Why Your Child Wets the Bed and How to Help

Podcast Transcript

Dr. Richard So:

Welcome to Little Health, a Cleveland Clinic children's podcast that helps navigate the complexities of child health one chapter at a time. In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Lynn Woo:

Well, welcome to Little Health, the Children's Hospital podcast, where we talk about common health concerns in kids in a way that we hope is clear, practical, and reassuring for families. Today, I'm Lynn Woo, one of the pediatric urologists at the Cleveland Clinic, and we are gonna be talking about something that many parents worry about but don't always feel comfortable bringing up, and that's the topic of bedwetting. And so if you're listening and thinking, "Is this normal," or, "should my child have outgrown this by now?" You're not alone. Bedwetting affects millions of children and for most families, it's not a sign that anything is wrong or that anyone is doing something wrong. In this episode, we're gonna talk about why bedwetting happens, what's normal at different ages, and when it's worth checking in with your pediatrician, what treatment options really help and also include what parents shouldn't worry about.

Joining us today is my good friend and colleague, Dr. Jessica Hannick. She's an assistant professor of urologic surgery and a board certified pediatric urologist at the Cleveland Clinic who works closely with children and families dealing with urinary tract problems. So thanks so much for being here. Let me know a little bit about yourself.

Dr. Jessica Hannick:

Thanks, Lynn. I am originally from the Chicago area where I did much of my training and then I did my fellowship training in pediatric urology in Toronto, Canada at the Hospital for Sick Children and then came to Cleveland for the job and I'm now a proud Clevelander enjoying the Metro Parks on the weekends.

Dr. Lynn Woo:

Awesome. Well, it's been wonderful working with you, I think, over this last six years and so without further delay, let's dive into today's topic. Dr. Hannick, starting with the basics, what exactly is bedwetting and how is it different from daytime urinary accidents?

Dr. Jessica Hannick:

Yeah, so bedwetting is when patients specifically only wet the bed overnight, but they don't have any issues during the day. Patients who have daytime and nighttime urinary incontinence will have issues both during the day and during the night, but that's not usually the case when it's just bedwetting.

Dr. Lynn Woo:

And how common is bedwetting at different ages? When do you consider it still normal and when should a parent be concerned?

Dr. Jessica Hannick:

Bedwetting is very common up until the age of about six years. It affects about 30% of children, seven years of age and under, and then that decreases about 5% in, uh, 10-year-olds. When we're looking at teenage patients, because yes, teenagers can also have bedwetting, there's an estimated one to 2% of US 15-year-olds that will have bedwetting.

Dr. Lynn Woo:

So I'm hearing that kids will outgrow this and the statistics are really in their favor as they get older.

Dr. Jessica Hannick:

Definitely.

Dr. Lynn Woo:

What causes bedwetting? Is it a medical problem, a developmental problem, or a mixture of both?

Dr. Jessica Hannick:

Most of the time bedwetting, the term we use as nocturnal enuresis, is developmental, but in some circumstances it can be due to medical conditions or medical issues such as a urinary tract infection, constipation, or bigger issues like diabetes, sleep apnea, or more rarely a urological or neurological condition. It is really important that when a patient is seen by their pediatrician or by ourselves for bedwetting, that we rule out these medical causes before we just provide them reassurance and assign a developmental cause.

Developmental causes can range from ones that affect the patient during the daytime, like you were discussing earlier, kids who also have daytime issues. So that would be someone who has issues with voiding dysfunction where they don't pee often enough or bowel holding or it can just simply mean that something they're gonna outgrow. Developmental causes can range from ones that affect the patient during the daytime, like you were discussing earlier, where they have daytime urinary accidents and voiding dysfunction or bowel holding, or it can simply mean that the patient will outgrow the bedwetting, but usually in an unknown matter of time as the neurological connections between their brain and bladder mature.

Dr. Lynn Woo:

A lot of parents will describe their kids as being really deep sleepers or being really hard to awaken. Is being a deep sleeper a big factor in bedwetting?

Dr. Jessica Hannick:

Absolutely. So if you think about it, if a child is a really deep sleeper and they can't wake up to an alarm or another loud noise, it's really unlikely that their body is gonna wake them up to subtle or not so subtle messages of fullness that their bladder's trying to send to their brain while they're sleeping. Furthermore, if they're very deep sleepers and they snore, they should be evaluated for possible sleep apnea of various causes, which can be a potential cause to exacerbate their bedwetting.

Dr. Lynn Woo:

How does someone's bladder size or the amount of urine or pee they make at night or their ability to wake up quickly play a role in bedwetting?

