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
Pediatric Advice on the Web
Friday, April 13, 2007
Wednesday, April 11, 2007
Death of a Friend
Dear Lisa,
My 5 year old daughter has had a friend die. She did not know her very well, only has played with her a few times. They attended the same school but were in different classes. But, the school became quite involved having fundraising activities. Her teacher had the class make several crafts for her during her illness (inoperable brain tumor) and her Daisy Troop also has made things for her. They have had discussions in class that were general and have hospice and counselors on hand for them if needed.
Here is my question. If my daughter does not understand what happened (death), and is not showing any signs of sadness or grief, should I take her to the funeral? Many of the families in my situation are contemplating taking their children. I'm not sure and do not want to cause any unnecessary stress for her or the family that has suffered this terrible loss(seeing a child that may be smiling or laughing or seeking out a playmate at the funeral). Hospice says let your child take the lead, should I ask her if she wants to go? This has been tough, her first exposure to sickness and death. The family of this child has welcomed the community to the interment. I have read the book, What’s Heaven to my daughter and she does not really understand or seem phased. What are your thoughts?
Thank you,
“Sad Situation”
Dear “Sad Situation”,
I am sorry to hear about the loss in your life. Understanding and coping with the concept of death is very difficult for a family, especially when a young child is involved. Children at different ages deal with death differently. The way a child handles death depends upon their developmental stage, psychological development, previous experience with death, emotional maturity, coping abilities, environment, culture and parental attitudes.(1) The way that your daughter is responding to her friend’s death is quite normal.
In order to help a young child cope with death it is important to understand their thinking processes. Because of your daughter’s young age and developmental stage, she does not fully comprehend the meaning of death. This is especially true because she has had no previous experience with death in her life. Young children may use the word “die” or “death” in conversation but this does not mean that they truly understand what the word means.
Naturally a young child will handle death much differently than a teenager or an adult would. This is because specific patterns of behavior and understanding are expected at different ages. Developmentally speaking, a pre-school child, or a child between 3 and 6 years old, views the world from the perspective of their own experience. In other words, they see themselves as the "center" of the world. Young children interpret experiences depending upon how they relate to them directly. Young children can not relate to the feelings of others or to situations that occur to families outside of their “world”. Therefore it is normal for a young child not to display sympathy for others or not to seem phased by something bad that happens to someone else. A death occurring to a person outside of their immediate circle may not seem to affect them.
Children at a young age also cannot comprehend the finality of death. It is hard for them to believe that death is a “permanent” separation. Very often children view death as a temporary situation. Most young children believe that death is reversible.(2) This may be due to their exposure to death from the media through the shows that they watch on television.(1) While watching a cartoon a child sees a character die only to see them come right back to life again, usually unharmed. A child can watch a television show one day where a character dies and the next day the same character is on the television appearing very alive and healthy. This only confuses their perception of death and reinforces their belief that death is reversible.
Since your daughter’s friend was a casual acquaintance that only played with her a few times, her death probably will not directly affect your daughter's everyday life or seem to bother her. Most likely she will not need the funeral ceremony to help her cope with this young girl’s death. Since her friend was not a close family member, your daughter’s attendance at the funeral would not likely be a necessary step in her coping processes and understanding of death.
Ultimately it is a parent’s decision if a young child should attend a funeral. When making this decision it is important to know that children under seven years old and girls are particularly sensitive to funeral activities. (2) Therefore having your daughter attend the funeral may not be beneficial in this particular situation. If a parent decides that their child should go to a funeral, it is a good idea to discuss it with the child first. A young child needs preparation and an explanation of what to expect; what it will look like and how others will be acting.
If you ask a young child if she wants to go to a funeral, chances are she will not have the ability to make that decision because she doesn’t have any experience with death and never has been to a funeral. When you explain to a child that a funeral is not a place for playing with friends or make noise, but a place to be quiet, most children will not want to attend.
If a child does not attend a funeral it is still important that you answer any questions that she may have about the funeral and death. Young children experience magical thinking and it is often necessary to clarify any misconceptions that they may have. Young children tend to believe that their thoughts can control what happens to others.(1) Therefore, if a young child had a disagreement with a friend and wished bad thoughts for that friend and then their friend died, the child may believe that they caused the death. This is why it is important to talk to a child about their understanding of a death that occurs in their life.
Children also lack the reasoning power that adults have. They cannot make appropriate connections between events or the sequence of events.(1) Young children do not have the cognitive ability to think through the beginning, the middle and the end of a story. Instead, young children tend to connect events that do not belong together. As a result they commonly fill in the blanks with their imagination. Many times the images that they conjure up are scarier then the truth itself. For example, if your daughter was playing with dolls the last time she played with her friend, she may come to the conclusion that the dolls caused her friend to die. This is why it is better to tell a young child the truth about the circumstnces surrounding a death experienced in their life. Specific details are not necessary, but the proper order of events is.
It is wonderful that you read your daughter the book that you did. She may not have seemed to understand the concepts that you were trying to teach her but spending time with her reading this book let her know that you are there to love and support her. I suggest that you sit down and talk to your daughter about her feelings about her friend’s death. Let her know that it is okay to ask questions. Answer any questions that she may have very simply and at a level that she can understand.
It is likely that you will need more emotional support than she does at this time. Seeking comfort and counseling from support systems for yourself will help you cope with this tragic loss and in the end benefit your family as a whole.
I wish your family peace during this sad time.
References:
(1)Huntley T. Helping Children Grieve. When Someone They Love Dies. Minneapolis, MN: Augsburg Fortress. 1991:9-42.
