What is Primary Nocturnal Enuresis?
Primary enuresis or primary nocturnal enuresis. (PNE) refers to the recurrent and uncontrolled urination that occurs while your child is asleep. PNE occurs when young children lack bladder control from infancy. Children develop nighttime bladder control at different ages. Persistent bedwetting, that is bedwetting that occurs at least once a week, is not considered to be a problem until your child turns five or six years of age. Most of these children experience urine control problems only when asleep; children who wet the bed do it neither consciously nor deliberately. It is estimated that approximately 16% of 5-year-olds wet the bed on a regular basis, dropping to 7% by age seven. While both boys and girls wet the bed, bedwetting is more common among boys than girls. By age 10 an estimated 3% of boys and 2% of girls wet the bed, while among adolescents this percentage drops to 1% for boys and even less for girls.
What are the Causes?
- The most common cause of bedwetting is a neurological-developmental delay. Children whose nervous systems are still forming may not be able to know when their bladder is full. Research suggests that children who wet the bed at night may have a nervous system that is slow to process the feeling of a full bladder. Consequently, these children do not wake up in time to relieve themselves.
- The risk of suffering from bedwetting increases for children who have a family member who also wet their bed, such as a parent, grandparent, aunt or uncle. For example, the risk of your child wetting the bed is 15% if neither your or your partner were affected as a child, 40% if one parent was affected and 75% if both of you wet the bed as children.
- Parents of children who wet the bed often comment on how heavy a sleeper" their child is. Researchers have shown that while deep sleeping certainly plays a role in bedwetting it is not the primary cause of why it happens in the first place. When the bladder is full and requires emptying it sends a message to the brain. Children who are particularly deep sleepers fail to wake in response to this message. The bladder then attempts to either store the urine until your child is able to wake-up and go to the toilet or it empties while your child sleeps.
- A small number of children wet the bed because they do not produce enough of the anti-diuretic hormone ADH. The job of the ADH hormone is to help monitor the amount of urine our body produces. The body normally increases ADH levels at night, which signals to the kidneys to produce less urine. If nighttime ADH levels are low, your child will continue to produce the same amount of urine as they produce throughout the day placing significant pressure on their bladder. Children will continue to wet the bed until their body begins to produce more of the hormone, this may not be seen until about 10 years of age.
- Some children are at greater risk than others for experiencing PNE. Children with a gross developmental delay (i.e., children with Downs Syndrome) or who experience delays in achieving motor milestones, children who were born prematurely or those with behavioural disorders such as hyperactivity or attention deficits (i.e., ADHD) are all more likely to wet the bed at night. Children with Attention Deficit Hyperactivity Disorder, for example, are 3 times more likely to experience difficulties with staying dry at night.
- Drinks or food high in caffeine can increase the risk of bedwetting due to their diuretic function. Caffeinated drinks, tea, coffee, and chocolate all stimulate the kidneys to produce more urine placing additional stress on your child’s bladder.
- Some children who wet the bed do so as a result of some underlying physical or medical condition. A very small percentage of children who wet the bed (<10%), do so because of a physical abnormality, such as a smaller than normal bladder. Less than 5% of primary bedwetting cases are caused by infection or disease, the most common being a urinary tract infection, followed by juvenile diabetes. Children who suffer from sleep apnea are prone to bedwetting. Chronic constipation can also contribute to children’s bedwetting.
- Contrary to popular belief, stress or other underlying psychological disturbances are not the cause of Primary Nocturnal Enuresis. Stresses in a child’s life such as a parental divorce, death of a family member, birth of a sibling, or starting school, are more likely to cause secondary nocturnal enuresis.
How should I respond to my child’s bedwetting?
