By Dr. Abirami Meenakshi, MD Pediatrics, Trained in Developmental Behavioural Pediatrics

As a parent have you ever experienced a wetness in your child’s bedsheet every morning while making their bed? Or in their underwear while taking out the laundry? Or have they complained that they are unable to completely empty their bladder while urinating? If yes then your child may be experiencing something called as “Nocturnal enuresis” otherwise called as bedwetting or “daytime incontinence” meaning daytime leak in urine.

Incontinence is defined as involuntary leak of urine occurring at least once every month for 3 consecutive months in children older than 5 years of age. Nocturnal enuresis is incontinence occurring during sleep periods and daytime incontinence is incontinence occurring during awake periods. There is a combination of genetic, neurobiological and environmental factors contributing to incontinence. It is understood that almost 75% children with a first degree relative (i.e. parent/sibling) with history of bedwetting will have bedwetting issues too. There are other “neurobiological” mechanisms in effect that can cause these symptoms like bladder muscle dysfunction or elevated hormones like vasopressin or reduced bladder capacity etc.

Also children with bedwetting or nocturnal enuresis are found to be deep sleepers; they are hard to wake up hence they do not know that they have wet their bed. Affected children can have associated constipation or sometimes constipation may also be the cause of the incontinence.

What is important to remember here is that children with bedwetting issues and those with daytime incontinence are at a higher risk of having associated behavioural problems and developmental issues like ADHD, oppositional defiant disorder, Autism, anxiety, and depression.

They tend to have a very poor self image and they tend to socialise less. They have poor peer relationships and do not attend any social events like parties or sleepovers for fear of accidents at that place. They tend to be poor in their academics. As these children grow into teenagehood if they continue to have incontinence they are more likely to end up depressed, introverted and some end up behaving irrationally or against the parents and society.

So How Do We Diagnose or Identify a Child with Bedwetting or Daytime Incontinence?

They experience symptoms such as hesitancy, urgency, prolonged holding of urine, increased frequency, straining while passing urine, leak after passing urine, pain while and after passing urine etc. They also experience constipation symptoms. To manage children with incontinence or bedwetting it is generally recommended to restrict fluid intake two hours before sleeping at night. During the day it is recommended to restrict or avoid intake of bladder irritating foods such as the following:

  • Citrus fruits and citrus fruit drinks like oranges, lemons etc
  • Caffeinated and carbonated drinks such as sodas, tea, coffee
  • Colored cool drinks
  • Milk and dairy products especially ice cream to be avoided after lunchtime

Maintaining a record of the accidents occurrence in a diary meant only for this purpose called as a “bladder diary” is extremely important. This diary must be maintained by the parent or caregiver AND the child if the child is capable of maintaining a diary. Every day the number of accidents and the time at which the accident occurs (for daytime incontinence) must be recorded and every day the previous day’s record must be reviewed by both parent and child. On days where the number of accidents are lesser than usual or have not occurred, the child must be showered with specific appreciations like “You have not wet your bed yesterday, that’s so awesome!!!” or “Oh you didn’t have as many accidents yesterday as you usually do. You deserve a special treat for this amazing achievement. Shall we go out to your favourite park/place today?”

You get the gist right? Whenever appreciating a child for any good behaviour being specific as to what you are appreciating or rewarding them for is of utmost importance. You can also follow the token system or star charts where you give the child a token or stick a star on the chart on accident free days and by the end of the week if the child gets a particular number of stars or tokens he/she gets a gift or a reward etc. Most children are able to resolve their condition by this way.

For those who continue to have bedwetting problems there is a very effective method to help them out which is called as “alarm therapy” where the child wears a moisture sensitive sensor in their underwear which detects the wetness when the child begins to urinate at night and sounds an alarm thereby waking up the child and the caregiver and the child will then go to the toilet to complete the urination. So what happens overtime is that these children experience something called as behavioural conditioning where they begin to feel a full bladder in their sleep and are able to wake up even before the alarm goes off.

For children with daytime incontinence the above mentioned diary system and avoidance of bladder irritating foods will work wonders. But along with that we must train the children to have a timed urinating schedule where every 2 to 3 hours once the child must urinate in the toilet regardless of whether they feel like using the toilet or not. They must be taught hygienic urinating practices like wiping from urine area to anus (front to back wiping) which helps prevent urine infections and also effective urinating postures which are comfortable for them. Children can also be taught “double voiding” where after passing urine in the toilet they must reuse the toilet within one to two minutes to ensure complete bladder emptying.

There are children who still do not attain a cure or undergo recurrence of symptoms even after trying all the above mentioned methods. For them certain medications can be tried. For children with persistent bedwetting a medicine called desmopressin can be used which is the first line medicine for treatment resistant cases. Desmopressin can be associated with side effects such as abdomen pain, headache, emotional disturbances and rarely lowering of sodium levels in the body and water intoxication. Hence care must be taken to restrict fluid intake in the evening while on desmopressin.

As these children can have associated serious developmental and behavioural disorders or they could have associated bladder or bowel problems that require a specialist consultation, please take your child for an evaluation with a developmental paediatrician if he or she is experiencing symptoms of bedwetting or daytime urine leaks. Once again thank you for reading through my article and I hope that my article helps you and your child.