(2) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA: W.B.Saunders Company. 1994:689-709.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice For Parents of Young Children
My 5 year old daughter has had a friend die. She did not know her very well, only has played with her a few times. They attended the same school but were in different classes. But, the school became quite involved having fundraising activities. Her teacher had the class make several crafts for her during her illness (inoperable brain tumor) and her Daisy Troop also has made things for her. They have had discussions in class that were general and have hospice and counselors on hand for them if needed.
Here is my question. If my daughter does not understand what happened (death), and is not showing any signs of sadness or grief, should I take her to the funeral? Many of the families in my situation are contemplating taking their children. I'm not sure and do not want to cause any unnecessary stress for her or the family that has suffered this terrible loss(seeing a child that may be smiling or laughing or seeking out a playmate at the funeral). Hospice says let your child take the lead, should I ask her if she wants to go? This has been tough, her first exposure to sickness and death. The family of this child has welcomed the community to the interment. I have read the book, What’s Heaven to my daughter and she does not really understand or seem phased. What are your thoughts?
Thank you,
“Sad Situation”
Dear “Sad Situation”,
I am sorry to hear about the loss in your life. Understanding and coping with the concept of death is very difficult for a family, especially when a young child is involved. Children at different ages deal with death differently. The way a child handles death depends upon their developmental stage, psychological development, previous experience with death, emotional maturity, coping abilities, environment, culture and parental attitudes.(1) The way that your daughter is responding to her friend’s death is quite normal.
In order to help a young child cope with death it is important to understand their thinking processes. Because of your daughter’s young age and developmental stage, she does not fully comprehend the meaning of death. This is especially true because she has had no previous experience with death in her life. Young children may use the word “die” or “death” in conversation but this does not mean that they truly understand what the word means.
Naturally a young child will handle death much differently than a teenager or an adult would. This is because specific patterns of behavior and understanding are expected at different ages. Developmentally speaking, a pre-school child, or a child between 3 and 6 years old, views the world from the perspective of their own experience. In other words, they see themselves as the "center" of the world. Young children interpret experiences depending upon how they relate to them directly. Young children can not relate to the feelings of others or to situations that occur to families outside of their “world”. Therefore it is normal for a young child not to display sympathy for others or not to seem phased by something bad that happens to someone else. A death occurring to a person outside of their immediate circle may not seem to affect them.
Children at a young age also cannot comprehend the finality of death. It is hard for them to believe that death is a “permanent” separation. Very often children view death as a temporary situation. Most young children believe that death is reversible.(2) This may be due to their exposure to death from the media through the shows that they watch on television.(1) While watching a cartoon a child sees a character die only to see them come right back to life again, usually unharmed. A child can watch a television show one day where a character dies and the next day the same character is on the television appearing very alive and healthy. This only confuses their perception of death and reinforces their belief that death is reversible.
Since your daughter’s friend was a casual acquaintance that only played with her a few times, her death probably will not directly affect your daughter's everyday life or seem to bother her. Most likely she will not need the funeral ceremony to help her cope with this young girl’s death. Since her friend was not a close family member, your daughter’s attendance at the funeral would not likely be a necessary step in her coping processes and understanding of death.
Ultimately it is a parent’s decision if a young child should attend a funeral. When making this decision it is important to know that children under seven years old and girls are particularly sensitive to funeral activities. (2) Therefore having your daughter attend the funeral may not be beneficial in this particular situation. If a parent decides that their child should go to a funeral, it is a good idea to discuss it with the child first. A young child needs preparation and an explanation of what to expect; what it will look like and how others will be acting.
If you ask a young child if she wants to go to a funeral, chances are she will not have the ability to make that decision because she doesn’t have any experience with death and never has been to a funeral. When you explain to a child that a funeral is not a place for playing with friends or make noise, but a place to be quiet, most children will not want to attend.
If a child does not attend a funeral it is still important that you answer any questions that she may have about the funeral and death. Young children experience magical thinking and it is often necessary to clarify any misconceptions that they may have. Young children tend to believe that their thoughts can control what happens to others.(1) Therefore, if a young child had a disagreement with a friend and wished bad thoughts for that friend and then their friend died, the child may believe that they caused the death. This is why it is important to talk to a child about their understanding of a death that occurs in their life.
Children also lack the reasoning power that adults have. They cannot make appropriate connections between events or the sequence of events.(1) Young children do not have the cognitive ability to think through the beginning, the middle and the end of a story. Instead, young children tend to connect events that do not belong together. As a result they commonly fill in the blanks with their imagination. Many times the images that they conjure up are scarier then the truth itself. For example, if your daughter was playing with dolls the last time she played with her friend, she may come to the conclusion that the dolls caused her friend to die. This is why it is better to tell a young child the truth about the circumstnces surrounding a death experienced in their life. Specific details are not necessary, but the proper order of events is.
It is wonderful that you read your daughter the book that you did. She may not have seemed to understand the concepts that you were trying to teach her but spending time with her reading this book let her know that you are there to love and support her. I suggest that you sit down and talk to your daughter about her feelings about her friend’s death. Let her know that it is okay to ask questions. Answer any questions that she may have very simply and at a level that she can understand.
It is likely that you will need more emotional support than she does at this time. Seeking comfort and counseling from support systems for yourself will help you cope with this tragic loss and in the end benefit your family as a whole.
I wish your family peace during this sad time.
References:
(1)Huntley T. Helping Children Grieve. When Someone They Love Dies. Minneapolis, MN: Augsburg Fortress. 1991:9-42.
(2) Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA: W.B.Saunders Company. 1994:689-709.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice For Parents of Young Children
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