Solve Your Child's Sleep Problems
Interruptions During Sleep
Bedwetting, or nocturnal enuresis, is a very common and frustrating childhood sleep problem that can upset parent and child alike. It occurs in all societies and has been recorded throughout history. Although figures differ somewhat among cultures and among groups within a culture, approximately 15 percent of all five-year-olds, 5 percent of all ten-year-olds, and 1 to 2 percent of all adolescents still wet their beds at least once a month. Almost two-thirds of enuretic children are boys. Although the causes of enuresis are only partially understood, several methods of treating the disorder have proven successful.
When a child wets the bed, it is not the urination itself but its aftermath that frustrates and annoys: the child’s pajamas and sheets get wet, she wakes up, and her parents might have to get up to change the bedclothes. Even if a child urinated nightly, if somehow nothing got wet in the process, it would not be a problem at all. For that reason, enuresis does not make its appearance as a “sleep problem” until a child is—or should be—out of diapers.
Many families aren’t especially perturbed by enuresis, especially if the child is younger than about seven years old and the bedwetting is infrequent. If that describes your family, you might choose to wait for it to stop on its own. Just be sure the wetting doesn’t upset your child (as discussed below) more than you think. You should be aware, however, that although most children do outgrow the problem eventually, for an individual child this may not happen any time soon: only about 15 percent of enuretic children, at each age from five to eighteen years, will spontaneously outgrow the problem over the next year. Furthermore, the older the child and the more frequent the wetting, the more likely both the child and her parents will be to want to find a solution.
The Impact of Enuresis
Enuresis can affect your relationship with your child, her own self-image, and her interactions with other children. Although she will not remember actually wetting the bed when she wakes, the wet sheets make it clear what happened: she doesn’t need you to tell her, as she would after a sleep terror or a sleepwalking episode. Also, since bedwetting generally happens unobserved (again in contrast to sleep terrors and sleepwalking), parents sometimes incorrectly assume that their child was awake and urinated voluntarily, making them angry and resentful rather than sympathetic and concerned.
Your reactions are very important. Without your understanding and support, your child will surely suffer. But even if you are fully supportive, even if you really don’t mind changing the sheets, your child may still feel ashamed and embarrassed, especially if she is at least four or five years old and still wearing diapers or pull-ups at night. She may be reluctant to have friends sleep over, to go to their sleepovers, or to attend overnight camp. If her schoolmates find out that she wets the bed (or, worse, that she still wears diapers), she may be teased. These emotional effects often prove to be of greater consequence than the bedwetting itself.
Although the frequency of bedwetting can usually be reduced greatly (using the techniques described below), it is not always possible to prevent it entirely. Whether the wetting stops completely or not, if the child’s view of herself and her relations with her family can be improved, both she and her parents will be much happier.
Antonio was a six-year-old boy who wet his bed almost every night, although he had been toilet trained since the age of three. He did have occasional dry nights, but he had never remained dry for more than a week. His parents were frustrated and angry. Sometimes they punished him, often by denying him special privileges, hoping that that would bring about some control. They made him sleep on a small cot and wear a diaper to bed, saying they would not buy him a regular-sized bed until he stopped wetting. Antonio’s parents were caring people and they loved their son, but they did not understand bedwetting, and the situation was not improving. Besides, they hated imposing the punishments, even though they thought they were necessary, and it was making them feel guilty. Finally they realized they needed help.
When the family came to see me, Antonio was surprised and delighted to hear me explain that it was not his fault, that punishment would not help, and that he should be required neither to wear diapers nor to sleep in a cot. I told him that many children his age still wet the bed—he had thought he must be one of only a few. His father admitted, with much embarrassment, that he himself had wet the bed as a youngster, something not even his wife had known.
Antonio’s parents were anxious to correct their mistakes, and I supported their efforts carefully in frequent initial meetings. We embarked on a program of behavior modification (described at length later in this chapter). The results were fairly good: although Antonio’s bedwetting did not cease entirely, it did decrease significantly. And even before that happened, the family had begun functioning much better. Antonio no longer felt ashamed about wetting, and his parents no longer suffered the guilt that punishing him had caused them.
