Which treatment is indicated for a 7 year old child who has nocturnal enuresis?

Begin by encouraging your child to drink one or two extra glasses of water in the morning or at lunchtime. Then in the evening, your child should only drink to quench thirst. Try to prevent drinking two hours before bed. Also, limit or stop your child from drinking caffeinated and carbonated drinks like soda.

Creating a schedule for bathroom use (changing toilet habits)

Bladder training is a way to set a bathroom schedule with your child. For example, have your child sit on the toilet five to six times each day and twice before bed, even if they say they don’t have to go.

Constipation management

Work with your doctor to determine if your child struggles with constipation. This is often seen by infrequent, hard to pass bowel movements, but can also be seen as small, frequent bowel movements, incomplete emptying of bowel movements or stool accidents. Your child may need increased fluid intake during the day, increased fiber and assistance with a medical bowel regimen. This can take some time to regulate but is of great value in helping with bedwetting.

Bedwetting (enuresis) alarms

Bedwetting alarms have a special sensor that detects moisture in a child's undergarments. It triggers a bell or buzzer to go off with wetness. The child wakes with the alarm and tries to get up to go to the bathroom before having an accident. An adult will need to help, since most children who wet the bed do not wake up by themselves at first. The alarm works by "conditioning" a child to wake when it is time to pass urine. This is a behavioral-type therapy known to be very successful.

Bedwetting alarms work with a sensor in the child's pajamas or underwear that links to an electronic alarm. The alarm is either attached to the child's clothing near the shoulder or clipped to the waist. The alarm unit may also be wireless and placed on the counter. When the sensor becomes moist, the alarm is triggered. Some alarms also have a vibration mode that shakes the device. The alarm wakes the child so they can get to the bathroom to pass urine or finish passing urine.

Success for alarm therapy depends on parents understanding that this is a learning process. There are stages a child and parents must go through for best results. Without patience, parent and child frustration will lead to quitting. Please try not to give up.

In the first and second stage of therapy, parents must wake up with the alarm and then wake the child from bed. The child then gets up, goes to the toilet and tries to pass urine for a couple of minutes. They should then clean themselves in the shower, change their bed sheet or put on a new Pull-up. The parent should be supportive and help. Then the child will turn the alarm back on, and go back to bed. You will start to see the child wake up on their own more and more over time.

In the third stage of therapy, the child should be able to wake on their own when their bladder feels full. Once the child successfully reaches this stage, parents should ask the child to use the device for two to three more weeks to reinforce this behavior. Everyone at this stage should feel proud and relieved.

Tips for success:

• Choose three to four months when a simple home routine can be made for treatment.
• Agree with the child on a date when therapy will begin.
• Perform a few drills with the alarm during the day so the child knows what to expect and what to do. 
• Keep a calendar in the child's room to monitor progress.
• Do not punish your child for accidents. Punishment is counterproductive. Instead, offer rewards for cooperating with therapy and completing tasks.

Advantages:

• Not a prescription medication, so there are no side effects.
• Low rate of recurrence after device is stopped upon successful treatment.
• If used the right way, the chances of success are about 75% with consistent use for at least one to two months.

Disadvantages:

• Alarms require hard work and commitment from parents
• May not be appropriate for children with sensory processing issues or other sleep disturbances. Talk about it with your child's pediatrician.
• They are not good for sleepovers.
• They disturb siblings who share a bedroom.
• Many health plans do not pay for these devices.

Prescription Drugs

Desmopressin acetate (DDAVP)

Desmopressin is a synthetic form of the hormone "ADH or vasopressin."

In normal conditions, ADH is produced by the brain and causes the kidneys to conserve water. For example, athletes secrete more ADH when they are active and sweating. Most people have naturally higher levels of ADH during sleep. That is part of the reason why we can sleep through the night without needing to pass urine. In many children with enuresis, this hormone surge is absent.

DDAVP is available as a pill. It can be given an hour before going to bed for a period of three to six months, with a one week break. Because it works to decrease the volume of urine made, it is used with a schedule of drinking less fluid in the evening and stopping fluid intake two hours before bed.

There is a DDAVP nasal spray but the pill form is preferred.

Advantages:

• When it works, it works very well.
• Can boost confidence on sleepovers.
• Can be used privately.
• The cost is usually covered by most health plans.

Disadvantages:

• This does not cure bedwetting but if it works, it can help decrease wetting while the child develops and matures. 
• This drug works best in children with normal capacity bladders and older children.
• The child's body can adapt with time and stop responding to the drug.

Oxybutynin and Tolterodine

These prescription drugs stop the bladder from having spasms with overactive bladder symptoms. It is helpful when a child has small bladder capacity, often seen in children with daytime urinary frequency, urgency and daytime wetting.

Advantages:

• The drug is safe and well tolerated by children.
• The drug can be combined with desmopressin to increase bladder capacity, while decreasing the amount of urine made, which can be more successful in some children.

Disadvantages:

• The drug doesn't work for everyone.
• Common side effects include dry mouth, constipation and facial flush. If constipation becomes a problem, be aware that this can make bedwetting worse.

Imipramine

Imipramine is an anti-depressant medication that has been used for many years to treat children with bedwetting but is not commonly prescribed. It does not mean that depression is a cause for bedwetting. It is not clear how imipramine helps in this case, but it is believed to improve the child's sleep patterns and bladder capacity.

Due to the severity of some side effects, this is not commonly used or recommended. Side effects can include irritability, insomnia, drowsiness, reduced appetite and personality changes. Other side effects include severe cardiac (heart) issues. Overdose can be deadly. Heart tests should be performed by your doctor prior to prescribing. This drug must be used and stored safely.

