Start of School Can Worsen Bedwetting in Children

Enuresis: Practice Essentials, Background, Pathophysiology

Start of School Can Worsen Bedwetting in Children | Johns Hopkins Medicine

Possible causes of PE and SE are summarized in Table 2 below.

Table 2. Possible Causes of Primary and Secondary Enuresis (Open Table in a new window)

Causes of Primary Enuresis Causes of Secondary Enuresis
IdiopathicDisorder of sleep arousalNocturnal polyuriaSmall nocturnal bladder capacity IdiopathicDisorder of sleep arousalNocturnal polyuriaSmall nocturnal bladder capacity
Overactive bladder or dysfunctional voiding Overactive bladder or dysfunctional voiding
Cystitis Cystitis
Constipation Constipation
Neurogenic bladder Psychological
Urethral obstruction Acquired neurogenic bladder
Psychological Seizure disorder
Ectopic ureter Obstructive sleep apnea
Diabetes insipidus Diabetes mellitus
Acquired diabetes insipidus
Acquired urethral obstruction

If no cause can be identified, the important pathophysiologic factors include a disorder of sleep arousal, nocturnal polyuria, and a low nocturnal bladder capacity.

Sleep studies reveal that children with enuresis do not wake up normally in response to an auditory signal; this finding confirms a problem in arousal.

Arousal to the sensation of a full or contracting bladder involves interconnected anatomic areas, including the cerebral cortex, the reticular activating system (RAS), the locus ceruleus (LC), the hypothalamus, the pontine micturition center (PMC), the spinal cord, and the bladder. The RAS controls depth of sleep, the LC controls arousal, and the PMC initiates the command for a detrusor contraction. Various neurotransmitters are involved, including norepinephrine, serotonin, and antidiuretic hormone (ADH).

Studies reveal nocturnal polyuria in some but not all children with enuresis.

Although nocturnal polyuria is important in the pathophysiology of enuresis, overproduction of urine per se cannot be the sole causal factor.

Nocturnal polyuria does not explain why children with enuresis do not wake up to the sensation of a full or contracting bladder or why enuresis can occur during daytime naps.

Nocturnal polyuria in children with enuresis may be multifactorial. Possible causes include the following:

  • Increased fluid ingestion from the time a child arrives home from school through the afternoon and evening to bedtime
  • Reduced fluid ingestion from the time a child wakes through the school day
  • Food consumption from the time a child arrives home from school through the afternoon and evening to bedtime
  • Low nocturnal secretion of ADH
  • Increased nocturnal solute excretion

Ingestion of fluids from the time a child arrives home from school through to bedtime is a common cause. Solid food ingestion is also a cause because excretion of solute by the kidney is accompanied by an obligate amount of water.

Many children with bedwetting drink very modest amounts of fluids at breakfast and throughout the school day.

Accordingly, they arrive home from school hungry and thirsty, and most of their fluid intake often occurs in the few hours between arriving home and bedtime.

Children who engage in strenuous physical activities will also become dehydrated and will drink large amounts of fluids in the evening.These patterns favor nocturnal polyuria.

Production of urine is controlled by several factors, including ADH, which directly controls water absorption, and atrial natriuretic peptide (ANP) and aldosterone, which control solute and thus indirectly affect water excretion.

Norgaard et al first reported the absence of the expected nocturnal increase in ADH secretion in adults with enuresis. [7] Subsequent reports suggested that low nocturnal secretions of ADH are present in some but not all children with enuresis.

[8] Urine sodium and potassium excretion are increased in some children with enuresis, but the reasons for these increases are not clear.

Rittig et al reported that secretion of ANP in children with enuresis shows a normal circadian rhythm and that the renin-angiotensin-aldosterone system is intact. [9]

Bladder distention may influence nocturnal secretion of ADH. Some studies report that ADH secretion is increased in response to bladder distention and reduced with bladder emptying. If ADH secretion falls with bladder emptying, the observed low nocturnal blood levels of ADH may be a consequence of enuresis rather than a cause.

Small functional bladder capacity (C) is now known to play a role in the pathogenesis of enuresis. For some time, it was considered a less ly explanation for enuresis in children without daytime symptoms, but studies confirmed that children without daytime symptoms may have a low nocturnal bladder capacity and that this is a very common factor in enuresis.

