It's been a while since the child has left the diaper during the day, but the months go by and he needs it at night. There is no way for your son or daughter to control the pee at night, keep wetting the bed and this may already be a problem at home, for you, for them and above all you may have doubts about it.
Is it normal what happens to the child? When should I stop wetting the bed? Should I worry if my child has nocturnal enuresis? Are there effective treatments? How to deal with this situation with the child? These are just some doubts about the enuresis that we will solve next.
Nocturnal enuresis is defined as an involuntary discharge of urine that occurs after the age at which night bladder control should have been achieved (between 4 and 6 years) in the absence of congenital or acquired defects of the urinary tract.
The nocturnal enuresis is a disorder that motivates numerous consultations to the pediatrician Because it is very common in childhood. From the age of five, bedwetting affects 10% of children between the ages of five and 16.
However, there are discrepancies between the different scientific societies regarding the age of the child with enuresis, that is, from what years it is considered that the child should have achieved bladder control and also about the frequency with which night escapes occur to be considered enuresis.
Despite this, in what they do agree, although not all professionals give the same importance, is that Bedwetting should be considered a disease because it makes a dent in the good health of the child, for several reasons: for the pathophysiological anomaly that it means, the causes that produce it, the limitations that it entails, the consequences that it can have when it is prolonged in time and because there are treatments capable of curing it .
Therefore, we can think (or can tell us) that nothing happens if the child wets the bed, that it is normal, that he passes by himself, that nothing needs to be done ... and although most of the time this will be so , we cannot help being aware that something is happening. That is more or less serious, will depend on that awareness that bedwetting matters and how we act.
And I don't mean "drastic" actions but the simple step of telling the pediatrician about the problem and know how to act properly with the child so that the problem is not aggravated. So, should I or shouldn't worry if my son pees at night?
Should I worry if my son wets the bed?
According to the Spanish Society of Outpatient Pediatrics and Primary Care (SEPEAP), nocturnal enuresis can be considered as a major health problem, whose early diagnosis and treatment can help children improve their quality of life. However, it is an underdiagnosed problem, largely because parents do not consider it important.
In fact, it is estimated that only two out of five parents consider nocturnal enuresis a problem, despite the fact that official medical positions do.
Therefore, we will not say that the specialists recommend that we worry, but they do advise that a professional assess the child's condition and Do not let the problem pass to avoid "greater evils" in this situation that usually resolves itself in most cases.
This disorder usually improves spontaneously as the years go by and almost entirely at puberty, having a prevalence in late adolescence of 1 to 3%, being rare in adulthood (yes, as more enuresis lengthens , more chances of suffering from adults).
But, as pediatricians warn, although the prevalence decreases with age, the frequency and severity of enuretic episodes increase and can extend to adolescence, so we as parents we should be aware of the possible complications precisely to have acted before and not happen.
Types of bedwetting
To act correctly, it is convenient to know the different types of existing enuresis. There are several classifications in the scientific literature, although we remain with the one followed by SEPEAP, which classifies nocturnal enuresis according to the moment of appearance and the conditions to which it is associated.
According to the moment of appearance there is primary and secondary nocturnal enuresis. In the ENP there is no prior prolonged period of dryness, that is, the child has never been dry at night. The ENS appears after a period of urinary continence of at least six consecutive months, without help (when the child is already more than five or six years old). Regarding the causes, it has been determined that in the ENP the genetic and hereditary factors predominate and in the ENS the psycho-affective factors.
According to the most recent terminology and according to the presence of other accompanying symptoms, there is monosymptomatic or uncomplicated nocturnal enuresis and non-monosymptomatic or complicated nocturnal enuresis. In the ENM there is no daytime symptomatology that suggests the existence of a nephrourological pathology. Non-M EN (some authors speak of "enuretic syndrome") occurs when, in addition, the child has urinary problems during the day (urinary urgency, increase / decrease in urinary frequency, leaks with underwear always stained, urine stream weak, pain ...) that suggest nephrourological pathology, such as overactive bladder, uncoordinated urination ... Some authors also include in this section the EN associated with encopresis / constipation or upper airway obstruction.
It should be noted that the case of complicated enuresis or enuretic syndrome is usually the symptom of other important problems, with malfunction of the bladder and pelvic floor muscles (sphincter) responsible for continence.
It is very important that if after four years the child continues to pee on when he is awake, we consult the specialist.
Why do you wet the bed?
Something that worries us a lot about parents is uncertainty, doubt, misunderstanding. So, we try to clear these issues so that the problem of enuresis appears less confusing. In this case we wonder What are the causes of nocturnal enuresis?
In the EN, educational, environmental, social, family, psychological, hereditary factors may have been involved ... and research frequently arises that attempts to systematize the most frequent possible causes of the disorder in certain population groups.
The clinical protocols of the Spanish Association of Child and Adolescent Psychiatry make the following distinction:
Biological factors of enuresis
- Genetic: Against the incidence of 15% of enuretic children from non-enuretic families, the incidence increases to 44% and 77% if one or both parents were enuretic in childhood.
- Delayed maturation: 30% associated with specific speech and language delay and motor clumsiness.
- Bladder dysfunction: decreased maximum bladder capacity (maximum volume of urine evacuated in a single urination), decreased functional bladder capacity (volume of urine from which detrusor contractions begin and therefore the urge to urinate).
- Sleep disorders: No significant differences in sleep architecture could be demonstrated between healthy and enuretic children. Bedwetting can appear in all phases of sleep. Associated in children with narcolepsy and with sleep apnea syndrome.
- Sensoperceptive dysfunction: the failure could lie in the production of bladder stimulation, in the transmission of sensations or in the cortical reception of them.