Even when parents are not terribly concerned about bedwetting, the child herself can be. Rebecca was an eight-year-old girl who wet the bed several times a week. Her home was happy and stable, and her parents were sympathetic; they accepted her bedwetting without complaint, and although they would have preferred that she be dry, they were not much disturbed by the problem. Rebecca’s father had been enuretic until age ten and he had openly discussed his own history with her. The parents sought my help not because of their own concerns but because Rebecca was deeply troubled by the wetting. An intelligent girl who expressed her concerns forthrightly, Rebecca was anxious to begin a program that would help her be dry at night. We started a behavior modification program, which she followed with determination, and to her delight it was successful.
Benjamin, twelve, still wet the bed at night, and like most older children and adolescents in his situation, he was very upset by it. In fact, it was affecting his whole life. His self-respect suffered badly. Children in the neighborhood teased him cruelly, and he was becoming withdrawn. He never slept at a friend’s house and never invited a friend to spend the night at his. He wanted to go away to summer camp but refused to do so until he stopped wetting. Benjamin urgently needed to get the problem under control. Simply knowing that there were other children his age who also wet their beds would not be enough. In his case behavioral treatments were unsuccessful, but he responded well to medication: his self-esteem was restored, and he was even able at last to go away to camp.
What Causes Enuresis?
Several factors may play a role in enuresis: heredity, maturation, small bladder capacity, nighttime awareness of the need to urinate, depth of sleep, medical issues, food sensitivity, emotional factors, and environmental and early childhood influences. (For only some of these factors is the relationship certain.) Each of these is discussed below. It may not always be possible to say which are the most important in a given child.
Overall, heredity is probably the single most significant factor contributing to enuresis. Children whose parents were bedwetters are much more likely than other children to wet their beds. While only 15 percent of all children wet their bed, the figure increases to almost half if one parent used to wet the bed and three quarters if both parents did. What specific inherited traits are responsible is unknown, but they may include one or more of the other factors described below, such as a small functional bladder capacity.
For a child to be continent, that is to have control over her urination, the part of her nervous system that controls her bladder has to reach a certain degree of maturation. An infant has little awareness of her bladder filling or of the need to urinate. Her bladder empties when necessary by a reflex contraction. At some point between the ages of one and a half and two and a half, a child begins to recognize when her bladder is full. She may stop playing when she has this feeling, and her facial expression may indicate her awareness that a urination is coming. If she is being toilet trained at that time, she will be able to get to the bathroom and remove her clothing in time to use the toilet. At this stage, however, she still can’t postpone the flow of urine. She will develop that ability over the next year. By age three or four she can urinate at will, even when her bladder is only partially full, and she can now interrupt her urinary stream after it has started. She can go to the bathroom before leaving the house, even if she does not feel the urge to urinate, and she can catch herself when she realizes she is starting to urinate at the wrong time. At this level of maturation, she is now physically capable of staying dry at night as well. If she continues to wet the bed, other causes are probably responsible.
Most children are dry at night before age four, but of course the actual age varies. A child’s bladder grows considerably between the ages of two and four and a half, making it easier for her to hold her urine all night. A few babies are even dry at night before their first birthday. By the age of two and a half about 50 percent of all children are dry, and by age three about three out of four no longer wet their beds. Although “delayed maturation” is often blamed for ongoing enuresis, it is unlikely for children of five or older to continue to wet for that reason. If your child is toilet trained in the daytime, then she has the ability to recognize when she is about to urinate and to hold it until she is in the bathroom or until her bladder stops contracting and the urge ceases. If she is dry at night even occasionally, it suggests that she has the ability to wake up from sleep and do the same thing.
Small Bladder Capacity
Many bedwetters urinate more frequently during the day than non–bedwetters do, and in smaller amounts. Although that seems to imply that their bladders are unusually small, when these children are examined under anesthesia, they are usually found to have bladders of normal size. Because their bladder contractions begin too soon, these children feel the sensation of a full bladder and need to urinate before their bladders are actually full. Furthermore, these early contractions can be very strong. At night, wetting may result. The “bladder training” techniques described later in this chapter are based on these observations.
