Bedwetting

​Nocturnal enuresis, commonly known as bedwetting, is wetting that occurs during sleep in a child beyond the age of five years.

Bedwetting is a common and troublesome problem in children. Traditionally it is seen as part of growing up, but when bedwetting persists beyond early childhood, it becomes unacceptable and can often be stressful and distressing to the affected children and their families.

Most children seeking treatment for bedwetting in Singapore are :

• Five years or older, most frequently between seven and twelve years of age.
• Suffering from a bedwetting frequency of at least two times a week, with a majority being almost every night.

Is bedwetting a problem that needs therapy?

Yes, especially when the child is of school-going age and the wetting is frequent. Studies have shown that constant bedwetting can adversely affect the psychosocial development of the child causing low self-esteem and poor social adjustment. It can also cause much resentment in parents and other family members towards the bedwetting child, and is a constant source of embarrassment that deters the sufferer from healthy outdoor activities like overnight camping and travelling.

The exact cause of bedwetting is not known, but some known contributing factors are :

• Heredity – Bedwetting often runs in a family. There were few gene mutations detected and reported to cause bedwetting within the same family.
  
• Deep sleep – Inability to wake up in the night to pass urine, as some children are very “deep sleepers”.
• Delayed development – Some children are developmentally slower to attain dryness at night but eventually will outgrow the problem.
• Problem of hormone regulation – Children who wet the bed may have a lower level of a hormone called the antidiuretic hormone, which suppresses urine production during sleep. This means that they may produce more than the normal amount of urine during sleep and that predisposes them to bedwetting.

Majority of children with bedwetting can improve significantly and even overcome it. There are two main treatments for bedwetting:

1. Medication (prescribed by a doctor)
2. Bedwetting alarm (prescribed by occupational therapists upon a doctor’s referral)

1. Medication (Desmopressin)

Bedwetting children typically produce large amounts of urine during sleep. To reduce this excessive urine production, the doctor may prescribe a medication called Desmopressin whose action is similar to antidiuretic hormone (ADH) that can reduce the production of urine. Up to 70 percent of children with bedwetting show a good response to this medication.

It is necessary to try out this medication over two weeks to assess the child’s response first as only about 70 percent of children will respond to the medication. If the response is satisfactory, then treatment is continued for at least three months, after which the treatment will need to be reviewed. Some children may need treatment for a longer period of time.

This medication is generally considered safe. However, as it reduces water excretion from the body, it can potentially cause water retention if the child drinks excessively after taking the medication. The excessive water in the body can cause fits which is a major unwanted side-effect.

Fortunately, bedwetting children are “deep sleepers” and do not wake up to drink water and the effect of the medication usually lasts for eight to nine hours or overnight. By the time the child gets up in the morning, the effect of the medication would have worn off and the child can then resume normal drinking. This side effect has, therefore, very rarely occurred in the treatment of bedwetting.

Precautions such as not drinking water one to two hours before bedtime and not drinking till the child wakes up in the morning are important with the use of this medication. It is also important to remember to discontinue the medication if more water intake is necessary e.g. if the child is febrile or having diarrhoea and vomiting. There may be an occasional occurrence of other minor side effects, which include headaches, loss of appetite and abdominal cramps.

2. Bedwetting alarm

This is a form of conditional therapy. As bedwetting children are “deep sleepers” and do not wake up when the bladder is full, enuresis alarm training is targeted at this problem by training the child to wake up when the bladder is full.

The alarm comprises a moisture sensor that connected to the alarm unit. When the chid starts to pee when asleep, the sensor worn by the child sends a signal to trigger the alarm to sound, awakening the child to wake up to complete voiding in the toilet. Several nights of being awakened in this manner results in the development of a conditioned response, enabling the child to hold and wake up to go to toilet to pee when the bladder is full.

How does the occupational therapist help?

Upon referral from a doctor, the occupational therapist (OT) assesses a child’s suitability for therapy. The OT then teaches the child and family how to use the alarm and set up a therapy program at home. As compliance and motivation are essential for success, the OT will follow-up with the child until he/she has attained dryness. During these follow-up sessions, the OT will work with the child and family to review progress and solve any issues or problems.

Consistent follow-up is critical in attaining dryness. Children who do not have follow-up may lose motivation resulting in lower compliance and treatment failure.