Bedwetting is a form of enuresis, or loss of bladder control. According to Dr Margaret Fockema, president of CASA, (Continence Association of South Africa) and vice chairman of the Enuresis Academy of South Africa (EASA), the full medical definition of enuresis is “an involuntary voiding of urine during sleep, with a severity of at least three times a week in children over the age of five, in the absence of congenital or acquired defects of the central nervous system”.
Trish Holgate, a social worker who specialises in counselling children, says“a child under the age of about four years who is wetting their bed should really not be considered enuretic. While the parent may long for dry sheets, the child may still not have the required bladder control. Even once dryness has been achieved, the odd wet bed can be expected. It should resolve itself by about the age of seven. Achievement of night-time dryness varies enormously, so comparisons should be avoided.”
Primary and Secondary Enuresis
There are two types of enuresis. Primary enuresis refers to when a child has never managed to achieve dryness at night. Dr Jacobus van Dyk, a paediatric endocrinologist explains: “We know that there are three contributing factors, namely going into a very deep sleep and not waking up from the sensation of a full bladder, having a small functional bladder capacity and, thirdly, the over-production of urine while sleeping, known as polyuria, which is caused by a lack of an antidiuretic hormone and affects 60 percent of sufferers.”
Secondary enuresis refers to children who have achieved dryness at night but then begin wetting their beds again. According to Dr Fockema, causes can be constipation, urinary tract infections and congenital defects. “The child needs to be evaluated and secondary causes need to be ruled out. Once these have been eliminated as possible causes, a diagnosis of primary enuresis can be made,” she explains. Interestingly, enuresis is three times more likely to occur in boys and a child is 70 percent more likely to develop this condition if both parents were enuretic themselves, suggesting a strong hereditary link. Some also hold the view that there is an emotional cause for secondary enuresis, says Holgate. “In my experience, the most common cause for secondary enuresis is an emotional crisis that causes anxiety. This crisis can be brought on by any big change such as starting school, moving home, illness, divorce or the birth of a new sibling. Even events that you may consider insignificant may cause a child anxiety. A child who is not able to express anxiety appropriately may well begin bedwetting.”
But Fockema disagrees. “Nocturnal enuresis was once thought to be a psychological condition but studies now indicate that the enuresis itself is likely to be the cause of the emotional problems.” In a recent survey in Denmark children were asked what would be most traumatic for them. They perceived the worst thing that could happen to be losing a parent, but this was followed closely by wetting their beds. Contrary to how it may sometimes seem, a child who wets their bed is not being stubborn, manipulative or “naughty”. “It is not their intention to keep you, the parent, slaving over the washing. If you and your child are battling with this problem, you need to consider possible underlying causes so that they can be addressed. Armed with some understanding, you will feel like you have more of a plan and be able to respond appropriately,” says Holgate.
Solutions vary, depending on the cause and the nature of the enuresis. Firstly, the attitude of the parent plays a vital role in addressing this problem. “Attacking, shaming or punishing the child will only increase anxiety levels and exacerbate the problem. This then leads to a vicious cycle with both the parent and the child ending up very unhappy and frustrated,” explains Holgate. “Rather, remain emotionally contained and show confidence in the child’s ability to eventually control his bladder function.” Dr Fockema adds: “Often letting your child know that you also suffered from this when you were a child provides comfort and reassurance”.
If you are concerned, let your GP examine your child and advise you of the appropriate steps to take. According to Dr van Dyk, “If the problem is an over-production of urine, medication such as an antidiuretic hormone can be given to slow down urine production at night”. It has an almost immediate effect of reducing urine output and therefore reduces bedwetting. The success rate is as high as 70 percent and it is very effective for special occasions such as sleepovers, when going through the night without wetting the bed is extremely important to the child. However, it has been found that once medication is discontinued, bedwetting usually reoccurs.
Changes in diet can also help. Certain foods such as dairy products, caffeine, carbonated drinks and acidic foods irritate the bladder. Reducing or eliminating these from your child’s diet can be effective. Consider also that a child’s bladder capacity increases by a mere 30ml per year during the first eight years of their life. The actual capacity can be measured by multiplying the child’s age by 30 and then adding 30, to get a volume in millilitres. Try limit fluid intake towards bedtime, but don’t be tempted to cut back during the day as this can lead to dehydration.
A method that is quite successful in stopping bedwetting is the use of a bed alarm. “A bed alarm has excellent results,” explains Dr Fockema. “It consists of a sensor that is placed inside the child’s underclothes and is connected to an alarm that goes off if the child starts to urinate. Many consider this to be the method of choice when treating bedwetting, especially in Europe.”
What we as parents need to keep foremost in our minds is that bedwetting is not bad behaviour that needs to be punished. Each child is different and each will eventually gain total bladder control. With our support and encouragement we can help to make this a smoother, easier process for our children.