From the Grampians Regional Continence Service on children’s bedwetting.
Today we’re going to be talking about bedwetting. Bedwetting is a very common problem and today we’re going to be discussing the different reasons that that might be happening. The first slide we’re going to look at is talking about normal development. And as you can see most kids are aware that they’re wet when they’re about 15 to 18 months old. They start to be able to be aware that they need to go to the toilet when they’re about two, and then they can usually hold on when they’re at least three years of age. And most kids can go off to the toilet and wee on demand when they’re about five.
As you can see as well, the incidence of bedwetting is quite high. A lot of people think that their child’s the only one that wets the bed, but as you can see, when they’re five in a classroom of 30 there’s usually another about five children that are wetting the bed of this at the same time, and by the time the child is 15 there’s still one in 50 children that are wetting the bed. So it is very very common and a fairly high incidence of it.
Now we’re going to look at a few myths about bedwetting. A lot of people think that if you’re wetting the bed or having trouble with your bladder, that if you stop drinking that it will help. And obviously, that’s not a good idea. Usually, that just makes your urine quite concentrated. It makes your bladder a little bit overactive and it makes you need to go to the toilet more often so it really doesn’t help to restrict your fluids at all. A lot of people also think that the the children are wetting the bed and it’s quite behavioral, but once you’re asleep you have no control over what happens to you when you’re in bed. Although we don’t make it a bother for our children these days when they do wet the bed, children still get embarrassed by it and you’ll find that some kids will hide their pajamas in the wardrobe or they’ll cover up their bed so that you won’t see that they’ve wet. So it does bother them even though we try and make it not such a bother. And a lot of parents will get their children up and take them to the toilet before they go to bed and we call that night lifting. It might keep them dry but they’re not actually dry themselves where their apparent dry so it’s not a good idea to lift them.
They’ve got to learn to be dry themselves overnight and not just mummy dry. If it’s not behavioural, why doesn’t, you know, every time that my son stays at someone else’s place why is he always dry then? I think that sometimes they’re just in a light asleep and they’re a little bit more aware of what’s happening. When they’re at home they’re safe they’re sleeping deeper. So that can happen. There’s three main reasons for bedwetting. The first one is an overactive bladder. The second is a reduced waking mechanism and then of course there’s decreased anti-diuretic hormone and we’ll touch on all of these in the next few slides.
There is quite a risk of bed wetting if parents wet the bed. If one parent wet the bed there’s usually about a forty percent chance that one of the children were wet. And of two of the parents with the bed ball there’s an eighty percent chance. There tends to be more boys than girls that wet the bed. There’s some other influences on bed wetting. Obviously you know there could be some upsets in the family that are causing the child to be having problems with bed wetting. A lot of children might wake during the middle of the night but the toilet might be at the end of the passageway and there’s no light and they’re a bit scared so they just roll over and go back to sleep again and then they may wet. Some country houses, farm houses have the toilet still outside which can be a bit of an issue and they get a bit scared so they won’t go. And there can be obviously changes to the normal routine and they can be having some issues at school or you know that sometimes when a new baby’s born in the family or there could be some tragedy in the family. Sometimes that can also initiate some bedwetting as well.
We’re going to talk a little bit about the functional bladder capacity. Now the bladder is our storage tank for our wee and it is supposed to store urine, it’s not supposed to be empty all the time. It’s supposed to fill up and then empty as we need to go to the toilet. So it’s just a muscle bag and it relaxes when it fills and when it needs to empty it contracts. And then we go to the toilet and we empty our bladder. It is normal to go to the toilet between four and seven times a day if we drink a good amount of fluid. As you can see there’s some average bladder volumes there for our children. And by the time they are ten they are usually able to hold about 300 mils in their bladder. A lot of the kids that we will be seeing or that are having trouble with bedwetting will have very small bladder capacities. They won’t be able to hold very much wee in their bladder for different reasons. And so the ultimate aim is to get them up to these volumes for their age.
Overactive bladder. This is what most of our kids look like when they have overactive bladder. They’re really urgent they need to get to the toilet quick and they usually can’t hold on. So if your child is doing that, they’re probably got some overactive bladder going on. So basically it is when they have a small bladder capacity, they can’t hold a very good amount of urine in their bladder. It often means that they are poor drinkers as well. But not always. Some people just go to the toilet too often therefore their bladders are small and don’t hold much. But a lot of these kids also don’t drink very much fluid. Sometimes it can just be because their bladder is irritated for different reasons. It can be that the urine is concentrated because they’re not drinking enough. It can also because they’re drinking the wrong things. If they’re drinking things like Cola sometimes it can be Milo, anything with caffeine in it. Really sugary drinks. But there’s also foods that can affect the bladder as well that can cause it to be quite irritated. And such unusual things like tomato sauce or apple juice. Also, most people will know what it feels like when they have a urinary tract infection and that’s what overactive bladder is like.
