Bed wetting in children: A guide for the science-minded parent
© 2010 - 2013 Gwen Dewar, Ph.D., all rights reserved
Bed wetting in children, also known as nocturnal enuresis, is a hassle and an embarrassment.
But it’s not a rare problem.
Some studies estimate that up to 20% of five-year-olds experience primary nocturnal enuresis (PNE)--meaning that these kids haven’t yet achieved the milestone of consistently dry nights (Glazener et al 2005).
Rates of PNE aren't much lower for school-aged children, and the problem isn’t confined to any particular part of the world.
Studies of kids from Taiwan to South Africa to Iran report remarkably similar rates of PNE (Tai et al 2007; Pashapour et al 2008; Fockema et al 2012; Hashem et al 2013; Gümüş et al 1999).
What are the causes of bed wetting?
Consider secondary nocturnal enuresis (SNE), in which a child who was previously dry for at least 6 months suddenly reverts to wetting the bed.
In these cases, pediatricians should screen kids for urinary tract infections and constipation.
Urinary tract infections can create a persistent urge to urinate. Constipation can put pressure on the bladder, so that the bladder’s capacity is greatly diminished (Caldwell et al 2005).
Secondary nocturnal enuresis (SNE) has also been linked with
• obstructive sleep apnea (Brown et al 2009)
• anorexia (Kanbur et al 2010; Kanbur et al 2011)
• obesity (Erdem et al 2006)
• migraine (Lin et al 2012)
• the onset of diabetes (Roche et al 2005), and
• stress (Caldwell et al 2005)
And primary nocturnal enuresis?
Some of the same medical conditions--like frequent urinary tract infections or constipation--might play a role (Robson et al 2005).
But for most kids who have never made the transition to night-time dryness, bed wetting may reflect patterns of sleep and urine production.
Compared with other kids, children with PNE seem to have more trouble waking up at night. They may also produce more urine during the night.
For example, a study of Swedish kids found that kids with PNE were more likely to be described by their parents as "heavy sleepers."
These kids were also harder to arouse from sleep in a laboratory test.
And--during the night--their bodies produced less of the hormone vasopressin, which suppresses nocturnal urine production (Wille 1994).
Other observations about bed wetting in children
What about psychological factors?
Does nocturnal enuresis indicate that a child is socially-maladjusted or emotionally-troubled? No.
The kids in the Swedish study were not more likely to suffer from emotional problems or conduct disorders.
Neither were the children in other, similar studies (Wille and Anveden 1995; Sureshkumar et al 2009; Shreeham et al 2009).
There is, however, evidence that children with chronic bed wetting problems suffer from lower self-esteem (e.g., Collier et al 2002; Kanaheswari et al 2012). But the causation seems pretty clear -- kids are embarrassed and upset by their condition. When they are treated successfully, their self esteem improves (Longstaffe et al 2000).
There is also evidence that children with ADHD are at higher risk. A large study of 8- to 11-year old American children found that kids with ADHD were more likely to show symptoms of nocturnal enuresis (Shreeham et al 2009).
Does bed wetting have a genetic basis? That seems likely.
For instance, mothers who report having to urinate frequently during the night are more likely to have kids who wet the bed (Montaldo et al 2010).
Researchers speculate that certain traits--like the amount of urine produced at night, or the tendency to sleep deeply--might be controlled by our genes (Schaumburg et al 2008; Wang 2007).
What is the best way to deal with bed wetting?
It makes sense to avoid drinking fluids before bed time. It’s also important to treat any underlying diseases, infections, and sources of stress. But for most kids with primary nocturnal enuresis, these steps aren’t likely to solve the problem.
One approach--called “lifting”-- is to awaken children during the night and take them to the bathroom. When this tactic was tested on 4- and 5-year olds, there was a reduction in PNE symptoms after six months(van Dommelen et al 2009).
But there are reasons for doubt. Because parents initiate these bathroom visits, the child’s bladder might not be full. As a result, the child might not learn to awaken in response to the sensation of a full bladder.
In addition, it seems reasonable to ask if “lifting” could trigger other problems, like insomnia. To date, I can’t find any studies addressing this possibility.
The most common therapies recommended by physicians are
(1) bed wetting alarms, and
(2) desmopressin, a synthetic version of the anti-diuretic hormone, vasopressin.
Bed wetting alarms use the same technology as diaper alarms.
A moisture sensor is attached to the child’s underpants. When the child urinates, a sound awakens him.
How do these therapies compare?
Recent research suggests that alarms are more effective than desmopressin.
In studies testing the effectiveness of alarms, kids slept with bed wetting alarms every night for 12 weeks. Approximately half the kids stopped wetting the bed (Glazener et al 2005).
And alarms seemed to work even better when training programs included an “overlearning” component—which means giving kids extra fluids before bedtime so that they have more opportunities to learn (Glazener et al 2005).
What NOT to do
In addition to testing effective methods, researchers have identified approaches that don’t help or that make things worse.
Punishments are inappropriate and counterproductive
Kids suffering from nocturnal enuresis don’t wet the bed on purpose or because they are lazy. So it’s unfair to blame kids for bed wetting, and it’s probably counterproductive, too.
To date, it’s not clear that bed wetting per se has any negative effects on children.
But in the few studies that do report negative effects, these are about feelings of embarrassment, shame, or poor self-image (Collier et al 2002). And, as noted above, secondary nocturnal enuresis has been linked with stress. So making kids feel bad about bed wetting is likely to make things worse (Glazier et al 2005).
Circumstantial evidence supports this idea. In a study of British children, parents who expressed displeasure in response to early bed wetting episodes were more likely to have kids who still wet the bed at age 7 ½ (Butler 2005).
