An estimated two million children struggle with staying dry during the night. This nocturnal bedwetting (enuresis) can be highly distressing and embarrassing for children and their families, especially as kids reach the age where they want to attend sleepovers or sleepaway camp.
Some kids with enuresis may have bladder problems, anxiety, or physical or mental conditions or developmental delays that affect their bladder control. However, many children wet the bed due to issues with sleep.
Chronic bedwetters over the age of 6 may have problems with the nervous system mechanisms that control how deeply they sleep—and when they should transition between sleep phases or awaken. This lack of proper system coordination can lead to eliminating during sleep—wetting the bed.
What Is Enuresis?
Enuresis is a voluntary or involuntary elimination of urine that leads to wetting one’s clothing or bed. When a child wets itself during the day, the medical profession refers to this as diurnal (daytime) enuresis. If the child wets the bed at night, the condition is called nocturnal (nighttime) enuresis.
Nocturnal bedwetting can be further divided into two categories called Primary Nocturnal Enuresis (PNE)—bedwetting that is more or less consistent since the child was an infant—and Secondary Nocturnal Enuresis (SNE), which is bedwetting that comes back after a long period of no incidents.
Generally, when doctors refer to a child having enuresis, they mean the child is experiencing nighttime bedwetting that is not directly linked to an organic disease or disorder; in other words, the bedwetting is not known to be related to some functional or structural problem in the body. It’s up to the parents and doctor to work together to find an understanding of the root cause, whether that be a small bladder that hasn’t yet caught up to the rest of the body’s growth, a sleep disorder, a behavioral issue, a response to toilet training conditioning, or some other cause.
If your child is wetting the bed, you’re right to keep an eye on the situation—but panic is probably unwarranted. Bedwetting is fairly common in young children, and most grow out of it. The numbers:
- By the age of 5, when a diagnosis of enuresis can first be made by doctors, researchers estimate that about 7% of boys and 3% of girls experience accidents regularly (often, at least twice a week for a period of three months or more).
- By the age of 10, bedwetting and daytime accidents often resolve in both boys and girls, and the numbers drop to 2-3% of the population.
- Very few children over the age of 10 (about 1%) persist in experiencing elimination problems.
- At what age do you consider bedwetting abnormal? Most children achieve bladder control by the age of 6. If your child is 7 or older and is wetting the bed two or three times per week, see a doctor.
If your child’s bedwetting is having an adverse effect on their self-esteem, their social life, or their sleep, seeing a pediatrician and a specialist may be a good idea.
If your child shows signs of poor sleep quality in general (such as dark circles under the eyes, listlessness or attention problems during the day, or mood fluctuations), the bedwetting may be a sign of an underlying sleep disorder requiring attention.
Causes of Bedwetting in Children
A child may experience involuntary bedwetting due to a variety of causes that can be diagnosed with routine incontinence testing and lab testing. These exams, along with a full medical history, can help your physician determine if your child’s enuresis is related to an anatomical irregularity, illness, or a sleep disorder.
For example, childhood bedwetting could be caused by:
- Medications your child may be taking. Some medications contain diuretics that can stimulate urination. Others may interfere with the mechanisms that allow your child to awaken from sleep in order to use the bathroom.
- A smaller-than-average bladder. A very small bladder may not be able to hold urine for 8-14 hours per night without incident.
- A defect, such as a blockage, in the urinary tract or kidneys. Anatomical or structural issues may be affecting proper function of the enuretic system.
- A developmental delay. An undiagnosed delay in brain development or motor function may be interfering with toilet training.
- A urinary tract infection (UTI), kidney infection, or bladder infection. Infections may be triggering an urgent need to eliminate to flush the system.
- Increased urination is a classic diabetes symptom. If your child shows other symptoms of diabetes, see a doctor for testing.
- In some children, bedwetting may actually be an abnormal behavior of the nervous system occurring during sleep. This means the cause of enuresis could be a sleep issue related to brain immaturity, not an illness nor a psychological or physiological issue related the bladder or kidneys. One recent study indicates that bedwetting of this type is associated with a flaw in the nervous system arousal mechanism that switches children out of deep sleep into the next stage of sleep. If that arousal mechanism is faulty, urinating may be a physical signal from the body to the brain that it’s time to transition between stages of sleep. If your child’s enuresis is a parasomnia, you may therefore notice the urination tends to happen during the first two hours of sleep, when the child is most likely to be in deep sleep. In some cases, this bedwetting is the main symptom, but in some children it may eventually phase out in favor of a different parasomnia such as teeth grinding or sleepwalking. The manifestation of the arousal problem may change, but the underlying issues remain the same.
What surprises some parents is that nighttime bedwetting is not always an issue for a pediatrician or urologist alone. A dentist working with a sleep specialist may be helpful in treating a child’s enuresis because in children, a parasomnia like bedwetting may also be linked to breathing and airway issues. Numerous research studies have found that children with a chronic bedwetting problem also frequently have obstructive sleep apnea (OSA) and other forms of sleep disordered breathing (SBD).
Although the connection is still being studied, researchers believe that repeated apnea events during sleep may alter blood pressure and abdominal pressure, which can in turn lead to fluctuations in sodium levels in the urine. These changes trigger hormonal responses that can lead to an increase in urine production—and thus causing nighttime accidents.
This link between sleep disordered breathing and bedwetting means that treating a child’s apnea may improve the overall sleep quality and therefore reduce the likelihood of factors that lead to the bedwetting.
Where sleep medicine dentistry comes in: If the apnea is found to be caused by an upper airway obstruction caused by a palate deformity or the position of the tongue in a small mouth, it’s possible to correct these issues with early intervention oral therapies.
One such option is myofunctional therapy, a form of physical therapy that involves exercises designed to strengthen and tone the jaw, tongue, and soft tissue of the throat.
Another is oral appliance therapy to expand the palate. Children’s faces are still growing, which means that their oral and dental development can be corrected with the help of a good therapist who understands the role facial growth plays in affecting breathing and sleep.
Signs of Sleep Disordered Breathing (SDB)
How do you know if your bedwetter also experiences sleep disordered breathing or apnea? In addition to the bedwetting, signs and symptoms of airway obstructions during sleep can include:
- Bruxism (tooth clenching and grinding)
- Daytime fatigue and sleepiness
- Chapped or cracked lips
- Heavy sweating during sleep
- Learning problems and behavioral problems at school
- Memory issues
- Mood problems like aggression or impatience
- Mouth breathing and issues that result from it, including: a forward head posture, a long, thin face, bad breath (halitosis), coughing, crooked teeth, dental and gum (periodontal) disease, dry mouth, or throat infections
- Night terrors
- Restless sleep
- Venus pooling under the eyes (dark circles)
If your child is over the age of 5 or 6, has been wetting the bed regularly for some time, and shows any of the above signs of SBD, make an appointment to see your pediatrician. Ask about the possibility of parasomnias and sleep disordered breathing, including sleep apnea.
Premier Sleep Associates in Bellevue, Washington is available to answer your questions by calling us at (425) 698-1732.