Cover image
THE DRY NIGHT
Advice for parents of children
who wet their bed

An Eight Step Guide

Contents

Foreword

Dry Night is one of three booklets about childhood enuresis (bed-wetting) originally developed by the Continence Foundation of Australia. The reprint of the very popular Sleepover, Dry Night and Watertight is made possible by the Australian Government’s National Continence Management Strategy. These booklets will be welcomed by the many parents and children struggling to overcome the problem.

Bed-wetting is a common and complex condition that can often be a source of worry for parents and their children. For parents the main concern is often the emotional and social effects for their children. Children can suffer feelings of embarrassment that can lead to low self-esteem. Also other issues of sleep disruption, laundry workload and costs, are not small concerns!

The Continence Foundation of Australia seeks to encourage good bladder and bowel habits in children by offering current information and encouraging parents to contact a health professional who is skilled in continence care.

Research has given a greater understanding of the likely causes of bed-wetting. Working with a general practitioner, paediatrician, continence nurse advisor or a physiotherapist specialising in this area of health is therefore highly recommended for children wanting to be ‘dry’.

Barry Cahill signature
Barry Cahill
Chief Executive Officer
Continence Foundation of Australia
(2005)

STEP 1 Recognising you have to take one step at a time

The first thing to say about bed-wetting—although you probably know it already—is that you’re not alone in having a child who wets the bed. Bed-wetting is very common. It’s usually treatable without drugs and shouldn’t be the cause of constant uproar at home.

By the time you opened this booklet many of you will have tried lots of different ways of keeping your child dry at night. You may have stopped drinks after dinner; you might have been ‘lifting’ your child and putting them on the toilet before you go to sleep yourself. You may have used star charts, rewards of other kinds, and even gone as far as bed alarms or medications.

You may be doubting your ability as a parent—and comments from relatives or friends may add to these doubts. Some people may even imply that your child is naughty or lazy. And the word to describe the financial and/or physical costs of the extra cleaning and washing? ...Well, it’s relentless. So you may be wondering what’s left and feeling helpless about it all.

This booklet won’t provide simple answers. If they existed, you’d have found them already. It aims to give you an organised way of thinking about bed-wetting—a way of tackling the challenge one step at a time—starting with the basics.

This includes understanding the problem better and explaining why some of the things you may have tried haven’t worked but perhaps could, given the right circumstances.

Bed-wetting is common...

In a school class of 30:

STEP 2 Understanding the processes behind bed-wetting

Your friends may have told you their children were dry as toddlers.

However, when you study large numbers of children in the population, the reality is that most aren’t reliably dry during the day until they’re between three and four, and not dry on most nights until the age of four.

Toddlers who become dry at night can probably thank luck and possibly their parents for taking them out of night-time nappies at an early age.

These children aren’t more clever, they’re not lighter sleepers and generally don’t drink sparrow-sized volumes of fluid before bed.

Where luck comes in is that they are more likely to have mothers and fathers who were dry at a younger than average age. Heredity does make a difference. If both parents were bed-wetters, then there’s a three out of four chance that their child will be a bed-wetter too.

Experts say there are two types of bed-wetters. The first—and the most common by far—is the one who’s never really been dry, and the second is the child who has been dry for a reasonable length of time then starts wetting the bed again. Although there are exceptions, there isn’t really much difference between these children.

A big step in life... the development of bladder control in childhood

Birth and Infancy... recent studies have shown that voiding (bladder emptying) happens in response to various bladder volumes and may involve complex nerve pathways.

1–2 years... becomes aware of a full bladder.

3 years... is able to hold urine for longer and longer periods (this increases the bladder’s ability to hold larger volumes of urine).

3–4 years... is able to empty bladder into a toilet when the bladder is full. The majority of children will achieve daytime dryness during this year.

4 years... can stop passing urine when child wishes—the majority of children will be dry on most nights.

6 years... can pass urine regardless of whether the bladder is full (i.e. the age at which it’s realistic to say “I want you to go to the toilet for a wee before we get into the car”).

The child who’s never been dry at night

It is extremely rare to find anything wrong with such a child. The main cause is that the child has difficulty in rousing from sleep in response to the sensation of a full bladder. In other words, the ‘wiring’ which allows a full bladder to ‘yell loudly enough’ at the brain to wake the child and make them go to the toilet isn’t fully mature yet.