Nighttime Awareness of the Need to Urinate
A child who wets during sleep may not yet have learned to recognize the sensations from a full bladder, or from a partially full bladder that is already contracting, as a signal important enough to trigger a full waking. You will recall from the discussion of sleep stages in Chapter 2 that a stimulus that is important to you (like your baby’s crying) is much more likely to wake you than an unimportant stimulus (like a bird chirping or the wind blowing). Somehow you have learned to make this distinction, even when you are asleep. Your child must learn the same. If she doesn’t, then she will not interpret the sensation of impending urination as an important enough signal to cause her to wake up and hold the urine in until either the urge passes or she gets to the bathroom; instead, she will not wake and will wet the bed. Conditioning and behavior modification techniques appear to work by helping your child learn to pay closer attention to these signals.
Depth of Sleep
Laboratory studies have shown that bedwetting does not take place during dreams. If your child wakes describing a dream about water and her sheets are wet, it does not mean that she wet because of the dream; the wetting episode came first, rather, and the feeling of wetness from the sheets and pajamas then stimulated the dream.
Many parents of enuretic children report that their child sleeps more deeply than most other children and thus is unusually difficult to wake. Those perceptions are probably inaccurate, arising, at least in part, because whenever the parents try to wake the child to use the bathroom before they go to bed themselves, the child will still be in the period of very deep sleep that predominates in the first few hours of the night. But although the sleep of enuretic children has been shown to be no deeper than that of many other children, it may be that enuretics’ sleep falls at the deep end of the normal range. Parents of enuretic children rarely if ever characterize their children’s sleep as “light.”
Because most bedwetting occurs in the first third of the night, usually during or immediately following an arousal from non-REM sleep, it has some similarity to the arousal disorders described in Chapter 13. That might seem to suggest that the urination occurs during the confusion of a partial arousal from deep sleep (even though the partial arousal may be completely normal otherwise). It is true that bedwetting does sometimes accompany sleep terrors and episodes of confused thrashing or sleepwalking. However, in most cases when a child has both confusional arousals and a tendency to wet the bed, the two behaviors do not occur at the same time of the night or even on the same nights. Furthermore, episodes of bedwetting also commonly occur during arousals from periods of relatively light non-REM sleep, when sleepwalking and sleep terrors are particularly unlikely to happen. We do know, however, that some bedwetters’ bladders contract more during non-REM sleep than during REM. It may be that these contractions sometimes trigger a partial arousal and, at different times, an episode of bedwetting.
Most of this chapter discusses what is called “functional” enuresis, meaning bedwetting that is not related to any medical disorder. Although most bedwetting is functional, you should not assume that your child’s wetting has no medical cause. All enuretic children five years of age or older should have a thorough physical examination before nonmedical treatment begins, both to rule out medical causes and to check for related problems. A urine specimen should also be examined to be sure the child does not have an infection. Urinary tract abnormalities and certain neurological conditions can occasionally cause bedwetting, but in these cases, as well as when there is a urinary tract infection, there will usually be other warning symptoms that occur in the daytime—dribbling urine, daytime incontinence, frequent strong urges to urinate, or frequent or painful urination—which you or your child will notice and which your physician will recognize as important. Although urinary tract infections don’t generally cause enuresis, they are more common in enuretic children, especially girls, and of course they should be treated.
Sometimes children begin to wet the bed after many months of dryness. This condition is called secondary, or onset, enuresis to distinguish it from primary enuresis, in which the child has never stayed dry at night for long. Medical factors are more likely to be involved in secondary enuresis. But if medical problems can be ruled out, a child with secondary enuresis should respond very well to the same techniques we use to treat primary enuresis.
In recent years, there has been a great deal of interest in the role of food sensitivity in a number of childhood health problems, bedwetting among them. In a few cases, nighttime wetting reportedly has decreased when certain foods were removed from a child’s diet. Although it is conceivable that particular foods irritate the bladder in some children, increasing contractions and decreasing bladder capacity, there is no good evidence to support this hypothesis. In any case, unfortunately, very few children respond at all to changes in their diet.
Bedwetting is somewhat more frequent among children who are emotionally disturbed. However, fortunately, such disturbances are not the cause of most bedwetting, and the vast majority of enuretic children are normally adjusted. Any related emotional problems are more likely the result of the bedwetting than the cause.
