The Bed-Wetting Report FAQ

By Dr. Anthony Page Ph.D.

As a clinical psychologist, I have been treating bed-wetting for over 30 years. I have prepared this report for you from the medical research, and from my experience from treating thousands of bed-wetters.

There's a lot of information in this report, but it's here for parents who care about their child's bed-wetting and who want to know everything before deciding what to do next.

How common is bed-wetting?
It's not a new problem, in fact there's research on bed-wetting that goes back over at least 50 years and it shows that between 10% to 20% of children around the age of five years wet the bed at night, and even at the age of 19, there are 2% who are still wetting. So this means that bed-wetting is a problem for about one out of seven children between the ages of 5 and 18.

Bed-wetting can be an agonizing problem, but there is a great deal that can be done about it. But first let's look at the facts about bed-wetting.

Why do children wet the bed?
First of all, most parents of bed-wetters say that their child sleeps very heavily. That's absolutely true, but just to confuse things, so do many children who do not wet the bed.

Secondly they also say that their bed-wetting child soaks the pajamas and the bed when they wet, and so they conclude that they have to cut down their child's drinking. Well, it's certainly true that bed-wetting children are producing a lot of urine in the night, but that's not because they drink too much before bed.

Thirdly, some parents remember that bed-wetting was an issue for them when they were young.

Essentially that sums it up, children who wet the bed sleep very heavily, they produce large amounts of urine during the night, and the problem runs in families. It's a combination of all three factors which results in a problem with bed-wetting.

Let's work backwards and start first with the genetics. It's known that if one parent was a bed-wetter, then there is 40% chance that the child will be a bed-wetter. If both parents were bed-wetters, then there is a 70% chance. So, it's in the genes.

Then there's the problem of producing far too much urine at night. This is due to a particular hormone which the brain produces during the night. This hormone has the job of reducing the amount of urine that is produced, and so mostly we can sleep through the night, or maybe get up once. In children who are bed-wetters there is not enough of this hormone being produced, and so they continue to produce urine at the same level as when they are awake. The result, they need to be empty their bladder two and sometimes three times during the night, and each time they go, they pass a large amount of urine.

Combine those two features with heavy sleeping and you've got a classic bed-wetter.

Is it possible that there is something physically wrong with my child?
It's unlikely. Only around 2% of children who are bed-wetters have a physical condition, such as a bladder infection, or diabetes, but it is still a good idea to have your doctor check out your child physically just to make sure.

Some parents think that their child's bladder must be too small, but that is not very often the case. However, if your child appears to need to go to the bathroom often during the day, and passes only small amounts of urine, then a small bladder is a possibility. Again, if you suspect this is case, check it out with your doctor, and maybe bladder stretching exercises are needed. However, if that is the case, this is usually only the first step in the treatment process, the underlying issue of heavy sleeping and producing too much urine is still likely to be there.

The situation to watch out for is when a child has previously been consistently dry at night for some years, and then begins to wet the bed. This is when there could be a medical cause, or perhaps an emotional upset. Again, this needs to be checked out with your doctor. This kind of bed-wetting is called "secondary" bed-wetting, because it is secondary to some other problem.

But, as I mentioned above, only 2% of bed-wetters are likely to have a medical or emotional problem, 98% will have the genetically determined kind.
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What can you do about it?
A simple strategy that many parents use is to have their child to wear diapers to avoid having to deal with wet sheets, plastic mattress covers, etc. But there are hidden problems with this. In the recent meeting of the American Academy of Pediatrics in November 2003, approximately 300 pediatricians and nurses in a seminar on bed-wetting were asked about the use of diapers with bed-wetters. 85% expressed concern that wearing diapers is going to "give the wrong message", that is, it is okay to wet at night and not get up and go to the bathroom. They believe that using diapers may actually prolong the bed-wetting problem. When children have been surveyed it is no surprise that many of them say they would prefer to wear a diaper and not to have to worry about getting up in the night to go to the bathroom.

Some doctors also have a concern that children get so used to wearing diapers, that it becomes almost a feeling of comfort to be wearing them, and this can continue into teenage years, and even adult life.