In a study by Mattsson and Lindstrom, C was positively correlated with nighttime urine output.

[10] It has been theorized that children with enuresis may maintain a smaller nocturnal bladder volume and that this situation may condition the detrusor muscle to contract at a lower volume.

According to this theory, the low nocturnal bladder capacity is a consequence of enuresis rather than a cause.

Bloom et al suggested a problem with the external urethral sphincter as a possible cause of low nocturnal bladder capacity, [11] noting that the control of voiding rests at the external urethral sphincter, where constant activity is present as a guarding reflex to preserve continence. They speculated that the activity of the external urethral sphincter might fall below a critical level during sleep and thereby trigger a detrusor contraction.

Chronic constipation may also lead to reduced bladder capacity due to accumulation of stool in the distal colon.

Overactive bladder or dysfunctional voiding is more common among girls in preschool or elementary school, usually presenting with urinary frequency, urgency, squatting behavior, daytime wetting, and enuresis.

Squatting behavior, a common and distinct symptom of overactive bladder or dysfunctional voiding, is a learned response and an attempt to suppress an unexpected and unwelcome detrusor contraction. The squatting posture elicits a bulbar detrusor inhibitory reflex.

In some children, a period of normal voiding occurs, and the onset of the bedwetting is compatible with SE. If enuresis is present, the cause is presumed to be a low nocturnal bladder capacity, but a disorder of arousal must also be present.

Squatting is commonly associated with a history of cystitis.

Symptoms tend to improve or resolve with time and are less common after puberty. Vesicoureteral reflux is more common in these children, and cystitis and constipation are frequent complicating problems. Urodynamic studies reveal unstable detrusor contractions early in the filling phase.

Cystitis is a common cause of enuresis and an aggravating factor associated with other causes; cystitis associated with enuresis may present at any age. Cystitis causes uninhibited detrusor contractions that can lead to episodes of day and nighttime wetting.

If cystitis is the only cause of enuresis, other symptoms of infection are usually present, and the wetting resolves with an appropriate antibiotic.

Cystitis is more common in children with overactive bladder or dysfunctional voiding, neurogenic bladder, urethral obstruction, ectopic ureter, or diabetes mellitus.

In these conditions, daytime symptoms do not resolve completely with antibiotic treatment.

Various common situations predispose to a psychological cause of enuresis, including birth of a new sibling, parental divorce or separation, death in the family, child abuse, or any other cause of social dysfunction at home or school.

A study by von Gontard et al found that children with SE have a significantly higher rate of behavioral disorders, life events, and continuous psychosocial stress than those with PE. [12] Stressful life events and psychiatric diagnoses are reported to precede the diagnosis of SE. The later the onset of SE, the greater the lihood of preceding psychological stress.

Constipation can cause both PE and SE and is a common aggravating factor that should be considered when other causes are present.

Although the mechanism is not clear, the pressure effect of stool in the descending or sigmoid colon ly restricts bladder capacity, and colonic movements at night might trigger an uninhibited detrusor contraction. Constipation is usually present in children with neurogenic bladder and is more common in those with overactive bladder or dysfunctional voiding.

Sleep-disordered breathing (SDB) is a disorder associated with both an abnormality in arousal and enuresis.

The most common cause of SDB in childhood is adenotonsillar hypertrophy, which has a peak incidence in children aged 2-5 years. Nocturnal polyuria is reported in individuals with obstructive sleep apnea (OSA).

A decrease in nocturnal secretion of ADH and an increase in ANP secretion are possible explanations for nocturnal polyuria.

A neurogenic bladder can result from a lesion at any level in the nervous system, including the cerebral cortex, the spinal cord, and the peripheral nerves. As many as 37% of children with cerebral palsy have enuresis.

Patients with myelomeningocele almost always have enuresis.

Other spinal cord abnormalities, such as caudal regression syndrome, tethered cord, tumors, anterior spinal artery syndrome, and spinal cord trauma, can cause enuresis.

Specific dysfunction in the external urethral sphincter can develop after pelvic extirpative surgery, radiation therapy for pelvic malignancy, pelvic fracture, or incontinence surgery. Sacral agenesis can be associated with a neurogenic bladder. As many as 5% of patients with an imperforate anus have a neurogenic bladder, and most patients also have a lumbosacral anomaly.

