What Can Parents Do About Bedwetting?

Millions of kids wet the bed, and though it's quite common, bedwetting can be a source of embarrassment and frustration for families. By age 5, most children (80%) experience dry nights most of the time and by age 10, almost all children (95%) no longer wet their beds. Many health professionals consider bedwetting to be a concern when the child is age five or older and is wetting frequently (at least twice a week over a three-month period), or if the bedwetting is upsetting to the child. According to this definition, a five-year-old child who wets her bed once a week and is upset by the wetting meets the health professions' standards for concern, just as does a five-year-old who wets twice a week. However, with the knowledge that one-fifth (20%) of all five-year-olds wet their beds, some professionals may not consider this to be a concern until age six or older. Children with developmental delays, intellectual disabilties, or autism spectrum disorder may require more time for toilet training.

Bedwetting is generally divided into two types: primary and secondary. Primary bedwetting refers to children who have never had an extended period of dry nights, whereas secondary type bedwetting refers to children who were dry for a period of time and then started wetting. Although there has been research that has examined differences between primary and secondary bedwetting, this handout will address general concerns that apply to both types.

The causes of bedwetting are not well understood. Bedwetting may be related to hormone secretions during the night, a failure to control pelvic muscles during sleep, sleeping very deeply, or unspecified developmental factors. Research has shown that family history may also be a factor, particularly when both parents experienced bedwetting in their childhood. Although the cause of bedwetting has not been clearly established, many studies have proven that treatment can be effective.

Key Strategies

Provide support, not punishment. Parents often wonder how they should respond when their children wet the bed. Negative reactions such as punishment or shame can be harmful to a child and are not likely to result in positive change. Many children do not perceive their bedwetting as a problem and only begin to experience distress when their parents react negatively, or when peers may gain knowledge that the child wets the bed, from the child’s participation in sleepovers or camps. When a child wets his/her bed, the parent should be supportive and patient. Parents should encourage children to replace the sheets and change into dry pajamas. Parents should provide as much assistance with the sheet/clothes changing as needed, and should encourage the child to begin to assume responsibility for changing.

Seek help from a physician. If the bedwetting is frequent or distressing, parents may wish to consider speaking to the child’s physician about treatment options. In developing a treatment plan, parents, in consultation with the child's pediatrician, should rule out any medical problems, such as a urinary tract infection (through a urinalysis) or juvenile onset diabetes, which might be related to the bedwetting. Parents should be prepared to provide the doctor with information regarding the child's bedwetting history, daytime toileting history/concerns, other medical conditions, medications, diet, etc.

Other strategies: If physical or medical factors are not considered to be contributing to the wetting, other treatment options may be considered. Some of these strategies, such as moisture alarm systems or behavior training, require significant amounts of parent time and energy. Providing support will pay off, however, when parents can be as loving and supportive as possible. Children are most likely to experience dry nights when they have the positive encouragement of their parents. Strategies including the following may be considered:

No action
Moisture alarms
Behavior changes/training
Drug treatments

No action, or waiting for the child to outgrow the problem, may be appropriate for some families and may be the first treatment option considered. If there is little to no distress about the wetting, or if the child is young, families may decide to take no action because the child may eventually stop wetting without treatment. Approximately 15% of children who wet their beds stop wetting within one year's time without treatment.

Dry bed training involves the use of behavior modification strategies that often involve the use of a moisture alarm. Moisture alarms are commonly used in the treatment of bedwetting. The early moisture alarms consisted of a large pad that was placed on the mattress. When the pad became wet from urine, an alarm would sound. These "bell and pad" devices have been replaced by smaller alarm systems that attach to the child's pajamas. When the child urinates in bed, an alarm sounds. Some of the newer models also contain flashing lights and vibration for the very deep sleeper.

When the alarm sounds, the child is encouraged to get out of bed, use the toilet, and change clothes/sheets as necessary. For many children, parental assistance will be needed during the time that the alarm system is used. It is perfectly natural for parents, awakened in the middle of the night, to feel frustration and stress. However, gradually, the child will begin to gain bladder control through the night. Treatment with an alarm system has a relatively high success rate, with approximately 75%-85% of children, in some studies, no longer wetting. Alarm systems require at least 2-4 weeks of nightly use before results are seen. The relapse rate for children treated with alarms is approximately 20-30%.

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Dry bed behavior training strategies do not require the use of an alarm, but can be used in conjunction with an alarm. Parents using a behavior training approach work with their children to:

· rehearse proper toileting

· reinforce dry nights with rewards

· wake their child at night and direct them to the toilet

· provide increasingly larger quantities of water in the evening

These behavior strategies require a tremendous amount of energy from parents and are, therefore, not usually the treatment of choice. However, combining one or more of the behavioral strategies with the use of an alarm system tends to increase the success rate, with parents using an alarm system and reinforcing dry nights.

Medication is sometimes prescribed to treat bedwetting. The success rates for drug treatments (10%-60%) are lower than those for alarms, and children taking medications tend to have a high relapse rate once the medication is discontinued, with one study reporting that up to 95% of children who took medication for bedwetting relapsed when they no longer took the medication. Parents should also be aware that medications can have potentially serious side effects. Therefore, parents should gather as much information as possible from their pediatrician regarding the range of treatments, possible side effects, and potential for success. Medications commonly used to treat bedwetting include imipramine, desmopressin acetate (DDAVP), and oxybutynin (ditropan).