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Ask Us Anything About… Bedwetting in Children

It may be a scenario familiar to many parents: They walk in to wake their child up in the morning, only to find wet pajamas, sheets and mattress. The child, who has been toilet trained for a couple of years, has wet the bed. Why did this happen? Is this something to be concerned with? Is there something the parents can do to help the child?

Dr. Amy Burns, pediatric urologist, and Karen Thompson, CRNP, pediatric urology, answer your questions.

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Description – The video begins inside the Penn State Milton S. Hershey Medical Center facility within a hallway area. Three individuals are standing together looking at he camera. From left to right is, Karen Thompson, nurse practitioner in pediatric urology, Penn State Health Children’s Hospital, Dr. Amy Burns, pediatric urologist, Penn State Children™s Hospital and Scott Gilbert.

Scott Gilbert – From Penn State Health, welcome to Ask Us Anything About Bedwetting in Children. I’m Scott Gilbert. It’s a scenario familiar to many parents. They may walk into their child’s room in the morning and find wet pajamas, sheets, and a mattress. And they may find themselves wondering why did it happen, especially when the child’s been toilet trained for a couple years. We’ll answer that question and talk about how parents can support their children in that situation as we talk here with Dr. Amy Burns. She’s a pediatric urologist. Dr. Burns, thanks for being here today.

Dr. Amy Burns – Thank you for having me.

Scott Gilbert – Also with us, Karen Thompson. She’s a nurse practitioner in pediatric urology here at Penn State Health Children’s Hospital. Karen, thanks for your time.

Karen Thompson – You’re welcome.

Scott Gilbert – Well, let’s start with, you know, normal is a subjective word, but what is normal with regard to bedwetting given that it seems like pretty much every child deals with this for at least some period of time?

Dr. Amy Burns – Yeah, so bedding or nocturnal enuresis is very common in children. A lot of children will outgrow it by the age of 5, but even at around 5 years of age for girls and up to 7 years of age for boys, about 20% of children will still have episodes of bedwetting. And then over time, about that number will decrease each year so that by age 15, only about 1% of children wet the bed.

Scott Gilbert – One percent, okay. And this is not a conscious decision by the child, right? We want to emphasize that.

Karen Thompson – That is true. It is completely out of their control.

Scott Gilbert – And that’s important to emphasize because it should not be a reason for punishment, for example, right?

Karen Thompson – Right, nor should they be rewarded for a dry night because that, too, is out of their control.

Scott Gilbert – So when it comes to the risk factors and causes of this, I mean, I can think of one, drinking too much liquid before bed, but it really goes beyond that, doesn’t it? There are a lot of risk factors possibly.

Karen Thompson – There are quite a few risk factors including parents that wet the bed as well will have an increased incidence in their children.

Scott Gilbert – So like when the genetic factor, when parents were young, if they tended to struggle with this, their children may?

Karen Thompson – Correct.

Scott Gilbert – What about some of the other causes?

Dr. Amy Burns – Well, along with genetics, which does play a strong role in many kids, if one parent wet the bed, there’s a 40% chance that their child will wet the bed. And if both parents were bedwetters, then there’s a 75% chance that the children will have bedwetting. Other things that can contribute to bedwetting though include certain behaviors, like you mentioned, drinking too much water prior to bedtime. Many children who wet the bed don’t go to the bathroom before they go to sleep or won’t empty their bladder completely prior to going to sleep. So that’s another contributing factor. Some kids will not drink much water throughout the day at school and so they’ll come home from school very dehydrated and thirsty, get the vast majority of their fluid intake in the late afternoon and early evening and then at night they wet. Sometimes it’s related to children just having a smaller bladder capacity than their peers. That can contribute to it as well. In some instances, there can be an abnormality in a hormone called ADH that regulates the production of urine overnight. In other instances, children who have significant bladder and bowel dysfunction during the day can have problems with bedwetting at night. Symptoms associated with that would be constipation, urinary urgency, frequency, wetting accidents during the day, prolonged holding of urine during the day, recurrent urinary tract infections. Sometimes if the child has sleep apnea or snoring, that is also a known risk factor for urinary tract infection. And then finally there are various other medical conditions that can contribute to bedwetting. But for most of these children, they have primary enuresis, so kind of the traditional bedwetting that we think of where the kid has just never become dry at night.