Urethral obstruction can be congenital (as with posterior urethral valves, congenital stricture, or urethral diverticula) or acquired (as with a traumatic or infectious stricture or with meatal stenosis after circumcision).

Traumatic strictures may develop after a traumatic urethral catheterization, a foreign body in the urethra, or pelvic trauma.

Infectious strictures are a complication of purulent urethritis due to bacteria such as Neisseria gonorrhoeae.

Meatal stenosis is a common cause of distal urethral obstruction in circumcised males, but it is not considered a cause of enuresis. It may, however, be associated with bladder overactivity and may be a contributing factor for enuresis.

SE may be a symptom of an unobserved overnight major motor convulsion in a child with a known seizure disorder. New-onset seizures rarely occur only at night; consequently, bedwetting is a rare manifestation.

Ectopic ureter is due to the insertion of the ureter in a location other than the lateral angle of the bladder trigone.

The most common site of the ectopic orifice is adjacent to the external urethral meatus and is below the external sphincter in females. Children with ectopic ureter tend to wet constantly.

Enuresis results when the insertion is distal to the external urethral sphincter. Ectopic ureter is three to four times more common in girls than in boys and causes incontinence only in females.

Enuresis usually is not the presenting complaint in a child with new-onset diabetes mellitus. Conventional symptoms of insulin deficiency usually overshadow the presence of bedwetting.

SE in a child with established diabetes mellitus may be a symptom of suboptimal control, with nocturnal polyuria due to hyperglycemia.

Although nocturnal polyuria is presumed to be the cause of the bedwetting, a disorder of arousal is also ly to be present because most school-aged patients develop nocturia but maintain a dry bed.

Diabetes mellitus is also associated with abnormalities in the afferent sensory pathways to the bladder, which may contribute to enuresis.

Diabetes insipidus is a very rare cause of enuresis. Although nocturnal polyuria is often presumed to be the cause of bedwetting, a disorder of arousal may also be present. Diabetes insipidus may be either central or nephrogenic.

Central diabetes insipidus may result from an intracranial tumor, head trauma, encephalitis, or meningitis; nephrogenic diabetes insipidus may result from any cause of renal failure, diffuse renal cortical or medullary damage, hypokalemia, hypercalcemia, or nephrotoxic drugs.

Source: https://emedicine.medscape.com/article/1014762-overview

Enuresis Treatment & Management: Approach Considerations, Initial Management, Alarm Therapy

Start of School Can Worsen Bedwetting in Children | Johns Hopkins Medicine

Desmopressin acetate is the preferred medication for treating children with enuresis. A Cochrane review of 47 randomized trials concluded that desmopressin therapy reduces bedwetting; children treated with desmopressin had an average of 1.3 fewer wet nights per week. [17]

The tablet and the orally disintegrating tablet (melt) have similar efficacy. The orally disintegrating tablet is not available in the USA. The intranasal formulation carries a black box warning from the US Food and Drug Administration (FDA) and is no longer recommended for enuresis, because of the risk for severe hyponatremia that can cause seizures and death.

Desmopressin acetate tablets or orally disintegrating tablets should be administered 1 hour before bedtime. The recommended starting dose for the tablet is 0.2 mg, and the drug can be titrated as necessary to a maximum dose of 0.6 mg. The equivalent starting dose for the orally disintegrating tablet is 120 µg, and the maximum dose is 360 µg.

Desmopressin’s immediate onset of action allows the flexibility of choosing either intermittent administration for special occasions or long-term use to maintain dryness. For long-term use, desmopressin can be prescribed in 3-month quantities and discontinued between prescriptions to determine whether the wetting persists and thus whether continued use is justified.

The safety profile of desmopressin acetate is favorable, and many studies have documented low rates of adverse effects. For the tablet, the incidence of minor adverse events is not significantly different from that for a placebo.

The only serious adverse effect reported in patients with enuresis treated with desmopressin is the development of seizure or other central nervous system (CNS) symptoms due to water intoxication. A review of case reports of water intoxication associated with desmopressin confirmed that excess fluid intake was a feature in at least six of 11 individuals. [21]

This serious adverse effect can be prevented by educating the patient not to consume an excess of fluids on any evening in which desmopressin is administered.