Dr. Jessica Hannick:

So let's tackle each of those separately. If a patient has a small bladder, they won't be able to hold as much urine for long periods of time before needing to empty their bladder. Then if a patient makes more urine overnight, say, either because they drank most of their daily fluid intake towards the end of the day or because they have an underlying medical condition that causes this, they're gonna have to empty their bladder more often because there's more fluid. So the longer they're asleep overnight, the higher the chances they have of wetting their bed. Add to that possible situations where a specific child's decreased ability to be woken up on their own or with subtle stimuli such as a full bladder overnight, they're just gonna be at an increased risk of wetting the bed.

Dr. Lynn Woo:

That totally makes sense. How about genetics? Can bedwetting be genetic and run in families?

Dr. Jessica Hannick:

Yeah, we definitely see that children who wet the bed will have siblings or even parents who wet the bed themselves till later in childhood. It's no one's fault, of course, it just happens.

Dr. Lynn Woo:

Can it also just be a random occurrence for a child if there's no family members that wet the bed?

Dr. Jessica Hannick:

Absolutely. That just sometimes happens.

Dr. Lynn Woo:

Are kids with ADHD, attention deficit or hyperactivity disorder, generalized anxiety disorder, or other behavioral difficulties more likely to have bedwetting?

Dr. Jessica Hannick:

Yes, patients with ADHD, neuroatypia, and psychological or emotional challenges are more often found to wet the bed. Making sure that these challenges are either properly diagnosed and treated is fundamental to successful treating of bedwetting.

Dr. Lynn Woo:

How about constipation? Earlier, I think you had mentioned constipation as part of the factors with having accidents. Is there a link between bowel and bladder function?

Dr. Jessica Hannick:

Yeah, my patients often giggle or look at me funny wondering why I spend so much time talking to them about their bowel movements, but yes, the bowels and bladder are closely related due to nerve connections they share in the body's pelvis. If a patient has issues with firm or infrequent poops, they're often gonna have painful bowel movements and receive extra messages from their bladder about having an urge to pee more frequently than they need to. In other circumstances, they might not poop or pee as often because of their constipation and that can send a lot of mixed messages to the bladder overnight as well.

Dr. Lynn Woo:

So you're saying parents need to work with their kids to find out exactly what their poop patterns are in order to determine whether that might be a contributing issue

Dr. Jessica Hannick:

Yeah, even though they think it's their child's normal, it might not be considered healthy in our perspective, so it's really important to know how often they poop and the quality of those poops.

Dr. Lynn Woo:

Now you alluded to this earlier, but can you re-highlight red flags with bedwetting that should prompt a parent to seek a more urgent evaluation?

Dr. Jessica Hannick:

Absolutely. So as I mentioned before, there can be medical causes for bedwetting that require additional evaluation. For example, if your child complains of new burning or pain with urination is having new day or nighttime accidents with or without an increased urge or frequency to pee, they should be checked out for a urinary tract infection.

Dr. Lynn Woo:

Got it.

Dr. Jessica Hannick:

Then if you start to notice that your child is drinking more fluids but still complaining of being thirsty, using the bathroom more frequently and still having large amounts of pee with each trip to the bathroom, they should be checked for diabetes. And if a child has a loud snore and has times where it sounds like they might even stop breathing overnight or they're excessively tired during the day, we should see if they have anything like sleep disordered breathing. Lastly, if they're repeatedly complaining of new leg or foot numbness, tingling or pain, or they're having increased frequency of trips and falls amidst their bedwetting, we should look for some sort of a neurological cause.

Dr. Lynn Woo:

Totally makes sense. I think another one that I'll look for is if they're having poop accidents or uncontrolled staining in the underwear since you had mentioned constipation is a factor.

Dr. Jessica Hannick:

Absolutely.

Dr. Lynn Woo:

Well, thanks for covering all that, but now let's focus on what an actual clinic visit looks like for patients and families. At what age should a patient with bedwetting be evaluated by a specialist like yourself?

Dr. Jessica Hannick:

So typically we recommend patients actually see their pediatrician for the initial intake of bedwetting to rule out many of those medical causes. If none of those are present and the patient is bothered by their bedwetting, they have new bedwetting after previously being dry for more than six months, they're having daytime wetting, or they're 12 years or older, then it's usually time to see a specialist to discuss possible treatment options.

Dr. Lynn Woo:

So parents and kids are gonna wanna know in addition to our getting a very good patient history and completing a good thorough urology exam, are there other tests that are gonna be performed and most importantly, does any of this hurt?

Dr. Jessica Hannick:

So most commonly we will only ask for patients to provide a urine sample during their visit. It's as easy as peeing in a cup, no pain. We may also do an ultrasound of their bladder to make sure that they're emptying it when they're peeing and sometimes like we've been talking about, we wanna check for constipation with an x-ray, but that's about it, not too painful.

Dr. Lynn Woo:

Sounds great. So if this initial evaluation is reassuring, then let's talk about the main management options you present for bedwetting. What are the first steps parents can try at home before they even see the specialist?

