My 7 year old still wets the bed, how can I help them?

Why does my child still pee the bed?

How can I help my child with enuresis?

First, I want you to know that you are NOT alone in this journey. 5-7 MILLION kids have enuresis. 15% of girls and 22% boys experience bed wetting.

Next, I want to acknowledge a concern many parents have around bedwetting. In my formal training at school I was taught that the number one cause of bedwetting was emotional or physical or sexual abuse. And I'm here to say, I'm sorry. I've learned a lot since then and I promise I'm working hard behind the scenes to change that education. No parent should be afraid to talk to their provider for fear of negative backlash. I want you know that your child's bowel and bladder habits are not a negative reflection on you or anything you have done. If you are afraid to ask your pediatrician for help, please reach out. I will do my best to find someone in your area that can help you with the compassion and listening skills you and your child deserve.

What is Bedwetting or Enuresis?

Bedwetting, or enuresis, is when a child over the age of 5 continues to wet the bed. The age of 5 is important because most kids don't have full bladder control until 4 years of age. Nighttime bladder control can take an additional 10 months after daytime control!

Primary enuresis affects 90% of children who continue wetting the bed. This is when a child has a negative UTI, a "normal" physical exam and who were previously dry for less than 6 months.

What's the likelihood my kid will "grow out of bedwetting"?

I'm going to do a gross generalization and say that most pediatricians are not trained in bedwetting or how to help with it. So you've probably been told to "wait and see" because they'll "grow out of it". The reason this is the main recommendation is because only ~10% of 6 year olds continue to wet the bed. After the age of 6 we expect a spontaneous cure rate of 15% each year with 1-3% of 18 year olds continuing to wet the bed.

A 90% success rate by the age of 6 sounds amazing, unless you're in that 10% and wondering what the next steps are to help your child stop leaking at night.

Genetics and Bedwetting

Did you or your partner wet the bed for an extended period of time? If so there's a chance your kiddo has nocturnal polyuria. If one parent had issues there's a 40% chance your child will too. If both parents had issues, that chance increases up to 77%.

Nocturnal polyuria is when your child pees the correct volume throughout the day but instead of peeing more during the day, the body produces more at night. This is because the body produces a hormone called antidiuretic hormone which should naturally slow the production and output of pee in the night. In those with enuresis this hormone decreases, causing the child to wet the bed.

The good news is that Desmopressin, a medication to increase the antidiuretic hormone, is fairly effective for these kiddos. The bad news is that it sometimes doesn't resolve the problem so if they forget to take the medicine or stop the medication, they may still have enuresis. Some families choose to keep it "on hand" for travel or sleep overs so the child isn't embarrassed if they have an accident when they aren't at home.

The other good news is that genetics interact with the environment to determine the outcome. So just because it's genetic, doesn't mean there isn't hope. Pediatric pelvic floor rehab along with bedwetting alarms and dry morning programs have been shown to help kids, even those with a genetic component, to decrease bedwetting.

Sleep Apnea or Upper Airway Obstruction and Bedwetting

Does your child snore louder than a train? Do they wake up tired or angry every morning? Do they occasionally gasp for air in their sleep or breath through their mouth at night? Can you hear them breathe while they sleep? Do they sleep in weird positions or arch their head back in their sleep? Do they possibly grind their teeth at night? Or maybe they wake up every single sleep cycle? Do they toss and turn in their sleep like they fought an alligator all night? Or maybe they have shiners under their eyes like they haven't slept in years. Does your child have difficulty falling asleep (have you researched the best sleep aids for kids) or do they wake in the middle of the night and have difficulty going back to sleep? Are they super light sleepers or deep sleepers and there’s no waking them? Do they wake up groggy and moody or feel tired during the day? Do they have nightmares or sleep walk and talk? Do they frequently fidget or seem hyperactive during the day? All of these are signs of sleep disturbed rest and warrant further evaluation to figure out why.