A maximum of 1 cup of fluid should be offered at the evening meal, no more than 1 cup between mealtime and bedtime, and no fluid at all within the 2 hours preceding bedtime. Early symptoms of water intoxication include headache, nausea, and vomiting.

If these symptoms develop, the medication should be discontinued and the child promptly assessed by a physician.

An FDA alert from December 2007 cited 61 postmarketing cases of hyponatremic-related seizures associated with the use of desmopressin. In 55 cases, sodium levels of 104-130 mEq/L during the seizure event were reported. In two cases, the patients died (both patients experienced hyponatremia and seizures).

There were 36 cases associated with intranasal formulations, 25 of which occurred in pediatric patients younger than 17 years. The most commonly reported indication for use in these 25 pediatric cases was enuresis. In 39 of the 61 cases, there was at least one concomitant drug or disease that was also associated with hyponatremia, seizures, or both.

Combination of alarm therapy with desmopressin therapy has been reported to result in dryness not achievable with either therapy alone.

An anticholinergic medication might be helpful in some patients, especially those with overactive bladder, dysfunctional voiding, or neurogenic bladder. These medications reduce uninhibited detrusor contractions, increase the threshold volume at which an uninhibited detrusor contraction occurs, and enlarge the functional bladder capacity.

Oxybutynin chloride and tolterodine are commonly prescribed in this setting. Oxybutynin chloride also has antispasmodic and analgesic properties. Anticholinergic adverse effects include dry mouth, blurred vision, facial flushing, constipation, poor bladder emptying, and mood changes. Constipation as an adverse event is especially problematic in that it might increase the risk for wetting.

Anticholinergic medications should not be administered during a fever, because an anticholinergic effect is a decrease in sweating. Similarly, they should be used with caution in children who exercise or play strenuously, especially on hot days.

Oxybutynin is given in a dose of 2.5-5 mg administered at bedtime. A long-acting preparation is available but has not been approved for use in children.

Tolterodine is not approved for use in children younger than 12 years.

Flavoxate, a urinary spasmolytic, might be helpful in some patients with overactive bladder and dysfunctional voiding but is approved only for children older than 12 years.

The combination of desmopressin acetate and oxybutynin chloride might be efficacious in children with overactive bladder or dysfunctional voiding who respond to anticholinergic therapy with improved daytime symptoms but who continue to wet at night. Long-acting preparations of oxybutynin may be more efficacious for combined use with desmopressin.  

A Cochrane review of 64 randomized trials concluded that imipramine is effective in reducing bedwetting; children treated with imipramine had one fewer wet night per week. [18] The relapse rate is high when the medication is discontinued. The usual dose, taken 1-2 hours before bedtime, is 25 mg for patients aged 6-8 years and 50-75 mg for older children and adolescents.

Adverse effects include constipation, difficulty initiating voiding, irritability, drowsiness, reduced appetite, and personality changes.

Imipramine overdose can be fatal, and a cautionary warning is necessary with every prescription.

Because of the unfavorable adverse effect profile and the significant risk of death with overdose, the World Health Organization (WHO) does not recommend imipramine for the treatment of enuresis.

Source: https://emedicine.medscape.com/article/1014762-treatment

Start of school can worsen bedwetting in children

Start of School Can Worsen Bedwetting in Children | Johns Hopkins Medicine

Bedwetting perennially drives parents to the pediatric urology clinic at Johns Hopkins Children's Center, but September — and the start of the school year — always brings a predictable uptick in visits, according to pediatric urologist Ming-Hsien Wang, M.D.

“Back to school is a physically and emotionally stressful time for many children, compounded by the sudden change in sleep patterns and schedules that generally wreak havoc on eating and other routines established over the summer,” Wang says.

Children who experience back-to-school flare-ups should stick to a regular “pee” schedule through the day, says Wang, who s to send parents home with a note to their child's teacher verifying the child's urologic condition and recommending bathroom visits every two or so hours. The brain controls the bladder, Wang explains, so establishing a clockwork potty routine during the day helps improve brain-bladder communication in general.

Bladder control develops gradually in children, with nighttime bladder control, the final stage of the process, reached generally by age 6 or 7. A small number of children continue to wet their beds until age 10 and beyond.