This also means that if the child’s own bladder can’t yell loudly enough then, as sure as anything, your yelling on discovering yet another wet bed won’t make any difference either!

Such a child really needs all the help and encouragement they can get. This can include the identification of barriers—such as a fear of the dark or monsters lurking in the toilet—that could be making things worse. But we’ll come back to that later.

An additional factor may also be that, in some of these children, the kidneys produce a lot of urine at night. You may have noticed, for instance, that your child doesn’t just have a tiny wet patch, they may flood the bed (or drench a disposable product)—and on more than one occasion each night.

This could be due to not having a natural rise in the level of a particular hormone at night. This hormone is a chemical messenger from the brain to the kidneys which tells them to slow down making urine. It’s called ADH (anti-diuretic hormone).

One of the reasons most of us get a good night’s sleep is that our ADH levels go up at night, so our kidneys produce less urine. This increase in ADH may not occur to the same extent in some children with a bed-wetting problem.

Bed-wetting in a child who’s never been dry... is NOT caused by

... is HARDLY EVER caused by

... is MOST COMMONLY caused by

The child who’s been dry but is now bed-wetting

In most cases these children are no different from those who have always wet the bed. But some specialists believe they’re more likely to have a medical or psychological cause such as a urine infection or significant emotional upset.

By the age of 10, about 8 children out of 100 will have relapsed into bed-wetting after having been dry for a time.

The children who are more vulnerable to this tend to be those who were older than average when they were first able to control their bladders throughout the night. In other words they have already shown some signs of delay in development of the right ‘wiring’.

How the body produces urine and gets rid of it

Production of urine

The brain:

  • should tell the kidneys to slow urine production at night, by sending a chemical message from a tiny gland called the pituitary
  • is told by the bladder when it’s full
  • should be able to tell the bladder when to empty itself

The kidneys:

  • clean the blood
  • adjust the amount of water and salt in the blood
  • get rid of all sorts of substances into the urine which the body doesn’t need

The bladder:

  • stores the urine which comes down from the kidneys
  • is like a bag that is wrapped in a layer of muscle
  • will empty automatically if the brain doesn’t send the right messages telling the bladder what to do

There are thousands of people, including adults, who lose control of their bladder at night while they’re asleep.

The most likely reason for this is they have difficulty in rousing from sleep in response to a full bladder.

For adults and children to be reliably dry at night they need:

STEP 3 Giving your child some say in the matter

All this is going to take time— perhaps not as much as you think—but it still needs a lot of patience and commitment, not least from the child. If your child isn’t bothered by it, then trying to force the issue almost guarantees failure.

Luckily that’s an unusual situation since almost all children want to be dry at night. It’s hard to underestimate the embarrassment and distress it can cause. Trouble really begins when the wet bed becomes the focus of anger or battle of wills.

It’s known that there are significant extra costs and workload—as well as the lack of sleep—for parents who have a child with bed-wetting. It’s normal for parents to sometimes feel tense, frustrated and at a loss. Nonetheless, it’s important to stand back a little and look at the situation coolly.

A quiet chat

Talk to your child about what they think and feel. You might uncover fears which might be stopping them going to the toilet during the night. It could be the way their bedroom is laid out, or that the dark bothers them, or something in the toilet or in the home may be a problem.

It’s also worth asking the child if they have any ideas for dealing with the problem. You’re not going to be able to impose solutions on your child because their co-operation is essential for success. Therefore reaching an agreement to proceed with getting help and treatment is very important.

From the child’s earliest age you should encourage them to take on as many responsibilities as possible in the treatment of bed-wetting, being sensitive to both the child’s age and ability.

STEP 4 Having your child assessed

It’s rare for there to be a medical problem associated with bed-wetting, but it’s important not to miss a child who does have something wrong. This is why a medical check by a GP is recommended.

Sometimes a child who has been dry during the day for months or years begins to wet. In such a case, it is necessary for the child to see a doctor immediately to check for infection or other physical or emotional problems.

You are also advised to observe your child’s drinking and toileting habits—this may give you some clues to helping further.