Scott Gilbert – You’re watching Ask Us Anything About Bedwetting in Children from Penn State Health. I’m Scott Gilbert alongside Dr. Amy Burns. She’s a pediatric urologist at Penn State Health Children’s Hospital and we also have Karen Thompson. She’s a nurse practitioner in pediatric urology. We welcome your questions and your comments in the comment field below this Facebook post. Whether you’re watching this video live or if you’re watching it on playback, feel free to ask some of those questions and we’ll get the answers here from the experts. You know, I think one question that a lot of parents watching probably have, Karen, is when is it time to possibly have your child evaluated, when is it time to talk to the pediatrician about this versus just writing it off as something that he or she will grow out of?

Karen Thompson – I think the biggest consideration there is whether or not it bothers the child. If they’re not bothered by it, medically this problem does not hurt them. It certainly can be a psychological problem and if they’re waking up feeling bad about themselves, I think it’s time to consider referral to a urologist.

Scott Gilbert – And if that referral takes place, Dr. Burns, tell me about the steps that you take to evaluate the child as to whether or not treatment may be necessary.

Dr. Amy Burns – For the initial evaluation for these children, it involves a good history and physical exam along with collection of data about their daytime voiding habits and their urologic history and then really just checking a urinalysis. So dipping their urine and checking for protein or signs of infection or any other abnormalities. I really reserve any sort of imaging like ultrasounds to look at the kidneys and bladder or any neurologic imaging like MRI if there’s a significant problem with daytime voiding dysfunction or a neurologic abnormality seen on physical exam, then that would prompt other studies. But for the most part, the initial evaluation is just history, physical exam, and urinalysis.

Scott Gilbert – You’re watching, again, this is Ask Us Anything About Bedwetting in Children from Penn State Health. If you find this information valuable, we encourage you to share this post on your Facebook feed. Think of all the parents out there. Pretty much every parent encounters this issue at some point. So we’re trying to give you some good information on that and we welcome your questions as we do so here for Dr. Amy Burns and for Karen Thompson. Karen, can we talk a little bit about some of the treatments? There’s a range of different treatments and I imagine it could depend on kind of what the cause is, but can you talk about some of the most common treatments that are utilized in the clinic setting?

Karen Thompson – Yeah, in general we have three treatments. One, do nothing because, again, this does not harm the child. Number two, there are bed alarms. This is a device that is clipped to the child’s underwear and it senses when there’s wetness and sets an alarm off. The child then wakes up and goes to the bathroom and finishes peeing. There will be a little bit in the bed. And over time, less in the bed, more in the toilet. And this has a very good success rate. It is a lot of work though. A lot of these kids are very, very sound sleepers. So that alarm is waking up other kids and —

Scott Gilbert – It’s a loud alarm, then?

Karen Thompson – Yes. And the child with the problem may sleep right through the alarm.

Scott Gilbert – So I’ve seen behavior modification as a form of treatment. That sounds like it fits into that category.

Karen Thompson – Right, right. And with any of these treatments, we recommend kids have nothing to drink two hours before bed and make sure they empty their bladder well before bed.

Scott Gilbert – There’s also a medication, DDAVP. Dr. Burns, tell us a bit about what that medication can do and when it might be time to go that route.

Dr. Amy Burns – Yeah, DDAVP is very effective. It doesn’t cure bedwetting per se. It basically treats the symptom, which is overproduction of urine in children. It’s basically a mimic of the hormone that your body naturally makes. It’s very safe in children. It can be increased or decreased to have a desired effect. About 30% of children will become completely dry on DDAVP with another 40% that will have significant improvements. It’s also really nice for kids that are just interested in being dry when they go to slumber parties or they’re going on vacation or they might be in social situations where wetting the bed would be embarrassing for the child. But it doesn’t actually cure the bedwetting. And then periodically, we’ll try to wean the child off of the medication and see if they’ve outgrown it. Whereas, you know, the urine alarm actually can cure the bedwetting.

Scott Gilbert – You’re watching Ask Us Anything About Bedwetting in Children from Penn State Health and Penn State Health Children’s Hospital. We have a comment here from Marie. She says, “Thank you for talking about this. I have a 7-year-old who pees the bed almost every night.” So I imagine, again, there are a lot of parents out there kind of wondering at what point is that something I should be concerned about. Is it age 6, is it age 7, is it 8? It just really depends on the child, I suppose?