Now I have left constipation to last because I think that needs a little bit more information. But constipation or a full bowel can make the bladder overactive and it irritates the bladder because there’s not much room down there and it tends to take up all the space and it can make the bladder quite small and they won’t be able to feel very much. Now how do you know if your child’s constipated? Most people wouldn’t because once our children are toilet trained they go off to the toilet on their own and we don’t ask the question. You know did the poo come out easy or not? So unless your child actually comes out and says to you I went to the toilet and did a poo and it hurt or they start soiling, you probably won’t know that there’s something wrong with their bowels. So it’s probably a good idea to have a little bit of a check on what’s going on with them.
This is a chart, just a urine color chart. It’s just showing you what the urine should look like. Now it’s most people when they get up in the morning after sleeping all night their urine will be quite concentrated and dark and it can be between the six, seven and eight. By the time they’ve started drinking and by the middle of the day in the afternoon their urine should be quite clear and it should be you know one or two. So how do we manage overactive bladder? We usually discuss some bladder training. So what bladder training means is that we’re encouraging the children to hold on, to be able to make their bladder hold more wee. And in doing that we also need to drink a little bit more because if we’re not drinking much we’re not going to be able to fill up our bladder so that it becomes nice and big. So we avoid going to the toilet just in case which is something that most parents do. I know, I did myself and that means that the only just in case time that a child should be taken to the toilet is before bed. They should get a desire to go to the toilet and then they should go. But we shouldn’t be encouraging to go when they don’t need to.
We should avoid all drinks that can irritate the bladder and we should encourage a really good fluid intake. So that’s a little bit difficult. As in how much should they be drinking and that sometimes depends on their age, but most children at least five year old should be having at least one and a half liters of fluid a day. And when it’s hot they probably should be having more than that. And some kids will drink that very easily and some children won’t. They should be encouraged to have drink bottles at school which most children are allowed to have at primary school now, but it might be worth a word to the teacher because the teacher that just because they’ve got a drink bottle at school doesn’t mean they’re encouraged to drink them, and if you have a word with the teacher the teacher will hopefully encourage them to have a drink. Also having the fluid spread evenly throughout the day. It’s no good having a couple of drinks in the morning and then having all their fluid in the evening because all that does is encourage their kidneys to produce more urine in the evening and overnight. And that doesn’t help when you’re trying to get them dry overnight. So it’s good to spread that fluid evenly throughout the day. So start early, get a couple of good glasses into them, make sure they’re having their drink bottles at school. If a big drink bottle keeps coming back full it’s probably good to have a few small ones, and in summer maybe freezing a couple of those so that they’ve got fresh cold drinks throughout the day. And when they’re home sometimes even having a drink bottle just for themselves in the fridge or maybe a jug with their name on it so they know exactly how much they’ve got to drink for the day and also using things like jellies and in winter using soups and yogurts and ice creams and ice blocks are all fluids, so you can use all of those to encourage them to drink a little bit more.
And obviously we’ve spoken about constipation in the last slide. We need to really make sure that they’re not constipated. If they are, treat them and avoid constipation. The next thing we’re going to talk about is the waking mechanism. So these kids will sleep through anything, usually smoke detectors will go off and they’ll sleep through everything. They have a part in their brain that is still maturing and they haven’t learned to wake up to the signals that the bladder sending to the brain. Basically, it’s a little bit like teaching your 15-year-old to wake up to an alarm clock in the morning. Usually doesn’t happen. It takes a while for their brain to learn that that’s what they have to do. We need to somehow wake up that brain and that’s where things like bed alarms and that come into it. There is an immature part of the brain but also sometimes it can be that the children have some sort of emotional upsets and it can also be some kids might be dry all the time but towards the end of the year and get very very tired with school that they can actually start wetting as well. Some kids will dream that they’re on the toilet. Usually that happens at the very early hours of the morning that’s not such a bad thing, they’ve nearly made it but they’ll often dream that they’re sitting on the toilet they might wet the bed then. And sometimes it’s just purely and simply because they’re wearing a pull-up and we train our children to wet into a nappy from the time they’re born. So subconsciously when they’re in that half sleep they feel the nappy on and they might wet into it as well.
