Dear Meg:

Our son Jeremy wets the bed at night, even when he uses the toilet right before going to sleep. He’s 6 years old now and he’s been toilet trained during the day for years. It’s frustrating for us because we’d like to be done with diapers for at least one child. Jeremy doesn’t seem as upset as we are, but he can tell that we’re disappointed.

It’s understandable to feel frustrated if your child can stay dry while he is awake during the day but cannot when he is asleep. You might think that Jeremy’s pattern is unusual. Many parents don’t know that night wetting is very common among young children, even at Jeremy’s age. Although some children begin to stay dry at night within a few months after achieving daytime dryness, for many children this next step may not take place for several years.

In fact, about 25 percent of all 4-year-olds and 15 percent of 5-year-olds wet their beds at least once a week. Most children find it easier to stay dry through the night as they grow older, but 15 percent of all 6-year-olds still wet their beds occasionally. Nighttime wetting is more common in boys than in girls, but not at all unusual in girls.

Staying dry during the night is related more to development than it is to motivation. Children who take longer than others to stay dry at night usually have two characteristics in common. First, they produce more urine during the night than their bladders (the place where urine collects) can comfortably hold. That may be because their bodies make a large amount of urine or because their bladders are smaller and stretch less than average.

Second, once their bladders are full, the sensation of fullness does not cause them to wake up to go to the bathroom. That may be because they are less sensitive to the feeling of a stretched bladder or because they are sleeping so deeply that they don’t notice when their bladder is full. Of course, many children sleep deeply, but they all do not wet their beds. No one knows for sure why some children can awaken to go to the bathroom when their bladders are full and others continue to sleep. What we do know is that nighttime wetting is not a sign of laziness or stubbornness.

Bad Memories

Nighttime wetting (which is also called nocturnal enuresis when a child is over 5 years old) often runs in families. Many times a parent, an aunt, or an uncle has had the same difficulty as a child staying dry at night. (When I ask parents if one of them wet the bed as a child, one parent is often quite surprised to hear that the other did, but never mentioned it. And why would they?)

Parents sometimes remember being scolded or punished for wetting the bed when they were young. They may have felt ashamed about wetting, and their parents may not have known that wetting was common in young children. If parents have unpleasant memories of their own difficulties staying dry at night, they may worry if their own child has similar problems. It is usually helpful to talk to your child’s health care provider about any worries you have. Talking to a counselor may help if parents find themselves unable to set aside their concerns.

Stay Positive

Parents do have an important role in helping a child to solve the problem of wetting the bed. Even if you have become angry with your child about a wet bed in the past, it is never too late to tell him that you now know that the wetting isn’t his fault. Express confidence that Jeremy will learn to stay dry all night in the same way he has learned to do other things on his own. Point out that there are some things that he has learned quickly, maybe faster than his friends, and that some kids learn other things faster than he does. Remind him that he has already figured out how to stay dry during the day.

Saying something like, “You know how during the day, when you notice you ‘have to go,’ you decide whether to go to the bathroom right away or hold your pee inside you for a while? Well, the next thing you are going to learn is how to do that during the night. You haven’t learned yet to do the same thing while you are sleeping, but you will learn it, for sure.”

This kind of positive attitude from parents will create an expectation for a child that is very powerful, but for some parents this shift feels hard.

Even though most children will not need counseling to help with the problem of wetting the bed, they may benefit from going with their parents to talk to their pediatrician or someone knowledgeable about the condition. Children need to hear that their parents want to help them, and they need to know that their parents understand that they are not trying to misbehave.

Once a child who is wearing diapers or Pull-ups® at night is able to stay dry for more than a week – either by holding his urine or by waking himself to go to the bathroom – it is reasonable to allow him to try sleeping without diapers. However, it is also a good idea to keep expectations realistic.

A child may have a few weeks of dry nights and then begin to have frequent accidents. If you have showered your child with praise for staying dry at night and he has a relapse, you don’t want him to feel as though he has failed. If accidents persist, you may want to return to diapers or Pull-ups and try again after a few weeks or months.

If a child has been dry at night for several months and then begins to wet the bed, he should be checked by his health care provider to make sure that there is not an underlying infection or illness causing the wetting.

Sometimes a step backward in nighttime dryness is a result of other stresses in the child’s life. Anew school, the birth of a new baby, a change in sitters, or family tension can cause wetting. It is important to address underlying stresses rather than to treat wetting the bed as the problem.

Parents may hear varying advice and suggestions for helping a child stay dry at night. Since many children simply outgrow the problem, it is difficult to know which approaches really work. Here are some approaches that are often recommended and any advantages and disadvantages of each one.