Anywhere from 8-47% of kids with enuresis also have upper airway obstruction (research, ya gotta love the wide ranges). This can be caused by enlarged tonsils and adenoids as 43.5% of kids become dry after having them removed. Now, the real question I ask is why are the tonsils and adenoids enlarged to begin with? And that usually comes back to open mouth breathing, the tongue hanging out on the bottom of the mouth instead of the roof, allergies and sinus infections, the inability to breathe through the nose, and/or tongue ties. A pediatric ENT is helpful to determine if the sleep apnea requires urgent attention or if it is safe to wait and try conservative care. If it's not urgent, finding a pediatric myofunctional therapist and pediatric airway-focused dentist is a great next step to find the cause of their disturbed sleep.

If you're new to the "how does breathing impact my sleep" world, I also invite you to check out this blog on CPAPs https://drlaurenkeller.com/blog/2023/8/16/are-there-alternatives-for-a-cpap and this one on the many aspects of a tongue tie https://drlaurenkeller.com/blog/tonguetiesandteamwork and for good measure, this one on the jaw and pelvic floor connection https://drlaurenkeller.com/blog/2022/5/23/5xlrzq50dx7n127nsavetabxr7jseg

Neurodivergence, Sensory Processing Disorder and Bedwetting

ADHD is associated with a three times greater risk of enuresis. Up to 38% of autistic children wet the bed past the age of 5. For sensory processing disorder, 44% of school-aged kids with incontinence also have SPD (they haven't looked at enuresis alone…yet). Admittedly, I couldn't find any information for AuDHD people, but my guess is that it's close to 38%, if not higher. We don't know for sure why this is the case but we have a couple of ideas:

*Interoception is the ability to feel what's going on in your body…those internal sensations and signals that say "oh, I'm hungry," or "I need to drink water," "I'm hurt," or "I have to pee or poop." Oftentimes ND people have decreased interoception, or they aren't able to perceive the signals their body is sending them. One key thing here is that if your child says they don't feel the urge to pee or poop, they are telling the truth!

If your child has an activity level of 10/10 at all times, can spin circles and never get dizzy, are "really clumsy" and constantly crash into things, or they are super picky eaters, they may have a sensory processing disorder. Not sure if your child might have sensory processing disorder? I highly recommend you check out https://sensoryhealth.org/basic/symptoms-checklist and fill out their symptom checklist. A great book to learn about this is Lindsey Biel's, "Raising A Sensory Smart Child."

If you have a Neurodivergent child, please find a play-based OT trained in sensory processing and interoception. I'll jump on a soap box here and beg you to not do ABA therapy for potty training. Greg Santucci, OT has an amazing facebook page to help you understand why ABA is not the best option for our kiddos. OTs trained in sensory processing and interoception can help your child better learn their body's cues and signals. If you're in Illinois, I absolutely love The Balanced Kid in Westmont/Naperville.

*Anxiety and Stress

Autistic children often have higher levels of anxiety than their peers. Anxiety is closely related to bedwetting. If you recently moved, had another child, divorced or if someone or a pet passed away and your child started wetting the bed, stress may be a cause. Sometimes navigating stress and increasing connection can help improve bedwetting. Mona Delahooke has an amazing book, Brain-Body Parenting, which goes over how to better understand and support your child's nervous system (this is great for ND people and neurotypical people).

Along with a sensory-based OT, I recommend finding someone trained in pediatric pelvic floor rehab (PT, OT, chiro) to assist with incontinence or enuresis after learning your child's sensory needs.

Muscle strength, coordination and tone for Bed Wetting

Technically this could go in the ND section above, but it's important enough I decided to give muscle strength its own section. Have you ever considered all of the coordination it takes in order to pee and poop? I could write another blog on it, but let's just say it's a lot. One thing I find fascinating is that 60-70% of kids with enuresis also have pelvic floor muscle insufficiency.