Environmental Influences and Early Childhood Experience
A child’s early experience may affect her ability to be dry at night by the usual age. For example, studies have shown that bedwetting is slightly more frequent than average in middle children, children in lower-income families, and children faced early in their lives with stresses such as chronic illness or their parents’ divorce. Stress is particularly disruptive during the third year of life, when a child is usually being toilet trained. If toilet training is handled punitively, a child is also more likely to become a bedwetter. But these differences are small. If your child wets her bed, rest assured that it’s not because you haven’t been a good enough parent or because you failed somehow to prevent it. At most, the early family environment can provide only a very small part of the explanation.
Approaches to Treating Enuresis
Throughout history people have described enuresis and treatments for it. Nowadays there are humane and caring methods for treating bedwetting, but in the past enuretic children were subjected to more questionable “cures.” As early as A.D. 77, Pliny the Elder recommended an elixir made from “boiled mice”; during the Byzantine Era, potions included a fragrant wine made of hare’s testicles; and the nineteenth and twentieth centuries brought plenty of new elixirs and potions, most of which have been no more effective than the “flowers of the white oxe” administered hundreds of years earlier. Special rituals have been tried as well: enuretic children in the Navajo tribe, for example, were forced to stand naked with legs apart over the burning nest of a phoebe, swallow, or nighthawk, since it was believed that birds do not wet their nests.
Some parents, like Antonio’s, still make the mistake of trying to stop the bedwetting by means of punishment, ridicule, and shame. Not only is it unhelpful to treat an enuretic child this way, but it may actually prolong or worsen the problem, and the child may suffer emotionally as well. George Orwell, one of the most famous self-admitted enuretics, described the dilemma eloquently:
I knew that bedwetting was (a) wicked, and (b) outside my control. The second fact I was personally aware of, and the first I did not question. It was possible, therefore, to commit a sin without knowing you committed it, without wanting to commit it, and without being able to avoid it.
You and your child will be encouraged to know that most enuretic children can learn to wet the bed less often, and many are able to stop doing it entirely. But before you begin your treatment program, you must understand that solving the problem will require patience, persistence, and family cooperation. Results may be very slow in coming, and your child may relapse. The behavioral methods of treatment require a good deal of consistency, and they will work only if both you and your child are willing to accept some temporary inconveniences. Your child can’t stop wetting without your full commitment, and you can’t make it stop if she isn’t interested in participating and doesn’t understand what the treatments are doing and why.
For these reasons, start by explaining to her (and reviewing for yourself) just how the urinary system works, what is necessary to avoid wetting, and what the approaches you will be using are actually trying to accomplish. Guidelines and pictures to help explain your child’s urinary system to her are shown in Figure 17. Some of that information may be new to you, too. Include as much or as little detail as her age and interest require, and modify or adapt the technical language to fit her level of understanding. She should understand that her bladder continuously fills and intermittently empties, that bladder contractions and the automatic (reflex) opening of the muscle of the internal sphincter lead to a feeling of urgency (the “need to go”), and that the weak muscle of the external sphincter is then the only thing keeping her dry until she can get to the bathroom or until the contractions stop and the internal sphincter closes again. If her bladder becomes capable of holding more urine before it tries to empty, it will become easier for her to get through the night dry. If her external sphincter gets stronger, she may be able to keep herself dry long enough to wake and use the bathroom. These are the goals of bladder training and start-stop exercises.
We treat enuresis using four main techniques, discussed in detail below: reinforcement and responsibility training, bladder training, conditioning, and medication. The first three are behavioral approaches and can be undertaken simultaneously or in succession. Many families start with reinforcement and bladder training methods, then try conditioning if the first two are unsuccessful. Medication therapy requires a doctor’s supervision and is usually recommended only in certain circumstances. The techniques of “lifting” and dietary change will also be described.
Do not restrict your child’s fluid intake during the day—it will not help. It is, however, reasonable to avoid large amounts of liquid after supper and especially near bedtime. Also keep in mind that an initial visit to a doctor is important. Don’t begin a program of therapy until you are sure your child does not have a medical problem that needs attention.
