Bedwetting (Nocturnal Enuresis) in Children

Nocturnal enuresis is a problem that affects young children. They end up urinating in their sleep and as a parent, there is no need to be overtly alarmed. It is a common occurrence that can be handled with proper care and love.

What is Nocturnal Enuresis or Bedwetting?

Nocturnal enuresis or bedwetting is involuntary urination while sleeping after the age at which bladder control usually occurs. It is a developmental delay and not an emotional problem or any physical illness. 5% to 10% of bedwetting cases are due to specific medical reasons. However, this could be associated with some family history.

Many children who wet the bed have a parent who did it too at the same age. This condition is not considered for diagnosis by many parents or doctors unless the child is five years or a little older. Enuresis is a common problem that can be troubling for children and their families.

Nocturnal enuresis in a child could be a symptom of an underlying disease or illness.

Main symptoms of nocturnal enuresis are:

• Bedwetting repeatedly
• Bedwetting in the clothes
• Bedwetting at least twice a week for approximately three months

How Common is Enuresis in Children?

Bedwetting in children is a common problem. It occurs in about 7% boys, and 3% girls who are five years old and below. This number drops to 3% in males and 2% in girls by age 10. Children mostly outgrow this problem in their teenage years with about 1% of boys and girls having this disorder at age 18.

Types of Bedwetting

There are two types of Nocturnal enuresis or bed wetting –

• Primary nocturnal enuresis (PNE)

It is the most common form of bedwetting. This means that bedwetting has persisted since childhood without any break. It is recurrent and affects those children who have never achieved night-time dryness. These can be further subdivided into primary nocturnal enuresis which occurs only at night and diurnal enuresis, which occurs during daytime, such as urgency, frequency or wetting at daytime. This is a developmental delay which can get resolved with time. Diet impacts enuresis in children.

• Secondary nocturnal enuresis (SNE)

This is the involuntary passage of urine during sleep by a child who has previously been dry. This could be due to a bladder infection.

Causes of Bedwetting

The reasons for nocturnal enuresis are as follows:

Primary Bedwetting

Primary bedwetting is a condition when the child has never attained control of his/her bladder during the night. Here are a few causes:

• The child’s body is still developing/bladder problems
• The child is unable to control urine for the entire night
• The child does not wake up when his or her bladder becomes full
• The child produces a significant amount of urine during the evening and night hours
• The child may have poor toilet habits. Children tend to ignore the urge to urinate and postpone urinating for long durations. Parents will be aware of various expressions like face straining, squirming, squatting etc. which children use to hold urine.
• An increase in urine production caused by the use of caffeine and diuretics
• Chronic constipation and soiling of pants

Secondary Bedwetting

Secondary bedwetting is when the child wets the bed after at least 12 months of not doing so. Its incidence tends to increase with an increase in the age of a child. Reasons for this include:

• Urinary tract infection: This causes irritation, a strong urge to urinate and frequent urination. The infection could also be due to some anatomical abnormality.
• Diabetes: Anyone who has diabetes will have an increased urine output.
• Anatomical abnormality: These could be abnormalities in the organs, muscles or nerves or any other urinary problems.
• A neurological problem: If the nervous system has a defect, injury or disease it can cause the neurological imbalance which affects urination.
• Social or psychological stress: Stress in family life caused due to conflicts between parents can cause children to wet the bed. Changes in lifestyle, like starting school or moving residence can be the cause of bed wetting. Children who are physically or sexually abused also begin bedwetting.
• Genetics: Enuresis can be genetic, which means if any parent had this problem then there could be a possibility that the child will also have the same problem.

Risk Factors for Developing Nocturnal Enuresis

Primary bedwetting – Primary bedwetting is more commonly found in boys than girls. 15% children get better every year from bed wetting.

• There is a genetic reason for initial bedwetting.
• Some people may urinate by accident while being awake. This tends to be related to some physical problem.
• Children who have attention deficit and are hyperactive may have bed wetting.
• Children living in disorganised families.

Secondary bedwetting –

• Family issues such as parents’ divorce or a loss.
• Physical abuse and negligence
• They could also have a disorder known as ‘confusional arousals’, where he or she wakes up during deep sleep. This makes the child urinate in a strange place. Secondary bedwetting occurs at any age.
• Diagnosis

For the correct diagnosis of bedwetting, the complete history should be obtained by carrying out a thorough medical examination to look for the causes.

• Causes of enuresis could include an abnormality of the spinal cord (associated with neurogenic bladder, urinary tract infection, and posterior urethral valves in boys and ectopic ureter in girls). Additionally, children who suffer from chronic constipation and encopresis (soiling the pants involuntarily).
• There should be careful and detailed questioning about the family history, genetics and medical history of the child. This helps in determining the type of enuresis and the possible cause for it.
• Often parents are not entirely aware of their child’s bedwetting habits. It is advisable that they maintain a diary to keep track of how many times the child has wet the bed in the daytime and at night.
• The child has to undergo a physical examination. However, the doctor needs to check for any other problem which could be causing bedwetting.
• A urinalysis should be conducted as it helps highlight any infection in the urine.If the results indicate diseases, then further investigation (by cystourethrogram and renal ultrasound) should be conducted.
• Bedwetting can be very stressing. However, it goes away on its own after a while. It causes embarrassment and guilt to the child which leads to anxiousness. Parents should provide emotional support to the child during this time.

