Bedwetting in children

Bedwetting is passing urine during sleep in a child who is old enough to be waking up dry. A soaked sheet in the middle of the night wears out the whole family: the washing, the broken sleep, the sleepovers turned down, the tears in the morning. Parents usually suspect character, laziness, or something they themselves got wrong. Almost always they are mistaken. What follows covers the age at which wet nights are simply ordinary, what actually lies behind them, what helps and what only burns energy, and the signs that mean a doctor should be seen without delay.

The age at which this is simply ordinary

Staying dry at night is a skill that matures on its own, much like walking, and it arrives at a different age in every child. Daytime control almost always comes long before night-time control, because staying dry through the night needs three things at once: the kidneys making less urine towards the night, the bladder holding what collects for several hours, and the sleeping brain picking up the filling signal and waking the child. The three pieces rarely fall into place together.

Up to about the age of five, wet nights are not regarded as a disorder at all — the skill has simply not matured. After that we speak of bedwetting, and even then it is no verdict. Every year a substantial share of children stop wetting the bed by themselves, with no treatment of any kind, and very few are still doing so as teenagers. Time, in other words, is on your side. That is not a reason to sit and wait if the child is miserable, but it is a reason not to panic.

One more fact that settles families down: bedwetting often runs in the family. If one parent stayed wet at night for a long time, the child's chances are noticeably higher. This is an inherited pattern of maturing, not a bad habit picked up from someone.

The child is not to blame and is not doing it deliberately

At night the child has no control over passing urine, because the child is asleep. This is worth saying plainly, because children are still told off, shamed and punished over it. A child who wets the bed is not lazy, is not getting even with anyone, is not after attention, and could not "manage it if they really tried". Punishments, screen time withdrawn, comparisons with a younger brother and remarks along the lines of "aren't you ashamed" speed up nothing at all. They reliably achieve two things: the child starts hiding wet bedding, and the child stops telling you what is going on.

The real harm here is shame, not the wet bed. Children who wet the bed turn down camps, trips and sleepovers more often, withdraw and think of themselves as worse than everyone else — and the weight of that has almost nothing to do with how many nights a week it actually happens. So the first move, before any treatment, is to lift the blame off the child. Tell them it happens to plenty of people, that it will pass, and that you are not angry. Set the household up so that a wet night costs as little stress as possible: a waterproof mattress cover, dry pyjamas and a spare sheet within reach, a night light and a clear route to the toilet. An older child can change the bedding themselves — not as a punishment, but so as not to feel helpless.

What is actually going on

Usually several causes overlap, and all of them are about maturing rather than behaviour:

• too much urine is made overnight. In an adult the body releases a hormone towards the night that cuts urine production; in some children that daily rhythm settles later, and the bladder fills twice before morning;
• the bladder holds very little. Daytime signs usually go with it: frequent trips to the toilet, a sudden dash "right now", occasionally not making it;
• the filling signal does not wake the child. These are very deep sleepers, hard to rouse in the small hours;
• constipation — covered separately below;
• stress and upheaval: moving house, a new school, a separation, a new baby, bullying. These are not tantrums; a child has no way of switching off the body's response by willpower.

Less often there is an illness behind it: a urine infection, diabetes, sleep apnoea, long-standing constipation, and rarely neurological or urological problems. Those are exactly what a doctor rules out first, which is why the child should be examined even when you are sure it is only a question of growing up.

Constipation, the first thing to look for

This is the commonest cause and the easiest to put right, and it is the one parents almost never think of. A loaded rectum sits directly against the bladder, presses on it and stops it filling and emptying properly. The child starts wetting at night, and sometimes has daytime accidents too. Clear the constipation and, in a fair number of children, the wet nights stop on their own — no alarm, no medicine.

The catch is that constipation can be invisible. A child may open their bowels every day and still be loaded: small amounts come away each time while the hard mass stays put. Infrequent or very hard stools, pain on opening the bowels, a stool so large it blocks the toilet, soiling in the underwear, tummy ache and a poor appetite all point that way. Mention it at the first appointment even if nobody asks — feeling the tummy is often done for exactly this reason.

What genuinely works

If wet nights are getting in the way of the child's life, there is no need to wait it out. Two approaches have solid evidence behind them, and both are started by a doctor.

