How to do it without nappies at night

Leon is crying. The mattress is wet again. His mum scolds him: «You're already five years old and you're still wetting the bed!» One thunderstorm follows the next, night after night. But the child just won't get dry. Like Leon, around 15 per cent of all five-year-old children still wet themselves regularly at night. Among seven-year-olds, the figure is ten per cent, and boys are affected twice as often as girls. Bedwetting is the second most common childhood condition after allergies. And the number of unreported cases is even higher: many parents and children shy away from going to the doctor out of shame.

However, only an expert can determine whether bedwetting requires treatment. They diagnose «enuresis», as bedwetting is medically known, when five or six-year-olds wet the bed at least two nights a month, and seven-year-olds or older children one night a month. But what is behind the uncontrollable bladder and how can you help your child?

Why exactly at night?

«Bedwetting can have many causes,» says urologist Daniela Schultz-Lampel, Head of the Continence Centre at the Schwarzwald-Baar Clinic in Villingen-Schwenningen. Firstly, the development of bladder control is crucial. All babies are born with what is known as an overactive bladder, which empties automatically as soon as it is full.

Over time, however, the child learns to control bladder emptying itself. «From the age of one to two years, inhibitory, controlling nerve pathways mature that calm the bladder,» says Schultz-Lampel. Such maturation processes are usually complete by the age of five. Children are then even woken by their full bladder during sleep.

Affected children are not yet able to properly control reflex bladder emptying.

Daniela Schultz-Lampel

In some children, however, the nerve pathways for this arousal stimulus develop relatively late and they are still unable to properly control reflex bladder emptying at the age of five. Developmental delays can also mean that the capacity of the bladder is still too small to hold urine at night.

«With these children, it is noticeable that they often have to go to the toilet during the day, but then only lose small amounts of urine or wet their pants while playing with concentration,» says the urologist. Other so-called daytime symptoms can include a strong urge to urinate, but also a burning sensation when urinating or delaying going to the toilet. «To prevent urination, girls can squat or cross their legs, for example,» explains Schultz-Lampel.

It is also possible that the child does not produce enough of the hormone vasopressin at night. Vasopressin (also known as antidiuretic hormone, or ADH for short) is secreted by the pituitary gland in greater quantities at night than during the day. «Vasopressin inhibits urine production so that we can sleep peacefully,» explains Daniela Schultz-Lampel. In some children, this mechanism is not yet fully developed.

In rare cases, enuresis is also caused by medical reasons such as an anatomical malformation of the urethra or chronic urinary tract infections. If these conditions are treated, the enuresis also disappears.

What about mental health problems?

In the past, psychological causes of bedwetting were drastically overestimated by doctors and families. «And even today, many parents try to find psychological problems as a trigger for enuresis,» says Schultz-Lampel. «But we now know: If a child has never been dry in their life, there are almost never psychological causes behind it.»

However, if a child has not wet the bed at night for more than six months in their life and then starts wetting the bed again, psychological stress may well be the trigger. Typically, bedwetting reoccurs after stressful life events such as parental separation, arguments, moving house, starting school, bullying or the birth of a sibling.

Can bedwetting also be inherited?

An overactive bladder and reduced production of the hormone vasopressin are at least partly hereditary. According to a study, the risk of enuresis is around 40 per cent if one parent was also affected as a child. If both parents were affected, the probability even rises to 77 per cent.

Does enuresis need to be treated?

An appointment with a paediatrician or urologist is advisable if the child suffers from enuresis, no longer wants to spend the night with other children, also wets during the day, has frequent urinary tract infections or sometimes wets itself. However, it is also important to note: «Around 15 per cent of all children become dry on their own every year without any intervention,» says the urologist.

What can parents do?

Many parents feel under pressure, as their friends' children have long been dry. However, despite these fears of failure, they should above all be patient with their child - after all, children don't wet themselves on purpose.

In practical terms, parents can initially keep a drinking and weeing log for one to two months in order to discover the cause of bedwetting. This should be noted in detail: When does the child wet the bed? When does it go to the toilet? How much did they drink and when? Do the symptoms also occur during the day?

Many parents feel under pressure, as their friends' children have long been dry. But despite these fears of failure, they should above all be patient with their child - after all, children don't wet the bed on purpose. In practical terms, parents can start by keeping a drinking and weeing log for one to two months in order to discover the cause of bedwetting. This should be noted in detail: When does the child wet the bed? When does it go to the toilet? How much did they drink and when? Do the symptoms also occur during the day?

Many children drink too much late in life.

Daniela Schultz-Lampel

Based on the protocol, a paediatrician or urologist can determine whether a simple change in drinking or toilet behaviour will have an effect. This is because many children drink too much too late - and this fluid presses on the bladder during sleep.

«This usually affects children who wet themselves in the first one to three hours at night,» says Daniela Schultz-Lampel. «In the last two hours before going to sleep, the child should not drink anything. Parents should also make sure they send them to the toilet again before going to bed so that their bladder is completely empty.»

Before a visit to the doctor, parents can also measure how much urine their child loses every time they go to the toilet. The specialist will use this information to calculate how large the bladder's capacity is.

What happens at the paediatrician?

There are precise guidelines for the treatment of bedwetting. The doctor first rules out organic, functional or neurological underlying diseases, examines the urine and performs an ultrasound. He then orders the child to drink a cup regularly during the day and to go to the toilet at certain times. If the bladder capacity is too small or there is an ADH deficiency, he may also prescribe medication.

If children are simply unaware of their full bladder at night, doctors use a behavioural therapy device. This involves children sleeping on a so-called ringing mat or wearing ringing trousers that sound an alarm as soon as they come into contact with moisture. The result: the child wakes up and goes to the toilet. In this way, the body learns to give a wake-up signal before wetting itself - a learning principle of classical conditioning.

Children who have been treated with alarm systems are 13 times more likely to become dry than those without alarm therapy.

Daniela Schultz-Lampel

Gradually, the child no longer wakes up at all, but simply sleeps through the night, dry. «How exactly this last learning step works cannot yet be explained,» says urologist Daniela Schultz-Lampel. But the fact is that the app-based behavioural therapy is very successful. Children who have been treated with alarm systems are 13 times more likely to become dry than children without alarm therapy.