If your kiddo "never lost the baby belly" or "has a really big curve in their low back" or they "have rigid 6 pack abs of steel," or they "dribble pee a little during the day," it's important to address muscle tone, strength and coordination. For these kiddos, a great next step is to find a pediatric pelvic floor rehab provider to help them improve muscle tone and learn how to use it for bowel and bladder support.

Non-Optimal Daytime Bladder Habits and Bedwetting

Does your child feel like they need to pee ALL the time and then take 2 seconds to actually go? Do they get to the house and immediately have to go, even if they didn't need to 2 minutes ago? Does the sound of a sink trickling water or a fire hose make them need to pee? Or maybe they have a "bladder of steel" and can hold it all day long? Both urgency and holding of urine throughout the day is related to increased enuresis frequency and severity.

Ideally kids should pee 5-6 times a day. If they aren't drinking enough during the day (especially at school), then they may drink a lot more fluids between the end of school and bedtime. This fluid loading before bed can lead to bedwetting. One way to help kiddos drink more throughout the day is to have a clear water bottle and mark how much water they should drink by key points in the day (2oz before math, 2oz more before lunch, 2oz after recess, 2oz before PE, etc). This is more helpful for the visual learners who may forget to drink throughout the day, but now have specific mini goals.

I often hear parents recommending to restrict fluids for 1-3 hours before bed. IF your child has consumed enough water throughout the day, this is an easy and safe thing to try. On the otherhand, if your child doesn’t remember to drink water during the day, the risks surrounding dehydration are usually far greater than bedwetting. The goal should first be to increase drinking throughout the day!

If this sounds like your kiddo, finding a pediatric pelvic floor rehab provider (OT, PT, chiro) is the next step to work on retraining the bladder.

Detrusor Overactivity

If your child experiences urge incontinence or the need to go pee RIGHT NOW, that's a sign of a possible detrusor overactivity. The detrusor is the smooth muscle of the bladder that is relaxed to let the bladder fill and store urine and contracts to release the urine. You can think of this as the kid with an overactive bladder or "small bladder."

Depending on the cause and other symptoms your child has, possible treatment includes timed voids (making sure they pee at regular intervals), anticholinergic medication, biofeedback, alpha blockers medication, or something as simple as urge control techniques. If your child experiences urge incontinence or can't feel the urge to pee until right before they need to go, a team of a pediatric urologist and pediatric pelvic floor rehab provider is key to hit all aspects of care.

Constipation and Bedwetting

There's a saying in pediatric pelvic floor that "you're constipated until proven innocent." Now, you might be thinking, "but my kid poops every day!" While that's true, that does not mean they are fully releasing their bowel movement everyday. 64% of constipated kiddos actually have "normal" bowel movement frequencies. Plus, 49% of constipated kiddos have normal stool consistency! If your child has any abdominal pain, weird body odor, extra large poops (they either clog up a toilet in size or you look at them and are amazed at how big and round they are), decreased appetite, are leaking urine or frequently have diarrhea or poop that is super skinny, they may actually be constipated! If you're not sure, a KUB with a rectal measurement or transabdominal ultrasound from your pediatrician or urologist can help rule out/in constipation.

The rectum (where poop exits from) sits directly behind the bladder in males and behind the uterus in females. When the rectum is stretched due to constipation, that pressure has to go somewhere and it often goes forward and puts pressure on the bladder. That pressure on the bladder then makes the detrusor muscle we just talked about a little weak and it's not able to effectively control the bladder and urine.

Some studies have shown that managing constipation alone improves enuresis. Other studies have shown that if a child has enuresis and daytime incontinence then treating the constipation alone does not improve enuresis. This is where a team approach excels. A functional medicine provider can help make sure your child is getting enough fiber (and not too much…if your child eats corn and you don't see it for a few days, then try to decrease fiber for a few days). Kids 4-8years old need 25 grams of fiber. Meanwhile, a pediatric pelvic floor rehab provider can work on any functional issues and offer conservative care while a urologist can monitor if the child needs extra care or is constipated!

