What To Do About Bed Wetting – So Your Child Can Stay Dry At Night

Episode Transcript

Dr. Nicole Beurkens 

Hi everyone, welcome to the show. I am Dr. Nicole. and today I am answering a question that many of you have written to ask about over the last several months: What to do about bedwetting? Bedwetting is an issue that’s fairly common until about age six or seven years, although many parents are looking for solutions to try to address it even before that age. After the age of seven, it’s definitely worth examining more closely to figure out what’s going on and to support your child in trying to stay dry at night. In this episode, I am going to cover the basics of things that can cause bedwetting, including the most common issues I have seen in my practice over the last 20 plus years. I will also talk about some ways to consider approaching it with your child and ideas for how to solve the issue. So the specific question around this comes to us from Sarah, and I chose Sarah’s question because I think it sort of captures what a lot of parents and families deal with when they have a bedwetting situation with a child. She says “I am struggling with how to handle nightly bedwetting with my six-year-old son. He was day-trained around three and a half years old, and that went quite well, but nighttime wetting has continued to happen. He’ll go around 11:30pm, 3am, 6am. I tried for two months to transition him into a nighttime routine out of Pull-Ups, but it didn’t work. He always would wake up soaked. I did all the tricks the doctors told me like bringing into the bathroom before bed, no drinks before bed, etc. I left him in Pull-Ups for two years and did notice that if he didn’t have a bowel movement before bed, he seemed to wet far heavier. I am trying again now because he said he wants to get out of Pull-Ups, but waking him several times each night makes us both exhausted. Trying not to make a big deal out of this and stress him out over being wet as I know he can’t help it, but it is hard to keep up with the laundry. What other things can I do or rule out to help with this issue and to help get them out of Pull-Ups?”

Well, Sarah, it’s a great question, and again, something that I know lots of families are dealing with. So let’s talk first about what bedwetting is, and what some of the things are that contribute. So bedwetting, sort of the official term is “nocturnal enuresis”. Enuresis is wetting, and that can happen during the day. Here we are talking about nighttime, so nocturnal enuresis, and it’s involuntary wetting at night. This involuntary piece is super important for parents and for kids to understand because there can be a lot of frustration, certainly as parents around us, especially as your kids get older, and it can be easy to fall into the trap of feeling like this is something your child can control, this is something that they are doing just because they are lazy, or just because they want to make life difficult. And kids themselves can even take on this idea that there’s something wrong with them, that they are just being a problem, that they are a bad kid for doing this or can get really anxious and upset with themselves over, “Why can’t I stop doing this?” And so it’s really important for us all to understand this is involuntary. This is not something that children are doing on purpose. It is not something that if we just give them enough stickers or other rewards, or we punish them enough, or we yell at them enough, or whatever, that we are going to make it go away. And that’s important to talk about from the outset of this because it really frames how we talk about it with kids and how we approach it. As I mentioned, it’s still considered fairly normal developmentally until about age six or up to age seven. Most kids who have nighttime wetting issues do outgrow it by then. Obviously, there is a percentage of children who don’t. The vast majority, by the teen years have outgrown it, but it is possible. There still are kids in their teen years, neurotypical kids, and certainly kids with neurodevelopmental issues who struggle with this. So just to give sort of that idea of developmentally, what is typical to expect.

So let’s think about some of the prerequisites for staying dry at night, because I think again, this is important to think about before we determine: Is nighttime wetting actually the problem that needs to be solved here? How are we going to do that? Let’s talk about what a child needs to be able to do in order to stay dry at night. And one of the areas that I see as an issue, particularly with kids with neurodevelopmental issues or developmental delays, is their parents will say that they are toilet-trained during the day, but in actuality the child is habit-trained, meaning the child, when an adult prompts them to use the toilet, brings them to the bathroom, tells them it’s time to go potty, they’ll go to the bathroom and urinate, but they are not independently toilet trained, meaning: Left to their own devices, they are not tuning into their bodies signals and recognizing when they need to urinate, and getting to the toilet in time to do that. Now, this is really important because that precedes being able to stay dry at night. So a child needs to be actually fully toilet-trained, independent with their toileting during the day, for them to be very successful with staying dry at night. So for some of you, the issue is that you need to really focus on actually helping them tune into those body signals and become independently toilet-trained during the day before you can expect them to do it at night. Now, if your child is independent with toileting during the day, then that’s good. That’s something that we need to have in place first. Some of the other prerequisites, obviously, this whole issue of toileting, and knowing when to use the toilet and being able to do that requires good what we call “interoception”, and I did a podcast episode a couple months ago now about this. Interoception is considered the eighth sense, and it’s the awareness and the integration of sensation from within our own body. So things like hunger and thirst, and hot and cold, and that sensation of “Do I need to urinate? Do I need to have a bowel movement?” That all requires us that sense of interoception, and kids with sensory processing issues, kids with autism, kids with ADHD, kids with a whole wide range of issues and anything in the sensory realm often struggle a bit more with that interoceptive sense, and that’s something that we need to strengthen and work on in order to help them not only be day-trained, but also be night-trained. And obviously it’s a prerequisite for a child to stay dry at night, they need to know what to do to use the toilet independently and be able to do that in the night if they wake up with an urge to go. Do we have nightlights, or is there a way that they can see to make it to the bathroom? Do they know that it’s okay to get up and go into the bathroom? Do we have the bathroom laid out in a convenient way that they can get to the toilet easily in sort of a sleepy kind of state? So, we want to be thinking about all those practical issues and making sure none of those things are getting in the way.

