Our son still wets the bed.

Our son Jeremy wets the bed at night, even when he uses the toilet right before going to sleep.  He's six now and he's been toilet trained during the day for years.   It's frustrating for us because we'd like to be done with diapers for at least one child.  Jeremy doesn't seem as upset as we are, but he can tell that we're disappointed.

It’s understandable to feel frustrated if your child can stay dry while he is awake during the day but cannot stay dry when he is asleep. You might think that Jeremy’s pattern is unusual.  Many parents don’t know that night wetting is very common among young children even at Jeremy's age.  Although some children begin to stay dry at night within a few months after achieving daytime dryness, for many children this next step may not take place for several years.  In fact, about twenty-five percent of all four year olds and fifteen percent of five year olds wet their beds at least once a week.  Most children find it easier to stay dry through the night as they grow older, but fifteen percent of all six year olds still wet their beds occasionally.  Nighttime wetting is more common in boys than in girls but not at all unusual in girls. 

Staying dry during the night is related more to  development than it is to motivation.

Children  who take longer than others to stay dry at night usually have two characteristics in common.  First, they produce more urine during the night than their bladders (the place where urine collects) can comfortably hold.  That may be because their bodies make a large amount of urine or because their bladders are smaller and stretch less than average.  Second, once their bladders are full, the sensation of fullness does not cause them to wake up to go to the bathroom. That may be because they are less sensitive to the feeling of a stretched bladder or because they are sleeping so deeply that they don’t notice when their bladder is full.  Of course, many children sleep deeply, but they all do not wet their beds.   No one knows for sure why some children can awaken to go to the bathroom when their bladders are full and others continue to sleep.  What we do know is that nighttime wetting is not a sign of  laziness or stubbornness.

Nighttime wetting (which is also called nocturnal enuresis when a child is over five years old) often runs in families.  Many times a parent, an aunt or an uncle has had the same difficulty as a child staying dry at night. (When I ask parents if one of them wet the bed as a child, one parent is often quite surprised to hear that the other wet the bed as a child, but never mentioned it.  And why would they?) Parents sometimes remember being scolded or punished for wetting the bed when they were young.  They may have felt ashamed about wetting and no one may have told their parents that the wetting was common in young children. If parents have unpleasant memories of their own difficulties staying dry at night, they may worry if their own child seems to be having similar difficulties.  It is usually helpful to talk to your child’s health care provider about any worries you have about this issue. Talking to a counselor may help if parents find themselves unable to set aside their worries.

Parents do have an important role in helping a child to solve the problem of wetting the bed. Even if you have made the mistake in the past of becoming angry with your child about a wet bed, it is never too late to tell him that you now know that the wetting isn’t his fault.  Parents can also should express confidence that their child will learn to stay dry all night in the same way he has learned to do other things on his own. They can point out that there are some things that he has learned quickly, maybe faster than his friends, and that some kids learn other things faster than he does. They can remind him that he has already figured out how to stay dry during the day.  A parent can say, ”You know how during the day, when you notice you ‘have to go’ you decide whether to go to the bathroom right away or hold your pee inside you for a while? Well, the next thing you are going to learn is how to do that during the night.  You haven’t learned yet to do the same thing while you are sleeping, but you will learn it, for sure.” This kind of positive attitude from parents will create an expectation for a child that is very powerful, but for some parents this shift feels hard. Even though most children will not need counseling to help with the problem of wetting the bed, they may benefit from going with their parents to talk to their pediatrician or someone knowledgeable about the condition.  Children need to hear that their parents want to help them, and they need to know that their parents understand that they are not trying to misbehave.

Once a child who is wearing diapers or pull-ups at night is able to stay dry for more than a week, either by holding his urine or by waking himself to go to the bathroom, it is reasonable to allow him to try sleeping without diapers.  However, it is also a good idea to keep expectations realistic.  A child may have a few weeks of dry nights and then begin to have frequent accidents.  If you have showered your child with praise for staying dry at night and he has a relapse, you do not want him to feel as though he has failed.  If accidents persist, you may want to return to diapers or pull-ups and try again after a few weeks or months.

(If a child has been dry at night for several months and then begins to wet the bed he should be checked by his health care provider to make sure that there is not an underlying infection or illness causing the return to wetting.  Sometimes a step backward in nighttime dryness is a result of other stresses in the child's life.  Beginning a new school, the birth of a new baby, a change in sitters, or family tension can be the cause of wetting the bed. It is important to address underlying stresses rather than to treat wetting the bed as the problem.)

Parents may be given advice and suggestions for helping a child stay dry at night.  Since many children simply outgrow the problem, it is difficult to know which approaches really work.  Here are some approaches that are often recommended and any advantages and disadvantages of each one.

• Have your child try to use the toilet at the beginning of the bedtime routine and then again right before going to sleep. Even a few minutes between voiding (the medical word for peeing) can make a difference in complete emptying. Some children do not empty completely when they go to the bathroom, and this gives them another chance. (This is a good technique during the day, too.)

