Nocturnal Enuresis in Children: Causes and Solutions

The issue of nocturnal enuresis in children?

My daughter will turn six this September.
It might be because I was always sleepy during my pregnancy and felt like I could never get enough rest, so my daughter has been sleeping longer than her peers since birth.
Now, she averages ten to twelve hours of sleep at night to avoid waking up grumpy.
Last summer, I trained her to get up at night to use the bathroom for about four months, but there was no progress.
This summer, I started training her again for a month, but she lacked energy in class, had difficulty concentrating, and her learning outcomes were poor.
She often seemed dazed and unaware of her surroundings.
Since I call her to get up 3-4 times each night, she ends up sitting on the toilet for a long time and falls asleep, only managing to urinate a little.
Shortly after returning to bed, she wets herself and has no recollection of me calling her to use the bathroom the next day.
There was even an incident where she was so hard to wake up that after trying to shake and pinch her with no response, we took her to the emergency room.
After a day of IV fluids and tests at the hospital, everything turned out fine, leaving me unsure of how to view this situation.
Some people have suggested that I should stop training her and let her wear diapers to sleep, claiming that if she sleeps well, her learning will improve, and that it would be better to train her when she is a bit older and no longer wants to wear diapers.
Is this a good approach? Are there any methods or medications that could improve this situation? I have tried traditional Chinese medicine, but it didn't seem effective and had an unpleasant taste, so I stopped taking it.

Mei, 30~39 year old female. Ask Date: 2006/05/29

Dr. Pei Rensheng reply Pediatrics

Hello, regarding your daughter's situation, I recommend the following examinations: a urinalysis and culture to rule out diabetes insipidus, urinary tract infections, and other abnormalities; a renal ultrasound to exclude structural abnormalities; and if she is difficult to wake from deep sleep, an EEG or brain imaging study can be arranged.
These evaluations can be conducted by a pediatric nephrologist or pediatric neurologist.
Generally, bedwetting is considered a concern if girls are over four years old or boys are over five years old and still wet the bed.
Doctors may consider treatment for bedwetting issues in such cases.
The incidence of enuresis tends to decrease with age, with only about 10% of six-year-olds and 3% of fourteen-year-olds experiencing bedwetting.
Very few individuals continue to have this issue into adulthood.
Enuresis is classified into two types: primary and secondary.
Primary enuresis occurs almost every night, with only occasional dry nights.
If this persists when the child starts school, appropriate treatment is necessary.
Secondary enuresis occurs after a long period of being dry, with occasional bedwetting episodes, often due to life stressors such as the birth of a sibling, starting school, or family issues.
If the problem continues for a while, a medical consultation is warranted to rule out physiological issues.
The causes of chronic bedwetting (Chronic Enuresis) primarily include:
1.
Physiological or neurological issues: immature bladder development.
2.
Deep sleep: the child sleeps so soundly that the brain does not register the bladder's fullness.
3.
Some hypotheses suggest a genetic predisposition, as children with enuresis often have family members with similar issues.
4.
Children with attention deficit, learning difficulties, or allergies seem to have a higher incidence of bedwetting.
The impact of enuresis on children and families includes:
1.
Withdrawal from social activities, avoiding overnight events.
2.
Low self-esteem in the child.
3.
Parental frustration, embarrassment, or even anger regarding the child's bedwetting.
Treatment for enuresis: Most children outgrow bedwetting as they mature, with increased muscle strength in the bladder and becoming less deep sleepers, making them more sensitive to bladder signals.
There are two main treatment approaches: pharmacological and behavioral.
Generally, behavioral treatments are more effective and safer than medications, although they require more time to show results.
Common medications include Imipramine (Tofranil) and Desmopressin acetate.
1.
Imipramine (Tofranil): A tricyclic antidepressant that can improve sleep patterns and bladder smooth muscle function.
About 30% of children show symptom improvement, but bedwetting often recurs after discontinuation.
This medication has significant side effects and should be used under medical supervision.
2.
Desmopressin acetate: A synthetic hormone that reduces urine production, administered intranasally.
This medication helps the body produce less urine during sleep, reducing the likelihood of bedwetting.
Its effects are rapid, but like Tofranil, bedwetting may recur once treatment stops.
However, Desmopressin acetate is generally safer than Tofranil, though it still has some side effects.
Behavioral treatment methods include:
1.
Retention Control Training: Involves training the child to hold urine during the day, starting with a few minutes and gradually increasing the duration to strengthen bladder muscles.
A medical diagnosis should precede this training, and it should be monitored by a physician.
2.
Night-lifting: Involves waking the child after a period of sleep and accompanying them to the bathroom to urinate before returning to bed.
This method trains the child to wake up independently to use the bathroom.
Parental attitudes are crucial for the child; negative attitudes can lead to feelings of failure.
Parents can help reduce negative feelings and provide positive support and understanding, encouraging the child to overcome bedwetting issues.
For bedwetting evaluations, consider ruling out constipation, conducting urinalysis and culture, and renal ultrasound, which can be done by a pediatrician.
Sincerely, Dr.
Pei Ren-Sheng, Pediatrician.