Physical and emotional stressors are well-known contributors to both night-time enuresis and daytime incontinence in children, says Wang, and the vast majority of cases are due not to anatomical or biological problems, but to lifestyle issues such as lack of regular potty times, good hydration and appropriate diets.

“Changes in lifestyle take care of 80 percent of these problems,” says Wang, who only rarely prescribes drugs, which can have side effects, or bedwetting alarms, which disrupt the sleep cycles of both the child and the family.

She advises: • Ruling out medical conditions that cause incontinence, including diabetes, urinary tract infections and kidney disease, as well as certain anatomic abnormalities of the genitourinary tract and some neurological disorders that affect brain-bladder signaling • Letting your child know that this is a fixable condition and providing lots of emotional support • Eating a diet rich in fiber with plenty of raw fruits and vegetables every day • Drinking plenty of water to ease urination: The marker of good hydration is urine color, which should be pale yellow or as clear as water • Send your child to school with a bottle of water (flavored, if necessary, with a bit of honey or lemon juice) rather than sugar-rich drinks • Stopping fluids about three hours before bedtime • Emptying the bladder immediately before going to bed • Keeping a toileting diary for several days before the visit to the doctor and writing down how often a child empties the bladder, along with the number of daytime and nighttime accidents

Although bedwetting can increase around back-to-school time, Wang says, the condition appears to be on the rise year-round.

“Anecdotally, we are seeing more and more patients referred to us by general pediatricians,” says Wang.

While experts have yet to verify the increase scientifically or tease out the factors behind it, Wang believes that more awareness of the condition, combined with lifestyle choices are the two main drivers.

Poor nutrition and eating and voiding habits are major contributors, Wang says, and children with constipation are also prone to bedwetting because both interfere with control of the pelvic muscles involved in toileting.

Story Source:

Materials provided by Johns Hopkins Medicine. Note: Content may be edited for style and length.

Source: https://www.sciencedaily.com/releases/2010/09/100925120432.htm

Bedwetting

Start of School Can Worsen Bedwetting in Children | Johns Hopkins Medicine

Bedwetting happens when a child pees during sleep without knowing it. Many children will use the toilet well during the day long before they are dry through the night. It can be many months, even years, before children stay dry overnight.

Most children, but not all, stop bedwetting between the ages of 5 and 6 years old. Bedwetting is more common in boys and in deep sleepers.

What causes bedwetting?

Bedwetting is most often related to deep sleep—the bladder is full but the child doesn’t wake up. Some children have smaller bladders, or produce more urine during the night. Constipation can also lead to bedwetting because the bowel presses on the bladder.

If your child has always wet the bed and has never had 6 months or more of dry nights, there is nothing “wrong” with your child. This type of bedwetting is NOT caused by medical, emotional or behavioural problems.

But if your child has been dry overnight for at least 6 months and starts to wet the bed again, talk with your doctor.

Does bedwetting run in families?

Yes. In fact, scientists have discovered a gene for bedwetting. A child with one parent who wet the bed when they were young is 25% more ly to wet to the bed. If both parents wet the bed as children, that number rises to about 65%.

When do children outgrow bedwetting?

Most children will outgrow bedwetting on their own over time.

  • At 5 years of age, 15% of children wet the bed.
  • By 8 years, 6% to 8% of children wet the bed.
  • Without treatment, about 2% of children still wet the bed by 15 years of age.

Does bedwetting need to be treated?

Usually not. The more important question is whether the bedwetting is a problem for your child. If bedwetting isn’t upsetting her, then you probably don’t need to seek treatment. Most children eventually outgrow it.

However, by 8 to 10 years of age, bedwetting may start to affect your child’s self-esteem and interfere with social activities sleepovers. If this is the case, you can talk to your doctor about the following options:

  • An alarm that your child wears at night. The alarm goes off when he starts to pee and helps teach him to wake up when he has a full bladder.
    • It’s a good idea to talk to your doctor before you decide to buy one because she can provide advice on how to use the alarm properly.
    • The alarm needs to be used daily over a 6 week to 3 month period to be effective.
  • Desmopressin acetate (or DDAVP) is a medication that has been used to treat bedwetting since the 1970s. It comes as an oral melt (a tablet that melts under the tongue) or a pill. Studies show that it works for most children on nights the medication is given. It won’t stop bedwetting completely, but it may be useful for special situations, such as sleepovers or camp.
    • Children should not drink water 1 hour before and 8 hours after taking DDAVP.
    • DDAVP can have mild side effects, such as headache or stomach pain. It can have severe side effects if not used properly or if your child has certain medical conditions such as cystic fibrosis or problems with fluid balance. Have a discussion with your child’s doctor if your child has any side effects.
    • all medications, DDAVP should only be used as prescribed by your doctor.

