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Bladder blues

Bed-wetting or urinary incontinence is frequently reported among children.

Bladder blues


Dr Sudhanshu Grover

Bed-wetting or urinary incontinence is frequently reported among children. It means involuntary urination by a child after an age when staying dry at night can be reasonably expected from him. It is seen in approximately 15 per cent children at five years of age. It decreases with age, occurring in only 1-2 per cent of children aged 14 years and older. While this is not a serious medical disorder, bed-wetting can have far-reaching effects on both the child and the family.

The causes 

  • A small bladder:  The child’s bladder may not be developed enough to hold urine produced during the night.
  • Inability to realise when the bladder is full
  • If the nerves that control the bladder are slow to mature. A full bladder may not wake up your child, especially if he sleeps well.
  • Hormone imbalance: Some kids don’t produce enough anti-diuretic hormone (ADH) to slow down urine production at night.
  • Stress: Stressful events like starting a new school, or sleeping away from home, or a conflict between the parents, or neglect by the parents.
  • Urinary tract infection: Infection can make it difficult for your child to control urination.
  • Sleep apnea: Sometimes bed-wetting is a sign of obstructive sleep apnea, a condition in which the child’s breathing is interrupted during sleep, often due to inflamed or enlarged tonsils or adenoids. Other signs and symptoms may include snoring, frequent ear and sinus infections, sore throat, or daytime drowsiness.
  • Deep sleep: Sometimes the child is in deep sleep, and fails to realise that the bladder is full. 
  • Chronic constipation: Same muscles are used to control urine and stool elimination. When constipation is long term, these muscles can become dysfunctional and contribute to bed-wetting. 
  • Genetic tendency: Many such children have a family history, with either their parents or siblings having gone through the same problem during their childhood. Most such cases resolve as the child grows older.
  • Rare causes: Diabetes in children, chronic kidney disease, diseases related to spinal cord, etc.

Watch out for these signs

Children learn to control daytime urination as they become aware of their bladder filling. Once this happens, the child learns to consciously control and coordinate his bladder. This generally happens by the age of four. Most children wet the bed only at night. They tend to have no other symptoms other than wetting the bed. However, this may interfere with child’s socialisation and can cause a significant stress within the family. It is important to consult a doctor if:

  • Your child is at least six years old, and he still wets the bed. A treatment for bed-wetting is not recommended before this age as it would not be effective enough, and many children get better on their own.
  • You or your child is troubled or frustrated by bed-wetting.
  • Your child wets or has bowel movements in his pants during the daytime.
  • Your child has stayed dry during the night for at least 6 months before slipping back into the habit
  • Your child has symptoms suggestive of an underlying medical or surgical illness like weak urinary stream, difficulty in the initiation of urination or straining while passing urine, or intermittent dribbling of urine, associated weight loss / fatigue, chronic constipation, etc.

Complications

Although frustrating, isolated bed-wetting generally doesn’t pose any health risks, especially if any of the danger signs mentioned above are not seen. However, bed-wetting can create some issues for your child:

  • Guilt and embarrassment, which can lead to low self-esteem.
  • Loss of opportunities for social activities, such as sleepovers and camps.
  • Rashes on the child’s bottom and genital area, especially if your child sleeps in wet underwear.

Treatment 

In most cases, other than a routine urine analysis, no major investigations are needed. It is important to look for danger signs as mentioned above. The treatment for nocturnal enuresis is simple in most cases but it’s important to show patience and understanding. There are a number of things parents can do to reduce the stress for their  children:

  • Remind children that bed-wetting is no one’s fault.
  • Let children know that many kids have the same problem.
  • Do not punish or shame children for being wet at night.
  • Make sure the child’s siblings do not tease him about it.
  • Let children know the examples of people who have overcome the problem. 
  • Encourage the child to empty the bladder before going to bed.
  • Encourage the child to wake up at night to urinate.
  • Limit the child’s fluid intake in the evening. He should take a good amount of fluids in the morning and afternoon, but not as much in the evening. About 40 per cent of the total fluid intake in the morning, 40 per cent in the afternoon, and 20 percent in the evening.
  • Avoid sugary and/or caffeinated drinks during the evening.
  • Motivational therapy and rewards: Make sure to give positive feedback to the child. A “good performance” should be rewarded in order to motivate the child
  • Alarm clocks: You may use simple alarm clocks to awaken the child in 2-3 hours and encourage him to use the toilet
  • Bed wetting alarms /sensors: These are medical devices which work using a sensor and raise an alarm as soon as the first drop of urine is detected in the child’s undergarment. These are rarely needed, though. 
  • Medicines: Medicines like desmopressin are infrequently required to treat such children. They should be taken only under the supervision of a paediatrician. It works best when used in association with behaviour therapy and lifestyle modification measures as mentioned above.

What you could do...

  • Do not criticise your child for bed-wetting
  • Treatment may be prolonged and rests mainly on behaviour therapy and lifestyle changes
  • Medicines and medical devices like alarm systems are rarely needed for treatment 
  • There may be a few cycles of success and failure, but almost all children outgrow the disease with supportive measures

Development of bladder control in children

  • Up to 18 months: The child is unaware of bladder filling or emptying.
  • 18-24 months: The child has a conscious sensation of bladder emptying.
  • 2-3 years: Most children develop the ability to voluntarily stop urination and develop appropriate toilet skills.
  • 3-5 years: Most children achieve urinary control and stay dry during the day as well as the night.

— The writer is a consultant- neonatologist and paediatrician, Cloudnine Group of Hospitals, Chandigarh

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