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Bed-Wetting

It's unrealistic to expect that every child should be completely dry, day and night, by the age of three.

Gaining consistent control of bladder and bowel functions during daytime hours is a significant milestone for a toddler or preschooler. For many children, keeping the bed dry at night is a more elusive goal, one that might not be reached until quite a bit later in life.

Children who still wet the bed at night well into their grade-school years too often take an emotional beating (and in some sad cases a physical beating) because of this problem — which is not under their conscious control. One of the greatest problems faced by bed-wetting children is a parent with unrealistic expectations that every child should be completely dry, day and night, by the age of three.

Causes

In 99 percent of children with enuresis, the problem may involve one or more of the following, but clinicians are not in complete agreement about the relative importance of each of these factors:

  • Delayed maturation. During infancy, the bladder automatically empties six to eight times per day when a certain volume of urine is present. As a child matures, this emptying reflex is inhibited (held in check) by the central nervous system so that he can hold larger amounts of urine and eventually release it voluntarily. In general, control is achieved earlier by girls than by boys.

    By the age of three, most children can consistently postpone urinating during waking hours. However, the ability of a child’s central nervous system to inhibit emptying of the bladder during sleep may lag behind daytime control by months or even years. By the age of five, as many as 10 to 20 percent of children are not consistently dry in the morning.
  • Small functional bladder capacity. A normal child can usually voluntarily hold urine in an amount of ounces equal to his age in years plus two. (A six-year-old child, for example, should be able to hold about eight ounces, or about 240 ml, of urine.) If a child cannot hold at least the same number of ounces as his age, this decreased capacity may contribute to enuresis.
  • Increased formation of urine during the night. A hormone called vasopressin, which is produced by the pituitary gland, reduces urine production by the kidneys. An increased amount of this hormone is normally secreted during the night, cutting the rate of urine production in half.
  • Some bed-wetters apparently do not secrete more vasopressin during the night and produce more urine than their non-bed-wetting peers. A similar result may occur, regardless of vasopressin levels, if a child consumes liquids before going to bed.
  • Difficulty awakening when the bladder is full. While the general patterns of sleep are similar in both bed-wetting and non-bed-wetting children, many parents observe that their child with enuresis will "sleep through anything" and seems very difficult to awaken during the night.
  • A family history of enuresis. Since so many of the factors contributing to bed-wetting have an inherent physiological basis, it should not be surprising that this problem often runs in families. Enuresis is seven times more common in children whose fathers were bed-wetters and five times more common if the mother had this problem. If both parents were bed-wetters, the likelihood that their child will have enuresis is greater than 75 percent, compared to roughly 40 percent if one parent was a bed wetter and 15 percent if neither parent was a bed-wetter.

Management

Remember that for the vast majority of children, bed-wetting will eventually resolve on its own as the central nervous system matures. (Each year after the age of six, 15 percent of children who still have enuresis will spontaneously stop wetting at night.)

Bed-wetting is not a sign of disobedience or weakness of character. The child who wets the bed is already embarrassed and uncomfortable about it; ridicule or punishment for bed-wetting, including teasing by siblings, is cruel, unjust, and ineffective. Not only will it cause additional emotional problems, but it might actually delay the resolution of enuresis.

Steps can be taken to eventually achieve one of two satisfactory goals: Your child holds his urine through the night and then voids into the toilet or potty-chair in the morning, or your child awakens during the night when his bladder is full and voids into the toilet or potty-chair.

The following measures may help a bed-wetting child:

  • Encourage fluid intake during the day and discourage drinking liquids after the evening meal or within two hours of bedtime. If your child wants a drink before bed, limit intake to one or two ounces (30 or 60 ml).
  • Have your child empty his bladder just before he goes to bed.
  • Encourage your child to get up during the night to urinate. A child who feels that his only goal is to delay emptying his bladder until morning may fail repeatedly. Giving verbal cues before bed ("Try to get up and use the toilet if your bladder feels full"), leaving the light on in the bathroom, or providing a potty-chair near the bed can help.
  • To a degree that is appropriate for his age, let him participate in the cleanup process when his pajamas and bed are wet. This should be presented not as punishment but as a matter-of-fact routine.

    This can include rinsing out his pajamas and underwear and taking a quick bath or shower in the morning if he smells of urine. Sheets can be left open to air-dry but should be washed if they have a disagreeable odor. A dry towel placed under the child’s bottom may help reduce the amount of laundry.
  • Protect the mattress with a plastic cover.
  • Offer praise and perhaps a smiley-face sticker on the calendar when he has a dry night or gets up to use the toilet.
  • Avoid expressing dissatisfaction, dismay, or anger when he is wet in the morning.
 

 
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