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Ask Nurse Judy: Bed-Wetting

Written by Katie Hintz-Zambrano

Photography by Photographed by Maria Del Rio

The seen-it-all, treated-it-all Nurse Judy Kivowitz of San Francisco’s Noe Valley Pediatrics shares her advice on common child health and behavioral conundrums. Below, she takes on the tricky topic of bed-wetting.

Nocturnal enuresis, otherwise known as bed-wetting, is something that many patients and families have to deal with. More than half of bed-wetters are boys. To give you a sense of numbers and make you feel not-so-alone: 15% of 5-year-olds still wet the bed and 5% of 10-year-olds continue to have issues of staying dry at night. Most of the persistent older bed-wetters will grow out of this by puberty without any intervention, but hopefully you don’t need to wait until your child is a teenager to get this resolved.

When it comes to bed-wetting, there is definitely a genetic tendency at work. It is worth knowing if you or your partner or one of your parents had a bed-wetting issue. For those of you washing the sheets every night for your 12-year-old, please keep in mind that there is a reason that most camp forms ask about bed-wetting. This is not an uncommon situation. The goodnight pull-ups come in such big sizes because there are plenty of older kids needing them. If a child has previously been dry at night and bed-wetting is new, check in with a doctor to make sure there isn’t something else going on.

For children who have consistently never been able to stay dry through the night, it can be a frustrating issue and there are many opinions about how to deal with it. Wetting the bed should not be a punishable offense. Waking up wet and feeling a loss of control is punishment enough. It is not okay to humiliate your child. Having your child begin to accept some responsibility however, is not a punishment.

The natural consequence for having a wet bed is to be part of the clean-up team. Perhaps your child can be in charge of stripping the wet sheets off the bed. Let them be a part of the solution rather than being the cause of the problem.
Until your child has shown that they can be dry at night, I would have them in special nighttime pull-ups and make sure you have waterproof pads on the bed. Expecting dry sheets before your child has shown they are ready is just going to be aggravating for everyone.

To fix the problem, there are some basic considerations and common sense approaches to start with:
Constipation is a huge factor and is the first step in eliminating bed-wetting. Once kids are out of diapers and off at daycare or school, many parents lose track of the kids’ bowel habits. Are they pooping daily? Do they have to sit for a while before the poop comes out? Does it come out in hard little pieces? Often times, kids are found to be constipated even if they are pooping once or twice a day and the poops seem normal. This may be because they don’t always take the time to get all of the poop out.
-Other common sense steps include having your children better hydrate during the school day. Some kids are “camels” at school and don’t drink. Talk about what the fluid options are. Is there an accessible fountain? Do you send something to drink with their lunch? The recommended fluid intake for children is measured by weight and is as follows:
Under 2 years and under 10 kg = 30-35 ounces/day
2-5 years and under 20 kg = 40-50 ounces/day
6-12 years and under 50 kg = 50-60 ounces/day
Teens = 60-70 ounces

-While we want to bump fluids during the day, it is time to start limiting fluids after dinner. Consider taking your child for a “dream pee” before the adults go to bed. Often you can walk your sleepy child to the bathroom without having them fully wake up. If these “twilight trips” to the bathroom appear to be disrupting their sleep cycle, see if you can adjust the timing. If they are impossible to rouse enough to get to the bathroom without you practically carrying them, it might be a sign that they aren’t ready yet.
-Give their bladder some exercise. The continence clinic does not generally recommend “kegels” exercises for their patients, but once in awhile it is okay to have them practice starting and stopping the urine stream if they can. Another activity is to see if they can hold the pee for a couple of moments when they first realize that they need to go. Without good relaxation of the perineum, children are unable to empty their bladder completely. Try to teach your child to relax when they are peeing. One way to do this is to have them give a big sigh. Sighing is a normal relaxation trigger.
-If none of the above actions has made a difference, it is up to you when you want to stage an intervention. I usually wait until your child has expressed readiness to tackle this. One of our doctors says that, in her opinion, once the kids are old enough to read, they are old enough to be dry at night. She gives her patients a little talking to and tells them that they are in charge of telling that good brain of theirs that they need to not pee at night. She claims a degree of success!
-Sometimes, once they are old enough for summer camp or sleepovers, kids are more invested in a cure. If they don’t care one way or the other, you can increase their role in the clean-up, but until they are an active and motivated part of the team, I would wait a bit.

Once you are ready to intervene there are several options:
-Some of my families have had long-lasting success with bed-wetting alarms and reward charts. There are several on the market.
-There is no medication that cures enuresis, but there are some medications that can address the symptoms. The most commonly used is DDAVP. This is a prescription approved for children over 6. It comes as a tablet. It used to be available as a nose spray, but that has been discontinued due to side effects. When the drugs are stopped, the bed-wetting usually returns unless the child has naturally outgrown the condition. It is nice to know that this possibility exists for use on an intermittent basis, such as an overnight or summer camp.
-Please note that even when you feel like you have successfully put this behind you, it is possible for mini relapses to occur with little illnesses or increased stress.

Find out how to sign up for Nurse Judy’s San Francisco-based classes and workshops here.

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