When Dry is Not Really Dry by Timothy J. Patrick-Miller, M.D., Mark B. Levin, M.D. and Louis J. Tesoro, M.D. The Pediatric Group, P.A., Princeton

This is the seventeenth article in a series written for Princeton Online. Click here for an archive of other articles.

We all recall the days when our child needed diapers. In our minds, we associate that time with our child’s immaturity and dependence on us for cleanliness. As parents, we are anxious to feel successful in our mission to enhance our child’s growth and development. Once (s)he becomes toilet trained, we feel that success is just around the corner (as well as the end of our interrupted nights of diaper changing and days of dealing with diaper rashes!). When our child continues to wet at night, especially after daytime control is achieved, we become impatient. We wonder what we have done wrong or what might be wrong with our child. After all, the neighbor’s child is dry at night! Once a child has daytime control, should (s)he not be dry at night, as well?

For many parents, this scenario causes anxiety as their children grow up. The recall their parents saying that toilet training should be accomplished by 1 or 2 years of age. So, they contact heir pediatrician for a "cure". They are often relieved to find out that they have done no wrong and their child is not ill. Their child is simply navigating through a normal developmental stage by experiencing nocturnal enuresis.

Nocturnal enuresis is the medical term for urinating during sleep. This article will not address diurnal enuresis, which is urinating into clothing while awake, be it involuntary or intentional. There are two types of nocturnal enuresis. Primary nocturnal enuresis means bedwetting without ever having been dry at night. Secondary, or acquired, nocturnal enuresis means bedwetting after being dry at night for a minimum of 6 months.

Primary nocturnal enuresis is usually developmental, and most children eventually outgrow it. At age five, 20-40% of children still wet at night. By age eight, 15% still wet and by ten, 1% are enuretic. Boys outnumber girls in this category by 6 to 1. Each year, about half of those that wet at night will outgrow it. Although the exact mechanism is debated, current theory is that small bladder size relative to the amount of urine produced and an infantile bladder-emptying pattern are the cause. Children that wet at night sleep so soundly that they do not sense the need to urinate. The amount of urine a child makes at night depends on production of a hormone called anti-diuretic hormone (ADH). Production of ADH increases with age at a rate that is probably genetically determined. This is why bedwetting tends to run in families. When a child outgrows nocturnal enuresis is also a family trait. Psychological stress is not a factor in primary nocturnal enuresis.

Children generally do not become concerned with nighttime wetting until 7 or 8 years of age. Pediatricians do not worry about primary nocturnal enuresis unless there is some atypical factor in the child’s history or the child is still wetting at age ten. X-rays and laboratory tests are generally not needed in primary nocturnal enuresis, although a negative urinalysis can be reassuring of the absence of underlying organic cause.

Because primary nocturnal enuresis is a natural phenomenon (there were no bed linens in the pre-civilization jungles), there is no need for medicinal treatment. Reassure your child that there are reasons for wetting at night and that they are beyond his or your control. Morning linen changes and discussion of enuresis should be open, matter-of-fact, shameless and blameless. With this understanding approach, your child’s developing psyche will not be wounded. You may wish to opt for the custodial convenience of a plastic mattress cover, pull-ups (if they still fit) or a protective liner over the sheet. Limiting fluids at night and waking your child to urinate at your bedtime are generally fruitless. Fluid limits are also inadvisable, as children are active and need extra fluid to replace their daytime losses. Medicines, alarms and behavior modification may be elected in the older child with primary nocturnal enuresis.

Secondary nocturnal enuresis can sometimes have a basis that requires treatment. Any of the following symptoms may indicate a medical problem:

If your child is experiencing any of these symptoms, or if primary nocturnal enuresis persists past age ten, advise your pediatrician so (s)he can undertake appropriate diagnostic studies and help you design a therapeutic approach that is right for your child. Remember that the mainstay of dealing with primary nocturnal enuresis is patience and reassurance. It is a normal phenomenon that disappears with time.

Dr. Timothy Patrick-Miller

Dr. Patrick-Miller has been a member of the staff at The Pediatric Group since 1985. Dr. Patrick-Miller has served on several Departmental and hospital committees. He has published original work while at The Pediatric Group. He and his wife enjoy travel. He also likes hiking, biking, gardening and reading.

Dr. Mark B. Levin 

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.

Dr. Louis J. Tesoro

Dr. Tesoro has been a member of the staff at The Pediatric Group since 1988. Dr. Tesoro is Chairman, Department of Pediatrics, Medical Center at Princeton, 1996 to present and Attending Pediatrician, Medical Center at Princeton, 1988 to present. He has served on several Departmental and hospital committees, lectured at the Universiy of Pennsylvania and has published original articles both while at The Children's Hospital of Philadelphia and at The Pediatric Group.