There is also a more serious concern expressed in the October 2000 issue of the Archives of Diseases in Childhood. The worry is that using plastic-lined diapers with boys can raise the temperature of the scrotum and testicles to the same temperature as core body temperature. The testicles are outside of the body and normally are several degrees cooler than inside body temperature, and that's what they are supposed to be. So having them at the same temperature as inside body temperature is considered to run the risk of lowering fertility. Having said that, the concern is not a certainty and only time will tell the degree to which this concern is justified.

Now that puts parents into a bind. On the one hand wearing diapers might prolong bed-wetting and have risks for boys in particular, but on the other, if nothing is being done to cure the problem, then the parent has to put up with a wet bed, sometimes more than once a night, and has a pile of washing to do the next day. Is it any wonder that bed-wetting creates a lot of stress for the whole household.

It would appear then that it is preferable not to use diapers with your bed-wetting child, but if you do, then it should be only short term, and you should be actively working with your child to teach him or her to learn to wake up to go to the bathroom.

Are there any quick fixes?
In a word, “no”.

As you can see from the earlier discussion, bed-wetting is a complex issue involving genetics, heavy sleeping, and overproduction of urine. It would be nice if there was quick cure for all of that, but there's not.

Pills are sometimes used, but be warned, the one which was commonly used in the past (Imipramine) is an antidepressant, and used to treat depression in adults. While in small amounts this could help some children to stop wetting the bed, it is found that after stopping the medication, the majority relapse to wet the bed again. The word of warning is that it is extremely toxic in high doses, and in a report by Dr Schmitt, a pediatrician in the Department of Pediatrics at the University of Colorado School of Medicine, he said that there are "... grave doubts that these drugs should be prescribed for any child at all". Not only that but there is recent publicity that adult antidepressant drugs should never be prescribed for children at all, even for depression.

Another medication, Desmopressin, is a synthetic hormone which helps reduce the amount of urine produced when a child is asleep. At first glance, it looks a very useful alternative because it does stop bed-wetting in a some users. The problem is that the majority of children return to wetting the bed after they stop using it, and it is very expensive, $60-$120 per month. Like any medications it has side-effects, in this case headaches and stomach aches, and it can interfere with the proper balance of the body fluids. This last side effect is the most worrying one, because it can cause a build-up of fluid in the brain if a child drinks while taking the medication, and that build-up has been found to cause mental confusion or even an epileptic convulsion.

It's rather a puzzle that this medication is recommended by some doctors for a child to take for short-term use, such as going to a school camp, when it is extremely important that the child is carefully monitored after taking the medication to make sure that he or she does not drink too much. It is not likely that the right kind of supervision is going to happen at a school camp. Some doctors even say that you should take the child to see the doctor again after starting taking the medication, another indication of this being a medication not to be trifled with. This also involves another doctor visit and extra cost.
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What about limiting drinks?
It's appealing to think that if the child is producing too much urine during the night, then the simple answer will be to limit drinks from late afternoon. In fact this achieves nothing, the brain of the bed-wetter faithfully sends out the message to continue to produce too much urine regardless. It may be useful to avoid caffeine and sugar based drinks which can affect the production of urine, but essentially, tinkering with fluid intake makes little difference. Not only that, but it is important that your child's fluid intake is maintained at the right level, because bodies, and brains in particular, need plenty of water to function correctly.

What about setting an alarm clock or getting the child up during the night?
Using an alarm clock, or alternatively the parent getting up to take the child to the bathroom during the night, may reduce the number of wet beds, but it does nothing to teach the child to wake by himself or herself. It is also frequently reported by parents that the alarm clock did not wake the child anyway.

