Children usually become dry at night between three and four
years old. Some do it sooner, often when they are being
trained in the day, others manage it a bit later, at four or
five. The question arises — at what age has the child
"got a problem" for which we need to seek medical advice, and
is there anything we can do in the meantime?
Firstly, you have to distinguish between those who never
became dry in the first place, and those children who start
to wet their beds at night after a long period of dryness.
Looking at the former group first. There are four main causes
of night incontinence. 1. The child fails to wake at the
signal that s/he needs to go to the toilet. 2. The child
fails to produce a hormone that shuts down the kidneys at
night, reducing the need to empty the bladder. 3. The bladder
is irritated or infected. 4. The bladder is too small.
Each cause has a different solution. 1. If the child fails to
wake, a pad can be placed next to the skin, and when it
becomes wet, a loud alarm rings which wakes the child (and
the rest of the house) and the child is supposed to stop
wetting and run to the bathroom. The treatment is often
successful after a few months (!) assuming that this is the
only issue of the four that needs addressing.
2. If the child is failing to produce the hormone that shuts
down the kidneys, then this can be given in an artificial
form, as a tablet, before bedtime. This does not cure the
problem, but after three months they should come off it for a
week to see if it is still needed.
3. Tests can be run to see if there is an undetected
infection, and suitable treatment given. There are treatments
for an irritated bladder as well. It is important to note
that not drinking makes the problem worse, and it is
important for the child to have plenty of fluids.
4. If the bladder is too small, there are various exercises
that can be done. Often the small bladder is also irritated,
as it is emptied too often. The child is encouraged to drink,
and to ignore the initial signs of needing to void. Medical
guidance is essential.
Now, without boring you with statistics and studies, most
children who have a problem in this area are boys, and most
have at least one parent who had this problem, as there are
strong hereditary links. Also, thankfully, most children grow
out of it, even without intervention, but perhaps not until
they are teenagers. Meaning, the bladder will eventually grow
big enough, or the hormone will start to be produced, or the
ability to wake will kick in.
What we also know is that children who wet their beds at
night suffer. They suffer having to be changed, and possibly
showered in the middle of the night. Some children get rashes
if they lie in wet pyjamas for some time before waking, or
being noticed by a parent. They suffer shame (even if parents
are careful what they say — the children themselves
know — and other children in the family may not be as
restrained as the parents) and guilt (all that extra washing,
and it's very hard to hide your exasperation at two o'clock
in the morning!).
All this affects their self-esteem, and can have long-term
emotional consequences. Professionals in this area often feel
this is such a major issue that anything that keeps the child
dry, even if not a long-term cure (like tablets of artificial
hormone), is worth it.
A child who is not reliably dry at night should not be taken
out of diapers. If you want to train at night, and feel the
diaper impedes the process because the child will not feel
wet, then by all means try it for a week or two. But if you
meet consistent failure, then give up, put the diaper back
on, and try another time. Keep in mind that training at night
is affected very little by rewards or punishments, as this is
truly not in the child's control.
At what age do you decide that there is a problem and you
have to seek help? Well, you can always ask your pediatrician
to check for infection, especially if the child was difficult
to train in the day, goes very often, or seems to experience
any pain or difficulty. However, most clinics for bed-wetting
will see children after the age of seven. This may seem very
old, but the logic is that as most children outgrow the
problem without intervention, why not leave them alone.
Keep them in diapers until they are consistently dry. If you
feel that the child suffers for staying in diapers, when
younger children are out of them, you'd be surprised. Firstly
they are used to it, and if it just continues, they just
might not bring the subject up. If they start to plead not to
have a diaper, then put it on when they are asleep (and so
are the siblings) and they or you can remove it in private
when they wake up, and now there are these lovely pull-up
type that look like underpants (not that the children are
really fooled!), which they can slip on and off by
themselves. All these alternatives have to be better than a
wet bed — for the child, and for the mother.
Once you are dealing with an older child, it is very
important to explain to the child that he is not stupid or
bad for what is happening, but that there is probably a
straightforward physical explanation for their difficulties,
and if you know what it is, explain it. If either parent had
this problem, then openness will help. The trouble is that
many parents feel so much shame as a result of their own
experience that they cannot deal constructively with their
child, and as a result, they unwittingly pass on the shame.
To break this cycle, the parent needs to work on overcoming
their own feelings (perhaps with a counsellor?) so that they
can help the child.
Once you decide to go for help, you should make a note of
some things that the doctor will want to know. Did either
parent have this problem, and when did they grow out of it,
or what type of intervention was used (ask your mother, if
you can, if you don't know yourself)? How often does the
child generally need to void in the day? How much do they
drink in a day? How often does the child wet? For example,
once a night a few times a week, or twice a night every
night? Make a note of the color of the urine during the day
and in the morning (on the odd dry morning — if there
is one), as ideally, it should be basically water colored in
the day, and a deep yellow in the morning.
These facts, together with others, and various tests, can
help the doctor pinpoint the problem as closely as possible,
and suggest remedial action. The doctor will also be
concerned to deal with the emotional issues that arise and
reassure the child that they are going to get over this
problem.
We now take the second group of children, those who were dry
for a long period and then start wetting. [This excludes
children who become dry when they are being trained in the
day, because it is so much on their mind that they wake at
night also, but a few weeks later relax and go back to
wetting at night.] Firstly, infection should be ruled out, as
often it occurs without clear symptoms, and if left
untreated, can cause damage from scarring. Most often,
though, the issues are emotional, and the bed-wetting is a
form of emotional regression. This can be caused by the birth
of a new baby, or the prospect of starting school, or a
holiday. Even exciting things can cause great anxiety, as
children differ in their ability to handle new, unknown
situations.
One should consider the possibility that the child is being
bullied, at home or school, or that he is feeling pressured.
Unfortunately, in today's world one must always keep in mind
that there might be something very hidden going on, like
abuse. You should not rest until you can determine why the
child has started to wet. The child cannot always tell you
what the problem is (he's not being stubborn or secretive
— he just doesn't know), and in this case, professional
help may be required — don't just leave it. Remember,
the wetting itself will become a new cause for anxiety, and
has to be dealt with sensitively.
One cannot possibly talk about this issue without
acknowledging how grateful we have to be for the myriad of
times that this system works without fault, both in ourselves
and in our children. Many people with difficulties in this
area have had a yeshuah from working on saying the
asher yotzor brochohh with increased kavonoh,
and this is certainly an excellent hishtadlus, without
ignoring our responsibilities to seek help from professionals
where indicated.
