Bedwetting in children

Bedwetting, also called nocturnal enuresis, is defined as involuntary urination at night in a child over the age of 5. Until this age, it is normal for children not to have full control of their bladder at night, and therefore it is not considered enuresis in younger children.

According to the Danish journal Ugeskrift for Læger, bedwetting is common in the first few years of school and gradually becomes less frequent as the child develops. Most children become dry on their own, but for a small group, bedwetting continues into the older school years or adolescence.

What is bedwetting and how common is it?

Bedwetting, also called nocturnal enuresis, is defined as involuntary urination at night in a child over the age of 5. Until this age, it is normal for children not to have full control of their bladder at night, and therefore it is not considered enuresis in younger children.

It is very common for children in the first years of school to still experience bedwetting. Around 10 percent of children in first grade wet the bed at night, and the proportion gradually decreases as the child's body develops. Most children become dry on their own, but for a smaller group it continues into the older school years or adolescence.

When should my child stop wetting the bed?

Most children achieve control over nighttime urination between the ages of 2 and 4, but there is great individual variation. Enuresis is not considered until the child is 5 years old and still experiences regular bedwetting.

It is important to remember that children develop at different rates, and that bedwetting at 5-7 years of age is far from always a sign of a problem that requires treatment. If the child is still experiencing bedwetting when they start school, and it begins to affect the child's well-being or self-esteem, it may be relevant to talk to a doctor about the options.

Symptoms of bedwetting

The primary symptom is involuntary urination during sleep, but the picture can vary from child to child. Some children wet the bed every night, while others only experience it a few times a month.

In most children, urination during the day is completely normal. However, in a smaller group, symptoms are also seen during the day, such as frequent urination, small urinations or sudden and intense urges to go to the toilet. When bedwetting is combined with symptoms during the day, it is called a mixed form, and this may have an impact on which treatment is most relevant.

It is worth noting that children with bedwetting typically sleep very heavily and often do not wake up even when their bladder is full. This is part of the condition and not an indication that the child is not trying hard.

What is the difference between primary and secondary bedwetting?

Bedwetting is divided into two types, which have different implications for diagnosis and treatment.

In primary bedwetting, the child has never had a prolonged period of being dry at night. This form is by far the most common and is typically due to the fact that the interaction between the bladder, brain and the hormone that reduces urine production at night (antidiuretic hormone) is not yet fully developed.

In secondary bedwetting, the child has previously had a period of several months without bedwetting, after which the problem has returned. This form is seen less frequently and may in some cases have an underlying explanation, for example a urinary tract infection, constipation or a stressful experience such as divorce or death in the family. If a child who was previously dry at night suddenly starts wetting the bed again, it is a good reason to have them examined by a doctor.

Causes of bedwetting in children

Bedwetting rarely has a single cause, but is typically due to a combination of factors related to the child's development.

The most common explanation is that the child's body does not yet produce enough of the hormone that reduces urine production at night. This means that the bladder simply fills faster than the child can register it while sleeping. In other children, the bladder's capacity at night may be less than expected for the child's age, so the bladder empties before it is actually full.

Heredity also plays a big role. If one or both parents have had bedwetting as children, the child is significantly more likely to experience the same. Finally, deep sleep can make it harder for the body to wake the child when the bladder signals that it is full.

In rare cases, bedwetting – especially the secondary form – can be associated with a urinary tract infection, constipation or psychological stress. However, these causes are far less common than the developmental explanations.

Can stress or psychological conditions cause bedwetting?

In the vast majority of children, bedwetting is not caused by psychological problems. It is a common misconception that children wet the bed as an expression of protest, dissatisfaction or psychological distress.

In children with secondary bedwetting – that is, children who were previously dry and now experience bedwetting again – psychological stress such as school problems, divorce or death in the family can sometimes play a role. If you experience that your child's bedwetting coincides with a major change in the child's life, it may be relevant to talk to a doctor about the overall picture.

Examination and diagnostics

When a child has bedwetting, the doctor will typically start with a conversation about the child's urination pattern, both at night and during the day. It can be helpful to keep a fluid and urination chart for a short period of time prior to the consultation, so the doctor can get a picture of how much the child drinks, and how often and how much they urinate.