Dr. Amy Burns – Yeah, I think it really depends on the child. I think, you know, age 5 for girls, age 7 for boys are kind of the rough cut-offs that I use because more boys tend to wet the bed a little bit later. You know, I tell families when they ask me about this, you know, if the child’s not bothered, then neither am I. And I won’t intervene and treat. But occasionally sometimes children are bothered by it. And so we do our best to reassure them that this is a normal behavior. We think that there’s just an immaturity between the bladder and brain communication. The child has no control over it. I think it’s always reasonable to, you know, offer reassurance. Since the spontaneous resolution rate is so high, oftentimes people feel better just knowing that. And then doing the simple behavioral changes, like the fluid restriction but just making sure that they’re drinking enough throughout the day, making sure they don’t have daytime issues, particularly with constipation. A lot of people don’t think their children are constipated and yet when you start asking questions about the children having hard stools, straining, having belly pain, having very large stools, you start to see the kid actually does have significant problems with constipation even if they’re pooping every day.

Scott Gilbert – So you’re talking about fecal issues but those do have a connection to urinary issues as well?

Dr. Amy Burns – Yeah, absolutely and I describe it to people as being a real estate issue. The rectum sits right behind the bladder. And if it’s filled with stool, then at nighttime the bladder just can’t expand to fill with urine and oftentimes kids that have constipation will also have urinary problems during the day. And I really think for any parent that’s going to commit to the urine alarm or use DDAVP, it’s very, very important to make sure that any daytime voiding issues like constipation or lower urinary bladder symptoms are treated because any intervention for nighttime wetting is bound to be much more successful after constipation and daytime voiding dysfunction are remedied. And we see that probably in 20 to 30% of our children.

Scott Gilbert – Karen, on rare occasion bedwetting may be a sign, not in all cases, but in some it may be a sign of more serious underlying medical issue. Can you talk about what some of those issues might be?

Scott Gilbert – Or I can throw that one at Dr. Burns.

Karen Thompson – I mean, it’s such a wide range. If it’s a spinal anomaly, you know, we would send them off to neurosurgery and be a big workup. I would say the vast majority of these kids do not have an underlying issue.

Dr. Amy Burns – It can be associated with, you know, most of the kids they don’t, so just to reassure the parents in our audience. But if we do detect something abnormal on physical exam or they have significant daytime voiding issues or they have secondary enuresis, where they might’ve been dry for a period of six months and then started to wet the bed again, that’s also a little bit more concerning for the child may be developing something like diabetes or have some sort of chronic kidney disease. And so but for the most part, these kids are healthy children and it’s a very common behavior in children.

Scott Gilbert – Good to know. And for that reason, I know we talked a bit earlier about praising and things you should and even should not praise a child for. So if the child who typically wets the bed has a dry night, that’s actually not a good reason to praise them. Right?

Karen Thompson – Correct, because, you know, then they’re going to feel even bad or may feel even worse when they have a wet night. The dry night is out of their control as well. They do have control about limiting fluids in the evening and always emptying their bladder well.

Scott Gilbert – So those are things you can praise the child for?

Dr. Amy Burns – Yeah, absolutely. So if the child has daytime peeing and pooping problems, if they’re peeing on a schedule, relaxing when they pee, taking their time, drinking fluid throughout the day, eating their fiber gummy bears or whatever treatment is being used for constipation, then you can praise the child for that and that in and of itself is effective for treating a good number of kids with bedwetting. But you got to be careful about praising the child when they just wake up dry because just like waking up wet, they don’t have control over either situation. And like Karen said, you do run into trouble if, you know, you’re praising the child and cheering them for a dry night and then the next morning they’re wet again. They’re going to feel bad and really, like, I know we’ve said this already but they really have no control over whether or not they wet the bed. And it’s a normal — It’s a normal thing for kids to do. So we really wanted to emphasize that today.

Scott Gilbert – So important take-away here as we wrap up. So thank you both for your time and thanks for all the great information today. We did get a comment from Megan. She commented to thank Dr. Burns for caring for her son. I’m sure that’s always great to hear.

Dr. Amy Burns – Thank you. That makes me happy.

Scott Gilbert – Thank you for your comment, Megan. Thanks to the others who commented. And we appreciate you watching this edition of Ask Us Anything About Bedwetting in Children. If you want more information about pediatric urology at Penn State Health Children’s Hospital, you can go online to, that’s, that’s, children™s, plural and just reminder to share this post on your Facebook feed if you found this information helpful. And make sure you subscribe to this Facebook page so that we can provide you with more updates and you can follow everything going on here and the good information from Penn State Health Milton S. Hershey Medical Center. One other question that just popped in. What if your child is age 12 and¦ [Lost Connection]

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