Dr. Jessica Hannick:

So most of the time we're gonna recommend starting with these behavioral changes if they haven't already done it. Then after that, we might recommend a bed alarm or medication. So we'll talk about that in a bit. So for some of those first steps that parents can work on at home, I like to recommend that patients stop drinking about one to two hours before bed. If you think about it, what you have put in, it's gotta come out so you have to give them a chance to pee out most of that liquid. I also recommend that patients pee every night right before they go to bed, even if they don't feel like they have to. You gotta empty the tank so it has room to fill overnight. Then like we've been harping on, we gotta ensure that children are having soft daily poops, that's pretty critical.

So think of a poop emoji, that's what we're going for. This can either be done with laxatives if you've got a picky eater or with adequately balancing water intake and dietary fiber intake.

Dr. Lynn Woo:

So you just mentioned a bed alarm. What is that? Is that a bedwetting alarm?

Dr. Jessica Hannick:

Yeah. So a bedwetting alarm is triggered by the moisture from a patient having an accident overnight, which I think confuses a lot of parents because they think, "Oh, it's gonna alarm them before they have the accident."

Dr. Lynn Woo:

Yeah, definitely tell me how this is different than just setting a regular alarm clock to wake a child up in the middle of the night.

Dr. Jessica Hannick:

Yeah, so if you do that, it's not correlating in any way with how things are going in the child's bladder. They may have had an accident minutes or hours ago or not even need to pee, so it's not really training the brain properly. A bedwetting alarm is triggered by the moisture. So it then makes a loud alarm, which typically, unfortunately, doesn't initially wake the patient up, but it wakes the parent up. The parent then goes into the room to help bring the child to the bathroom where they should then be encouraged to try to pee again. I often tell parents have the kid wash their face or brush their teeth to make sure that the child is truly awake. This encourages the brain to gain alertness to the messages that the child's bladder is trying to send to it. If effective, this can take up to three months as the child begins to wake up on their own to the alarm and then wake up on their own to the sensation of their bladder being full overnight.

I find that alarms work best for children over seven years of age who are also motivated to get dry and then also have supportive involved parents who can consistently stay on a routine with the alarm. Sometimes kids just aren't interested in being dry or there is a big family and there's younger children or sibling roommates for whom the alarm may disrupt sleep, so it's just not logistically feasible.

Dr. Lynn Woo:

So I'm hearing a lot of really good advice here. These alarms sometimes are a mystery to families and we had talked about how heavy sleeping can contribute and I heard you say it's critical that if the child doesn't wake up, the parents should be the backup and get their child up. And it sounds like the key here is getting that child to become fully awake after the accident.

Dr. Jessica Hannick:

Exactly.

Dr. Lynn Woo:

I'm also hearing that there's some other keys to success, which every family probably needs to evaluate for themselves, including the motivation of their child, the ability to comply with a routine and to be consistent. When is medication an option for patients with bedwetting? Are they safe for kids and how do they work? What do they do?

Dr. Jessica Hannick:

So I usually wait to prescribe any medications till when a patient themselves is bothered by their bedwetting. They are safe for kids as long as parents and children follow their doctor's recommendations. The most prescribed medication is Desmopressin, we sometimes call it DDAVP, which is a medication form of vasopressin. It's 65 to 75% effective in yielding a dry night when it's taken properly. And vasopressin is a hormone that regulates how much urine the kidney produces. Taking it encourages the kidneys to keep more fluids inside the body rather than making as much pee so that less urine is passed to the bladder overnight. Because it can lower the salt content of your blood though while it's in the system overnight. Children really should not drink more than eight ounces of fluid after taking the medication one hour before bed. And make sure to explain to parents and patients that Desmoepressin usually does not fix the bedwetting. It's really just a bandaid that can make the patient dry when it's taken while they're working on the other aspects of bedwetting treatment that we've discussed.

Dr. Lynn Woo:

So I'm hearing there are medications, they are safe, but they may not work for everyone.

Dr. Jessica Hannick:

Yeah. There are some other ones like Oxybutynin or Tolteridine that we'll add during the night and/or during the day to reduce bladder contractions so the patients leak less, but those are kind of secondary options that the DDAVP doesn't work.

Dr. Lynn Woo:

Do you have any advice on what not to do when caring for a child with bedwetting?

Dr. Jessica Hannick:

Absolutely. It's so important to me that kids understand that bedwetting is not their fault and that they did not do anything wrong to cause it to happen. Parents should also understand this and avoid any negative emotions such as guilt or shame towards their child's bedwetting. Punishment verbally or physically is unacceptable and will only exacerbate the stress and self-esteem issues bedwetting can cause. Parents should also make sure that children are not avoiding drinking all day so that they don't wet overnight because that will cause other health issues. And I often tell parents not to waste their time with the random nighttime awakenings or bathroom trips either because it's just not gonna work.

