Bed-wetting and Other Toileting Concerns
While most kids are fully potty-trained by age 4, many go on to struggle with nighttime bed-wetting or daytime accidents. Though frustrating and embarrassing for kids and their parents, these conditions – known medically as enuresis (accidental urination) and encopresis (stooling somewhere other than a toilet) – are common and treatable.
Dealing with Enuresis
There are two types of enuresis:
• primary – when a child consistently wets (day or night), either daily or having a few episodes per week; and
• secondary – when a child maintains a period of dryness and then reverts back to wetting.
Secondary enuresis can be a symptom of other medical problems, such as a urinary tract infection or a psychological condition, notes Peter Greenspan, M.D., medical director and vice chair of pediatrics at Massachusetts General Hospital for Children. Your child’s pediatrician can pinpoint these causes with a thorough medical exam.
The AAP cites several causes for primary enuresis, including small bladder capacity, increased nighttime urine production, poor arousal from sleep and constipation. The important thing for parents to remember is that enuresis is not a behavioral problem. It’s a developmental delay between the child’s brain and bladder, in which a wake-up response is not invoked, says Kimberly Dunn, a pediatric nurse practitioner for Boston Children’s Hospital and lead instructor for the hospital’s toilet training program.
While the ordeal can be challenging and costly (due to excessive laundering and the need for “pulls-ups”), Greenspan and Dunn advise parents to hang in there. Applauding a dry night and not scolding when there’s a setback is key.
“If the child is 5 or under, I would encourage parents not to worry [about bed-wetting],” Greenspan says. Sleepovers with friends can be a big motivator for change. Once the child becomes uncomfortable about wetting and is interested in doing something about it, Greenspan says it’s time to act. Let the child know that others have the same problem and it can be overcome.
Then talk with your child’s pediatrician, who may recommend one or more of these strategies:
• Bed-wetting alarm – Pediatric experts say the bed-wetting alarm, a small device that goes into the underwear or clips to pajamas, yields the highest success rate. When the device’s wetness sensor detects moisture, an alarm goes off, prompting the child to awaken and get to the bathroom. After weeks of alarm conditioning, experts say, the child will begin to wake up and go to the bathroom on his or her own.
• Limit the liquids – Some pediatric experts suggest eliminating fluid consumption after dinner.
• Keep your child regular – Regularity is key because when a child is constipated, stool puts pressure on the bladder and that pressure may prompt nighttime accidents.
• Ask about medication – Sometimes a doctor will prescribe desmopressin (with the brand name DDAVP), a synthetic hormone given at bedtime that reduces urine production. Medication is a temporary measure that won’t cure the problem.&pagebreaking&
Dealing with Encopresis
The AAP defines encopresis as the passing of stool in the underwear beyond the toilet training years. It is a chronic, complex problem, but it is solvable.
The primary cause, experts say, is constipation. If a child is constipated (due to holding stool in, unsuccessful toilet training, toilet refusal or the child is anatomically predisposed to constipation), a fecal mass forms, grows and hardens. As the intestinal walls and the nerves within them stretch, nerve sensations in the area diminish. The intestines lose their ability to contract and expel the stool.
Over time, passing stool becomes increasingly uncomfortable and painful – further exasperating the problem. Eventually, the sphincter muscle that holds the stool in the rectum no longer functions properly, and the large fecal mass is stored in the colon. Liquid stool begins to seep around the mass, causing soiling or smaller stools in the child’s undergarments. In fact, because of the decreased sensation, a child may pass stool unaware.
Under a doctor’s care and with a long-term plan in place, Greenspan and Dunn first suggest an intestinal clean-out using a suppository and/or an enema. The next step is to keep the child regular.
A diet rich in fiber and water, and daily, consistently timed visits to the bathroom are key. During toilet time, encourage the child to read a favorite book or play with a hand-held gaming device, with the goal being to create a stress-free toileting experience.
Medications, such as a stool softener, Lactulose (a synthetic sugar) or laxatives might also be prescribed. Consult with your pediatrician before introducing any of these.
If your child has experienced a trauma, behavioral changes or mental health issues in conjunction with encopresis or enuresis symptoms, contact your pediatrician for further medical investigation.
Occasional relapses are normal. Maintain a low-key attitude when accidents occur, never scold or punish a child for them, and praise successes. “Celebrate the small gains,” says Dunn. “Stay the course and stay positive.
Maureen McCarthy is a freelance writer and mother of two in Hanover.
Search these health websites for more information on enuresis and encopresis.
• American Academy of Pediatrics – www.aap.org.
• Massachusetts General Hospital, Boston – www.massgeneral.org.
• Boston Children’s Hospital, Boston – www.childrenshospital.org.