Okay, so let’s talk about some of the common causes of bedwetting. So assuming that a child is developmentally at an age and a developmental level where it’s appropriate to expect them to stay dry at night, and they are independent and really good with using the toilet on their own during the day, and they get that sensation of when they need to urinate, and we have made sure that there are no obstacles getting in the way of them being able to use the bathroom at night. Okay, so now we want to talk about if a child under all those circumstances is still wetting at night, what might be going on? Well, we know that there are genetic connections here. We know that if one or both parents wet the bed until older ages, that that tends to run in families and it’s more likely that the child will as well. So that’s one piece to consider. Sometimes kids are super, super sound sleepers, meaning when they go into those deep phases of their sleep cycle, they are really difficult to rouse and they are not going to be aware of those internal body signals. So that can be an issue for some kids. On the flip side, kids who are super restless sleepers, who are moving around constantly all night, they are never getting in to good sleep rhythms, they are overtired as a result, they are constantly kicking, thrashing, moving, and that can also make it more likely that they will wet the bed. Some children have really small bladders, and that can be an issue that can make it harder especially in the night during sleep to make it to the bathroom. As I mentioned, kids with sensory processing issues, particularly interoceptive kinds of issues, are going to struggle more with this. Then we also know that stress, anxiety, those types of issues can play a big role in bedwetting. In fact, if you are a parent with a kid who was dry at night, who was night-trained for quite a while and now all of a sudden is having wetting, one of the things that we look at and think about is: Has there been a lot more stress? Is the child more anxious? Has there been a recent major change? Things like a new baby coming into the home or being born, death of a family member, maybe something traumatic that happened, a major change at school — We know that these things can create a lot of dysregulation emotionally in kids, they can create more stress and anxiety, which can cause them to regress in many ways developmentally, and that includes with toileting both during the day and at night. So we want to think about that.

Also a big one: We want to identify if there’s constipation going on. Here’s why: Because you might be thinking, “Well, we are talking about wetting at night, not pooping at night.” Well, here’s why constipation becomes a problem, and in my clinical experience with children, chronic constipation is one of the biggest driving factors behind prolonged nighttime wetting. Day accidents too, for sure, but nighttime accidents, absolutely. And when we resolve chronic constipation in kids, the vast majority of the time, the nighttime wetting resolves too. So why is this? Well, because when a child’s chronically constipated, they have stool that is not passing through the colon the way that it should, it’s getting stuck in there. They are having bowel movements not as often as they should, and when stool stays in the colon for longer periods of time, it stretches the walls of the colon and our body’s sensory system, the nerves, and everything in that area of the colon adjusts to and gets used to having pressure on it all the time. So why is that a problem for wetting? Well, because the way that we know that we need to go to the bathroom, and urinate, or have a bowel movement, is that sudden feeling of pressure or that sensation in our pelvic region that tells us that, “Oh, I need to urinate” or “I need to have a bowel movement.” When kids are chronically having stool filling that area of the body, they lose that sensation and they are not able to tell when their bladder is full and they need to go. So constipation not only creates bowel movement issues and all of the GI issues associated with that, but can also create problems with day and nighttime wetting. So we need to know if constipation is happening. Now, sometimes people think of constipation, or they are told by their child’s primary health care provider that as long as a child has a bowel movement a week, they are not constipated. That is just wrong. Children should be having a bowel movement at least once a day. At least once a day. And it should be easy to pass, shouldn’t be painful, shouldn’t take them a long time to get it out. It should look kind of like a soft, but well-formed brown snake in the toilet. And if that’s not what your child’s bowel movements look like, and if they are not going on a daily basis, they are going couple days in between, it takes them a while, it looks more like pebbles, or it’s really huge amounts of stool, your child is constipated, and that may very well be one of the driving factors behind their wetting, so that’s definitely something that you want to look at and address.