Before trying any of the behavioral approaches, discuss your plans with the whole family. Everyone will need to feel comfortable about cooperating to solve this problem. If anyone resents the work or teases the bedwetting child, it will be an obstacle. If you have been punishing or criticizing your child for bedwetting, explain to her that you have learned that you were wrong to do so and that you now understand that she wasn’t to blame. Let her know that you want to work with her to help her control the problem and to feel better about herself. Don’t treat her like a baby. You should probably not leave her in diapers at night if she is past her fourth birthday—definitely not if she is already five—and toilet trained in the daytime. She should sleep in a regular bed; you can use a waterproof pad under the sheet to protect the mattress. Don’t restrict her in any way because of the bedwetting. You will need to monitor your own behavior carefully, too. Even the most well-meaning of parents can inadvertently show subtle disapproval when the bedwetting continues.
FIGURE 17. YOUR CHILD’S URINARY SYSTEM
Use this text as a guide when going over the accompanying picture with your child. Depending upon your child’s age, you may want to replace words like urine with the words you use at home to help your child understand.
Kidney: These important organs are filters that remove unneeded chemicals from your blood. The filtered fluid (containing the unneeded chemicals) becomes urine.
Ureter: A soft tube down which your urine drips on its way from your kidney to your bladder.
Bladder: A storage container for your urine. It is actually a special kind of muscle. When it gets full it starts to contract, or squeeze closed, to push out the urine. When that starts to happen, you feel the need to go to the bathroom.
Urethra: A short tube through which your urine passes [boys: through your penis] on its way out of your body.
Internal sphincter (often easier to describe to children as the “first stopper”): This part of the urinary system is a muscle, too. It controls the flow of urine out of your bladder, the way a plug controls the flow of water out of a bathtub. Most of the time, it is automatically squeezed closed so that no urine can leave your bladder. When you go to the bathroom, this stopper relaxes and opens so urine can come out. When you are at the toilet and want to urinate, it just seems to relax and open automatically, but only because you want it to. However, when your bladder gets very full and starts squeezing and trying to empty, this stopper starts to open on its own whether you want it to or not. When that happens, you feel the need to go to the bathroom in a big hurry. The only thing keeping your urine inside of you now is your “second stopper.”
External sphincter (“second stopper”): This stopper is another muscle that works to control your urine. It is usually relaxed and open, because the first stopper is closed and keeping your urine in your bladder. If the first stopper starts to open and you haven’t gotten to the toilet yet, you have to close this second stopper to hold your urine in until you get there. This muscle does not work automatically: you can control it. When you hold your urine in, or stop urinating after you have started but before you are done, you can feel it tighten. But it is not a very strong muscle. If you have to go to the bathroom badly and cannot get to a toilet quickly, it gets harder and harder to keep holding the urine in. If the muscle gets stronger, holding your urine will become easier.
When you practice your start-stop exercises (by starting to urinate, then stopping before you’re done, then starting and stopping again repeatedly), you are strengthening the muscle of this second stopper and getting better at closing it even if you have already started to urinate. This is what you must do at night when you’re sleeping. If your bladder starts to squeeze and your first stopper starts to open, you need to close your second stopper quickly and strongly so that you have enough time to wake and go to the toilet. By doing your exercises, you will get better at closing it quickly—you will hardly even need to be aware that you are doing it. If you are also doing bladder-stretching exercises (seeing how long you can hold your urine and how much urine you can hold) you are not only making the muscle of the second stopper stronger but also making your bladder able to hold more urine before it tries to squeeze and empty. That also makes it easier to get through the night without wetting.
Reinforcement and Responsibility Training
The first approach to treatment combines two related goals: first, helping your child learn to take on responsibility for dealing with her bedwetting, and second, reinforcing her ability to stay dry. The goal of the responsibility training is to help her learn to be more in control of herself in general. She should feel good about this endeavor, so present it as a privilege and an opportunity, not as a punishment. Once she becomes accustomed to responding promptly and automatically to her own needs, responsibilities, and obligations during the day when she is awake, she will have an easier time doing the same at night when she is asleep. In particular, the sensation of needing to urinate may become significant enough to her to signal her to wake herself enough to prevent wetting and, if necessary, to walk to the bathroom.
