary Nocturnal Enuresis. Primary Nocturnal Enuresis is a common condition, affecting 5 to 7 million children over the age of five years old.(1)

A question frequently asked by parents of children with Nocturnal Enuresis is, “When will my child stop wetting the bed?” In order to answer this question it would be helpful to investigate the child’s family history. Nocturnal Enuresis is an inherited trait that runs in families. In many cases it is found that the mother or father suffered from the same condition when they were a child. A good indicator regarding when the bedwetting will stop is the age that the parent stopped wetting their bed.(1) Children are often consoled when they find out that their mother or father suffered from “Bedwetting” until they were 9 or 10 years old. It also helps a child to realize that is not their fault that they cannot stay dry at night.

There are multiple reasons why a child may suffer from Nocturnal Enuresis. The most common cause is decreased arousal from sleep.(1) When this occurs, the child does not have the ability to sense a full bladder during sleep and spontaneously awake in response to this message. Bedwetting may also be caused by a small bladder capacity. A small bladder capacity does not allow the child to store the urine that the body makes overnight.

In order to determine a child’s bladder capacity the urine output is measured over the span of three days. This is done by collecting 10 daytime voids over a three day period. Each individual amount is measured and recorded and then the average is calculated. The average of the collections is that particular child’s bladder capacity. This number is then compared to the average bladder capacity of a child that same age. The sum of a child’s age in years plus two equals the number of ounces of average bladder capacity.(2) For example, a 5 year old child is expected to have a bladder capacity equal to : 5 + 2 = 7 ounces. It is not unusual for the bladder capacity of bedwetting children to be much less than average for their age.(1)

Some children experience bedwetting because they do not have sufficient amounts of anti-diuretic hormone or ADH.(3) The production of this hormone normally increases at nighttime in a person who does not suffer from enuresis. This normal physiologic change causes a smaller amount of more concentrated urine to be produced at night. In children with decreased secretion of ADH, diluted urine continues to be produced at night at the same rate that it is produced during the day. As a result children need to wake several times during the night to eliminate the urine that they produce.

Children can also suffer from other medical conditions that may contribute to Nocturnal Enuresis. Food sensitivities, Constipation, Obstructive Sleep Apnea, Attention Deficit Disorder, Psychological factors and stress can all cause a child to wet their bed at night.(4) Side effects to certain medications such as antihistamines or antidepressants are another potential cause of bedwetting in the pediatric population.

Generally speaking, interventions to alleviate bedwetting are not initiated until a child is six years old.(1) It is quite normal for many children to experience daytime control first with night time wetting continuing on a nightly basis. Nighttime dryness is then achieved gradually, where a child experiences less frequent wet nights over a period of time. (4) In about 15 % of the cases ,night time dryness is spontaneously achieved with no intervention.(1) Therefore a child following this pattern may not need any interventions in order to stop the behavior.

For children who require interventions, natural measures are recommended before the initiation of pharmacological therapy. Typically medication is not utilized as first line therapy because of the potential for high relapse rates and potential side effects to the medication.(4)

Children with daytime wetting, daytime leaking, stool incontinence, constipation, history of Urinary Tract Infections, a sacral dimple or tuft of hair, or abnormal gait should be evaluated and treated by a health care professional without delay. These are concerning signs that may represent complications or more serious health conditions. Otherwise pressuring a child to accomplish dryness at night before they are ready may cause undue stress and feelings of inadequacy or embarrassment. Measures such as punishing or shaming may also be harmful and can contribute to feelings of low self esteem.(5)

From the information that you gave, your daughter’s symptoms are consistent with Primary Nocturnal Enuresis. It also seems that the measures that you have taken so far have not made a difference in her behavior. It sounds like these failed attempts are beginning to frustrate you. Be assured that Primary Nocturnal Enuresis is a common condition found in children your daughter's age. Your daughter may just not be mature enough at this point to overcome her problem.

Since your daughter was already evaluated by your Pediatrician, is not suffering from any health conditions and is not experiencing any concerning signs, a good approach at this point would be to not bring attention to her condition. This does not mean that you should ignore her bedwetting all together, but instead re-address the issue when she is 6 years old just as your Pediatrician suggested. Otherwise the negative feelings and defeat that you are experiencing may be transferred to your daughter which may ultimately worsen the situation.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Secondary Enuresis

Food Sensitivities and Enuresis

Treatment for Bedwetting

Urinary Tract Infection

Attention Deficit Disorder

Obstructive Sleep Apnea

Risk Factors for Obstructive Sleep Apnea

Constipation

References:
(1)Mercer R. Dry at Night. Advance for Nurse Practitioners. 2003.February:26-29.
(2)Maizels M, Rosenbaum D, Keating B. Getting to Dry: How to Help Your Child Overcome Bedwetting. Boston, Mass: The Harvard Common Press;1999.
(3)Rittig S, Knudsen R, Horgaard J, Pedersen E, Djurhuus J. Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. Am Physiologic Soc. 1989.363:6127-6189.
(4)Zacharyczuk C. Psychosocial implications of nocturnal enuresis demand treatment.Infectious Diseases in Children. 2006. April:72-73.
(5) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1042-1043.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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