Remember, children need to drink plenty of water daily for optimal bladder function. Good drinking habits will encourage the bladder to learn to hold more urine.

If your child is running to the toilet frequently during the day, then it’s possible that their bladder hasn’t been trained to accept larger volumes of urine. It is advisable to seek professional advice for an assessment of this problem. A simple bladder training program may be all that is required.

It is normal for children to have occasional accidents during the day until they reach school age. There are a small number of school age children who wet during the day and night. It is strongly recommended that these children be examined by a doctor.

If your child wets day and night, it is beneficial to help the child achieve day dryness before tackling the night-time bed-wetting.

STEP 5 Changing or stopping things known not to be helpful

Don’t restrict fluids in the evening (unless bedtime drinking is excessive): It seems to make sense to restrict your child’s fluids in the evening to prevent bed-wetting, but in fact cutting down fluids doesn’t work. It can actually make the problem worse by reducing the bladder’s ability to expand and hold larger volumes of urine (see Step 4).

Encourage water in the evening:* Some experts argue that only water is acceptable after dinner, since fizzy drinks and drinks containing caffeine (such as cola drinks) may irritate the bladder or produce extra urine during the night.

Avoid routinely waking the child to empty their bladder: You are encouraged not to ‘lift’ your child. This ‘lifting’ or regular waking of children to go to the toilet at a similar time each night will reduce the degree of wetting, but can also delay the child achieving dryness independently.

Be careful about incentive schemes for your child: It’s easy to overdo these. Set achievable targets without overly generous rewards. Only reward behaviours that are achievable, or reward what your child has control over. Remember that praise is the best reward of all.

Don’t make the cleaning up process a punishment for the child: It is important that the child looks after themselves as much as possible and that this is seen as part of the treatment, not a punishment.

Encourage the child to drink lots of fluids throughout the day:* This makes for healthy bladder activity. It doesn’t make the bed-wetting worse.


*A general guide to FLUIDS. It’s important that you are aware of what type of drinks make up your child’s daily fluid intake, as well as ensuring that the amount is sufficient. Water is best.

As a GENERAL rule, children should be drinking ABOUT 6–8 glasses of fluid a day, but they should certainly drink whenever they feel thirsty.

The fluid intake should be spread fairly evenly over the day. Remember that if you increase the fibre in the diet, you will need to increase the fluid intake.

STEP 6 Putting in place a program of activities

Be aware of the child’s age, personality and what they can cope with:

Keep a diary: To begin with, you need a calendar or diary (which ideally the child has helped to make) to record activities and progress.

Help your child to be more self-reliant: You hopefully now have the child on side and feeling motivated. They’re helping you with changing the bed and is generally taking on more responsibilities in relation to the effects of the bed-wetting.

Set realistic targets: It is vital that you set targets that are achievable. So the first improvements you might aim for could be:

Reward improvement: There is a lot of debate about whether reward systems (such as star charts) work. They may help to motivate the child.

If you are thinking about rewards and your child has never been dry, don’t aim initially for dryness itself since that may set up the child to fail—not a good idea! Acknowledge improvements as well as the achievements. Praise is the best reward.

It is better to aim for success with some of the activities and objectives outlined on this page without making the rewards too big.

You could run out of inducements or give presents that are out of proportion to the progress the child has made.

Watch the fluid intake: Aim for an increased intake of fluids regularly throughout the day and no fizzy drinks and/or caffeine containing drinks in the evening. Tea and coffee also contain caffeine and it’s worth remembering that chocolate may too.

Improve the diet: Constipation disturbs bladder function and some experts think that constipation may make bed-wetting worse. Constipation is defined as difficulty in passing a bowel motion and/or having 3 or less motions per week.

If your child has this problem, encourage drinking more fluids and eating more fruit, vegetables and whole grain cereals, as well as encouraging some regular, enjoyable exercise.

Children should also be taught to respond promptly to the need to empty the bowel, rather than to hold on—even if it means using the school toilets, which some children try to avoid.

Keep the monsters away: It is wise to keep the way to the toilet and/or bathroom lit at night to make it less scary for the child. Re-arrange the bedroom if the child identifies any problems there.

Bladder train during the day: The child who has to go urgently and frequently to the toilet during the day will benefit from a bladder-training program (after ensuring that there’s no urinary infection). This training is best supervised by a continence consultant and involves the child learning to ‘hold on’ for longer periods.