I just wanted to ask, my child’s a really deep sleeper so is that why they’re wetting the bed? The wetting can happen in the light cycle but we sort of talked a bit about that with the dreaming and the last thing in the morning and whatever but when they’re in a really deep sleep, nobody really knows what’s happening with the brain and the bladder. But what we think happens is the bladder sends a signal to the brain and says I need to go to the toilet in the middle of the night, and for most people, the brain says a signal back saying it’s three o’clock in the morning go back to sleep. With these children that doesn’t happen. The brain’s not registering what’s going on and pretty much they just start to wet.
So if the child’s not waking and going to the toilet during the night we need to make sure that there’s no stresses that everything’s you know nice and smooth and going along quite nicely. And we would have already discussed bladder training. We’ve already made sure that their bladder volumes are good and all that sort of thing and then we would take the pull-up off and we would encourage responsibility. These kids need to be responsible for what’s happening. It’s not a punishment if your child helps you make the bed in the morning or change the bed or changes their jammies or takes their pull up off. Because they need to take responsibility. If you or I wet the bed we would have to clean up after ourselves. Punishment is when we growl at them. Getting them to help and making it a responsibility – they’re totally different things. So really taking responsibility is good and you won’t get them to do the things that you want them to do like drinking and holding unless they really are bothered, and they want to take responsibility. So if they get up and say I hate having this pull up on that’s a really really good time to start doing things.
So different types alarms that we can use as well. We have clip-on ones, which we don’t tend to use very often. A lot of people do use them in the home situation but we don’t use them very much we tend to use the mat alarm, The sticker charts and rewards. I use quite a bit but it’s no good rewarding your child for a dry night because the next night that could be wet and it’s very very confusing. So what you should be rewarding our there? How much they’re drinking and how well they’re doing drinking and how they can hold on and whether they can hold on a little bit longer. So those sorts of things are really good to reward them. It is sometimes nice to have a goal at the end, you know might be that we know when we get all through this and you’re nice and dry we’ll get some really nice linen for you or whatever. But actually rewarding for dry nights is not a good idea.
So I’m just going to show you the the alarms. This is the little clip on alarm. The sensor goes into the underwear and then the clip usually is clipped up near the shoulder of the child. And when the sensor becomes wet the alarm goes off and it should wake them but it’s fairly quiet and we don’t tend to use it very much. But it is an option this is the mat alarm. Basically this goes onto the bed with a very very light sheet over the top and children that that tend to perspire a lot we would suggest they just wear their singlet and undies maybe to bed but something very light. So a very light sheet goes over the top they lie directly on it. The alarm’s turned on. When the child wets, the alarm goes off, then the child wakes up, goes to the toilet, finishes their wee, comes back, cleans up their bed, remakes their bed, puts new jammies on, gets back into bed, turns the alarm on and goes back to sleep. Doesn’t happen overnight, usually takes a couple of weeks for them to get into the swing of actually doing that. And you’ll find for the first few nights you usually have to go in there and physically wake the child up while the alarm’s still going because they will just sleep through it. But when and if your child actually needs an alarm we will bring you in. We will do a full assessment and we will discuss the alarm and different options for you at that stage.
Carrie, I’m quite sure that my child wets more than once a night so what do we do and how do we manage the alarm if that’s happening? It’s common especially at the beginning for the alarm to go off more than once at night, so each time it goes off it’s the same process turn the alarm off, off to the toilet to come back clean up the bed change the jammies, turn the alarm back on and get back into bed each time. But I would suggest that if it’s going off the third time that possibly you would then turn it off and just let yourselves get some sleep. Usually that doesn’t happen for a long period of time though. The first two weeks of the alarm is usually the worst. If you can get past that, usually we can get somewhere.
So now we’re going to talk about night urine production. We should have two-thirds of our fluid intake within the first two-thirds of the day. We shouldn’t drink the majority of our fluid at the end of the day because as I said before that just encourages our kidneys to produce more urine at the wrong time of the day. So we’ll be having to go to the toilet more often at night than during the day. So some children go to school, don’t drink very much, come home and then drink a lot in the evening. So that needs to be monitored and brought back to drinking more during the day. And you might find that that’s all they need to do and then they’re not wet at night. But some children can have an increase in the urine production at night if they have insufficient antidiuretic hormone.