• A bedwetting alarm. A small sensor in the pants or on the sheet picks up the first drops and sets off a sound or a vibration. The point is not to get the child up to the toilet; it is to let the brain gradually connect a filling bladder with waking. It asks for patience: for the first weeks the parents wake along with the child, the effect is not immediate, and a course runs for weeks or months. In return, the result more often holds once the alarm is stopped, and that is its great advantage.
• Desmopressin. This is a version of the same hormone that reduces urine production overnight. It works quickly, helps a great many children and is genuinely useful when a dry night is needed on a particular date — a trip, a camp, a night at a friend's house. Wet nights often return once it is stopped, so it is used in courses or for specific occasions. It is a prescription medicine and comes with one condition that must not be ignored: fluids are limited in the evening and overnight. The dose and the schedule are the doctor's decision.

The two are sometimes combined, and where there are daytime symptoms and signs of an overactive bladder, other treatment is added. If nothing helps, the child is referred to a paediatric urologist or a kidney specialist.

A simple diary earns its keep too: for a few weeks, note the dry and wet nights, how much the child drinks, how often they go during the day and whether the bowels have opened. It is dull work, but that record is what shows a doctor the shape of the problem, and it picks up improvement that nobody at home would notice by eye.

What does not work, and what does harm

A whole set of measures has grown up around bedwetting, passed down the generations and worth nothing:

• restricting drinks during the day is harmful. A dehydrated child concentrates worse and gets constipated more, and a bladder kept permanently on small volumes loses the habit of holding on, so the daytime gets worse rather than better. Normal, free drinking through the day is what is wanted, school included;
• cutting out fizzy drinks, tea, coffee, cocoa and energy drinks in the evening does make sense. Caffeine increases urine production, and this is the one sensible restriction of the lot. Shifting most of the day's fluid into the earlier hours is reasonable; refusing a thirsty child a drink is not;
• waking the child at night and carrying them to the toilet achieves nothing. The child passes urine half asleep, learns nothing from it, and the moment the lifting stops everything returns. Meanwhile the parents have gone months without sleep;
• a nappy past a certain age neither spoils nor cures anything in itself; it is a question of convenience and of how the child feels about it;
• punishments and privileges withdrawn "for motivation" do not work, full stop. Rewards make sense only for something the child can actually do — using the toilet before bed, helping to strip the bed — never for a dry night, because a dry night is not within their control.

When to see a doctor without delay

It is worth seeing a doctor if a child over five is still wetting the bed and it bothers them or the family; there is no need to wait for it to be outgrown. But some signs mean the appointment should not be put off, because what lies behind them is illness rather than maturing:

• the child was dry for six months or more and has started wetting again. This is secondary bedwetting and it always needs explaining: a urine infection, diabetes, constipation, sleep apnoea and difficult events in the child's life are all looked for;
• daytime wetting, damp underwear, sudden uncontrollable urgency, going to the toilet far too often or, conversely, very rarely;
• pain or burning on passing urine, cloudy or smelly urine, fever, pain in the back or tummy — this is how a urine infection shows itself, and it is treated straight away;
• heavy thirst, drinking and passing large amounts, losing weight, unusually tired — this can be diabetes appearing for the first time. A doctor is needed the same day; with drowsiness, vomiting and breath smelling of acetone, call an ambulance;
• loud snoring with pauses in breathing, mouth breathing in sleep, restless nights and daytime sleepiness. Sleep apnoea in children often shows up precisely as wet nights, and it is treated by an ear, nose and throat specialist;
• a weak stream, straining, a sense of not emptying fully, constant dribbling of urine;
• soiling in the underwear, tummy pain, bowels opening fewer than three times a week — the marks of the constipation that should be dealt with first;
• the child is low, has withdrawn, avoids school and friends because of the bedwetting. That is a reason to be seen as well, and no less pressing than the rest.

Online consultation

An online doctor can go through the details with you: how many wet nights there are, whether daytime symptoms exist, how the bowels are working, what has already been tried and how the child is coping. They will say whether a urine test and a face-to-face examination are needed, explain how a bedwetting alarm works and whether it suits your family, and what comes next if it has not helped. They can separate ordinary late maturing from the signs that call for investigation — and, not least, take away the parents' feeling that they must be doing something wrong.

This material is for information only and does not replace medical advice.