As part of the examination, the doctor will often take a urine sample to rule out that the bedwetting is due to a urinary tract infection or another condition in the kidneys and urinary tract. In most cases, further tests are not necessary, but in special cases, an ultrasound scan of the kidneys and urinary tract may be considered if the doctor finds reason to rule out a physical explanation for the problem.

The vast majority of children with bedwetting do not need a comprehensive evaluation and can be assessed and followed by their own doctor.

Treatment of bedwetting in children

Treatment of bedwetting is individual and depends on the child's age, motivation and the type of bedwetting. It is always the doctor's assessment that determines which approach makes the most sense for the individual child and family.

In the youngest children, the primary "treatment" is often information and advice to the family, as many children simply need more time to develop the necessary control. Treatment is typically only considered when the child himself experiences bedwetting as a problem, and when both child and parents are motivated - this is often around the age of 6-7, but for some children not until the age of 8 or later.

For children who need a more active approach, there are two well-documented treatment methods.

Bedwetting alarm (bell)

A bedwetting alarm, also known as a ringer, is a sensor that is placed in the child's underwear or on the mattress. The sensor responds to the first drops of urine and triggers an alarm that wakes the child. Over time, the child's body learns to respond to the fact that the bladder is full before a leak occurs, so the child wakes up and makes it to the toilet on their own.

Treatment with a ringing device requires patience and typically takes place over several weeks, with parents initially helping to wake the child when the alarm goes off. The method requires motivation from the entire family, but is one of the most effective solutions in the long term.

Medical treatment

If bedwetting is primarily due to high nocturnal urine production, medication may be relevant. The medication is taken as a disintegrating tablet at bedtime and can be effective from the first night, but the effect ceases when treatment is stopped, which is an important difference from ringing device treatment.

The choice between the two forms of treatment depends on an overall assessment of the child's symptoms, age and the family's situation, and it is always an individual decision that the doctor makes in collaboration with the family.

Practical advice at home

Whether you choose to treat actively or wait, a few adjustments to your daily routine can make the situation easier. It can help to shift some of your child's fluid intake to the morning and afternoon and avoid large amounts of drinking in the last hour before bedtime. It is also a good habit to make sure your child goes to the toilet immediately before bedtime.

Perhaps the most important thing is that bedwetting is not made into a problem that the child should be ashamed of. Children do not wet the bed on purpose, and a calm and supportive approach from the parents has a great impact on how the child experiences the situation.

What is diurnal enuresis (daytime incontinence)?

Diurnal enuresis, also called daytime incontinence, is a separate condition in which the child experiences involuntary urination during the day – for example, frequent urination, spotting, or sudden and intense urges to go to the toilet. The condition is seen more frequently in girls and most often occurs between the ages of 3 and 8.

Daytime incontinence and bedwetting can occur at the same time, and if this is the case, the doctor will often consider that daytime incontinence should be treated first, as it is generally more difficult to achieve dry nights if the child also has problems during the day.

When should you see a doctor about bedwetting?

Bedwetting up to the age of 5-6 is normal and does not generally require medical attention. However, it can always be reassuring to talk to your doctor if you as a parent are in doubt.

It is particularly relevant to seek medical attention if the child is 6-7 years old and still experiences regular bedwetting, if the bedwetting begins to affect the child's self-esteem or social life – for example, by the child avoiding sleepovers with friends – or if a child who has previously been dry for a long period suddenly starts wetting the bed again. In the latter case, the doctor should always be involved, as it may be important to find a possible underlying explanation.

Treatment at Charlottenlund Private Hospital

At Charlottenlund Private Hospital, your child can be examined by a pediatric specialist who, together with you, can map out the causes of the bedwetting and make a plan for the further course of action. You will find an overview of all departments on our department page. We emphasize a safe and calm examination situation, where both the child and you as parents are informed throughout.

If you experience that your child continues to have difficulty staying dry at night, and you would like a professional assessment of what can be done, you are welcome to book an appointment with us.

Sources:

- Weekly Journal for Doctors: Nocturnal enuresis in children – diagnosis and treatment.