Clinical Reference Systems: Pediatric Advisor 10.0
Enuresis (bed-wetting) is the term used for the involuntary
passage of urine during sleep. We consider it normal until
at least age 6.
Most of these children have inherited small bladders, which
cannot hold all the urine produced in a night. In addition,
they are deep sleepers who don't awaken to the signal of a
full bladder. The kidneys are normal. Physical causes are
very rare, and your physician can easily detect them.
Emotional problems do not cause enuresis, but they can occur
if it is mishandled.
Measure your child's bladder size to help you understand how
important it is for him to get up at night. Do this by
having your child hold his urine as long as possible on at
least three occasions. Have your child urinate into a
container each time. Measure the amount of urine in ounces.
The largest of the three measurements can be considered your
child's bladder capacity. The normal capacity for children
is 1 or more ounces per year of age.
Most children who are bed-wetting overcome the problem
between ages 6 and 10. Even without treatment, all children
eventually get over it. Therefore, treatments that might
have harmful complications should not be used. On the other
hand, treatments without side effects can be started as soon
as your child has had complete bladder control during the
daytime for 6 to 12 months.
Home Care for a Child of Any Age Who Is Bed-Wetting
- Encourage your child to get up to urinate during the
This advice is more important than any other. Tell your
child at bedtime, "Try to get up when you have to pee."
- Improve access to the toilet.
Put a night light in the bathroom. If the bathroom is
at a distant location, try to put a portable toilet in
your child's bedroom. Boys will do fine with a bucket.
- Encourage daytime fluids.
Encourage your child to drink a lot during the morning
and early afternoon. The more your child drinks, the
more urine your child will produce, and more urine leads
to larger bladders.
- Discourage evening fluids.
Discourage your child from drinking a lot during the 2
hours before bedtime. Give gentle reminders about this,
but don't worry about normal amounts of drinking. Avoid
any drinks containing caffeine.
- Empty the bladder at bedtime.
Sometimes the parent needs to remind the child. Older
children may respond better to a sign at their bedside
or on the bathroom mirror.
- Take your child out of diapers or Pull-ups.
Although this protective layer makes morning clean-up
easier, it can interfere with motivation for getting up
at night. Use Pull-ups or special absorbent underpants
selectively for camping or overnights at other people's
homes. Use them only if your child wants to use them.
They should rarely be permitted beyond age 8.
- Protect the bed from urine.
Odor becomes a problem if urine soaks into the mattress
or blankets. Protect the mattress with a plastic
- Include your child in morning clean-up.
Including your child as a helper in stripping the
bedclothes and putting them into the washing machine
provides a natural disincentive for being wet. Older
children can perform this task independently. Also,
make sure that your child takes a shower each morning so
that he or she does not smell of urine in school.
- Respond positively to dry nights.
Praise your child on mornings when he wakes up dry. A
calendar with gold stars or happy faces for dry nights
may also help.
- Respond gently to wet nights.
Your child does not like being wet. Most bed-wetters
feel quite guilty and embarrassed about this problem.
They need support and encouragement, not blame or
punishment. Siblings should not be allowed to tease
bed-wetters. Your home needs to be a safe haven for
your child. Punishment or pressure will delay a cure
and cause secondary emotional problems.
Additional Home Care When Your Child Reaches Age 6
Follow the previous recommendations in addition to the
guidelines given below:
- Help your child understand his goal.
The key to becoming dry is to learn how to self-awaken
every night and find the toilet. Getting up and
urinating during the night can keep your child dry
regardless of how small the bladder is or how much fluid
he drinks. Help your child assume responsibility for
doing this. Some children think that enuresis is the
parent's problem to solve; they need to be reminded that
"only you can solve this."
- Have a bedtime pep talk about self-awakening.
To help your child learn to awaken himself at night,
encourage him to practice the following routine at
- Lie on your bed with your eyes closed.
- Pretend it's the middle of the night.
- Pretend your bladder is full.
- Pretend you feel the pressure.
- Pretend your bladder is trying to wake you up.