So what is it? Basically, the antidiuretic hormone is the hormone that tells our kid needs to have a bit of a rest in the middle of the night. It’s very common for our kidneys to have a rest for about three hours during the night and not to put out very much wee. So that gives it a chance to just recover to start producing more urine for the rest of the day. So most people, we have this antidiuretic hormone, but in children, they tend to acquire it as they grow up. Some kids acquire it quite young and some children don’t acquire it until later on. So how do we test for it? We don’t really, we tend to do all of the other things that we would do with most children: increase their fluids, do their bladder training and then if they need an alarm they have an alarm. If the alarm isn’t working so well and they’re still really wet at night and they’re flooding out the bed, you might consider that it’s something to do with their antidiuretic hormone and you may speak to the local doctor about starting them on some medication. But surprisingly sometimes even when we think that it might be the antidiuretic hormone, you know week later these children are dry. So it’s not something that we test for and it’s not something that’s very common, but it is something that can be there with some of our children.
So obviously if they’re drinking too much at night we need to reduce their fluid tonight and spread that evenly throughout the day. And I’ve spoken about the antidiuretic hormone. The medication that actually is used is called Minirin. Now Minirin basically masks the antidiuretic hormone. It pretends to be it, it doesn’t stop the child from producing their own antidiuretic hormone it just pretends to be it so it does the job of that for the time being. So it is a medication that’s used with a lot of children. Some children use it for just for school camps and things but that doesn’t necessarily mean it’s going to work. As I said it’s not something that we would test for but it is something that we always keep in the back of our mind that we might need to look at down the track if we’re not getting anywhere.
I just wanted to ask is that medication you’re talking about is that a spray like a nasal spray? I’ve heard about. Minirin did originally came in and come in a nasal spray but we don’t use the nasal spray anymore. It now comes in tablets and melts which are a lot more easy for the children to use and a lot safer as well. But yes that the nasal spray was the old-fashioned way of actually having this medication.
So assessments. We don’t tend to do many investigations. With most children, there’s nothing wrong with these children. They just wet the bed. But the most useful tool that we have is the bladder diary and the bowel chart. So the bladder diary tells us how much these children are drinking and how much and how often they’re going to the toilet and the volume of what they’re doing. So it’s really important for us to figure out whether they need to increase their fluid intake and whether we actually need to be working on their bladder volumes or not. They might have wonderful bladder volumes but they’re just not waking, so we might then take their pull up off and then put them straight onto a bed alarm. But it just gives us so much information. And it can be simple things like what they’re drinking ,how much they’re drinking when they’re drinking it whether they’re going to the toilet when they shouldn’t be going to the toilet and whether they’re doing a lot or a little – so it’s just a huge amount of information that we use and will help us in evaluating what we need to do with these children.
How do I measure? I’m not so I don’t know how to how do we measure? It was the question good question. For the boys that obviously it’s a lot easier, you can just go down to any you know two dollar store whatever and buy a jug with measurements on the side and they can just wee into the jug. If you find it difficult, if they’ve got brothers or even dad you can make a bit of a competition out of it so that makes it a little bit fun, With the girls you can use something like a witch’s hat or you can use just a small ice cream container into the toilet and then when they’re finished you just tip that into the measuring jug and measure that. But we really need to know each individual time they go to the toilet. It’s no good just giving us how much they wee’d for the whole day, we need to know each individual measurement.
It’s very important to know what your child’s bowels are doing as well and this is called the Bristol stool form scale. It is how we look at poo and it tells us a lot because it will tell us whether a child is having trouble and maybe needing to strain and might be constipated or whether everything’s going quite normal.
Now it is normal for us to have our bowels open between three times a day and three times a week. Anything within that range is within normal limits. Not everyone goes to the toilet for their bowels every day. Most do but not everyone. As long as when you go there’s no straining, there’s no pain, there’s no bleeding or any of those sorts of things and that’s your normal habit – that’s fine. But it is very good to maybe just keep a bit of charting of your child so that we can make sure that there’s no constipation involved in this issue as well. Obviously, type 4 is what we’d like.
I don’t think my child’s got a problem at all with their bowels but you know I mean for the fact that I think they only in sort of go once a week, but I’m sure it’s soft and they never have a problem so do I need to do anything? I think that it’s still worth maybe doing some charting. I would suggest that you do some bowel charting with that child because it might be their normal – but how do we know? We really need to find out that it is soft, that they’re not straining and that the bowel motions not too big because if the bowel motions quite large it tends to suggest that their bowel is quite large and distended as well. So I think that if that’s the case and they’re only going once a week and it’s a massive big poo that we need to do some charting and sort that out a little bit at the start.
