For the past 10 years I’ve been treating children who wet the bed in my pelvic health Physiotherapy practice. Here are a few things that I wish all Parents knew.
Firstly, it isn’t their fault that they are wetting at night. If your child could, they would be dry all night.
Secondly, removing pull ups/diapers and telling a child that they now need to be dry ay night fails 99.99% of the time.
It’s almost impossible to ‘train’ a child to be dry at night, their bladder emptying while they sleep is beyond their control. There are however a few steps you can take to help to optimise their chances of night time dryness.
What age is night time wetness considered ‘bed wetting’?
We expect children to be dry at night a year after they are full dry and toilet trained in the day. If you are reading this and your child is still having pee and poop accidents during the day, you need to rather prioritise their day time dryness before addressing night times. We expect to children to be fully daily time toilet trained by age 4. Which would make night time dryness expected by age 5, but many places only consider a typically developing child to be ‘bed wetting’, if they are older than 6.
I used to tell Parents to only contact me after the age of 5. But I now encourage all the below tips to be implemented as soon as they are dry in the day. If you have covered all the below, sometimes their nervous systems just need a little longer to mature.
How common is bed wetting in Children?
The prevalence may be higher than you think.
1 in six 5 year olds are wet at night.
1 in eight 6 year olds are wet at night.
1 in ten 7 year olds are wet at night.
1 in fourteen 8 year olds are wet at night.
1 in twenty 10 year olds are wet at night.
Between 1-3 in a hundred (the research varies) of 18 year olds are wet at night.
Won’t it resolve on it’s own?
Historically, Parents were advised that they just needed to wait for their child to outgrow bed wetting. And for 15% of children who are wet at night, it will resolve spontaneously in a year.
It’s been found that 20% of children who bed wet also experience daytime wee leaks and !5% of children who are wet at night also have poop accidents.
I will always address and treat day time accidents, and often the night time wetting stops on it’s own after doing this.
Who is most at risk of bed wetting?
- Younger children are more prone to wetting and boys are twice as likely to wet than girls.
- Children with a history of urinary tract infections.
- A Family history of bed wetting.
- Obesity is also a likely risk factor
Other conditions that can contribute to bed wetting:
- Chronic kidney disease
- Diabetes,
- Neurogenic bladder
- Behavioural disorders
- Sickle cell disease
- Hyperthyroidism
If both Parents struggled with bed wetting, there is a 75% chance a child will struggle with it too.
There is a 50% a child will struggle with it when only one parent had history and there is a 15% chance a child will wet if neither Parent had a history of wetting.
Primary Versus Secondary bed wetting
Primary: Children who have never achieved six months of continuously dry nights.
Secondary: Children who were previously dry for 6 months but have relapsed.
Monosymptomatic versus Nonmonosymptomatic bed wetting
Monosymptomatic: Only symptom is nighttime bed wetting
Nonmonosymptomatic bed wetting involves daytime lower urinary tract symptoms such urgency, frequency, dribbling, incomplete emptying or daytime incontinence, dysuria, or holding maneuvers (standing on tiptoes, crossing the legs, pressing the heel or hand into the perineum).
So what causes bed wetting? In my experience with treating children who are wet at night for the past 10 years,
The Biggest Cause of Bed Wetting is Constipation.
A loaded rectum full of poop, puts BIG pressure on the bladder. If you think how small a child’s pelvis is, and how close together the bladder and bowel are, it’s no wonder a full and stretched rectum can make the bladder ‘hiccup’ and wet over night.
Constipation can be tricky to diagnose in children, and I’ve treated loads of children pooping once, twice or even three times a day who are in fact backed up with poop, have a stretched rectum and are constipated.
This video is from my How to Help a Constipated Child video Series and shares 14 signs your child may be constipated.
If your child is displaying any signs of being constipated, I would suggest you address their constipation before doing anything else. You can watch my video series or see a Doctor or Pelvic Health Physio trained in bladder and bowel dysfunction near you.
We used to think that Children who bed wet, just struggled to wake up from sleep when they had the urge to empty their bladders.
- Why do most children not need to get up at then?
- Conflicting research on whether children who bed wet are light or deep sleepers or no different from controls.
Children shouldn’t need to regularly get up at night to empty their bladders.
The majority of kids I treat whose siblings are dry, the siblings do not get up at night to wee.
So the question I pose to Parents is not, why are they not waking up to pass urine, it’s why are they needing to empty their bladders at night?
We know that some kids make more urine overnight than they should do. This is called Nocturnal Polyuria. In my experience, these appear to be the children who have never been dry at night and wet more than once a night.
This increased urine production while asleep can be due to:
- Excess fluids before bed (ideally avoid fluids for 2 hours before bed)
- Reduced production or response to antidiuretic hormone (ADH)
- Our kidneys should make less urine while we sleep and it’s ADH that tells them to do so. We think that some children produce less ADH and this can contribute to bed wetting because their kidneys are making more urine at night than they shou
A study also found that children who bed wet may not only produce more urine at night but they may also have a smaller capacity for urine storage.
