Recent reports highlighted the fact increased numbers of children starting school are having accidents in the classroom. Eileen enurJacques from ERIC explains why and offers tips to help reduce incidences of both day and night time wetting.


Are you aware that over half a million children in the UK regularly suffer from nocturnal enuresis (bedwetting) and another 100,000 children have wetting accidents in the day? It is not unusual for the under-5s to still be wet at night, to need reminding to go to the toilet, or to have occasional wetting accidents during the day. One in six five-year-olds also wet the bed either occasionally or regularly1. Of those who wet at night, 3.3% also have day wetting problems and are more likely to need reminding to go the toilet in the day2. Children who have a combination of day and night wetting problems are regarded as being clinically more complex than children with isolated bedwetting2. The impact of day and/or night wetting on children and their families can be dramatic and is often underestimated, especially if the problems continue as the child gets older. Expectations from friends, families and even nurseries and schools for children to be clean and dry can lead to parents and children feeling anxious, ashamed and frustrated and there is often the additional stress of dealing with extra washing, coping socially and waking at night to change sheets. Early intervention is always recommended - for bedwetting this would usually be from the age of five, depending upon the child's maturity, and from the age of four for a child with daytime wetting problems3.

Bedwetting  

Bedwetting is defined as involuntary wetting during sleep4. Most children who wet at night have "primary" enuresis (they have never been dry at night) and 10% have "secondary" enuresis (the wetting started after having been dry for six more months). The frequency of bedwetting varies enormously with only a small percentage wetting every single night and the largest proportion wetting less than once a month. At four and a half years of age 30% of all children wet the bed and there is a spontaneous decline in this of approximately 15% each year. In the younger age group boys are more likely than girls to wet the bed by a ratio of 3:25.

Why does bedwetting occur?  

Bedwetting occurs during sleep and a child has no conscious control over it - it is not caused by laziness. It is known that a tendency towards bedwetting can run in families; there is evidence of a hereditary component and this genetic predisposition may be linked to genes on identified chromosomes6. Bedwetting often happens as a result of one or more of the following factors:

● The child does not react to the signal from the bladder to the brain which tells them to "hold on" or to wake up.
● The body's system, controlled by a natural hormone called vasopressin (which acts on the kidneys and slows down the production of urine during sleep) is not yet working and the child has to cope with large quantities of urine in the night.
● The bladder holds smaller amounts of urine than expected before sending a signal that it is full; this may be due to an overactive bladder. There may also be a need to go to the toilet urgently or more often than is usual in the day.
● Other factors such as constipation, urine infections, kidney conditions, changes in routine or emotional upset.

Case historyenur2
Fiona rang the ERIC Helpline frustrated that her daughter Evie, aged 5, was being "lazy" and not going to the toilet when she needed to. She had been potty trained at two and had been dry for more than 18 months, but now Evie's knickers needed to be changed at least three times a day and Fiona's patience was running low. It was clear to Fiona that Evie knew she wanted to go as she would stop what she was doing and crouch down onto her ankle. Evie seemed to be ignoring the fact that she needed the toilet and when asked Evie would often say no, but would wet shortly afterwards. It was beginning to get embarrassing as Evie was coming home from school with damp, smelly knickers and Fiona knew that wherever they went there would be the inevitable mad dash to find a toilet. There was no point even trying to get Evie out of nappies at night when she seemed to be going backwards in the day. This scenario is not unusual on the ERIC Helpline; parents can feel at their wits end because they cannot find any explanation for their child's toileting behaviour.
The ERIC Helpline discussed the reasons why daytime wetting occurs and explained that often the child is not able to control what is happening. For example if the child is showing signs of an overactive bladder they will have a desperate urge to go to the toilet but once the bladder spasm passes the child will no longer feel the need to go to the toilet. Parents are always be encouraged to make an appointment with a health professional for an assessment. Depending on the child's age this may be a health visitor, school nurse, continence nurse or GP. Often for many parents who call the ERIC Helpline, simply having a greater understanding of what may be happening is enough to relieve the stress and help them move forward to resolve the problem.


Interventions for bedwetting  

It is recommended that an assessment for bedwetting occurs in a child-friendly environment and that sufficient time is required to carry out a detailed history of the bedwetting, including information about daytime toilet habits, drinking and toileting patterns, as well family attitudes and the child's perception of the problem. Initial treatment will include recommendations on drinking and toileting routines. A bedwetting alarm is often the first line of treatment if suitable for the individual child and family. If rapid onset or short improvement is the priority, then desmopressin may be prescribed4.

Daytime wetting  

Daytime wetting is a common problem in young children, but unlike bedwetting, it cannot be contained at home so effectively. As daytime wetting can often be managed fairly well by parents at home, with regular prompts for the toilet and changes of clothes, it is often not identified as a problem until a child starts school. Severity of daytime wetting can vary from damp pants through to full bladder emptying and is usually diagnosed in terms of frequency and urgency. From the age of four normal voiding frequency is four to seven times a day, if a child regularly voids more than this, it may be a sign of detrusor instability (an overactive bladder). Persistent daytime wetting and relapse in daytime wetting is more common in girls than boys7.