Reduce workload and stress: The National Continence Helpline (FREECALLTM 1800 330 066) or your continence consultant can advise you on bedding protection and/or containment products.

It is worth noting that many children achieve ‘dryness’ independently more quickly when they discontinue wearing disposable containment products. Therefore, long-term use of disposable products is generally not recommended by continence consultants.

The next step: In the child under 6, the above 9 activities are the prime activities to have in place.

In the child aged 7 or over, it is worth trying the bed alarm. (Sometimes the alarm can be used in a well-motivated child from about the age of 5 years.)

STEP 7 Using a bed-wetting alarm

An alarm is a treatment for bed-wetting which has been consistently proven to work for the majority of children.

But there are many things you must be careful about because this isn’t an option which works well with a casual approach:

It can’t be over-emphasised that both you and your child must be properly taught how to use the alarm and have someone to call if you’re having difficulties of any kind.

Your aim should be to have your child use the alarm as independently as possible according to their ability. All children benefit from parental encouragement and support throughout an alarm-based program.

How the alarm has its effect

The alarm conditions the child to become aware that their bladder’s full and they should now wake up and go to the toilet. When it goes off, the child must first wake up, go to the toilet and empty their bladder fully. One common mistake made by the unwary, exhausted or poorly-taught parent is not re-setting the alarm after the evening’s first episode of wetting. The conditioning process won’t work well if only some wetting episodes trigger the alarm.

A sustained effort over many weeks, perhaps as long as two to three months, might be required.

The child who doesn’t wake up to go to the toilet

If your child doesn’t wake to the alarm, you may find that initially you need to wake the child when the alarm is triggered.

Don’t be put off if your child struggles to wake up. Learning to wake is difficult for some children. However, as long as you’re following the routine, then your child has a good chance of eventually ‘tuning in’ and waking to the alarm themselves.

Success rates

If the bed-wetting alarm is properly used with well-motivated children under the guidance of a continence consultant, more than 75% will become dry permanently.

Once your child has been dry for two weeks then there’s some evidence of a benefit from really pushing your child hard with extra drinks before bed for a few nights to make sure the message between bladder and brain has been learnt well. Discuss this with your continence consultant.

Where to obtain an alarm

It is recommended that you discuss this with a continence consultant.

STEP 8 Using bed-wetting medicines

In the past doctors often prescribed antidepressant drugs. This practice is now strongly discouraged by most experts in the field as it has limited benefits and unpleasant side-effects. Their most worrying feature is that they are highly dangerous if a child should take an accidental overdose.

Medications may be used in children who do not become dry with an alarm program and also in children for whom the alarm treatment is considered unsuitable.

Some medications will reduce the amount of urine produced overnight. Children must carefully follow their doctor’s instructions regarding any medication to avoid any dangerous side effects.

Medications can be very useful on occasions for responsible adolescents to allow them to sleep over at friends or attend camps with more confidence.

Understanding the jargon and urine production

Anti-diuretic hormone (ADH): This is a chemical messenger manufactured by a tiny organ under the brain called the pituitary gland. ADH is released into the blood-stream and travels to the kidneys to hand over its message of ‘Stop making so much urine’.

ADH levels have a natural daily rhythm and normally are lower during the day and higher at night. For some reason, a proportion of bed-wetting children don’t produce enough ADH at night and as a result their kidneys generate too much urine. (Desmopressin nasal spray mimics the action of ADH)

Bladder: This is a hollow muscular organ that stores and expels urine. The bladder’s activity is coordinated with other muscles, such as the sphincter in the urethra. We can ‘train’ our bladders to take more urine by holding on when we feel the need to go to the toilet. Bladder sensation is perceived by the brain via the nervous system.

Enuresis: This is the involuntary loss of urine in a normal child over 5 years old. When it happens during sleep at night it is called nocturnal enuresis (bed-wetting).

Kidneys: These organs lie behind the abdomen on either side of the spinal column. They ‘clean’ the blood, adjust the body’s salt and water content and manufacture urine which is collected into the ureters.

Micturition: The process of passing urine.

Nocturia: Waking at night to pass urine one or more times.