Causes of Secondary Enuresis
In children who have previously been dry and then start wetting, the following are often contributing causes.
- Diabetes (I always want children with new onset bed wetting to see a Dr for a urine screen)
- Urinary tract abnormalities
- Anatomic abnormalities (a tethered spinal cord)
- Constipation
- Psychological disturbances
- New baby, new school or a change routine
I usually find that the new baby or school or life change links more to a change in routine and constipation occurring than psychological distress impacting on a child’s nervous system and bladder.
In children who are bed wetting, there is often something else going too.
Is your child also battling with any of the below?
- 33 to 75% are constipated
- 18 to 60% struggle with bladder infections
- 10 to 54% have obstructive sleep apnea (snoring, enlarged adenoids)
- Up to 41% have daytime bladder issues
- 12 to 17% have ADHD
Why snoring, mouth breathing and sleep apnea can impact on bed wetting.
We think that mouth breathers and those with enlarged adenoids are more prone to bed wetting because they aren’t getting into a deep enough sleep to make the ADH hormone that tells the kidneys to shut down shop with urine production at night.
A study that looked at children who were bed wetting and then had their tonsils and adenoids removed, showed fascinating results.
Postoperatively:
- 61% of the children were free of bed wetting
- 23 % had a decrease in their bed wetting
- and 16% had no change
I’ve seen huge improvements in night time dryness in children who mouth breathe and have their tonsils and adenoids removed. Parents also frequently better sleep and daytime concentration at school after the surgery.
Unsurprisingly, bed wetting has been found to come with psychological implications for children.
Bed wetting has been found to be associated with:
- Poor self-image
- Diminished achievement in school
- An increase in the time spent by families compensating, both financially and personally, for the symptoms.
- Attention-deficit/hyperactivity disorder (ADHD) was strongly associated with being wet at night.
What can you do if your child is bed wetting?
Most importantly, remind your child and your family that it is not the child’s fault. Try and remove any shame and stigma from the situation. Seek help from a Psychologist or a play therapist if your child is taking strain psychologically from their bed wetting.
Encourage your child to wear pull ups as long as possible. Only stop pull ups once your child is dry 6 out of 7 nights. Stopping pull ups or having the monkeys or fairies take them for their children, does not solve bedwetting. Pull ups usually mean a better nights sleep for both children and their parents
For older children that are leaking through a pull up at night, place a waterproof protector and then a sheet and then another protector and a sheet. That way, if they wet in the night, you can just remove the top sheet and protector to deal with in the morning.
TREAT CONSTIPATION, a stretched rectum puts big pressure on a bladder at night. You can watch my video series for constipation treatment and advice.
Avoid bladder irritants (ideally completely or from midday if they can’t be avoided). Juice, tea, fizzy drinks (including fizzy water), tea and milk. All of these have the potential to irritate the bladder wall and make it contract over night. Our bodies were made to drink pure water.
Avoid fluids for 2 hours before bed and don’t leave a water bottle beside their bed overnight. If your child is very thirsty before bed, don’t deprive them, but it’s they likely haven’t had enough to drink in the day. We don’t want to burden their kidneys with making with urine overnight.
Get boys to sit to wee before bed, it can help to empty the bladder more thoroughly.
Ensure there is a foot stool at the toilet so your child has their feet well supported. Tensing thighs to balance on the loo can prevent the pelvic floor relaxing and the bladder emptying fully.
A double void before bed can help. Wee, stand up inhale and reach to ceiling, exhale and bend forwards x 2. Try and wee again.
Always encourage a wee last thing at night and again first thing in the morning. Even if your child’s pull up or bed is freshly soaked, get them to try and wee first thing in the morning to try and train the brain to know we empty our bladders first thing in the morning.
To carry to the toilet or not. I’ve had mixed success with this over the years. I do find it’s best to fully wake the child and get them to walk there if you are doing this. Lifting them on to the toilet while half asleep doesn’t appear to train the brain very effectively. I no longer regularly recommend waking and taking children to the toilet during the night in my treatment programs.
Ensure your child is doing 6-8 wees a day. Many of the older bedwetters I see are only emptying their bladders 2-3 times a day and this can contribute to them wetting at night.
Is your child drinking enough water? Dehydration impacts on the bladder as the more concentrated urine irritates the bladder lining and can make the bladder contract at night. I encourage 30mls per kg pf body weight a day of PURE water. So a 20kg child needs 600mls water. This must all be drunk by 2 hours before bed.
See your Doctor to address any snoring, mouth breathing, sleep apnea or tonsil or adenoid enlargement. Consider having these removed.
Consider a bed wetting alarm. Once you have addressed all the above, you may want to consider buying a bed wetting alarm. Which alarms as the child starts to wet and gets them to get up and wee in the loo. I am recommending these more frequently than I used to and have been getting some good results.
Medication. If you have addressed all the above, you may consider getting some medication from your Doctor to help to reduce the volume of urine created overnight by the kidneys. I find these don’t work very well if constipation is the main driver of the bed wetting. Many families prefer to not use these long term, and rather as ‘sleep over’ or school tour drugs. Discuss this with your Doctor.