Is practicing before bed any use?
Practicing the procedure of waking up to the need to empty the bladder and going to the bathroom should be a part of any bed-wetting treatment program. This involves the child, just before bed, practicing by lying down in the bed, and saying out loud, using the words that are most appropriate for your child, something like, “my bladder is getting full, I need to get up and go to the bathroom to empty it.” Then your child should get up and run to the bathroom and pretend to pass urine by standing in front of the toilet bowl, or sitting for a few moments on the toilet seat. You then repeat this at least five times so that the idea is lodged in your child's mind as he or she is going off to sleep. As you may have found, if you say to yourself that you want to get up at a certain time, and set an alarm clock, quite often you will wake exactly at that time, or before the alarm clock actually goes off.

Why not leave a child to simply grow out of it?
A percentage of bed-wetter's will stop wetting the bed each year, and this is why the number of bed-wetter's in each age group is gradually reducing until there are approximately 2% to 3% at the age of 19.

Therefore you may simply decide to wait until your child grows out of bed-wetting, and is there any problem with that? As with so much to do with bed-wetting, the answer is not necessarily simple. Because, if you are continuing to use diapers for your child, especially for boys, this carries a risk that overheating the testicles may cause damage. The use of diapers can also prolong the problem of bed-wetting, because it is just too easy for a child to go to sleep with no concern about wetting the bed. If you do not use diapers, then there is the ongoing issue of dealing with wet beds every day. But probably most important, there is the negative effect on you child's self-esteem, and the way in which low self-esteem can affect almost all areas of the child's life. Finally, there is no reliable way to guess just when your child will stop. So just waiting is not a recommended option.

Summing all that up:
The vast majority of bed-wetting is caused by genetics, with heavy sleeping, and a tendency to produce too much urine at night being part of that pattern. When the child needs to wake to go to the bathroom, he or she is too heavily asleep for the full bladder to wake him or her up.

Gradually as the years pass more children become dry at night, but there is no means of predicting when any particular child will become dry, and in the meantime it is not advised to limit drinks, nor should diapers be used because at the very least it prolongs the problem, and at worst it may damage a boy's testicles.

While there are pills that can help, they are expensive, and in the majority of children they work only while the pill is being taken. More than that, the side-effects mean that these should be used only with caution and good supervision.
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An approach that research shows does work:
Having said all of that, there is a method which research shows is the only effective method of treating bed-wetting long term.

This uses a particular learning process which is the foundation of much of the day-to-day learning which happens for us. Let me explain. The gym I go to has a small café I have to pass as I go to the weights area. It does not matter what time of the day it is, as I smell the fresh muffins and coffee, I instantly feel hungry and it is an act of will for me to keep walking past! Perhaps you have also noticed that when you see the McDonald's golden arches that you feel hungry. This is a classic case of conditioned learning, those golden arches, or the smell of fresh muffins and coffee, are associated with feeling hungry, and so the sight or smell of them can trigger the hunger feeling.

This principle was discovered by Pavlov in the early 1900s, when he found that if one powerful stimulus is associated with one which is quite neutral, after a time the neutral one acquires the same power as the powerful one. In Pavlov's case he discovered that putting food in a dog's mouth was a powerful stimulus triggering the production of saliva. He then experimented with ringing a bell each time he gave the dog some food, and after a time he found that simply ringing the bell would produce saliva, just as if the dog had food in its mouth.

We are affected by this kind of learning all the time, and mostly we are completely unaware that learning has just happened. It does not require any thinking, you just have to be there, for the powerful and neutral stimuli to occur together, and the link is made.

It is this principle which is thought to lie at the basis of the most effective treatment of bed-wetting that there is. Here we have stimulus of a full bladder which should trigger waking, but it does not. However, the sound of a loud noise can trigger waking, and so the trick is to pair up the full bladder and the loud noise, so that in time the full bladder will do the waking, just like the loud noise does.

This is where the bed-wetting treatment alarm comes in. We have an alarm which has a moisture sensor connected to it which goes in the pants of the bed-wetter, and the instant the bed-wetter starts to urinate, then the alarm is triggered making a loud noise. Now, everyone says, “what's the point of that, it's too late.” But remember, the principle of Pavlovian conditioning, says that when a powerful stimulus and a neutral (or ineffective) stimulus are paired together, in time the ineffective or neutral stimulus becomes as effective as the powerful stimulus. The fact that the alarm was triggered after the bed-wetting starts does not matter. The brain can even connect backwards, and so it connects being woken up by the alarm and the sensation of what was happening in the bladder. In time the sensation in the bladder by itself becomes just as powerful as the loud noise from the alarm to wake the bed-wetter up.