Polyuria: Passing excessive amounts of urine. Sometimes this is a sign of diabetes, especially if the child is losing weight, has a poor appetite and is drinking a lot.

Ureters: These are the two narrow tubes which carry the urine from the kidneys to the bladder. Urine flows unhindered from the kidneys into the bladder although there is a one way ‘valve’ of sorts where the ureters connect to the bladder which prevents backflow when the bladder empties. Some children are born with ineffective ‘valves’ and thereby suffer repeated urine infections. This condition requires medical attention.

Urethra: This is a tube which transports urine from the bladder to outside the body. The control of urine flow through the urethra is controlled by a ring of muscle known as a sphincter.

Urinary Tract System: This is the ‘plumbing’ system from the kidneys to the urethra.

Urine: This is a fluid which comes from the kidneys and contains water, salt and by-products of the body’s metabolism. The body disposes of many medications and toxic chemicals in the urine.

The teenager with a bed-wetting problem

It is known that around 1 in 100 adolescents wet the bed. They are slightly more likely to have behavioural problems but these could well be as much due to the bed-wetting as causing it. There is a range of reasons why past treatments may not have worked and professional advice and assessment is recommended. The reasons for bed-wetting among teenagers are the same as in young children. In other words, in most cases teenagers haven’t developed the appropriate brain control of bladder function at night. They’re no more likely to have a sleep disorder than anyone else, although some parents are convinced their bed-wetting children are deeper sleepers.

Adolescents are also very unlikely to have a medical problem with their kidneys or bladder. However, they should be checked out by a GP or specialist if this has not already been done.

It is unusual for an adolescent with bed-wetting to have reached the teen years without having had some form of bed-wetting therapy. Even so, as with the younger child, it is definitely worth taking the systematic approach suggested in this booklet, including re-trying an alarm program.

In a program using an alarm, adolescents sometimes prefer the body-worn alarm. But whatever is used, you need to pay careful attention to the correct use of the recommended equipment for the right length of time.

Some doctors encourage the careful use of a nose spray by teenagers. This may allow them to sleep away from home without fear of embarrassment.

A final message and further help

A final message

We hope that reading this booklet will help you feel empowered to assist your child overcome bed-wetting.

Do seek professional help and be optimistic about a successful outcome for your child.

For further help contact

The National Continence Helpline (FREECALLTM 1800 330 066) can give you the details of a clinic or continence advisor nearby, as well as advice on helpful products available.

Continence Foundation of Australia (CFA) Resource Centres:

CFA in New South Wales
T 02 8741 5699
E contfoundnsw@ozemail.com.au

CFA Victoria (Victorian Continence Resource Centre)
T 03 9816 8266
E cfavic@continencevictoria.org.au

CFA in WA
T 08 9386 9777
E info@continencewa.org.au

Acknowledgements

The set of 3 Childhood Enuresis Booklets—Sleepover, The Dry Night, and Watertight—were originally produced in 1996 under the guidance of the Childhood Continence Working Party, a national, multi-disciplinary group drawn from appropriate academic, professional and community organisations.

The Continence Foundation of Australia is grateful to these people for their contribution, particularly those who contributed their efforts on an honorary basis in addition to usual work commitments:

Ms Janet ChasePhysiotherapist
Ms Rowan CockerellContinence Nurse Advisor
Ms Chris HarkessContinence Nurse Advisor
Ms Susan HouldsworthConsumer Representative
Dr Martin KnappPhysician and Nephrologist
Ms Susan McCarthyContinence Nurse Advisor
Assoc Prof Richard MillardUrologist
Assoc Prof Terry NolanPaediatrician
Dr Jan PatersonContinence Nurse Advisor
Dr Norman SwanAuthor of the original set of three booklets

Call the National Continence Helpline on FREECALLTM 1800 330 066 *

The Helpline has a team of clinical advisors providing free and confidential information, leaflets and referrals to local services.

For more information, you can also visit:

* Calls from mobile telephones are charged at applicable rates.



The Dry Night

ISBN: 1–74186–640–5
Online ISBN: 1–74186–641–3
Publications Approval Number: P3-3925


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A project of the National Continence Management Strategy, an Australian Government Initiative.

Developed by the Continence Foundation of Australia,
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