Another issue that I see is chronic urinary tract infection. This can be a bacterial infection, what we traditionally think of as a UTI, but it can also be a yeast infection in the urinary tract, and I have seen several kids over the years with chronic UTI issues, and that makes it very, very difficult for them to night-train. It also can make it difficult with wetting issues during the day, but certainly at night. So you want to rule out if that’s something that’s going on. I mentioned a urinary tract infection that’s fungal, a fungal infection, but candida overgrowth, yeast overgrowth, in the child’s body, typically in the gut, can also be a big problem for wetting. I see many kids each year who have chronic yeast overgrowth in their GI tract, and that can cause wetting issues. In fact, many parents will say to me that that’s one of the ways that they know that the yeast is getting to be too high again in their child system, is because they start to have lots of wetting again at night. They were trained, they were dry at night, now they are having wetting suddenly at night, and that can be an indicator of that. So yeast overgrowth, Candida overgrowth, can be an issue.

Then we have got issues with sleep disorders that can absolutely be connected to wetting: Sleep apnea, any kind of airway issue in the night, any type of sleep disorder can have a higher connection to bedwetting. So we want to make sure if our child is having any kind of sleep issue, that we are getting that addressed because that may be what’s going on with the wetting. Another issue that I see commonly in my practice is children with food allergies or food sensitivities and wetting issues. So these may be kids with frank, medically diagnosed food allergy, but often it’s the kids I see who don’t have food allergies, but they have food sensitivities or intolerances that aren’t being treated, and that’s creating issues with wetting accidents at night. So sometimes it’s gluten. Dairy is by far the biggest one that I see connected with this, to the point where once I have ruled out all of these other kinds of things that I am talking to you about, I will very often suggest that parents do a two to three week trial of no dairy or very limited dairy to see if that resolves the bedwetting, because often it will. So dairy is a big one, but it could be sensitivity to any kind of food group or ingredient. Also, some of the other big ones I see with wetting are kids who are having sensitivities to salicylates, which are naturally occurring in many fruits and vegetables and things, but also very high in food dyes and things like that. So that can be an issue with wetting. And certainly the food dyes and chemicals I have seen connected to bedwetting as well. So if you’ve ruled out some of these other things, and your child is still having wetting issues, looking at the food allergy or sensitivity/intolerance issues can be super important. So those are the things that I wanted to touch on as far as potential driving factors, underlying causes that you want to be thinking about and looking at.

Okay, and obviously what we do about it then, the solution is going to be different, depending on what the underlying issue is, but I am going to give you some general types of solutions that can be helpful, again, depending on what the driving factor is. The first thing is we want to make sure we are having good daytime habits with using the toilet. That means making sure that kids are urinating every few hours during the day, that they are not holding it for long periods of time, that they are having healthy urination, healthy response to their body signals all throughout the day. It’s also really important to make sure that they are fully emptying their bladder. I see this in particular with kids who are just very active, kids certainly with more significant ADHD symptoms, kids who are super impulsive or hyperactive. Often they are rushing through the process of using the toilet, barely emptying their bladder, and these might be kids then who it’s like, “You just used the bathroom 20 minutes ago, now your underwear is wet!” Or they are constantly going in and using the bathroom. It’s really important that we teach them to be mindful of their body when they are using the bathroom, that we slow them down, that we have them fully, fully empty. This is really key. And that they are able to use the bathroom independently and do all those good daytime training things that I talked about earlier. So those are some good things that we need to be working on during the day with all kids who are struggling with this.

Also important from the parenting perspective to be really empathic around this, to talk about this as something that you understand is not under their control, that you know they are a great kid, you know that they want to stay dry at night just as much as you want them to, and that this is a challenge that you and they are going to get through together, you are going to work together on it, that there isn’t this blaming or this shaming around it. That is going to make the whole situation infinitely worse for them, and ultimately, for you. So we want to approach it as a problem that we are going to work together to solve and take blame and shame out of it. We also want to make sure that we are praising their efforts. They may not be dry, especially when you start working on this and figuring out what’s going on, they may not be dry in the morning, but you want to praise their effort. “Oh you did such a great job with the nighttime routine of using the bathroom twice before bed and not drinking liquids. You did such a great job with helping me throw things in the washing machine this morning.” We want to praise their effort around it, not just reserve our praise for the “success” of being dry in the morning. Something to help in the meantime is to make sure that you are waking them before you go to bed, to use the bathroom. This can help, if not eliminate the nighttime wetting, it at least can help with them not being as soaked in the morning. So if your child goes to bed at 8 or 9 o’clock, and you go to bed maybe at 11, to just wake them and have them use the bathroom with your assistance before you go to bed. That can cut down sometimes on the volume of urination that’s happening in the night, if nothing else. You also want to have a very absorbent mattress pad, obviously a waterproof pad or zip-up sort of case for the mattress, and have something really absorbent, whether it’s cloth underwear or Pull-Ups or things: This is why, because this is very embarrassing for children, even from a young age. Once they get past the age of five, they are very, for the most part, embarrassed by this. They feel ashamed by it. And the bigger a deal it is every morning, the harder it is. So the more we can minimize the problems that it causes, the better. So making sure that the mattress stays protected, making sure we have things that are easy to throw in the wash, making sure we have got a system in place where we just don’t need to have big drama or a big deal about it, that’s really helpful for your child on an emotional level. And remember, we want to keep stress and anxiety around this down, because the more stress and anxiety that a child has, the more difficult it’s going to be to resolve the nighttime wetting. We want to obviously limit fluids in the evening hours, dinner perhaps should be the last time that your child has any significant amount of liquid, and making sure that they are using the bathroom several times then in the evening. There is a strategy that is called double elimination, which means having them use the toilet at the start of the bedtime routine, and then again right at the end of the bedtime routine right before they get in bed. That helps to make sure that they have fully emptied their bladder before they get into bed. That can be really, really helpful. And then again, some basics are: No caffeine. In my opinion, kids shouldn’t be having caffeine anyway, but certainly no caffeine later in the day, because it is a stimulant for the bladder and can stimulate urination. Same with chocolates, spicy things — anything that can stimulate the bladder, we want to avoid as much as possible.