If you’re wondering when a child stops wetting the bed, about 90% children around seven years age stop bedwetting on their own. Most doctors do not routinely suggest bed wetting treatments for children younger than seven years. The reason being bladder control function during sleep is the last stage of potty training. Hence, children wet the bed during sleep during the learning process.

Treatment of Bedwetting in a Child

Bedwetting is normal while growing up. Mentioned below are some child bed wetting solutions which you can be used –

There are some homoeopathic remedies for bedwetting in children which are safe, gentle and help treat bedwetting:

• Causticum

This remedy can be useful for children who wet the bed particularly when they first fall asleep.

• Kreosotum

This remedy is used for children who are unable to go to the washroom quickly enough as they get the urge to urinate. The child is awake because of the urge but cannot retain the urine or dreams that he or she is urinating and wets the bed.

• Lycopodium

The child who needs this remedy has involuntary urination during sleep during which he or she may pass large quantities of clear urine. These patients crave sweets and hot drinks.

• Pulsatilla

The child who requires this remedy suffers from urine discharges that are involuntary. The urine dribbles while sitting, walking and at night in bed.

• Sepia

The child needing Sepia often must keep her mind on her bladder, or she will lose her urine. The bed is wet almost as soon as the child goes to sleep.

There are bedwetting alarms for children as well which can also prove to be helpful.

Teaching the child bladder exercise (muscle strengthening and bladder stretching) can control the release of urine and increase the capacity of the bladder. The child should be made to tighten the pelvic muscles for about 5-10 seconds and then relax for five seconds. The exercise should be repeated thrice daily. You should encourage the child to hold going to the washroom when the urge arises. This will help the child avoid bed wetting during the daytime and lessen the frequency at night. The bladder gets trained to hold an increased amount of urine.

If your child suffers from constipation, your doctor may recommend a stool softener.

Sometimes, surgery may be required to correct bedwetting.

Medication is used to treat bedwetting where behavioural treatments are not proving to be effective, namely –

1. Desmopressin acetate
2. Oxybutynin chloride
3. Hyoscyamine sulphate
4. Imipramine

Oral antibiotics are prescribed where the cause of bedwetting is urinary tract infection, like –

1. Bactrim
2. Amoxicillin
3. Macrobid
4. Levaquin

Lifestyle Changes to Prevent Bedwetting in Children

There are a few lifestyle changes that can be made to ensure that the bedwetting incident gradually reduces:

• Parents should monitor the intake of fluids (restricting fluid intake) by the child; he should have more fluids during daytime and less at night. By limiting the fluid intake, bed wetting can be controlled.
• The child should be encouraged to urinate at the beginning of bedtime and right before falling asleep. You should emphasise that it is OK to use the washroom during the night. Night lights can be utilised so that the child can find the way to the toilet.

• The child should be encouraged to use the toilet at regular intervals (2 hours) or often enough to avoid a feeling of urgency.
• It is important that parents are supportive when an incident of bedwetting incident happens. You can make the child change the sheets, explaining that it is not a form of punishment. Positive reinforcement the child has had a dry night proves useful.
• Avoid beverages and foods with caffeine. Drinks with caffeine are discouraged for children at any time of day. Because caffeine may stimulate the bladder, it is not recommended.

Homemade Remedies for Bedwetting in Children

There are some easy and simple natural remedies which can be included in the daily diet of the child.

• Cinnamon – It keeps the body warm. You can have the child chew on a piece of cinnamon once in a day. A combination of sugar & cinnamon sprinkled over a buttered toast can be fed to the child at breakfast.
• Amla or Indian Gooseberry – Amla is considered to be a very effective remedy for bed wetting. Crushed and deseeded amla added to a teaspoon of honey with a pinch of turmeric can be given to the child every morning.

A teaspoon full of amla pulp mixed with a pinch of black pepper can also be given to the child

• Olive Oil Massage: Massaging the abdomen with warm olive oil for several minutes is another remedy for bed wetting.
• Cranberry Juice: Cranberry juice is recommended for children with bed wetting problems. It is good for the bladder and urinary tract. 1 cup of cranberry juice can be given to your child for a few weeks. If the bedwetting is due to a urinary infection, then you give your child 1.5 cup of juice thrice a day.
• Walnuts and Raisins: Walnuts and raisins can also be given as a snack to the child. Two walnuts and five raisins should be given to the child before going to bed. This helps in stopping bedwetting.

All the above-mentioned medication, lifestyle changes and home remedies can help in the management of nocturnal enuresis or bed wetting.

Few Facts About Bedwetting

Here’s a few facts about bedwetting that could help:

• 15% of 5 yr olds or about 3-4 children in the first grade are not dry every night.
• 85% of children outgrow bedwetting without any treatment.
• In their teenage years, only 2%-5% of children continue to wet their bed.
• The ratio of boys to girls for bedwetting is a ratio of 4 to 1.

Conclusion

The parents of a child who experiences bedwetting can feel confused and frustrated. Hence, it is important that you discuss the issue with your paediatrician and include your child in the discussion. This helps instil confidence in the child that they have family support which makes them comfortable and they respond well to treatment.