So when do we start treatment? Well, I think that we should start with our children fairly young and make sure that they’re having a good fluid intake. There are good drinkers out there and there are bad drinkers and we if we start them young maybe we would encourage most of our kids to drink a little bit better than what they do. A lot of kids especially when they go to school they say oh no I drink a lot I drink out of the bubble taps at school but really that’s a mouthful or two so we really need to be encouraging our children to be having a good fluid intake for just their healthy well-being for the rest of their lives. And to get them on a good step to the future. So that’s something that we should be doing whether they’re wetting the bed or not.
And also we need to now find out whether they’re ready. It needs to be a problem for them. If it’s not a problem to them, you will have trouble getting them to drink. You will have trouble getting them to hold on. So it needs to be a problem for the child, not just a problem for the parents. If they hate wearing the pull-up is a really good indicator that they’re getting a bit ready to do something about wetting the bed and they need to obviously take responsibility. So if you get them to help change the bed. If you get them to take their pull up off and dispose of it – all of those sorts of things get them to have some responsibility. If they don’t like doing all those jobs they’ll tend to want to do something to change it, if they don’t really care you might have a little bit of trouble changing their ideas. So and also the family has to be stable because if that bed alarm is going off in the middle of the night, you know you want to make sure that everyone’s in a stable you know not moving house or renovating or going on holidays or any of those sorts of things. It needs to be a stable situation to be able to do these things. And you need to be prepared to maybe change a few things at home. You know the child that’s where you might be sharing a room with another child well it’s probably best to move that other child out, you know make it a bit of fun for them you know. Set up something in the lounge room or whatever so that we’re not disturbing all of the children and everybody in the household. And of course, it’s they can be very tured. I can get tired, they can get a little bit grumpy when all this is going on so being supportive of them and giving them the encouragement of how good a job they’re doing is is always a really good idea.
My child’s going on camp in two weeks. She hasn’t wanted to go on camp earlier because she’s still wets the bed. What can I do? That’s a very common problem we get a lot of our referrals when people start to be have camp coming up. And so they want their child to be dry before they go to camp. Obviously within two weeks, the chances of them being dry at night aren’t really good but there’s lots of things you can do. You can still start making sure they’re drinking well and start their bladder training off. But you can if they’re going away for two nights for example you can use a pull-up you can put the pull-ups into their sleeping bags and have a plastic bag in there so that they can actually put the pull-up on when they get into bed no one would know they had it on and then they can slip it off and put it into the plastic bag at the end of the sleeping bag. So there’s little tips like that that you can try so that these children can still go away and enjoy their camp. But as to being dry at night within a couple of weeks, I’m not saying it wouldn’t happen but it would be unlikely.
So what are we going to do now? Are they drinking enough is the first thing. So we might need to make sure that they are drinking enough. If their bladder volumes are still small, we need to keep working at the bladder training. So encouraging them to hold on, but remember holding on is really difficult if you sit down and think to yourself I’ve got to hold on I’ve got to hold on. You’re better off when they need to go to the toilet to try and distract them. It’s so much easier when they’re in the car and you can say or how many white cows are in the paddock or things like that count the yellow cars but trying to distract them is easier than trying to tell them you must hold on, because the more you think about it the more you need to go. And you know that yourselves.
If the bladder volumes are good the first thing you do is take the pull-up off and give them a trial without the pull-up on. But I would suggest that you get some bed protection first just in case they continue to wet. And of course, you know they could still be wet. So if they are, it’s probably best to put the pull-up back on for the time being and because you’ve been in contact with the continent service, it means that you are on our waiting list and when you’re a child comes to the top of the waiting list they’ll be contacted for an appointment. If they’re dry you’ll just let us know and we’ll take them off the list. If they’re not dry, they’ll be given an appointment and they’ll come in and have an assessment. But at least at this stage, you’ve got somewhere or something that you can do in the meantime which is really important.
Carrie, my child is six is that a great age to pop the alarm on the bed and can I put it on my four year olds bed while I’ve got it? We tend not to give alarms out for children under the age of seven but there’s always exceptions to the rule There are some six year olds that are very motivated and really really want to be dry, I’ve done all the right thing and we may give them a go in with an alarm. It would be very unusual to use it on a four-year-old because it’s not really considered to be an issue at four years of age, it’s very very common at that age. Mind you I’m sure that some parents when they have it for another child will try it on the next child as well and that’s your decision. You’ve got it at home. Probably best to let us know so that we can give you some tips but it would be very unusual on a four-year-old.
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