• Take your child to use the toilet at your own bedtime or in the middle of the night. This method may prevent your child from wetting the bed or reduce the amount of soaking, but it will probably not help him to learn to stay dry independently. Some parents who want a child to be out of diapers may feel better about helping in this way. Other parents will find this a burden.

• Put a night light in the child's room, and a night light or motion sensor light in the bathroom and in any rooms in between.  Some children do not like to leave their rooms if it is dark around them.  You can also put a potty chair near the bed.  Keeping the child's room and your home warm at night may help since some children will wet more if they are chilly and some children will not want to get out of bed if the room is cold.

• Encourage your child to drink more liquids earlier in the day.  If your child does not drink very much during the day he may be thirsty after dinner and then be more likely to wet during the night. It is not a good idea to restrict fluids after dinner, since most children will view the restriction as a punishment.  Caffeine, fruit juice and sweet drinks can increase nighttime urination, so limit after dinner liquids to water.

• Once a child is able to stay dry several nights a week he may like to have a chart where dry nights can be marked with stars or stickers. Some children love this approach, but others get so disappointed in themselves that they get discouraged. Some parents feel that introducing a reward system has helped their child to stay dry at night, but rewards only work if a child is developmentally ready to be dry anyway.  If you want to try a reward system, it's better to offer small token rewards for small steps rather than a big prize for the final goal.  For example, you could give Jeremy a sticker for staying dry for one night until he is regularly staying dry two nights in a row.  Then you could begin to add a sticker every time he stayed dry for two nights.  Once he was collecting stickers regularly, you could offer him a tiny toy for dryness three nights in a row.  Each small step will get a new incentive until Jeremy is staying dry for a week at a time.  Then, if you want to have him collect stars for a bigger prize, he's had lots of time to practice and consolidate all of the skills he needs.  If at any time he stops earning tokens at a certain level, he's letting you know that you are expecting too much, so cut back to the previous level. 

 • Some people feel that a child will not learn to stay dry as long as he is in diapers or pull-ups. However, if a young child usually wets the bed at night, wearing the diaper will be less work for parents. If a child is wearing a diaper at night a parent should take him to the bathroom when he wakes up in the morning, remove his diaper, and have him sit on the toilet. If a child does not want to wear a diaper at night, he should be expected to help remove wet sheets and to put them and any wet clothing in the washing machine.  It will help if the mattress is kept covered with plastic and a towel wrapped plastic pad is placed on top of the sheets for quicker clean up. It is often helpful to use two layers of sheets, towels and plastic liners so that if a child wakes up wet during the night the first layer can be quickly stripped and everyone can go back to sleep. Helping should be seen as a responsibility that goes along with deciding to sleep without diapers, not as a punishment for wetting the bed.

• Once your child has begun to stay dry at night on his own, you can remind him of his success at bedtime.  If a child has stayed dry by getting up and going to the bathroom, he can try imagining himself getting out of bed, walking to the bathroom, sitting on the toilet, going, and returning to bed.  If he has stayed dry by holding on to his urine, he can imagine himself sleeping and holding in the way he does during the day.  If a child does not want to do this imagining, parents should not insist, because the child will feel pressured.

• If the bed wetting has not resolved by the time a child is seven or eight years old, you can try using a moisture sensitive "alarm" device.  These alarms are attached to underpants or pajamas and vibrate and sound off when he first wets his clothing or bed. The noise will awaken the parents to get the child to the bathroom.  Eventually, the child will be awakened by the bell and later on, by the vibration. Over time, these devices are  successful for highly motivated older children and highly motivated parents. They are not as useful for younger children, because children under seven often cannot sustain motivation for the weeks or months of practice needed to get to regularly dry nights.

• Hypnosis and guided imagery can be used with children as young as five years old. This is the approach that I have used for years and most children have great success.  I talk to a child about how his body has already learned to stay dry during the day, and how he will be able to learn the same thing for night.  Then, while the child is relaxed and comfortable, I use storytelling and imaginative metaphors to help him visualize how he will take that step.  Parents are a part of the process and help the child at home to practice the visual imagery. If you'd like to use this approach, make sure that the person who helps your child is a health care professional who has experience both with children and with treating enuresis.

• In the past, medications were prescribed for children who wet the bed at night.  However, the health risks associated with medications must be weighed against benefits, and this method of treatment is usually not advisable.  It is best to schedule a conference with your child's health care provider to discuss the risks, costs and benefits of such treatment

Even though nighttime wetting is described as a problem, it is perfectly normal for many young children, even at Jeremy’s age, so don’t get discouraged. The most important role for parents in helping him to understand that even though his wetting is frustrating for everyone, he is just a "late bloomer" and that he will be able to solve the problem as he grows older.

Meg Zweiback is a pediatric nurse practitioner in Oakland, California.  She consults with families whose children are having difficulties with any aspect of toilet training, including enuresis.