- Pretend your bladder is saying, "Get up before it's
- Then run to the bathroom and empty your bladder.
- Remind yourself to get up like this during the night.
- Daytime practice of self-awakening.
Whenever you have an urge to urinate and you're home, go
to your bedroom rather than the bathroom. Lie down and
pretend you're sleeping. Tell yourself this is how your
bladder feels during the night when it tries to awaken
you. After a few minutes, go to the bathroom and
urinate (just as you should at night).
If self-awakening fails, use parent-awakening to teach
your child the correct goal: urinating into the toilet
during the night. It makes much more sense than putting
your child back into pull-ups and having him urinate in
bed every night (the wrong goal). Your job is to wake
your child up; his job is to locate the bathroom and use
the toilet. You can awaken him at your bedtime. Try a
hierarchy of prompts (the minimal one being the best),
ranging from turning on a light, saying his name,
touching him, shaking him or turning on an alarm clock.
If your child is confused and very hard to awaken, try
again in 20 minutes. Once he's awake, he needs to find
the bathroom without any directions or guidance. When
he awakens quickly to sound or touch for 7 consecutive
nights, he's either cured or ready for an enuresis
- Encourage changing wet clothes during the night.
If your child wets at night, he should try to get up and
change clothes. First, if your child feels any urine
leaking out, he should try to stop the flow of urine.
Second, he should hurry to the toilet to see if he has
any urine left in his bladder. Third, he should change
himself and put a dry towel over the wet part of the
bed. (This step can be made easier if you always keep
dry pajamas and towels on a chair near the bed.)
The child who shows the motivation to carry out these
steps is close to being able to awaken from the
sensation of a full bladder.
Additional Intervention When Your Child Reaches Age 8
Follow the previous recommendations. Talk with your
physician about possibly using enuresis alarms or drugs as
well, as described below:
- Bed-wetting alarms
Alarms are used to teach a child to awaken when he needs
to urinate during the night. They go off when they
become wet. One type awakens you with a loud noise
(buzzer), the other type with an annoying vibration.
They have the highest cure rate (about 70%) of any
available approach. They are the treatment of choice
for any bed-wetter with a small bladder who can't
otherwise train himself to awaken at night. The new
transistorized alarms are small, lightweight, sensitive
to a few drops of urine, not too expensive (about $50),
and easy for a child to set up by himself. Some
children as young as 5 years want to use them. Children
using alarms still need to work on the self-awakening
For further information see Bed-wetting Alarms.
- Alarm clock
If your child is unable to awaken himself at night and
you can't afford a bed-wetting alarm, teach him to use
an alarm clock or clock radio. Set it for 3 or 4 hours
after your child goes to bed. Put it beyond arm's
reach. Encourage your child to practice responding to
the alarm during the day while lying on the bed with
eyes closed. Have your child set the alarm each night.
Praise your child for getting up at night, even if he
isn't dry in the morning.
Most bed-wetters need extra help with staying dry during
slumber parties, camping trips, vacations, or other
overnights. Some take an alarm clock with them and stay
dry by awakening once at night. Some are helped by
temporarily taking a drug at bedtime. One drug (given
by nasal spray) decreases urine production at night and
is quite safe. Another drug (taken as a pill)
temporarily increases bladder capacity. It is safe at
the correct dosage but dangerous if too much is taken
or a younger sibling gets into it.
If you do use a medication, be careful about the amount
you use and where you store the drug, and be sure to
keep the safety cap on the bottle. The drawback of
these medicines is that when they are stopped, the
bed-wetting usually returns. They do not cure
bed-wetting. Therefore, children taking drugs for
enuresis should also be using an alarm and learning to
get up at night.
Call Your Child's Physician During Office Hours If:
- Urination causes pain or burning.
- The stream of urine is weak or dribbly.
- Your child also wets during the daytime.
- Your child also drinks excessive fluids.
- Bedwetting is a new problem (your child used to stay
- Your child is over 12 years old.
- Your child is over 6 years old and is not better after 3
months of following this treatment program.