Melanie Cole, MS (Host): Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. I'm Melanie Cole. And today, we're joined by Dr. Angela Allevato. She's a board-certified pediatrician with Children's Health of Orange County, and she's here to talk to us today about bedwetting.

Dr. Allevato, I'm so glad that you could join us. I'd like you to speak to parents today. How common is bedwetting in children? Is this a normal part of childhood development? Could it be a sign of an underlying medical issue? And for parents that are really concerned, does wetting the bed at night also mean that a child might have issues controlling their bladder at school and out in public?

Angela Allevato, MD: Yes. Thank you for the question. It is very common. Actually, 10% of six-year-olds still wet the bed, 8% of eight-year-olds and 5% of 10-year-olds still wet the bed, with a smaller percentage of teenagers who still wet the bed.

I want to talk about the younger child, less than 8 years old today and focus on them. And we can go over signs and symptoms and things that would be more concerning that wouldn't be considered normal. But in general, bedwetting is a common and normal part of development. Just like achieving a milestone of walking or talking, everyone meets that milestone at a different time. And it is normal for children to be dry at three years old sometimes, and sometimes not until we talked about eight to ten years old. So, every child is an individual, and we can talk today about how to encourage them and support them in positive ways.

Melanie Cole, MS: So when is the most common time that bedwetting happens? Is it deep in sleep? Is it more toward the morning? I remember my parents waking me up midnight or so, walking me to the bathroom, walking me back. I was mostly asleep. When is it that this is something that parents are looking for.

Angela Allevato, MD: It absolutely is during the deepest part of sleep, and that can occur in the middle of the night or even early in the morning because children go into REM sleep at different times of the night. They are completely unaware that they're wedding the bed. And I really want to stress that because I've had parents use the term, "Oh, he sleeps too deeply," or "He is lazy." No, he's asleep. You know, we can't really train a child who's asleep, and we just have to recognize that they just haven't matured yet, and there are some factors we can talk about in why it happens.

Melanie Cole, MS: Well, and the fact is that this really can affect the quality of life for these children's sleepovers, sleep away camp, when they're with their friends, these kinds of things can make for embarrassing situations. So, I would like you to tell us some steps that parents can take if their children are wetting the bed, and past what age. As you said, Dr. Allevato, milestones happen, and we all know, as parents, we're not supposed to put too much stock in the milestones, day by day, if it hasn't happened by this exact day. You know, children grow at different levels and talk at different levels. And as you said, so this is something being able to keep dry that happens at different times for kids. When do we get concerned and what should we do?

Angela Allevato, MD: Well, we would be concerned if a child has achieved nighttime dryness for more than three months. And then starts to wet the bed again. This is a red flag that something else might be going on when there are many things that could be. It could be stress, it could be an illness, it could be an infection, it could be diabetes, you know, at that point, definitely the parents should speak to their pediatrician. But I want to say too that at every well visit, a parent should be speaking to their doctor about bedwetting. It's something that should come up during the well visit so that they can get some guidance and specific instructions for their child at developmental stage.

The other times I would be concerned is at any time, even if a child has never achieved dryness more than three to six months, but if bedwetting is associated with blood in the urine, fever, painful urination, weight loss, excessive thirst, constipation as well, because constipation and urination go hand in hand and sometimes children need to have both problems taken care of so they can remain dry at night.

Melanie Cole, MS: So when we're thinking about, we've called our pediatrician, our children are wetting the bed, maybe It's Four years old. You know, there's a lot of different things out there now. There's pullups and there's all these things that we try as we transition out of diapers and into underwear. And I'll just say this quick story that I remember my son begging me to stop his pullups. "Please, I promise I'll be dry." And he was, but now kids can't just wish it away. What are some things we can try? Should we not be giving them liquids at night? Should we be waking them up? What should we do?

Angela Allevato, MD: What we can do is realize a couple of things. First of all, there are factors that increase the amount of urine that a child is producing at night and we want to try to reduce that. If a child is not drinking all day long, they're too busy playing and now it's three o'clock in the afternoon and they're very thirsty, they're going to make up for the whole day by drinking their fluids late in the afternoon and evening, therefore producing a lot of urine overnight and over distending their bladders. And the problem with children's bladders, the younger they are, the more immature they are, their bladders are smaller, their sphincter is not as strong, so they don't have the bladder capacity to hold urine all night like we do. Also, their sphincter muscle, which controls the bladder from passing urine, is not strong enough to maintain a very full bladder. And that in conjunction with the deep sleep, they don't even feel their bladder being distended and they will pass urine at night. So, one of my favorite tips is to have them drink their fluids early in the morning. As soon as they wake up, we have them drink. And then, we do something called time voiding, which is every three hours, give or take. We're going to remind a child to drink and try to pee every three hours. If they don't drink, it's okay, but we try to remind them to drink. That way, they're not so thirsty after dinner.