Why does daytime wetting happen? enur3

The acquisition of bladder control is a gradual process following a developmental progression - physical maturity, communication skills, cognitive ability, mobility and social skills all play a part7. Some children have an immature bladder which simply means they achieve the ability to control their bladder during the day later than others8. Children with general developmental delay or an identified physical or learning problem may be later in their toilet training, but this does not always follow. Common causes of wetting in four to seven-year olds include being engrossed in play or an activity and ignoring the signals of a full bladder; allowing insufficient time to reach the toilet, not fully emptying the bladder, unable to manage clothing, avoiding unwelcoming or intimidating toilet environments, changes in routine, illness or tiredness, emotional upset, a urine infection or constipation9. Some drinks and foods can irritate the bladder and increase urine production including carbonated drinks, tea, coffee and chocolate. Simply removing a drink or a food for a few days will help identify whether the drink food is having an effect on the bladder. The most common cause of daytime wetting for children over five is an overactive bladder. This term describes the condition in which the detrusor muscles contract suddenly before the bladder is full, creating the need to void with little or no warning. This can arise from urinary tract infections or constipation but it is often idiopathic in origin with no pathological cause and can settle down spontaneously10. Dysfunctional voiding can develop as a long term consequence of an unstable bladder and is thought to occur due to the child learning to hold on and failing to relax the urethra and pelvic floor. It is recognised by interrupted stream voiding and incomplete voiding and can often result in a UTI (urinary tract infection)11.

Interventions for daytime wetting  

There are several reasons why daytime wetting accidents occur, but it is always important to get a full assessment carried out by a health professional. This will include a routine urine test to check for infection - a strong factor in daytime wetting, especially in girls. Questions should also be asked about wetting incidents, urgency and related stresses. It is worth noting that constipation is often a factor in daytime wetting10. It is important to identify if daytime wetting is functional or if there is likely to be an organic cause such as urethral valves or sphincter incompetence. Functional daytime wetting is almost always urge incontinence due to an unstable bladder and treatment should be focused on those children with frequent daytime wetting12,13.

If there is no evidence of a UTI and there are no other indications, it is usual to suggest bladder training which encompasses encouraging a child to drink through the day - the recommended amount for children aged four to eight-years-old is 1000-1400ml4 (six to eight drinks) - and a regular prompted toilet routine every two to three hours during the day (a vibrating reminder watch can be a useful aid)10. For many children fluid intake may decrease after starting nursery or school, it is therefore important that nurseries and school encourage regular drinking to ensure children have an adequate fluid intake spread through the day. Oxybutynin is an anticholergenic drug available on prescription only and is appropriate for children who appear to have a low functional bladder capacity and or overactive bladder.

Interventions for daytime wetting problems are almost always proposed before interventions for bedwetting are instigated. For some children, resolving a daytime wetting problem will have a positive impact on night time wetting.

Further information

The ERIC Helpline is available on 0845 370 8008 or email info@eric.org.uk. A range of leaflets and other resources can be downloaded free from the ERIC website www.eric.org.uk. ERIC runs seminars for professionals on bedwetting and daytime wetting; details can be found on the ERIC website.


References

1. Butler R, Holland P, Devitt H et al. The effectiveness of desmopressin in the treatment of childhood nocturnal enuresis: predicting response using pretreatment variables. British Journal of Urolology 1998; 81 (Suppl 3): 29-36
2. Butler R, Golding J, Northstone K; ALSPAC Study Team. Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs. BJU Int 2005; 96(3): 404-410
3. Butler R, Holland P. The three systems: a conceptual way of Understanding nocturnal enuresis. Scand J Urol Nephrol 2000; 34(4): 270-77
4. NICE clinical guideline CG111 Nocturnal enuresis: the management of bedwetting in children and young people. 2010
5. Butler R, Heron J. The prevalence of infrequent bedwetting and nocturnal enuresis in childhood. A large British cohort. Scand J Urol Nephrol 2008; 42(3): 257-264
6. Arnell H, Hjälmås K, Jägervall M et al. The genetics of primary nocturnal enuresis: inheritance and the suggestion of a second major gene on chromosome 12q. J Med Genet 1997; 34(5): 360-365
7. Joinson C, Heron J, von Gontard A et al. A prospective study of age of initiation of toilet training and subsequent daytime bladder control in school age children. J Dev Behav Pediatr 2009; 30(5): 385-393
8. Oppel WC, Harper PA, Rider RV. The age of attaining bladder control. Pediatrics 1968; 42(4): 614-626
9. Weaver A. Ready for school? Helping children with continence problems. Irish nurse. 2005 7(3)
10. Butler R, Swithinbank L. Nocturnal Enuresis and Daytime Wetting: A Handbook for Professionals. Education and Resources for Improving Childhood Continence (ERIC) 2007
11. Rogers J. Paediatric continence promotion: an overview. J Commun Nurs 2003; 17(7): 22-25
12. Hjälmås K, Tamminen-Möbius T, Olbing H. Historical clues to the complex of dysfunctional voiding, urinary tract infection and vesicoureteral reflux. J Urol. 1992;148(5 Pt 2):1699
13. Swithinbank LV, Heron J, von Gontard et al. The natural history of daytime urinary incontinence in children: a large British cohort. Acta Paediatr 2010; 99(7): 1031-1036

Eileen Jacques Information and Helpline Manager ERIC (Education & Resources for Improving Childhood Continence)