Over the course of one spring week, four healthy children from four different families came in for annual physical exams. The two boys and two girls ranged in age from 6 to 11, but all four shared one nagging problem - bed-wetting. I could tell from my conversations that the parents were very worried, while their kids were a little embarrassed. Each family felt it surely was the only one in the world dealing with such a frustrating issue.
Bed-wetting is a common problem, affecting up to 7 million kids in the United States, but the issue is not discussed much outside of the doctor's office. When I hear of this nighttime concern, my first priority is to make sure the individual child's bed-wetting is not a sign of an underlying pathological condition. A careful history-taking, focused on a few basic questions, usually helps sort this out. In kids who have already established night dryness and then abruptly start to wet the bed again, a urinalysis can usually rule out diseases such as new onset diabetes or urinary tract infections as causes of bed-wetting, or enuresis.
If the child has never been dry at night, and there are no problems with urination or bowel movements during the day, bed-wetting is referred to as primary enuresis. Though bothersome, it is generally a benign condition.
The American Academy of Pediatrics explains that the vast majority of childhood bed-wetters are normal, healthy kids who simply are experiencing "delayed maturation of bladder control mechanisms." Only 1 percent of children with enuresis are found to suffer from an actual disease process.
Enuresis is almost always outgrown, though the age of resolution can vary widely, and in extreme situations can extend into the mid-teen years. Experts at the AAP explain that the incidence of bed-wetting steadily decreases with age, with enuresis affecting 40 percent of 3-year-olds, 20 percent of 5-year-olds and only 3 percent of 12-year-olds.
Primary enuresis has a genetic link, and if they're willing to open up, one or both parents often report experience with bed-wetting from their own childhood. In an article published in Pediatrics in Review, pediatricians Michael Lawless and Darby McElderry note that as many as 70 percent of children with enuresis have a parent with a similar bed-wetting history.
Drs. Lawless and McElderry outline therapeutic approaches to bed-wetting, stressing that treatment can be tailored to fit the child's developmental stage as well as the child and family's level of concern. Children younger than 8 usually respond best to reassurance, along with the application of motivational or behavioral therapy.
Motivational therapy involves education and positive reinforcement. If the child is willing, he can stop drinking fluids two hours before bedtime, and should avoid evening consumption of caffeinated drinks, dairy, citrus juices and chocolate, which are all known to increase overnight urine production. The child should also take time to void completely, right before falling asleep. Praise is given for dry nights, while kids can be asked to help strip the bed when accidents do occur. Parents need to keep in mind that enuresis is not intentional, and that wet nights should never lead to punishment.
Behavioral therapy, which often incorporates the use of a bed alarm system, can be successful in very motivated younger children, and in the middle group of 8- to 11-year-olds still dealing with bed-wetting. Wet underwear sets off an alarm that wakes the child (or more likely, his parents during the more challenging initial weeks of therapy). With time, the child becomes trained to wake before, instead of after, urination. Lawless and McElderry state that though the process may take several months to become fully effective, bed alarms result in the highest cure rate of all recognized enuresis treatments.
The pediatric authors endorse a more aggressive approach for kids 12 and older, who are more likely to feel the full negative psychological impact of continued bed-wetting. If bed alarms do not lead to success, medications such as DDAVP can be added to the regimen. DDAVP, available in prescription nasal spray or tablet form, acts by increasing water reabsorption by the kidneys, resulting in smaller volumes of overnight urine production.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.