The reinforcement part of the treatment is intended to increase your child’s motivation to react to these nighttime signals and to help her learn to recognize nighttime bladder sensations as important. You should use rewards for this purpose, not punishments: most people will work harder to earn a reward than to avoid a punishment. If parents and child work together in a spirit of cooperation, the treatment works even better.
Begin by discussing with your child how she can assume more general responsibility around the house, perhaps by taking on a job such as clearing the table, taking out the garbage, or feeding the dog. Above all, she must take on more responsibility concerning the bedwetting itself. She should change her own pajamas, and if she is old enough—usually about seven—she should help change the sheets and do the laundry. (But remember, this isn’t a punishment: don’t saddle a young child with the entire responsibility for these chores. Instead, give her extra privileges as she takes on the new responsibilities). These changes alone may lead to improvement. But even if they don’t, you will be doing your child a service. Her view of herself, and you, will improve.
Next, set up a system for recording and rewarding dry nights. A sticker chart, specially drawn or kept on a calendar, is often successful, at least for children aged up to about ten. Give your child stars for dry nights, and award her special prizes after a certain number of stars. You can structure the system to suit your child’s age and interests, but you may want to base it on the following example, which has worked well for many children. Choose one color of stars to record dry nights, another color to be used after every fourth dry night (consecutive or not), and a special sticker to mark any seven consecutive dry nights. Instead of stars, your child may prefer stickers with animals, cartoon characters, or 3-D images—let her help choose them. Agree in advance on a special (but inexpensive) treat or prize that she will earn for every two seven-day stickers. Have your child attach the stickers to the chart or calendar, and congratulate her when she has earned one. In the meantime, remember never to scold her or make her feel bad in any way after she has wet the bed.
Bladder Training and Start-Stop Exercises
The next approach is to help your child develop the abilities to hold more urine and to exercise more control over her urination. You can begin bladder training at the same time as responsibility training, or postpone it for a while if you wish. Now would be a good time to (again) review with your child the nature of her urinary system and how it works (see Figure 17).
Once a day, at the same time each day, have your child hold her urine as long as she can, at least to the point of some discomfort. Then, when she urinates (into a bottle, urinal, or pan), measure the volume. Her efforts to beat her previous record will gradually increase her daytime bladder capacity. To pick a starting point, measure the volume each time she urinates at home for the first two days, and use the largest single volume of urine over the two-day period as the initial record to beat. Also note the amount of time between urinations: if your child urinates more often than once every three or four hours, have her try to wait fifteen to thirty minutes longer each day between urinations until she achieves a three- to four-hour minimum.
There is no specific volume that will guarantee nighttime continence, but ten to twelve ounces, or at least one ounce per year of age, is a reasonable goal. If that seems too ambitious, then try for at least a 50 percent improvement over the initial record.
At least once a day, also have your child practice starting and stopping the stream of urine several times. She should stop the stream not just momentarily but long enough to get good control over it.
When your child has been dry at night for two consecutive weeks, reinforce the success with a program of “overlearning”: encourage her to drink more and more fluid during the day and as much as two to four glasses just before bed so that she will keep getting better at controlling her bladder.
Conditioning systems have been very successful in treating enuresis. These devices rely on a sensor that fits into the child’s underwear at night. When it gets wet, a loud alarm (usually attached to the child’s pajamas or wrist) is triggered. Several units are available commercially in the United States and can easily be ordered online. Although older versions of some of these devices posed slight risks of irritation or burns from the electrical current, modern designs have rendered them completely safe.
The object of conditioning is to wake your child as soon as she begins to wet the bed, on the theory that she will gradually come to unconsciously associate the sensations she feels just before urinating with the need to wake. To use this method successfully you will need your child’s full cooperation and understanding, so it is unlikely to be much help before she is at least seven (although some younger children are able to profit from it). Both the parents and the child should understand how the mechanism works, but the child should take responsibility for testing it and turning it on when she gets into bed at night.
If the alarm rings at night and your child does not wake immediately, it is up to you to wake her as soon as possible. Leave the alarm ringing, however, until she gets up and turns it off herself. She should then go to the bathroom to try to complete her urination there, then help remake the bed, if necessary, and reset the alarm. If she wets so early in the night that she simply cannot wake when the alarm sounds, try “lifting” her (see below)—take her to the bathroom before the time when the first alarm of the night usually rings. Later in the night her sleep will be lighter, so she should wake more easily and will still learn to respond to the alarm (and eventually, if all goes well, to the bladder signals that occur before that). Whether or not she wets later, gradually move the time of lifting toward bedtime, and then stop lifting her altogether.