Whether you and your doctor decide to treat the bedwetting or simply wait for your child to outgrow it, be sure that your child knows that bedwetting is not a bad behaviour or laziness. Don’t ever punish your child for bedwetting. It is not his fault. Your comfort and support are very important.

What else can I do to help my child?

  • Make sure your child doesn’t drink too much fluid before bedtime.
  • Avoid drinks with caffeine (such as pop).
  • Encourage your child to go to the bathroom before bedtime.
  • Use training pants instead of diapers.
  • Make sure your child can easily reach the bathroom at night. For example, use a night light in the hall or in the bathroom.
  • Use a hospital-strength plastic mattress cover to avoid damage to the mattress.
  • Place a large towel underneath the bed sheet for extra absorption.
  • It’s not necessary to change a sleeping child who is wet. There is no harm in sleeping in wet PJs. Leave a towel and change of clothes in case your child does wake up.
  • Don’t wake your child up to pee when you go to bed. It doesn’t help with bedwetting and will just disrupt your child’s sleep.
  • When your child wets the bed, help him wash well in the morning so that there is no smell.

When should I talk to my doctor?

Talk to your doctor if your child:

  • is concerned or upset by the bedwetting.
  • is having daytime accidents.
  • has been dry for many months and suddenly starts bedwetting.
  • has other symptoms, such as a frequent need to pee or a burning sensation when peeing.
  • is still wetting past 5 to 6 years of age.

Reviewed by the following CPS committees:

  • Community Paediatrics Committee

Last Updated: November 2017

Source: https://www.caringforkids.cps.ca/handouts/bedwetting

Back to school

Start of School Can Worsen Bedwetting in Children | Johns Hopkins Medicine

The first day of school is a big (and sometimes stressful) step for kids and parents a. But for parents continuing to manage a child who is wetting the bed, the start of school can present its own unique challenges.

While we know stress isn’t a direct cause of bedwetting, it can make the management of bedwetting more difficult. Changes to your child’s normal routine, starting school, can affect the progress you may have made in stopping bedwetting.

Even if your child is already a few years into school, returning to a new teacher or classroom, or even a new curriculum, may produce new challenges that can add to stress.

Above all, it’s important to not be too disheartened if your child wets the bed again once they have started school. Here a few simple techniques worth considering if your child continues to wet the bed (or ‘relapses’) once they start school:

  • Re-establish routine: The start of school presents a shake up to your regular day to day life, so establishing a new routine that’s right for your family and maintaining this may help, i.e. regular post-school routine, bath, dinner and bedtime throughout the week.
  • Get to know the environment: Get in touch with the school to see if a tour of the school / classroom is possible (ideally in advance of the new school year). This familiarises your child with their new environment, to help them feel comfortable and less stressed when school starts.
  • Speak to the teacher: A quick chat or brief email to your child’s teacher, to let them know you are managing bedwetting, puts everyone on the same page, and ensures they’re aware and can discretely cater for your child’s needs if necessary.

How can your school help?

In addition to having a conversation with your child’s teacher, there are a number of initiatives that could be worth bringing to the school’s attention. For example, The Continence Foundation of Australia offers the Healthy Bladder and Bowel Habits in Schools project, which encourages schools to raise awareness of the importance of healthy bladder and bowel habits.

This project offers schools a kit with activities, resources, and surveys tailored for educating children on healthy bladder and bowel habits. Resources such as these not only offer support for your child, but to other families who are experiencing similar difficulties. For further information visit www.continence.org.au or contact the free Helpline on 1800 33 00 66.

How can your doctor help?

Your doctor or continence professional can provide you with advice on how to help your child adjust to a new routine, including starting school, and recommend adjustments to the management of their bedwetting if required. If you haven’t downloaded our checklist already, click here – it provides a helpful starting point for your discussions with your doctor.

