DESPERATELY
SEEKING DRYNESS
Families struggling with bedwetting are not alone
BY COURTNEY MCGEE
edwett ing is an issue many parents
deal with, yet few discuss. They
may fear violating their child’s privacy
or feel that others will criticize their
parenting; or maybe they wrestle with
their own feelings of concern and
frustration. It can be isolating.

The American Academy of Pediatrics
says that 5 million children older than
6 continue to cope with nocturnal
enuresis, or bedwett ing. About two
out of three of these are boys, and
most have a parent who struggled
with bedwett ing as a child. The AAP
also says that enuresis can often go
away on its own in a certain number of
aff ected children each year. But what
is a parent to do when a child doesn’t
“grow out of it?”
Marlo Eldridge, a nurse practitioner,
is director of the Pediatric Voiding
Improvement Program at Johns
Hopkins Hospital’s Brady Urological
Institute. Eldridge understands the
strain that bedwett ing can put on family
14 December 2018
washingtonFAMILY.com functioning, and she helped shed light
on this nightt ime challenge.

Involuntary Action
Let’s start with a key fact: “There is
nothing tied between intelligence and
continence,” Eldridge says with great
emphasis. Primary nocturnal enuresis
is involuntary urination during sleep,
after an age when bladder control
generally occurs. The Type A parent in
all of us may fi nd it hard to ignore the
parents who boast about litt le Jane who
pott y trained at age 1 and kept dry all
night at 2. Stop comparing.

Ordinary Development
Bedwett ing often resolves by about
age 4 but is still not uncommon even
between ages 8 and 10, according to
Eldridge. Most often, development
will resolve the issue over time. By age
10, about 95 percent of children are
dry at night. But as many as 2 percent
still present at age 18—mostly due
to unresolved or missed diagnostic
opportunities. “It is not considered
out of the ordinary until the seventh
birthday,” Eldridge says. “When it
persists beyond age 7, there are factors
to investigate.”
Tank Size
I wondered if continence was more
a factor of age or body size. Eldridge
reminded me that it varies by child, as
she’s seen some bedwett ing 9-year-olds
weighing 50 pounds and others 100
pounds, so there’s no magic number.

“Instead, think about tank size,” she says,
“and what could be limiting capacity.”
An undersized bladder, or incomplete
emptying of the bladder, may be a
root cause. Find baselines of functional
bladder capacity by measuring urine
output. “A 7-year-old’s max urine output
is about 270 cc (cubic centimeters),”
Eldridge relates for perspective. “If he or
she is only voiding 120 cc, think about
that. That’s four ounces (about a juice
box). Some kids may need to urinate
after only 60 cc. What is limiting that tank
capacity?” Talk to your pediatric primary-
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care provider about your concerns. You
may want to discuss imaging studies,
such as an abdominal X-ray and renal/
bladder ultrasound, with your child’s
provider. These can sometimes be done
before seeing an urologist and help
expedite proper diagnosis.

Other Issues
Functional elimination syndrome
refers to bladder issues with bowel
involvement (constipation). Eldridge
says that, in her experience, 95 percent
of the time the answer is that a stool is
causing the wett ing. “Think of it like a
brick on top of the bladder,” she says.

“Many kids poop daily and show no
signs of constipation, yet a scan may
reveal blockages.” That stool is taking
up space and putt ing pressure on the
bladder, causing it to feel full before
normal capacity. In some cases, a one-
day cleanout followed by a regimen of
MiraLAX resolves the issue.

Regulatory Hormones
Another possible cause of bedwett ing
is defi ciency of arginine vasopressin—
an anti-diuretic hormone that tells the
body to slow down kidney production
overnight and prevent the bladder from
fi lling up during sleep. Some bedwett ing
is resolved by supplementation with
desmopressin acetate (DDAVP). It’s
not dosed by weight, so providers may
begin with a .2 milligram oral tablet
at bedtime and adjust from there. “If
desmopressin defi ciency is the culprit,
you would know within the fi rst three
days if it works,” Eldridge says.

Super Deep Sleep
“Sleep quality can defi nitely be another
factor,” she says. “About 90 percent of
the parents we see say, ‘Oh, you could
drive a truck through the room and he/
she wouldn’t wake up,’ which implies
very deep sleep, and that means trouble
rousing for bladder signals.” Deep sleep
may be due to chronic fatigue. Ensuring
healthy sleep habits, eliminating
caff eine, restricting fl uid consumption
in the evening and waking a child to
urinate partway through the night
are some of the many ways you can
help heavy sleepers. Obstructive sleep
apnea from oversized tonsils causes
poor airfl ow while sleeping and leads
to chronic fatigue. Although this would
not be a reason for a tonsillectomy, the
elimination of bedwett ing is sometimes
a bonus outcome.

Some children can benefi t from
bedwett ing alarms, which detect
moisture and trigger a loud noise to
rouse the child and condition them to
wake at the sensation of a full bladder.

However, kids may desensitize to
the alarm over time. Also, the use of
absorbent nightt ime underpants would
render an alarm ineff ective.

Pull-ups and Pads
Today there are abundant commercial
products for bedwett ing, particularly
those geared toward children over
preschool age. Eldridge says it does
not mean that the problem has become
more common, rather that we are doing
a bett er job with information. “More
products mean more kids are bett er
able to socialize and participate in
things and function normally, and that
is a huge step,” she says.

A common question is whether pull-ups
hinder progress. “The answer
is no,” Eldridge says. “Think of
it this way: Waking up in wet
sheets does not set the stage
for a positive day.” Children
feel ashamed and guilty for
something that wasn’t even in
their control. Parents fi nd it hard
to respond with understanding
to running yet another load
of laundry and scrubbing a
matt ress. “It is worthwhile to use
products that allow the child to
wake up dry, as the issues are
resolved,” she says. What’s more,
those absorbent underpants for
bigger kids help unlock potential
to go to sleepovers with less fear
of embarrassment.

Risks for Older Kids
What happens when children don’t
outgrow bedwett ing? The biggest
issue is self-esteem, particularly as
they get older. Some pediatric urology
offi ces have a behavioral psychologist
on staff to help children and families
with compliance, to address self-image
and to guide families in developing
healthy habits. “Pressure, shaming or
punishment for a condition they cannot
control is psychologically damaging
to children,” Eldridge says. “Check all
underlying factors. Get them motivated.

Treat them fully and holistically.

Prepare the body to be successful.”
Who Can Help?
If your child is past the seventh
birthday and still not staying dry at
night, ask your pediatrician or pediatric
nurse practitioner for help in fi nding
the root cause. If you need to see a
specialist, Eldridge advises, “Seek out a
fellowship-trained pediatric urologist.

Any urologist can hang a shingle that
says they’ll treat peds, but they cannot
have the depth of knowledge that a
pediatric specialist will have. I don’t try
to treat prostate cancer, but I know all
about pediatric elimination issues.”
Rest assured, bett er days (and nights)
are within reach.

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