The fact is, this has been known for at least 50 years, and so there is 50 years of research to back this up, a bed-wetting alarm is the most effective way of treating bed-wetting long-term.

Is really that simple?
Mostly, yes. But remember, we are dealing with a child, and not all children function exactly according to the rules. For this reason it is important to have a professional involved in the process whom you can turn to for advice as you are using the bed-wetting alarm.
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So, what do you do now?
It is clear from research that the only reliable method for treating bed-wetting is to use a bed-wetting alarm.

Mostly the treatment is quite straight-forward. Children who wet several times a night will begin to wet less often, then after a week or two (but the time is quite variable), your child will begin to wake more and more quickly as the alarm is triggered; you will notice that there will be less wetting because the alarm enables your child to stop the urine flow. Step by step your child will wake more quickly until he or she is waking consistently without the need for the alarm. To get to this stage usually takes from six to eight weeks, but can vary either side if that range.

The final step occurs spontaneously, after a few weeks your child will mostly sleep through the night with no need to wake to go to the bathroom. Of course, just as with the adult pattern, there will times when waking to go to the bathroom is necessary.

A few children relapse, and if that happens then the technique is to return to using the alarm again, and then also to use a relapse prevention approach. The relapse prevention technique is simply to use the alarm until the criterion of 14 consecutive dry nights is reached, and then to have the child drink a glass of water before bed, so that within an hour or two he or she will need to use the bathroom. That will result in waking or the alarm will be triggered. Either way your child receives more training to wake. This is continued for 7 nights and then the extra drink is stopped and attaching the alarm each night is continued until 14 consecutive dry nights is attained.

Scientific references used in this report

Baller, W.R. Bed-Wetting: Origins and Treatment, 1975, Pergamon, New York.

Black, Dora. Psychotropic drugs for problem children. British Medical Journal, 1991; 302: 190-191.

Forsythe, W.I. and Butler, R.J. Fifty years of enuretic alarms. Archives of Diseases of Childhood, 1989; 64: 879-885

Grellis, S.S. etal Current Pediatric Therapy, 1976, Volume 17. B. Saunders, Philadelphia.

Glazener, C.M.A., et al. Alarm Interventions for Nocturnal Enuresis in Children (Review). The Cochran Database of Systematic Reviews 2005, Issue 2.

Hjalmas, Kelm. GP Weekly News,1994, 23 March. Nocturnal bed-wetting is in the genes.

Houts, Arthur C., Berman, Jeffrey S., and Abramson, Hillel. Effectiveness of Psychological and Pharmacological Treatments for Nocturnal Enuresis. Journal of Consulting and Clinical Psychology, 29:21.

Lister-Sharp, D et al. A Systematic Review of the Effectiveness of Interventions for Managing Childhood Nocturnal Enuresis. NHS Centre for Reviews and Dissemination, University of York, 1997.

Partsch, M., Aukamp, M., Sippell, W.G. Scrotal Temperature Is Raised In Disposable Plastic Lined Nappies. Arch. Dis Child, 2000; 83: 364-368.

Rauber, Albert and Maroncelli, Regina.Prescribing practices and knowledge of tricyclic antidepressants among physicians caring for children. Pediatrics, 1984; 73: 107-109. 1994; 62: 737-745.

Schirky, H.C. Pediatric Therapy, 1980, 6 Ed.Mosby, St Louis, Missouri.

Schmitt, B.D. Nocturnal Enuresis: An Update on Treatment. Pediatric Clinics of North America, 1982; Steele, Brian T. Nocturnal Enuresis: Treatment Options. Canadian Family Physician, 1993; 39: 877-880.

Wille, S. Comparison of desmopressin and enuresis alarm for enuresis. Archives of Diseases of Childhood, 1989; 61: 715-726.

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