Bedwetting can be incredibly upsetting for all involved. Bedwetting puts social limitations on children’s behaviour and carries with it a social stigma that can be incredibly damaging to their self-esteem and emotional wellbeing. Many parents feel at a loss as to how best help their child through this often trying and difficult process. Others choose to avoid the situation with the hope it will go away on its own or take out their frustration and feelings of inadequacy by punishing their child for their bedwetting. Parental responses to bedwetting can either help diffuse a potentially stressful situation, or make a bad situation even worse. If handled poorly bedwetting can lead to feelings of incompetency, shame, confusion and anxiety. Parents can help by being empathic, loving and supportive. It is important to never punish a child for their bedwetting, this only provides children with the message that they somehow have control over what is happening and that the bedwetting is their fault. Assure your child that you love them and that you will manage their bedwetting together. Reassure children by explaining that what they are experiencing is perfectly normal and in no way their fault and that with time this will all come to an end. Your child will feel less isolated and alone when they know that there are many children out there just like them. The level of support you receive, as a parent is equally as important as the level of support you provide for your child. Parents of children with nocturnal enuresis can feel isolated, ashamed and incompetent. Due to common misperceptions parents are often made to feel that they are somehow responsible for their child’s bedwetting.
When and What type of treatment?
The majority of children between the ages of 5 and 7 years with primary nocturnal enuresis will become dry on their own without the need for treatment. Treatment is recommended if (a) your child is older than 6 years of age and wets the bed at least twice a week or more, (b) is visibly upset or disturbed by their bedwetting, or © their bedwetting begins to impact on their everyday functioning or social relationships. In deciding what treatment to recommend doctors will consider the age of your child, the frequency of the bedwetting as well as the motivation and needs of your child and your family. Additional factors that may impact on the choice of treatment include whether your child has easy access to the toilet, as well as your child’s sleeping arrangements, for example, does your child have their own room or do they share with a sibling? This is particularly important if choosing to use a moisture alarm.
Conditioning or bedwetting alarms are currently the most effective form of treatment. Bedwetting alarms come in two main forms. One is a body alarm with a small sensor that can be worn inside children’s underpants or used with DryNites. The second type of alarm is a bell and pad alarm that is placed like a mat over the bottom bed sheet. This is connected to an alarm box placed at the end of your child’s bed. Bedwetting alarms work by helping children learn to recognise the need to pass urine and either wake-up and go to the toilet or learn to hold on until morning. Alarms come with different settings that allow you to vary the sound; a louder alarm may be needed in order to raise a particularly deep sleeper. Some alarms include a vibration option, while others can even be programmed so that your child wakes to the sound of a voice recording rather than an alarm. Parents may need to initially help children to wake in response to the alarm. It can take a few weeks until your child begins to respond and can take children up to 3 months to achieve continence. Children should continue to use the alarm until they have achieved at least 2 weeks of uninterrupted dry nights. Before purchasing a conditioning alarm it is important that you speak with a continence specialist who will be able to advise you which one is best for your child. The success of the alarm is highly dependent on how motivated children are to become dry, sustained involvement and commitment, correct instruction, as well as the level of support you receive.
Medications are generally seen as a form of treatment, not a cure. Two commonly used medications to treat bedwetting are Imipramine and Desmopressin (also called DDAVP). Desmopressin works by mimicking the action of the hormone ADH, reducing the amount of urine produced by the kidneys and is available both in tablet form and nasal spray. Imipramine is only available as a tablet. Desmopressin is reported to have the least side effects, although both should only be taken under close medical supervision. When considering the use of the medication for treating bedwetting, the question you should ask yourself is “What am I hoping to achieve?” If you’re looking for a permanent solution to your child’s bedwetting, then this is probably not the way to go. Many children do experience a relapse when they stop taking the medication. Sometimes using medication in conjunction with a bedwetting alarm helps do the trick. Medication may also be useful for the treatment of bedwetting among children with particular developmental, attentional, behavioural or emotional difficulties.
Families sometimes turn to complementary and or alternative medicine when more conventional treatments fail to produce a positive outcome. While there is very little research evidence to support the efficacy of these alternative treatments, anecdotal evidence supports their use across a range of situations. These treatments include: Psychotherapy, Acupuncture, Homeopathy, Hypnotherapy, Naturopathy and Chiropractic care. Many of these approaches are still viewed as experimental so it is a good idea to speak with a continence advisor first. Parents should consider involving a professional with psychological expertise if your child experiences emotional or behavioural problems in conjunction with their bedwetting.