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Parenting With Grainne Ryan

Tuesday, 10 February 2009

Grainne Ryan:
Presenter of Baby on Board Series 2. Grainne is a public health nurse and midwife and mother of three children. Areas of interest child development, parenting issues, adolescent development and post natal depression and works as a public health nurse in Ennis Co. Clare.

Bed-wetting, also known as night time incontinence or nocturnal enuresis, isn't a sign of toilet training gone wrong. It's often just a developmental stage. Children who've never been dry at night are considered to have primary enuresis. Children who begin to wet the bed after at least six months of dry nights are considered to have secondary enuresis.

Generally, bed-wetting before age 6 or 7 isn't cause for concern. At this age, nighttime bladder control simply may not be established.

If bed-wetting continues, treat the problem with patience and understanding. Bladder training, moisture alarms or medication may help.

Bed-wetting is characterized by involuntary urination at night.
Most kids are fully toilet trained between ages 2 and 4 - but there's no target date for developing complete bladder control. During the preschool years, about 40 percent of children wet the bed. It is more common in boys than girls. It affects 15% of 5 year olds, 7% of 7 year olds, 3% of 12 year olds and 1% of 15 year olds. There tends to be a family history present. If one parent suffers from bedwetting the risk of the child being affected is 40%, if both parents suffer then the risk is 75%.

No one knows for sure what causes bed-wetting, but various factors may play a role.
-A small bladder. Your child's bladder may not be developed enough to hold urine produced during the night.
- Inability to recognize a full bladder. If the nerves that control the bladder are slow to mature, a full bladder may not rouse your child from sleep - especially if your child is a deep sleeper.
-A hormone imbalance. During childhood, some kids don't produce enough anti-diuretic hormone, or ADH, to slow nighttime urine production.
-Stress. Stressful events - such as becoming a big brother or sister, starting a new school or sleeping away from home - may trigger bed-wetting.
-Urinary tract infection. A urinary tract infection can make it difficult for your child to control urination. Signs and symptoms may include bed-wetting, daytime accidents, frequent urination and pain during urination. (Your G.P. will be able to confirm this).
-Diabetes. For a child who's usually dry at night, bed-wetting may be the first sign of type 1 diabetes. Other signs and symptoms may include passing large amounts of urine at once, increased thirst, and fatigue and weight loss in spite of a good appetite. (Discuss with your G.P.).
-Chronic constipation. Sometimes children who don't have regular bowel movements retain urine as well. This can lead to bed-wetting at night.
-Anatomical defect. Rarely, bed-wetting is related to a defect in the child's neurological system or urinary system.

Coping and Support-Tips for Parents

Children don't wet the bed to irritate their parents. Because your child's bed-wetting is involuntary, it's illogical to punish wet nights or reward dry nights. Try to be patient as you and your child work through the problem together.
-Adopt good habits. Limit your child's fluid intake during the evening. Make sure your child urinates before going to bed -Remind your child that it's OK to use the toilet during the night if needed. Use small nightlights so that your child can easily find the way between the bedroom and bathroom.
-Be sensitive to your child's feelings. If your child is stressed or anxious, encourage him or her to express those feelings. When your child feels calm and secure, bed-wetting may become a thing of the past.
-Put your child to bed earlier. Perhaps surprisingly, an extra 30 minutes of sleep a night helps some children stop wetting the bed.
-Plan for easy cleanup. Cover your child's mattress with a plastic cover. Use thick, absorbent underwear at night to help contain the urine. Keep extra bedding and pajamas handy. Try not to become dependent on disposable night pants as your child may never get the sensation of wet due to absorbency. I like to keep them for sleep overs !.
-Celebrate effort. Don't punish or tease your child for wetting the bed. Instead, praise your child for following the bedtime routine and helping clean up after accidents.

With reassurance, support and understanding from your family, PHN/GP, you and your child can look forward to the dry nights ahead.

When to seek help

Most children outgrow bed-wetting on their own - but some need a little help. In other cases, bed-wetting may indicate an underlying condition that needs medical attention.

Consult your child's Doctor if:

-Your child still wets the bed after age of 7
-Your child starts to wet the bed after a period of being dry at night
-The bed-wetting is accompanied by painful urination, unusual thirst, pink urine.