Another trick is the Kegel exercise to be done halfway through the stream. So when they're urinating and passing urine, when they're about halfway done, they would count to 10 and hold their urine flow and then pass the rest of the urine. We wouldn't have them stop and go and stop and go, but rather pass urine, count to 10, pass urine. If we do that every day, it will strengthen the sphincter muscle.

And by encouraging fluid intake early in the day, we're also increasing bladder capacity. So, those factors help the maturation of the bladder and bladder control. That probably works better in children who are over the age of four or five, because children under five years old naturally sometimes are not dry at night anyway and maybe don't have any problem wearing pullups. And I have no problem with pullups for older children. I think it should be their choice. I think that waking up to a wet bed and having to change the sheets is sometimes discouraging and shaming for a child. And this is the last thing we want them to feel. It is not their fault. They aren't doing it on purpose and the pullup doesn't usually allow or give the child permission to go ahead and pass urine at night, they're not doing it because they have a pullup on. So, I have no problems with pullups until the child decides on their own that they don't want them anymore.

Now, there's another option and that is bedwetting alarms. They are an instrument that is little sensor that goes into the undergarment and it senses wetness. And as soon as a child starts to pass a little bit of urine, it gently wakes the child up with a buzzing sensation. And that's meant to wake them up before they fully empty their bladder so they can go to the bathroom and pass urine. I know the CHOC urologists do recommend that alarm, I'm not a fan of that for the younger child. I feel that a child under the age of seven or eight probably should be having a good night's sleep. And not being interrupted at night to go to the bathroom to me is paramount for normal development and, good sleep and rest. But that, again, is a choice that parents can make.

The other question you mentioned was sleepovers. What would we do about children going to sleepaway camp or science camp in fourth grade, et cetera.? There are medications that are used to help increase bladder control through the night. One of them is called desmopressin or DDAVP and it is a man-made version of a hormone that we normally produce from our pituitary gland and that tells our kidneys to not produce urine all night long. And children who have bedwetting oftentimes have low amounts of naturally-occurring ADH. So, this man-made version does help pretty reliably. I would have parents usually try it before the sleep away to make sure it does work, and then have that as an option so children can still participate in social sleepovers and camps. we don't use them every day though. We would use them only for special occasions and not for long term use.

Melanie Cole, MS: So, if a child then has been dry for a while and they're real proud of themselves and then starts bedwetting again, is this a cause for concern? Do we look to a psychological factor involved, then do we call our pediatrician, let them know this has happened? Tell us a little bit about that.

Angela Allevato, MD: Yes, absolutely. And the definition of primary enuresis or primary bedwetting is that it's normal for a child to stop bedwetting and then be dry for up to six months before then we say, "Oh, there's a problem here and this should be looked at." Six months is a very long time. I start to get concerned if they've had more than three months of dry at night and all of a sudden starting to wet the bed again. And look at what factors have occurred. Have they moved? Has there been a separation or death in the family? is the child being bullied at school? Or just even has he started a new school and he's nervous? Then of course, the other physical factors. We talked about signs and symptoms of infection, fever, pain on urination, signs and symptoms of diabetes, weight loss, excessive thirst, and excessive daytime urination.

Also if bedwetting recurs at night and/or is also happening during the day and a child is now incontinent of urine during the daytime as well, that is a red flag. Another reason to speak to your pediatrician quickly.

Melanie Cole, MS: Well, this is so interesting and so helpful for many parents. Dr. Allevato, I'd like you to wrap it up with a summary for us about some of the things. Just kind of reiterate the things that we parents can try to help our children that are wetting the bed past a certain age when it's important we call our pediatrician.

Angela Allevato, MD: Absolutely. So, achieving nighttime dryness is a developmental goal and children should be encouraged and given positive reinforcement until they're fully developed in their ability to stay dry at night. Speak to your pediatrician at your child's preventative well visits about this developmental milestone and seek sooner medical attention if if they start to have bedwetting after prolonged period of dryness or if they have any of the symptoms we discussed. We can help our child to achieve nighttime dryness by encouraging to drink fluids during the day; having them try to urinate, pass urine every three hours during the day, practicing a Kegel exercise halfway through the stream, holding urine for 10 seconds; and trying to limit fluid intake after dinner, as well as obviously emptying the bladder right before bed, which is very important. And encouraging the child and just letting them know that it's okay and, with time, things will get better and there's nothing wrong with them. A lot of children do wet the bed at their age and they will probably outgrow it sooner rather than later.

Melanie Cole, MS: Great advice, Dr. Allevato. Thank you so much for joining us today. And for more pediatric health and wellness tips, please visit choc.Org. Thank you so much for listening to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. Together, we can keep kids happy and healthy. Please always remember to share on your social channels as we're all learning from the experts at CHOC Together. I'm Melanie Cole. Thanks so much for joining us today.