Similarly, a study comparing different ethnic groups in the Netherlands found that nocturnal enuresis was more likely to persist in children belonging to groups that practiced punishment for bed wetting (van der Wal et al 1996).
Offering rewards is probably not helpful, and may send the wrong message
To date, there is little evidence that rewards are effective (Glazener et al 2005; van Dommelen et al 2009).
Some physicians recommend trying rewards anyway, on the grounds that it can’t hurt. I’m skeptical.
When parents offer rewards to kids for staying dry at night, the implication seems to be that bed wetting is under conscious control.
But it’s not. Kids wet the bed while they are asleep. And I’d wager that most kids want their parents to understand: Kids are already motivated. They don’t need bribes. If they could wake themselves up, they would do it.
For more information about nocturnal enuresis, check out the article
Bed wetting in scientific perspective: Destructive myths and misconceptions.
Butler RJ, Golding J, Heron J; ALSPAC Study Team. 2005. Nocturnal enuresis: a survey of parental coping strategies at 7 1/2 years. Child Care Health Dev. 31(6):659-67.
Collier J, Butler RJ, Redsell SA, and Evans JH. 2002. An investigation of the impact of nocturnal enuresis on children's self-concept. Scand J Urol Nephrol. 36(3):204-8.
Erdem E, Lin A, Kogan BA, Feustel PJ. 2006. Association of elimination dysfunction and body mass index. J Pediatr Urol. 2(4):364-7.
Fockema MW, Candy GP, Kruger D, and Haffejee M. 2012. Enuresis in South African children: prevalence, associated factors and parental perception of treatment. BJU Int.110(11 Pt C):E1114-20.
Glazener CM, Evans JH, Peto RE. 2005. Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 18;(2):CD002911.
Gümüş B, Vurgun N, Lekili M, Işcan A, Müezzinoğlu T, and Büyuksu C. 1999. Prevalence of nocturnal enuresis and accompanying factors in children aged 7-11 years in Turkey.Acta Paediatr. 1999 Dec;88(12):1369-72.
Hashem M, Morteza A, Mohammad K, and Ahmad-Ali N. 2013. Prevalence of nocturnal enuresis in school aged children: the role of personal and parents related socio-economic and educational factors.Iran J Pediatr. 23(1):59-64.
Kanbur N, Pinhas L, Lorenzo A, Farhat W, Licht C, and Katzman DK. 2010. Nocturnal enuresis in adolescents with anorexia nervosa: Prevalence, potential causes, and pathophysiology. Int J Eat Disord.
Kanbur N, Pinhas L, Lorenzo A, Farhat W, Licht C, Katzman DK.2011. Nocturnal enuresis in adolescents with anorexia nervosa: prevalence, potential causes, and pathophysiology. Int J Eat Disord. 44(4):349-55.
Kanaheswari Y, Poulsaeman V and Chandran V. 2012. Self-esteem in 6- to 16-year-olds with monosymptomatic nocturnal enuresis. J Paediatr Child Health. 48(10):E178-82.
Lin J, Rodrigues Masruha M, Prieto Peres MF, Cianciarullo Minett TS, de Souza Vitalle MS, Amado Scerni D, and Pereira Vilanova LC. 2012. Nocturnal enuresis antecedent is common in adolescents with migraine. Eur Neurol. 2012;67(6):354-9.
Longstaffe S, Moffatt ME, and Whalen JC. 2000. Behavioral and self-concept changes after six months of enuresis treatment: a randomized, controlled trial. Pediatrics. 105(4 Pt 2):935-40
Montaldo P, Tafuro L, Narciso V, Apicella A, Iervolino LR, Del Gado R. 2010. Correlations between enuresis in children and nocturia in mothers. Scand J Urol Nephrol. 44(2):101-5.
Pashapour N, Golmahammadlou S, and Mahmoodzadeh H. 2008. Nocturnal enuresis and its treatment among primary-school children in Oromieh, Islamic Republic of Iran. East Mediterr Health J. 14(2):376-80.
Roche EF, Menon A, Gill D, Hoey H. 2005. Clinical presentation of type 1 diabetes. Pediatr Diabetes. 6(2):75-8.
Schaumburg HL, Kapilin U, Blåsvaer C, Eiberg H, von Gontard A, Djurhuus JC, and Rittig S. 2008. Hereditary phenotypes in nocturnal enuresis. BJU Int.102(7):816-21.
Shreeram S, He JP, Kalaydjian A, Brothers S, and Merikangas KR. 2009. Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among U.S. children: results from a nationally representative study. J Am Acad Child Adolesc Psychiatry. 48(1):35-41.
Sureshkumar P, Jones M, Caldwell PH, Craig JC. 2009. Risk factors for nocturnal enuresis in school-age children. J Urol. 182(6):2893-9.
Tai HL, Chang YJ, Chang SC, Chen GD, Chang CP, Chou MC. 2007. The epidemiology and factors associated with nocturnal enuresis and its severity in primary school children in Taiwan. Acta Paediatr. 96(2):242-5.
Wang QW, Wen JG, Zhang RL, Yang HY, Su J, Liu K, Zhu QH, Zhang P. 2007. Family and segregation studies: 411 Chinese children with primary nocturnal enuresis. Pediatr Int. 49(5):618-22.
Wille S, Anveden I. 1995. Social and behavioural perspectives in enuretics, former enuretics and non-enuretic controls. Acta Paediatr. 84(1):37-40.
Content last modified 5/13
image of child & bear ©iStockphoto.com/matka_Wariatka