It is crucial that the system be used every night and that you keep accurate records of the results. The conditioning process can be slow. Be prepared to continue for four to five months, although most children respond sooner. In general, 25 percent of children are dry within two to six weeks, 50 percent within three months, and 90 percent within six months. When conditioning is unsuccessful, it is most often because the family used it inconsistently or incorrectly or because they stopped too soon.
After your child has been dry for two weeks, begin an “overlearning” process, as described in the section above on bladder training: have her drink extra fluid during the day and two to four more glasses before bed, and continue to use the alarm until she has stayed dry for an additional twenty-one consecutive nights.
Be aware that when children stop using the alarm the first time, the bedwetting often starts again. If that happens, simply use the alarm again exactly as you did before. Several courses of conditioning therapy are sometimes necessary when the problem is stubborn.
When enuresis is a major problem and behavioral approaches are unsuccessful, medication is occasionally necessary to help bring the problem under control. If you think your child may be a candidate for medication, discuss it with your pediatrician.
One medication commonly used is desmopressin. This drug, a synthetic hormone, resembles the naturally produced hormone vasopressin, also known as “antidiuretic hormone.” Vasopressin is normally secreted at night and helps draw water from the urine back into the bloodstream. The urine that remains is more concentrated; hence there is less of it, making it easier to stay dry through the night. Although there is evidence that some enuretic children produce less than the typically expected amount of vasopressin at night, it is not clear that their hormonal levels are abnormally low. Nevertheless, desmopressin taken at bedtime, as a nasal spray or a pill, may help to suppress nighttime urination. It is generally not recommended for children under six years old. When it does work, it is often useful for special occasions such as overnight visits, travel, and camp. It can also be used nightly, especially for older children who are distressed by frequent wetting and for whom other approaches haven’t worked. Bear in mind that the medication itself usually does not cure the underlying problem, so the bedwetting typically reappears when the desmopressin is stopped.
You may already be “lifting” your child—that is, taking her to the bathroom at some point after she has fallen asleep, probably when you are about to go to bed. This precaution sometimes prevents wetting, especially in children who wet only once a night at a regular, predictable hour that is not too late. However, it is unlikely to have any long-term benefits.
By rousing the child rather than letting her learn to wake on her own from bladder signals, lifting may actually delay nighttime continence. Besides, the child may already be wet when the parents go in, or she may wet again later in the night. On the other hand, when it does work, at least the child is dry, everyone is less frustrated, and there are fewer sheet and pajama changes to deal with. If you do find lifting useful, I suggest that every three months you try going two weeks without lifting, to check your child’s progress and to give her a chance to learn nighttime control or to see if she has already attained it and whether the lifting even needs to be restarted.
Major dietary changes are rarely useful as a means to decrease wetting: they require a lot of work and improvements are rare. Although advocates of this approach can be persuasive, there is little evidence to support their claims. If you do want to try this method, follow the same diets that are described in books on dietary therapy for hyperactive children. Ask your librarian for help. But remember, any improvement you see may only be coincidental. In any case, don’t keep your child on a severely restricted diet indefinitely. Gradually add back the foods you have taken out of her diet. Be sure that a particular food is responsible for increased wetting before you make your child do without it for more than a few weeks.
Enuresis can be difficult to stop entirely, and persistent enuresis is certainly frustrating. Although the treatments described in this chapter do not guarantee success, when they are carried out diligently, most children’s wetting diminishes significantly and many children stop wetting altogether. Although enuresis is only a minor sleep disorder in itself, it can still be seriously disruptive. It is important that you understand the problem and respond to your child’s needs appropriately. Even if there is nothing you can do but wait until she outgrows the bedwetting, she must see that you are waiting patiently and sympathetically. Work with her positively, as part of a team. If you do that, you will help her avoid months or years of unnecessary suffering, her self-image will improve, your own relationship with her will remain unharmed, and she will get along better with her friends—and your attempts to reduce wetting will be more likely to succeed.