Some kids really benefit from a bed alarm system. There are lots of them out there. I don’t have ones that I specifically recommend. I have seen families and kids have success with lots of different options. Some of them vibrate to wake the child when the first drop of urine hits the pad underneath them or the sensor in their underwear, some of them have buzzers and sounds. There are different ones, but that can be really helpful, especially if you have ruled out all of the physiological things, having an alarm system can help to train their brain to tune into that sensation, or even during sleep, and to wake them up and have them use the bathroom. So that can be helpful. And I have seen that even work well for kids with more significant developmental delays, neurodevelopmental issues as long as we have ruled out other things that might be causing it, to just help to train their brain to be more aware in the night.

I always like to have an iron level checked on kids, do an iron panel again just looking at everything that’s going on, especially if they are a problematic sleeper, and bedwetting is a piece of that, often low iron levels can be an issue that’s something easy to crack. So we want to look at that. I should have mentioned that under potential causes. Some other things that can be helpful: Magnesium supplements. Magnesium is very calming, it can relax the system. So if stress, anxiety, those types of things are part of the picture of what’s going on, magnesium supplementation can be helpful, especially at bedtime. Some kids do well with an Epsom salt bath, which also then they get magnesium absorbed through the skin, or a magnesium lotion, or spray can also help with relaxation, if that’s a part of it for your child. I have seen probiotics, beneficial bacteria, probiotics work well for some kids, especially if we are dealing with underlying causes like constipation, chronic yeast issues, UTI, those types of things, probiotics can be a very helpful part of the solution to bedwetting. Obviously treating constipation. So often parents are told “Give your child MiraLAX”. That’s a subject for a whole other episode, but I am not a proponent of daily use of MiraLAX to keep a child from being constipated. It’s a band-aid and it can create more problems than it solves. So we want to get to the root of it and make sure that we are feeding kids a diet that allows for healthy bowel movements, that we have their gut bacteria properly regulated, and use things like magnesium and aloe vera juice and other kinds of options, fiber, things like that, to keep their bowels moving and prevent them from being constipated. But that’s a big one to look into treating.

There are some people who report having good success with some homeopathic options for treating bedwetting. Specifically, there’s a little bit of research literature on belladonna, causticum, and sepia. I am not a homeopath, those aren’t things that I routinely used in practice, but I throw them out there just as something for you to research and be aware of, with which some people have really good success. Again, you need to rule out any of these other underlying physiological kinds of things, but homeopathy could be helpful here. And then kind of along those same lines, there are reports of some families finding that something like chiropractic care, chiropractic adjustments, or even acupuncture, have been helpful for their child when nothing else has worked. So those are some options to think about. Medication is available, prescription medication. However, it is not super effective for most kids. Once in a while, I will see a kid who took prescription medication for bedwetting, and it was really helpful. Most of the time parents say to me that they have done the medication and it didn’t work, or that they had concerns about doing the medication because of side effects and things like that. So if a family is thinking about medication, my approach as with everything is that we rule out all the potential underlying things and we try all the other approaches that make sense before resorting to a prescription, but do know that that is available and something to talk about with your child’s healthcare provider if you’re interested.

So that was a quick surface-level kind of run-through of things for you to be thinking about if your child is having bedwetting. Ways to approach it, underlying causes, and some solutions. I hope that it’s helpful for Sarah and all the rest of you who emailed in with a question about bedwetting, and for all of you listening who are looking for bedwetting solutions for your kids. Remember: If you have a question you would like to hear answered on a future show, email it to support@drbeurkens.com. Thank you, as always, for listening and I will catch you back here next time.b