- Constipation and encopresis: up to 25% of encopréticos in samples of enuretics. Persistent dilation of the rectal bleb causes bladder dysfunction responsible for bedwetting.
- Antidiuretic hormone: absence of nictameral rhythmicity of vasopressin in enuretic children. In these children the response to treatment with DDAVP is very positive.
- Urinary tract disorders: unstable bladder, dysfunctional evacuators, urinary tract infections, intense bladder trabeculation, enlarged bladder, ureteral reflux, etc.
- Enuresis induced by other psychoactive drugs: lithium, valproic acid, clozapine, theophylline.
Psychological and social factors
- Stressful situations: secondary enuresis is often associated with stressful experiences, such as divorce or parental separation, death of a parent, birth of a sibling, change of residence, school trauma, sexual abuse and hospitalization, accidents and surgical interventions.
- Social class: the higher the lower the socioeconomic level.
- Training in bladder control: unstructured or neglected families that have never encouraged bladder training.
- Emotional and behavioral disorders: psychiatric disorders are more frequent in enuretic children than in nonuretic children, although only a minority of enuretics have some emotional disorder. It has not been possible to demonstrate the existence of specific associations between enuresis and any specific disorder. Daytime bedwetting is more common in females, and is more related to the association of psychiatric disorders.
It is estimated that in 90% of enuresis cases there is a genetic and / or physiological cause in the background and only in the remaining 10% it may be due to an unusual event in the child's life or in his family structure such as the birth of a brother, separation from parents ...
It is important to remember that the control of sphincters is a maturation process, but that there are psychological issues that can affect the enuresis and ultimately it can be complicated.
If enuresis begins to affect the habits, emotional health or rest of the child, as well as the general family functioning, it is better to see a specialist.Bedwetting Treatment
The pediatrician, once informed of the child's enuresis, for the diagnosis and treatment will elaborate a careful medical history (history, type of enuresis, frequency, accompanying symptoms ...), will explore the evolutionary and affective aspects of the child. After physical examination and general neurological examination, pathology can be ruled out before refer the specialist.
Parents will be offered general principles of therapeutic intervention (we specify them in the following section) and also the protocols speak of a behavior modification therapy:
- Pipi-stop mechanisms (60-80% answers), which consists of alarms in a kind of belt that detects moisture and warns the child when he is starting to urinate, so that he wakes up and has just done in the toilet. This mechanism is effective as long as it does not negatively affect the child's sleep (that he cannot go back to sleep, he becomes frightened ...).
- Training in voluntary retention during the day.
- Training in cleaning the wet bed (changing sheets when urinating), waking the child at night, positive practice.
About the pharmacological treatments was enuresis, always prescribed by the specialist, are imipramine and DDAVP (desmopressin, which acts as the hormone ADH, the hormone that regulates the amount of urine that is filtered) at the indicated doses. Desmopressin slightly increases blood pressure and some children have nausea and headache, therefore, according to the American Academy of Pediatrics, it should be the last resort.
How to act with the child who wets the bed
As much or more important for the well-being of the child and the family in these cases, which always alter the functioning of the home, is to know how to act with our son or daughter in case you keep peeing on at night.
Among the general measures that specialists advise for bedwetting, the demystification of the problem, avoiding punishment, restricting fluid intake before going to sleep and going to the bathroom before bedtime.Parents should know that it is a benign disorder and that it is usually self-limiting. Fluid intake should be reduced before going to bed (at least one hour before). The child has to pee just before going to bed. You can also lift the child at night to urinate and get used to feeling the full bladder feeling at night.
It is also important the emotional side, for this we must ensure the child, explain that wetting the bed is normal and usual, and avoid feeling guilty to prevent emotional side effects. You never have to punish the child or get angry with him: you don't pee on purposefully.
In addition, it is appropriate to establish an observation period of at least two weeks of self-records (here we find examples of "voiding calendars") and positive reinforcements before starting a more specific treatment, given the high rates of spontaneous healing.
The issue of punishment is fundamental. The child should not feel guilty or ashamed. If the child is not yet five or six years of age after which it is considered bedwetting and also pees every night, it may not be necessary to remove the diaper. If this is done, this feeling of normality must be reinforced.
Start treatment or wait?
We have already seen that nocturnal enuresis may be a matter of maturation, that it does not secrete enough antidiuretic hormone, that nocturnal enuresis may be due to a physical problem ... Well, this is what the pediatrician should investigate and determine.
The specialist can request an ultrasound showing the shape of the organs and decide whether to refer to the urologist or if everything appears normal and is due to another reason. If it is not a physical issue, you can choose to try to do something about it or wait.
Many pediatricians are favorable to start treatment after five years. This is because, although the spontaneous annual remission is high, the fact that they can reach adults over 20 years of age wetting the bed up to 3% means that "the natural solution" is slow and insecure. Will my son stop peeing at seven, at eight, at twelve?
There are some "definitive" clues "but that can indicate that the end of wetting the bed is closer. These are, according to Mojarlacama:
- Wet the bed less than five times a month.
- Only in circumstances, special and specific, such as parties, birthdays, drinking long before bedtime ...
- If when wet the bed is only once in the night
- If bedwetting occurs very close by the time you wake up
But in general there is no way to calculate the duration of bedwetting in each child.
In defintiva, very calm before bedwetting and consult the pediatrician if the child is more than five years old, as well as the maximum understanding with the child, which is probably the worst happens when he wet the bed.
Photos | iStock
More information | AEPED, SEPEAP
In Babies and more | What if after five years there is no way to remove the diaper at night? The nocturnal enuresis, What is the nocturnal enuresis, Children with nocturnal enuresis can suffer it in the adult life, Some data on the nocturnal enuresis