When no physiological cause for bed wetting is found your G.P. or Public Health Nurse (PHN) will then carry out a comprehensive assessment in an effort what is the cause of the bed wetting.
Bed wetting may be described as a problem in one or more of the following three systems(prescribed by GP).

1. Lack of arousal from sleep
Most children who don't wet the bed sleep through the night, however if a child has low vasopressin or bladder instability, staying dry at night requires the child to wake to a full bladder. The ability to wake is not determined by the depth of sleep but how easily your child can wake from sleep.

Ability to awaken from sleep can be assessed. If your child is able to do the following, it suggests they have potential to wake from sleep:
. Occasionally wake to void.
. Wake but fail to void
. Wake to external sounds
. Wake to internal signals
Under these circumstances your child's waking ability can be improved by the use of an enuresis alarm.

2. Active Bladder
This is where the bladder wall muscles contract before the bladder is full and, when the child is asleep bedwetting occurs.
Signs of an active bladder

. Frequent day time voiding
. A Sense of urgency
. Voiding small amounts
. Small or variable wet patches
. Waking up after wetting


Treatment is designed to reduce the increased activity of the bladder and to increase the volume contained by the bladder. It involves increasing day-time drinking, regular voiding and sometimes the use of medications prescribed by your G.P.

3.Hormone imbalance
. Vasopressin is a hormone which is naturally released during sleep
. It acts to reduce the volume of urine produced at night
. Many children with bedwetting fail to produce sufficient vasopressin therefore the bladder quickly becomes full and if the child fails to wake they wet.

Signs of hormone imbalance
. Wetting soon after sleep
. Consistently large wet patches
. Weak urine concentration on a morning

It involves increasing day-time drinking, regular voiding and the use medication

Although frustrating, bed-wetting without a physical cause doesn't pose any health risks, however the guilt and embarrassment a child feels about wetting the bed can lead to low self-esteem. Interrupted nights sleep, attending to your child's wet bed not to mention the extra amount of laundry it generates can leave the most calm of us parents tearing our hair out. Rashes on the bottom and genital area may be an issue as well - especially if your child sleeps in wet underwear. To prevent a rash, help your child rinse his or her bottom and genital area every morning. It also may help to cover the affected area with a barrier cream.

Treatment and drugs
Most children outgrow bed-wetting on their own. If there's a family history of bed-wetting, the child likely will stop at the age the parent did.

Limiting fluids before bedtime and double voiding - urinating at the beginning of the bedtime routine and then again just before falling asleep - may help.

You may want to encourage your child to delay daytime urination as well. If the bladder isn't completely full, the urge to urinate may fade within a few minutes. With practice, this simple "stretching exercise" may help your child's bladder hold more urine at night.

If your child is still wetting the bed by age 7 - and is motivated to stop - your PHN or GP can carry out an assessment and recommend a programme of treatment for your child. Motivation on the part of parents and the child are crucial for success.

Enuresis alarms

These small, battery-operated devices - available from your PHN or pharmacy - connect to a moisture-sensitive pad on your child's pajamas or bedding. When the pad senses wetness, the alarm goes off. Ideally, the moisture alarm sounds just as your child begins to urinate - in time to help your child wake, stop the urine stream and get to the toilet. If your child is a heavy sleeper, another person may need to listen for the alarm.

If you try an enuresis alarm, give it plenty of time. It often takes two weeks to see any type of response and up to 12 weeks to enjoy dry nights. Enuresis alarms are highly effective, and they may provide a better long-term solution than medication does. Good motivation on the part of your child is important. If your does not yet see the bedwetting as a problem he is probably nor ready to start on the alarm Your PHN will provide support for you while working with the alarm. Star charts can be used effectively by rewarding dry nights, or improvements with stars.

Your child's doctor may prescribe medication to stop bed-wetting depending on the cause of the bed wetting.
-Hormone imbalance. The drug desmopressin boosts levels of a natural hormone (anti-diuretic hormone, or ADH) that forces the body to make less urine at night.
-Calm the bladder. If your child has small bladder/bladder instability, an anticholinergic drug may help reduce bladder contractions and increase bladder capacity. Side effects may include dry mouth and facial flushing.

Sometimes a combination of medications is most effective. There are no guarantees, however, and medication doesn't cure the problem.

Alternative therapies
Therapies such as massage, acupuncture and hypnosis have been touted as helpful treatments for bed-wetting, however more research is needed before such therapies can be proved effective.