Reply Date: 2006/05/29

More Info

Nocturnal enuresis, commonly known as bedwetting, is a prevalent issue among children, particularly those around the age of six. It can be a source of distress for both the child and the parents. Understanding the causes and potential solutions for this condition is crucial for effective management.

Causes of Nocturnal Enuresis
1. Developmental Factors: Many children experience bedwetting as part of their normal development. The bladder control mechanism may not fully mature until later in childhood. Children who sleep deeply may not wake up when their bladder is full, leading to involuntary urination.

2. Genetic Predisposition: There is a significant genetic component to bedwetting. If one or both parents experienced bedwetting as children, their offspring are more likely to experience it as well.

3. Psychological Factors: Stressful life events, such as changes in family dynamics, moving to a new home, or starting school, can trigger or exacerbate bedwetting. Emotional factors can play a significant role in a child's ability to control their bladder at night.

4. Medical Conditions: Although less common, underlying medical issues such as urinary tract infections, diabetes, or anatomical abnormalities can contribute to bedwetting. It is essential to rule out these conditions, especially if the bedwetting is a new occurrence or accompanied by other symptoms.

5. Sleep Disorders: Some children may have sleep disorders that prevent them from waking up when their bladder is full. This can include conditions like sleep apnea, which can lead to excessive daytime sleepiness and difficulty concentrating.

Solutions and Management Strategies
1. Behavioral Interventions: Establishing a consistent bedtime routine can help. Encourage your child to use the bathroom right before bed. Limiting fluid intake in the evening can also be beneficial, but ensure your child stays hydrated throughout the day.

2. Bedwetting Alarms: These devices can be effective for some children. They work by detecting moisture and waking the child, helping them learn to associate a full bladder with waking up.

3. Positive Reinforcement: Encourage and reward your child for dry nights. Avoid punishment or negative reinforcement, as this can lead to feelings of shame or anxiety, which may worsen the situation.

4. Medical Consultation: If behavioral strategies do not yield results, consulting a pediatrician or a specialist in pediatric urology may be necessary. They can assess for any underlying medical issues and discuss potential medications that can help manage bedwetting.

5. Patience and Understanding: It is essential to approach the situation with empathy. Bedwetting is often out of the child's control, and they may feel embarrassed or ashamed. Providing a supportive environment can help alleviate anxiety and encourage progress.

Conclusion
In your case, it seems that your daughter may be experiencing a combination of developmental factors and possibly some stress related to the training process. It is crucial to balance the need for bladder training with her overall well-being, including her sleep quality and daytime alertness. The suggestion to allow her to wear diapers at night while she matures may be a reasonable approach, as it can reduce pressure and anxiety surrounding the issue.
Ultimately, every child is different, and what works for one may not work for another. Continuous communication with your child about her feelings and experiences, along with a supportive approach, will be vital in navigating this challenging situation. If the problem persists or worsens, seeking professional guidance will be the best course of action.

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