Although it affects some 5 million to 7 million children in the United States, bedwetting is not a subject most kids, or their parents for that matter, like to talk about. The words, "You're still a baby," linger in the minds of children for whom wet sheets are a weekly, if not daily, reality. For such children, mornings can bring embarrassment, frustration and, in many cases, a scolding.
In the vast majority of cases, bedwetting, or nocturnal enuresis, as it is known in medical terms, is beyond a child's control. While the exact cause may vary, bedwetting is most often linked to a delay in a child's physical maturation. While most outgrow the condition, there are a number of therapies available.
Everyone who suffers from this condition thinks they're the only ones, says actor Michael Landon, who wet his bed until the age of 12. "When I was growing up in the '40s, we didn't have the information available we have today," recalls Landon, who endured so-called remedies that included consuming pickled herring and saltines. He awakened many mornings with a dry mouth and a wet bed, the actor remembers.
In seeking a solution to the problem, Landon's mother employed a method not altogether unusual. Each day, while he was at school in his hometown of Collingswood, N.J., she would hang his sheets out the window. And every day at lunchtime he would run the mile or so it took to get home and take them down to avoid being embarrassed in front of his friends. Landon's childhood experiences eventually became the basis for the film, "The Loneliest Runner."
The older children get, the more likely they are to feel embarrassed or ashamed when it comes to bedwetting, says Anne Wake, a clinical psychologist at the Kingsbury Center, an educational institution providing counseling and other services to Washington-area children.
It particularly becomes a problem between the ages of 6 and 7, when children are asked to spend more nights away from home, Wake says. Going over to a friend's house or joining the Cub Scouts is often an important part of a child's socialization process. The guilt and shame associated with bedwetting can lead to a child's denying or blocking bad feelings, she adds, urging parents and children to discuss the problem.
In a large number of cases, bedwetting appears to run in families, according to H. Gil Rushton, a pediatric urologist at Children's National Medical Center in the District. While childhood stresses can aggravate the problem, bedwetting results largely from a delay in maturation of the central nervous system, says Rushton. "The signal from the bladder is not getting to the brain early enough, is not being heard loudly enough." Some children may simply have smaller bladders, he explains, while others may be deficient in a particular hormone that limits urine production at night. Rushton quotes a 1973 study in which 44 percent of the children in families where one parent had a history of bedwetting were found to be enuretic; the figure rises to 77 percent if both parents had been bedwetters.
Most bedwetting goes away naturally with age. While 20 percent of all 5-year-olds experience it frequently, only 5 percent of 10-year-olds continue to have the problem, says Rushton. The figure drops to between 1 and 2 percent by the time a child reaches the age of 15.
Parents are cautioned, however, not to treat the phenomenon lightly, particularly if a previously dry child begins to have wet nights or if uncontrolled wetting is a problem during the day. "Any type of wetting can be a sign of urinary tract disease," according to Peter Scheidt, a medical officer at the Center for Research on Mothers and Children at the National Institutes of Health. Parents of bedwetters are advised to have their children examined, says Scheidt.
While 15 percent of bedwetters naturally outgrow the problem each year, there are several therapies available that have proven effective.
Bladder stretching involves prolonging the periods between the times a child goes to the bathroom. One third of the children who practice this method consistently will be cured over a six-month period, according to Rushton.
Motivational therapy involves counseling parents and children as to the causes of bedwetting. Sometimes, just getting it out in the open can alleviate the household stress it can produce.
Douglas Tynan, a clinical psychologist at Children's National Medical Center, speaks of the importance of maintaining communication between parent and child. "Parents react best when they deal with it rationally," he says, "laying out the hope that it will eventually get better."
Tynan counsels parents to be neutral when accidents occur, allowing children to assume some responsibility -- taking the sheets to be washed, for example. Parents might consider praising or rewarding their children for dry sheets, he says.
One of the most successful forms of therapy, according to Rushton, involves behavior modification through the use of an alarm device. A hidden sensor, either incorporated into a sleeping pad or sewn into a child's underwear, triggers a buzzer once wetness is detected. Children eventually learn to associate the sensation of a full bladder with waking up, he says.
Nina Gomez-Ibanez of Weston, Maine, tried the alarm device with her son, Dan, then 9, and had successful results within several weeks. It helps if both parents are supportive, she says. "The key is to get up cheerfully when it rings and work with the child to re-make the bed."
Dan, now 12, says, "I hated it at the time. That's why it worked."
What most parents don't realize is that any form of behavior modification takes time. Likewise, the child must learn to accept the device. While some grow to resent the intrusion into their sleep, others snooze right through it. The alarm can cost $40 to $50 and averages a 70 percent success rate; but, cautions Rushton, it may take four to six months for positive results to be achieved.
For a smaller proportion of children, drug therapies may prove more useful. The Food and Drug Administration recently approved a nasal spray, DDAVP, or desmopressin acetate. Scientists believe that many children who wet their beds may be deficient in an anti-diuretic hormone, which signals the kidneys to limit urine production at night. DDAVP contains a hormone that provides that signal, its manufacturers say. But the spray is not generally considered in the first stages of therapy, Rushton says, because not all bedwetters seem to suffer from the hormonal deficiency.
Further tests are needed to determine which children would benefit most from the drug and how long a patient should be advised to use it, he adds. As is the case with many drug treatments, Rushton says, the effects of DDAVP frequently subside after a cessation in use. Additionally, it remains an expensive form of treatment, costing anywhere from $20 to $40 per week, depending on the dosage.
Other drug treatments have been in use for years. Imipramine, an antidepressant that Rushton says may allow a child to arouse from sleep more easily, is prescribed particularly in cases in which a child experiences anxiety about spending nights away from home, traveling or camping out. Doctors don't usually prescribe the drug until a child reaches 7 or 8 years of age, says Rushton, and parents are warned of possible side effects -- mood alterations, nervousness or insomnia.
Another drug, Oxybutynin, controls the unstable bladder contractions often responsible for bedwetting and is used for more severe cases, especially when daytime wetting is also a problem.
Other time-honored methods of dealing with the disorder, such as withholding fluids before a child goes to bed and waking a child midway through the night, have proven, for the most part, ineffective long-term remedies, Rushton says.
For some parents, the best means of dealing with the problem is simply to do nothing, says NIH's Scheidt. Generally, all it takes is time and a great deal of patience.
Sheila Kinkade is a Washington freelance writer.