In the meantime, you can make sure your child is first and foremost hydrated with both water and electrolytes. You can try to increase their fiber intake (unless they have super slow poop), increase their activity level and avoid constipating foods like bananas, applesauce (apples with the peel are okay), marshmallow, peanut butter, and dairy products including cheese. You can also have them try sipping warm water in the morning and sitting on the toilet within 30 minutes of meals to try and stimulate the bowels.

There are also plenty of clean out protocols like the M.O.P. that can help with constipation but those need to be followed closely by your urologist or pediatrician. If you're interested in a clean out, reach out to one of those providers as they are not easy and a child can become dehydrated if not properly followed.

Side note because it's important…if your child withholds their stool, suffers from encopresis or skid marks, please know this is involuntary. They are probably just as frustrated or embarrassed and they need your unconditional love and connection. Oftentimes parents are told kids are "stubborn" or "doing it for attention" or they just need "more consequences or rewards." What they really need is to know that you love them even if they wet the bed. That their bowel habits don't make them bad. That they haven't learned to stop wetting the bed YET and you can work on it together as a team.

Bladder irritants and enuresis

I want to start this section by reminding you that your child is unique. These are common bladder irritants that can cause the bladder to overreact. That doesn't mean they irritate your child's bladder.

Bladder irritants include acidic foods, tomato-based products, soda/pop, coffee ;), tea, curry, citrus fruits and juices, spicy foods, milk/dairy, anything carbonated, artificial sweeteners, chocolate and foods with red or blue dye in them.

Oftentimes if you remove common bladder irritants from your kid's diet for two weeks and then add them in one-by-one waiting three days in between, you can find out what does and does not irritate your child's bladder. If you find yourself needing extra support, a functional medicine provider who can give personalized nutrition and supplement advice is a great next step.

Training Systems and Alarms

GoGoBand: The research on the GoGoBand System showed far greater improvement in frequency of bed wetting episodes than alarm systems. I personally like this band because it uses HRV (which can also monitor stress) to wake the person right before they need to pee. This system uses your kid's individual response to bedwetting as a way to learn about their body and alert them to wake up if they need to pee. The exciting part of this is that there's a 96% success rate for those in the weaning phase of the system.

Other Considerations for Bedwetting Causes:

If your child was previously dry and you've ruled out all of the above, there are a few other things to consider like diabetes, UTIs, anemia, kidney issues (dehydration or too much water and not enough electrolytes) and musculoskeletal dysfunction. All of these factors need to be ruled out so make sure you talk to your pediatrician about your child's bedwetting.

If your child has never been dry, you might look into structural/anatomical differences through a pediatric urologist.

Supporting Your Child with Enuresis in the Meantime

Peejamas is an eco-friendly, super absorbent pajama that goes up to size 8/9. They are designed to hold up to three average sized pees a night (but they do sometimes leak). For the heavy wetters they also have extra booster pads to go in the pajamas and mattress protectors. If you're tired of constantly buying pull-ups, having two pairs of these and washing them daily or every other day may be beneficial.

PeepodMats is another great option to help in the meantime. Think of the little white and value pads that dogs pee on, but these are soft cloth ones made for humans. They can be washed and used again. These are especially helpful for the big wetters who may pee through pullups.

Meditate

This one's for you. I wish I could say this journey was easy and quick. Unfortunately, as you have probably already realized, it usually isn't. It takes time, patience, an awesome team of providers and a lot of work. It's a journey…and not always an easy one. But I don't want you to give up hope. The next time you find yourself frustrated and annoyed that you're cleaning sheets again or because you feel your kiddo took a step backwards in their bedwetting, take a deep breath. Reset yourself. Meditate or practice Non-Sleep Deep Rest (https://youtu.be/5ZRH-S9Aucs?si=j-jf9d0gEmBZ2jVc) so you can reset your nervous system so you can be there to support your child on this journey.