Summertime is a child’s favorite time of year, marked by the things most kids look forward to, like camps, vacations, and sleepovers. However, if a fear of waking up in a wet bed is weighing on a child’s mind, participation is these activities will likely be limited. That’s why summer is a good time to get help for kids struggling with bedwetting, or primary nocturnal enuresis (PNE). By this point, many families have tried to clandestinely manage the situation and everyone is ready for a solution.
Five to seven million children between the ages of six and 15 are affected by PNE.Fortunately, 95 percent of children will spontaneously resolve this troublesome behavior by their mid-teens. But to understand the treatment of any condition, one must know the causes, and there is no single cause of bedwetting. One very common observation a pediatric urologist hears from a parent is that a child sleeps very soundly. When the bladder reaches fullness, it must empty. The child is unable to sense a full bladder and awaken in time to void in the toilet. This is called impaired arousal.
Another factor influencing bedwetting is the production of too much urine while sleeping. We all have a naturally occurring antidiuretic hormone in the body called vasopressin. Vasopressin decreases urine production while sleeping. Some children who wet the bed have deficient levels of this hormone. One form of treatment focuses on improving the level of this hormone with a safe medication.
Some children might experience a small and/or overactive bladder during sleep. An overactive bladder contracts and empties with little or no warning or control. The result is a smaller than expected bladder capacity or an unrecognized urge to empty the bladder before the child can awaken to go to the bathroom. Constipation is another factor which may result in diminished bladder capacity. It is important for the child to have good bowel habits and regular elimination, as this can have a major influence on the amount of urine contained in the bladder.
The focus of initial treatment is examination of the child’s diet and elimination of detrimental habits. In addition to a normal bowel movement daily, the child should empty his or her bladder regularly, especially before bed. Normal fluid intake should be 32 to 40 ounces per day depending on age. In the evening, fluid intake should be reduced. Bladder irritants such as caffeine and red dye should be avoided as they result in bladder overactivity as well as increased urine production.Caffeine is the number one chemical resulting in irritative bladder symptoms.Soda is the primary culprit for kids when it comes to excessive caffeine. Chocolate in milk or candy is another source of caffeine.The red dye found in soda and punch has similar effects, resulting in unexpected spontaneous discharge of urine while sleeping. Additional troublemakers in the evening may be citrus fruits, juices such as orange and grapefruit, and even lemonade in some kids.
If these measures are not successful or your child shows only modest improvement, parents who want to avoid medication might try the moisture-sensitive alarm or bedwetting alarm. This is a small battery-operated device, available online or at your local pharmacy, which is connected to the undergarment or even a pull-up.The initial drop of urine triggers the alarm, signaling the child to wake up, hold his or her urine and go to the bathroom. For this kind of behavior therapy to be effective, family members must practice patience and assistance. Generally, because children with PNE are very diffi cult to arouse, the alarm alone may not be enough. A designated wake-up coach is necessary. With the right family support, alarms can be highly successful, are cost-effective, and carry a low risk of relapse.
Your physician may recommend medication as a treatment choice. The most common one used for bedwetting is desmopressin acetate (DDAVP), which addresses the defi ciency of antidiuretic hormone. Desmopressin is taken before bed on an empty stomach – no food or Drink one and a half hours before taking the medication. The result is less urine production during the night, allowing the child to sleep through the night without the need to empty the bladder. After taking this medication, the child should not eat or drink to avoid unwanted side effects.When used properly this medicine has been shown to be quite safe and effective.
Some children have a small or overactive bladder, requiring usage of anti-cholinergic medications such as oxybutynin (brand name Tolterodine). These drugs calm the bladder, resulting in an increased bladder capacity and preventing uncontrolled discharge of urine. When coupled with desmopressin, they have been effective in achieving dry nights. When used alone, these medications are not as successful and are reserved more for the child with isolated daytime frequency.
Another medication, imipramine (brand name Tofranil), is a type of antidepressant that can have a calming effect on the bladder and the added benefi t of improving your child’s ability to awaken to a full bladder. While it is no more effective than other medications, it can have some very disturbing side effects and over dosage could be fatal. As a consequence, this medication should not be used as a primary treatment and reserved for failure of other measures.
For the child with resistant bedwetting, combination therapy including dietary measures, alarm therapy, and medication may be necessary. Parents and children should be patient and realize these measures are not curative. Rather, they allow the child to manage the condition until he or she matures and a dry bed is the norm.
