Doctors caution against overreacting to kids' wetting problems

HealthColleges and UniversitiesChildren's Memorial HospitalLoyola University Health SystemWake Forest University

Jaylin was a real trooper, learning to go the night without an accident by age 2. But when she turned 3, the Aurora girl started having nighttime accidents again and periodically wet her pants during the day.

Though the girl's mom has tried withholding liquids after dinner and giving her rewards for a dry bed, Jaylin, now 6, continues to wet. Pediatricians have told her she shouldn't need further treatment for her daughter unless it continues after age 7.

For the mother, a medical assistant with a busy schedule, the wetting means monitoring Jaylin constantly and often re-showering her in the morning after a night's wetting.

Wetting issues have become an increasingly common problem, according to pediatric urologists, who say physical issues and daily pressures may be at the root of daytime wetting and a deep sleeping pattern the cause of most bed-wetting.

Daytime wetting is usually caused by "holding," called dysfunctional elimination syndrome, or DES, brought on by inappropriate relaxation of the pelvic floor musculature, said Dr. Earl Cheng, professor of urology at Children's Memorial Hospitaland the Feinberg School of Medicine at Northwestern University. Bladder distention/irritability and constipation follow.

Cheng said that possible contributing factors include busy schedules, constipation as infants, or starting toilet training before age 3 — which remains controversial.

"All those things are contributing factors, but the bottom line is these children hold and, when they hold their bladders, become over-distended and overactive," said Cheng. "It's like any other muscle that becomes irritable and starts to squeeze when you don't want it to, which results in wetting," said Cheng.

Bed-wetting, which often runs in families, is usually caused by a deep sleep pattern, although in some cases, DES can also contribute. Cheng said he had seen an increase in patients with wetting problems in recent years.

Treatments for daytime wetting focus on teaching the child how to void correctly with appropriate relaxation of the pelvic floor musculature, sometimes using biofeedback, timed voiding and aggressive treatment of constipation, said Cheng.

Most kids who wet the bed after age 6 are physically normal and will outgrow it by their teen years, said Cheng. Specialized urinary alarms that awake the parent or child when wetting occurs and/or medication can be used if the problem interferes with a child's psychosocial development, said Cheng. Some health care professionals recommend acupuncture.

The author of a new book on potty troubles says constipation is a main cause of wetting, in addition to societal pressures like too early toilet training, hectic schedules and schools with restrictive bathroom break policies. The book, "It's No Accident: Breakthrough Solutions to Your Child's Wetting, Constipation, UTIs (urinary tract infections) and Other Potty Problems," by Dr. Steve J. Hodges with Suzanne Schlosberg, a health and parenting writer, was released Feb. 7.

"I think over time as constipation has become more prevalent, it leads to this growing epidemic," said Hodges, associate professor of pediatric urology at Wake Forest University in North Carolina. "The frustrating thing for me is that in almost all cases it's preventable."

The book addresses not only Hodges' theories about wetting, but also a host of ways to combat the problem, such asX-raysto determine if a child is constipated, high fiber diets and teaching kids to use the toilet.

When treating a 3 1/2-year-old patient named Zoe last year, Hodges found by X-ray a mass of feces in her bowels, which was putting pressure on her bladder and causing the wetting. The girl had been kicked out of a preschool in December 2010 for too many wetting episodes.

"I don't want to condemn anybody or any school system, but I think we can all agree for bladder growth and best bladder health you need uninhibited voiding, meaning when the bladder is full, the kid goes," said Hodges, adding preschools should let toddlers who aren't toilet trained wear "pull-ups."

Cheng, a colleague of Hodges', said he thought constipation was a contributing — but not a main — cause of daytime wetting, and both "underappreciated and undertreated."

Pediatricians generally emphasize that bed-wetting can be addressed with simple tips, such as not drinking too much fluid before bedtime, and understanding. Dr. Patrick Dolan, a pediatrician at Advocate Good Samaritan Hospital in Downers Grove and pediatric emergency room doctor at Condell Medical Center in Libertyville, said a bed-wetting alarm could be used, as well as positive reinforcement with a chart and stars each time the child achieved dryness at night.

Dr. Hannah Chow, a pediatrician at Loyola University Health System in Maywood, said toilet training should be started when a child felt ready and that most kids would outgrow bed-wetting.

"Parents should be supportive of their child no matter what ... helping any way they can with a high fiber diet, going to the bathroom regularly, and good bladder and bowel habits," said Chow.

Copyright © 2014, Los Angeles Times
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