References

  1. Fries W C. Could Stress or Anxiety Be Causing Your Child’s Bedwetting? Available online: http://www.webmd.com/parenting/features/bedwetting-stress-anxiety#1 (last accessed 23 Jan 2017)
  2. Parenting SA. Bedwetting. Available online: http://www.parenting.sa.gov.au/pegs/peg22.pdf(last accessed 23 Jan 2017)
  3. Johns Hopkins Medicine. 2010. Start of school can worsen bedwetting in children. ScienceDaily. Available online: www.sciencedaily.com/releases/2010/09/100925120432.htm (last accessed 23 Jan 2017)
  4. Stone D. 6 ways to take the stress the first day of school. Available online: https://www.babble.com/kid/6-ways-to-take-the-stress-out-of-the-first-day-of-school(last accessed 23 Jan 2017)
  5. The Continence Foundation of Australia. Healthy bladder and bowel habits in schools. Available online: http://www.continence.org.au/pages/healthy-bladder-and-bowel-habits-in-schools.html (last accessed 23 Jan 2017)

Source: https://www.treatbedwetting.com.au/back-to-school/the-first-day-at-school

Start of School Can Worsen Bedwetting in Children

Start of School Can Worsen Bedwetting in Children | Johns Hopkins Medicine

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Bedwetting perennially drives parents to the pediatric urology clinic at Johns Hopkins Children’s Center, but September — and the start of the school year — always brings a predictable uptick in visits, according to pediatric urologist Ming-Hsien Wang, M.D.

“Back to school is a physically and emotionally stressful time for many children, compounded by the sudden change in sleep patterns and schedules that generally wreak havoc on eating and other routines established over the summer,” Wang says.

Children who experience back-to-school flare-ups should stick to a regular “pee” schedule through the day, says Wang, who s to send parents home with a note to their child’s teacher verifying the child’s urologic condition and recommending bathroom visits every two or so hours. The brain controls the bladder, Wang explains, so establishing a clockwork potty routine during the day helps improve brain-bladder communication in general.

Bladder control develops gradually in children, with nighttime bladder control, the final stage of the process, reached generally by age 6 or 7. A small number of children continue to wet their beds until age 10 and beyond.

Physical and emotional stressors are well-known contributors to both night-time enuresis and daytime incontinence in children, says Wang, and the vast majority of cases are due not to anatomical or biological problems, but to lifestyle issues such as lack of regular potty times, good hydration and appropriate diets.

“Changes in lifestyle take care of 80 percent of these problems,” says Wang, who only rarely prescribes drugs, which can have side effects, or bedwetting alarms, which disrupt the sleep cycles of both the child and the family.

She advises:

  • Ruling out medical conditions that cause incontinence, including diabetes, urinary tract infections and kidney disease, as well as certain anatomic abnormalities of the genitourinary tract and some neurological disorders that affect brain-bladder signaling
  • Letting your child know that this is a fixable condition and providing lots of emotional support
  • Eating a diet rich in fiber with plenty of raw fruits and vegetables every day
  • Drinking plenty of water to ease urination: The marker of good hydration is urine color, which should be pale yellow or as clear as water
  • Send your child to school with a bottle of water (flavored, if necessary, with a bit of honey or lemon juice) rather than sugar-rich drinks
  • Stopping fluids about three hours before bedtime
  • Emptying the bladder immediately before going to bed
  • Keeping a toileting diary for several days before the visit to the doctor and writing down how often a child empties the bladder, along with the number of daytime and nighttime accidents
  • Although bedwetting can increase around back-to-school time, Wang says, the condition appears to be on the rise year-round.

“Anecdotally, we are seeing more and more patients referred to us by general pediatricians,” says Wang.

While experts have yet to verify the increase scientifically or tease out the factors behind it, Wang believes that more awareness of the condition, combined with lifestyle choices are the two main drivers.

Poor nutrition and eating and voiding habits are major contributors, Wang says, and children with constipation are also prone to bedwetting because both interfere with control of the pelvic muscles involved in toileting.

“When children cannot move their bowels, they also tend to hold their urine, which in turn makes them more ly to have accidents.”

Source: https://www.hopkinsmedicine.org/health/wellness-and-prevention/start-of-school-can-worsen-bedwetting-in-children