Treatments That Are Not Recommended

Stopping all food and fluids before bedtime

Many parents think that if their child stops eating and drinking many hours before bed, it will help reduce or get rid of bedwetting. But this rarely helps. It is a good idea to stop drinks two hours before bed and to always limit caffeinated and carbonated sodas. If a child is hungry or thirsty, it is okay to provide small amounts of food and water. (Note: Limiting drinks is needed for treatment with DDAVP.)

Scheduled night waking

Before seeking medical care, many parents try waking a child during the night to take them to the bathroom. Some families try this more than once during the night. While it can be helpful in the short term, it is hard to continue over time. It is hard on family members and does not always work.

Pelvic floor muscle exercises

Adults with bladder control problems may find help with pelvic muscle exercises, like the Kegel. During these exercises, adults are asked to hold a full bladder and try to stop their urine stream. This effort has not been proven to help children with bedwetting.

Alternative therapies

Homeopathy, herbal cures and chiropractic practices have not been found to help with children's bedwetting.

It is common for children aged 6 and under to wet the bed, but older children can wet the bed too. If your child is over 6 and wetting the bed, there are things you can do about it.

What is bedwetting?

Bedwetting happens when a child doesn’t wake up during the night when they need to empty their bladder (urinate or wee). It can happen every night, or now and again. Bedwetting is also known as nocturnal enuresis.

Some children continue bedwetting from birth, while others start bedwetting again when they are older.

It can be very upsetting for a child, and distressing and frustrating for you. But it isn’t their fault. Bedwetting has nothing to do with bad behaviour.

What causes bedwetting in older children?

Some children sleep very deeply and don’t wake up when they need to urinate.

They might have a bladder that only stores a small amount of urine. Or they might produce a lot of urine at night.

Some children don’t make enough of a hormone called antidiuretic hormone (ADH). This makes the urine less watery overnight. If children don’t make enough of this hormone, their bladder can struggle to store the extra liquid.

Bedwetting can also be related to constipation in children.

Bedwetting tends to run in families. If one or both parents wet the bed when they were young, then it is more likely to happen with their children.

Emotional problems, caused by a stressful event, can sometimes cause an older child to wet the bed. Physical problems are uncommon.

When should my child see the doctor?

It’s a good idea to seek professional help if your child continues bedwetting after about 6 or 7 years of age. If your child starts wetting the bed again after a period of being dry, you should take them to your doctor for a check-up.

Also see your doctor if you are worried, or your child is very upset about bed wetting.

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How is bedwetting in older children diagnosed?

Your doctor will ask about your child’s bedwetting, including how often it happens.

They may also ask about your child’s:

• sleeping patterns
• bladder and bowel (toileting) habits
• whether they have any problems with wetting during the daytime

Your doctor might examine your child. In some circumstances they might recommend a urine or other tests, but further testing is often not needed.

The doctor might refer your child to a health professional with specialist training in children’s bedwetting.

How can bedwetting in older children be treated?

It’s important to encourage your child to not feel embarrassed or ashamed about bedwetting. Bedwetting generally doesn’t need to be treated before the age of 6 years. That’s because it usually gets better on its own.

There are several treatments available for bedwetting in older children, including self-help measures and bedwetting alarms.

Self-help measures

Here are some tips to help your child stay dry.

• Remind your child to go to the toilet before going to bed.
• Put a nightlight in the toilet and encourage your child to get up to urinate (wee) during the night if they need to.
• Encourage your child to drink plenty of water during the day.
• Avoid any food or drinks that contain caffeine (for example, chocolate or cola drinks) before bedtime.
• Protect the mattress from urine with a waterproof pad or cover, if not using nappies or pullups.
• Note that waking your child and walking or carrying them to the toilet does not help them become dry long term.

Remember to be patient, encourage your child, and involve them in treatment.

Bedwetting alarms

Alarm therapy is the most effective treatment available for bedwetting in children older than 6 years. Both you and your child need to be motivated for a bedwetting alarm to work.

Bedwetting alarms work by teaching your child to wake up and go to the toilet when their bladder needs to be emptied. The alarms are designed to be loud enough to wake your child from sleep at the first sign of any moisture. Vibrating alarms are also available.

It takes 6 to 8 weeks for bedwetting alarms to work. Using a reward chart for waking and using the toilet (even when your child is not completely dry) can be helpful. Keeping a diary to chart your child’s progress is also usually recommended.

Your doctor can advise you whether your child could benefit from alarm therapy and how to use it.

Are there medicines available to help treat bedwetting?

In most cases medicine is not needed for bedwetting, but it can be useful in some situations where a night alarm has been tried and not worked.

Your child’s doctor may prescribe a medicine called desmopressin, which reduces the amount of urine made at night. Short-term use of this medicine may sometimes be tried for special occasions, such as sleepovers or school camps. This medicine is only available on prescription and is not suitable for all children.

Tips for encouraging your child

A child's self-esteem can be damaged by punishing or embarrassing them. It also hurts when siblings or friends make fun of them. To encourage your child:

• be understanding and do not punish your child for wetting the bed
• do not get angry — it does not help and may make your child more anxious
• do not shame your child — it does not help your child gain bladder control
• be patient and supportive, and remember that bedwetting is not your child's fault

Resources and support

Talk to a continence nurse adviser by calling the National Continence Helpline (1800 33 00 66).

The Sleep Health Foundation has more advice on bedwetting in children.

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