Dr. Lynn Woo:

Dr. Hannick, parents sometimes wonder if using pull-ups or pads or anything is somehow going to slow their child's progress or ability to outgrow the bedwetting. What do you think about that?

Dr. Jessica Hannick:

Yeah, I get that one a lot actually. And no, I, I think if anything, if they can be dry overnight because they've got a pull-up on or they've got a mattress pad, they're not freezing and they're getting good quality sleep, that's what's really important. Having a pull-up or a diaper or whatever you wanna call it on is not going to encourage the child to continue bedwetting. It's just gonna give them some confidence because they're comfortable.

Dr. Lynn Woo:

So you definitely don't feel it's a crutch in any way.

Dr. Jessica Hannick:

Not at all, no.

Dr. Lynn Woo:

What about late-night gaming? We know kids really love to be playing games into the night on their screens. How do you think this can affect the bedtime routine and bedwetting in the long term?

Dr. Jessica Hannick:

Yeah, so it's definitely not great in general, but in terms of bedwetting, it can create some issues with good quality sleep. And so if a child is not getting adequate sleep, then they're potentially gonna go into even deeper sleep, thus exacerbating the risk of having bedwetting. So I usually will recommend the entire family stop screen time about half an hour at least before bedtime, so that's TVs, tablets, phones, whatever you have and that's gonna get everybody on the same page. But the other thing is that I don't want kids staying up as late as possible overnight so that they think maybe I can trick my body not to wet the bed by staying up super late. That's gonna have the same downside as that their quality and duration of adequate sleep is hindered and then they're gonna have bigger issues during the day.

Dr. Lynn Woo:

And in that same vein, we know that bedwetting can affect a lot of the social aspects of a child's life like sleepovers or sleep away camps and then ultimately affect their self-esteem. What do you say to kids? How do you help kids navigate those situations?

Dr. Jessica Hannick:

Yeah. So I usually recommend children actually try out the medications like DDVP before the special events so that they can know the correct dose that they need to take to have the confidence to know that they're gonna have a dry night when they're at a sleepover. Once they figure that out, then they can rest assured that while taking their meds, they don't need to worry about the stress and shame that may come from bedwetting. Sometimes we even just have them take these meds every night if they're experiencing significant distress and low self-esteem from the bedwetting.

Having another trusted adult guardian who is also aware of the bedwetting if on a sleepover or at camp can provide discreet access to pull-ups for the child as needed and assist with clothing changes to help give your child the security and trust they need to engage in these activities.

Dr. Lynn Woo:

And again, can you tell me, do most kids eventually outgrow bedwetting?

Dr. Jessica Hannick:

Yes. Most kids will eventually outgrow bedwetting. I wish I had a magic eight ball, but unfortunately I don't, so we can't predict when that will happen. But only about 2 - 3% of adults over 18 will have primary nocturnal enuresis.

Dr. Lynn Woo:

And what's the one message you hope parents will remember after listening to this episode?

Dr. Jessica Hannick:

So I want kids and parents to come away knowing that they are not alone, but that there are many things we can offer to help them as they grow out of their bedwetting.

Dr. Lynn Woo:

I think that's great advice. Obviously easier to talk about than to do in real practice, but great tips for our parents and listeners.

So before we wrap up today, I just wanna take a moment to speak directly to parents who may be listening and feeling worried, frustrated, or even guilty. This is a common problem. It's a physiologic and developmental issue. It's not a character flaw, as you've heard Dr. Hannick explain.

Most importantly, it's not your child's fault and it's not a reflection of your parenting. Some kids just take longer for the systems that control nighttime bladder function to mature and that's totally okay. But the good news is, is there are effective strategies that can help and most kids do outgrow bedwetting over time. You don't have to handle this alone and you don't have to wait until things feel overwhelming to ask for help.

So if bedwetting is affecting your child's confidence, sleep or daily life, or if you have concerns about other symptoms that were discussed today, talk to your pediatrician and when needed, Cleveland Clinic specialists like Dr. Hannick, including our team of pediatric urology nurse practitioners who can help guide families through the next steps in a way that's supportive and kid centered.

Dr. Hannick, thank you so much for your time and sharing your expertise today and for helping to normalize a topic that so many families struggle with quietly. And to our listeners, thanks for being with us today. If you found this episode helpful, we encourage you to share it with other parents or caregivers who might benefit. If you'd like to schedule an appointment with Dr. Hannick or another pediatric urologist at Cleveland Clinic, please call 216-444-5600. That's 216-444-5600. Thank you so much.

Dr. Richard So:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the Little Health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/littlehealth.