  • Have your child try to use the toilet at the beginning of the bedtime routine and then again right before going to sleep. Even a few minutes between voiding (the medical word for peeing) can make a difference in complete emptying. Some children do not empty completely when they go to the bathroom, and this gives them another chance. This is a good technique during the day, too.
  • Take your child to use the toilet at your own bedtime or in the middle of the night. This method may prevent your child from wetting the bed or reduce the amount of soaking, but it will probably not help him to learn to stay dry independently. Some parents who want a child to be out of diapers may feel better about helping in this way. Other parents will find this a burden.
  • Put a night light in the child’s room, and a night light or motion sensor light in the bathroom and in any rooms in between. Some children do not like to leave their rooms if it is dark. You can also put a potty chair near the bed. Keeping your home warm at night may help, since some children will wet more if they are chilly and some children will not want to get out of bed if the room is cold.
  • Encourage your child to drink more liquids earlier in the day. If your child does not drink very much during the day, he may be thirsty after dinner and more likely to wet during the night. It is not a good idea to restrict fluids after dinner, since most children will view the restriction as a punishment. Caffeine, fruit juice, and sweet drinks can increase nighttime urination, so limit afterdinner liquids to water.
  • Once a child is able to stay dry several nights a week, he may like to have a chart where dry nights can be marked with stars or stickers. Some children love this approach, but others get so disappointed in themselves that they get discouraged. Use this approach only if your child is enjoying it. I don’t recommend prizes for “seven days straight” because if a child wets after five days, he will lose everything. But a small prize for “seven days” is just fine.
  • Some people feel that a child will not learn to stay dry as long as he is in diapers or Pull-ups. However, if a young child usually wets the bed at night, wearing a diaper will be less work for parents. If a child is wearing a diaper at night, a parent should take him to the bathroom when he wakes up in the morning, remove his diaper, and have him sit on the toilet. If a child does not want to wear a diaper at night, he should be expected to help remove wet sheets and any wet clothing and put them into the washing machine. Helping should be seen as a responsibility that goes along with deciding to sleep without diapers, not as a punishment for wetting the bed.It will help if the mattress is kept covered with plastic and a towel-wrapped plastic pad is placed on top of the sheets for quicker clean-up. It is often helpful to use two layers of sheets, towels, and plastic liners so that if a child wakes up wet during the night, the first layer can be quickly stripped and everyone can go back to sleep.
  • Once your child has begun to stay dry at night on his own, you can remind him of his success at bedtime. If a child has stayed dry by getting up and going to the bathroom, he can try imagining himself getting out of bed, walking to the bathroom, sitting on the toilet, going, and returning to bed. If he has stayed dry by holding on to his urine, he can imagine himself sleeping and holding in the way he does during the day. If a child does not want to do this imagining, parents should not insist, because the child will feel pressured.
  • If the bed wetting has not resolved by the time a child is 7 or 8 years old, he can try using a moisture-sensitive “alarm” device. These alarms are attached to underpants or pajamas and vibrate and sound a bell when he first wets his clothing or bed. The noise will awaken parents to get the child to the bathroom. Eventually, the child will be awakened by the bell, and later on by the vibration. Over time, these devices are extremely successful for highly motivated older children and highly motivated parents. They are not as useful for younger children, because children under the age of 7 often cannot sustain motivation for the weeks or months of practice needed to get to regularly dry nights.
  • Hypnosis and guided imagery are often very successful with children as young as 5 years old. The child first learns about how his body has already learned to stay dry during the day, and how he will be able to learn the same thing for night. Storytelling and imaginative metaphors are used to help the child visualize how he will take that step. Parents are a part of the process and help the child at home to practice the visual imagery. The person doing the hypnosis should be a health care professional who has experience both with children and with treating enuresis (bedwetting).
  • In the past, medications were prescribed for children who wet the bed at night. However, the health risks associated with medications must be weighed against benefits, and this method of treatment is usually not advisable. If you are thinking about medications, it is best to schedule a conference with your child’s health care provider to discuss the risks, costs and benefits of such treatment

Even though nighttime wetting is usually described as a problem, it is perfectly normal for many young children, even at Jeremy’s age, so don’t get discouraged. The most important role for parents is helping him to understand that even though his wetting is frustrating for everyone, he is just a “late bloomer” and that he will be able to solve the problem as he grows older.

Meg Zweiback was a pediatric nurse practitioner and family consultant. She had a private practice in the East Bay and was an associate clinical professor of nursing at the University of California, San Francisco.