Tonsils and Bedwetting

Interesting study indicating that about half of the bedwetters (ages 5 to 18) with breathing difficulties while asleep (apnea or snoring) stop wetting the bed after a tonsilectomy. Those who stopped wetting “had significantly more arousals and obstructive apnea episodes but fewer awakenings than” those who continued to wet.

Confirming again a connection between sleep patterns and bedwetting.

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Protection for better sleep

A very interesting article, suggesting that bedwetting children should wear protection to get a good night’s sleep.

The first finding is perhaps not surprising: undiapered bedwetting children have significantly worse sleep quality than non-bedwetters. Undiapered bedwetters have more activity during sleep and shorter periods of continuous sleep.

The second finding may be more surprising, and is certainly more interesting: Diapered bedwetters have significantly better sleep quality than undiapered bedwetters – indeed, the sleep quality for diapered bedwetters is substantially similar to that of non-bedwetters.

Results

In comparison to [non-bedwetters], children with enuresis who did not wear night diapers had poorer sleep quality as reflected by both actigraphic measures (more activity during sleep and shorter periods of continuous sleep) and one reported measure (lower sleep quality). However, no differences were found on any of the sleep measures between children with enuresis wearing night diapers and [non-bedwetters]. The reported sleep quality of all children with enuresis with and without night diapers was lower than [non-bedwetters].

Given the importance of quality sleep, the authors conclude that doctors and nurses should recommend that a bedwetting child sleep in a diaper:

Conclusions

Our results suggest that sleep patterns of school-aged children with enuresis who do not wear night diapers are impaired, and the sleep quality of children using night diapers is similar to those of [non-bedwetters]. Thus, clinicians and healthcare providers should consider recommending sleeping with night diapers for untreated children with enuresis, based on its positive impact on sleep.

This confirms my advice that parents offer protection to a bedwetting child. Indeed, this indicates that my advice was not be strong enough:  For a good night’s sleep, protection may be essential. As I say in the update to that post,

A bedwetter should wear protection.

A parent of a young bedwetter should insist on protection.

A parent of a bedwetter old enough to make a mature decision should offer and very strongly recommend and encourage protection.

The authors close with an interesting comment: Diapering at older ages does not have a negative effect on a bedwetter, nor does it perpetuate bedwetting. Diapering will lower stress and shame and improve “the child’s well-being and psychologic functioning”.

Speaking from my own, my siblings’ and my children’s experience, I think that is certainly true. A wet diaper is less stressful and shameful than a wet bed, and no child wants to wake up in either a wet bed or a wet diaper.

Of course, as I have suggested, it is probably not good salesmanship to call it a diaper, even if the authors of the study do!

Kushner, Cohen-Zrubavel, Kushnir, “Night diapers use and sleep in children with enuresis”

[Thanks to commenter George for passing on this citation.]

“You will grow out of it” – followup

Following up to “You will grow out of it”:

I don’t want to encourage pessimism. Nearly everyone does outgrow it, almost all (97%, if this and many similar surveys are accurate) by age 10. Even 7-year-old bedwetters are overwhelmingly likely (80%) to stop by age 9.

Parents tend to start worrying about bedwetting at a ridiculously early age (3 years, if this study is to be believed). Judging from postings on the internet, worry becomes obsession by school age.

Doctors, on the other hand, are generally unconcerned about bedwetting per se up to age 7, and downplay concerns even up to age 10. And with good reason; almost everyone in those age cohorts does outgrow it.

On the other hand, doctors are concerned if there are other symptoms of something other than late-developing hormones or bladders.

The pessimism is for teenaged bedwetters. That study indicates that a child that wets at age 10 is probably still going to be wetting at age 20. That’s a very tiny fraction of the population, but it’s a real problem for those in that fraction.

“You will grow out of it”

An interesting medical journal article, which is likely to be depressing to a teenage bedwetter (and parents).

Nothing surprising in the basic findings: Parents of a 5-year-old (or even 8-year-old) bedwetter shouldn’t be very worried. First, it’s common: About 16% of 5-year-olds wet the bed, with boys about twice as likely as girls. More important, the vast majority (about 80%) of 5-year-old bedwetters will stop wetting by age 9, and 85% will outgrow it by age 19.

Unfortunately, that means that a teenager who wets the bed is unlikely to outgrow bedwetting. Most 9-year-old bedwetters will still wet the bed at age 19.

And frequent bedwetters are the ones least likely to outgrow it. Kids who wet at least 3 nights a week are more likely to continue wetting the bed. At age 5, less than 15% of bedwetters wet every night. By age 19, almost half of the remaining bedwetters wet every night.

Conclusions:

The present finding suggesting that PNE [primary nocturnal enuresis, i.e., bedwetting] spontaneously resolves with increasing age probably applies only to those with mild enuretic symptoms. There are significant differences in characteristics between younger enuretic children and older subjects. As age increases there is an increasing proportion of enuretic patients with more severe bed-wetting. Enuretic children aged >10 years and adolescents have significantly more daytime urinary symptoms and incontinence.

“Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study”, Yeung et al. Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong. BJU International. Volume 97, pages 1069 to 1073 (May 2006).

Parental anxiety

An interesting paper reporting on a survey of doctors and parents:

“Although both [parents and doctors] thought that bed-wetting is a maturational problem, the parent group thought emotional causes were important and were less likely to accept small bladder size as an etiology.”

Medical research in the last generation has found genetic, hormonal and physiological causes for bedwetting. That would explain why doctors focus on those factors. Parents who don’t know about those studies probably still accept an earlier generation’s belief that bedwetting has emotional or behavioral causes. Or maybe it’s parents’ natural human tendency to believe that their children can control things to a greater degree than their children actually can; that a child could stop wetting if he tried hard enough.

An even more interesting result:

“Parents thought that children should be dry at a much younger age than did the physicians (2.75 vs 5.13 years, respectively)”

Wow. “Should be dry” before age 3.

Perhaps the parents interpret, “children should be dry”, as, “when would I like my kids to be dry”. Three might be a defensible answer to that. Most parents would like their kids to be dry by 3. I would have overjoyed, although given their genes, I didn’t expect it. (I’m sure Mom would really have loved for all her kids to have been dry at 3!)

On the other hand, that’s a high expectation. Surveys say that most kids still wet the bed at 3. I’m generally skeptical about the accuracy of these sorts of estimates, but these surveys seem well constructed.

Part of it may be that parents don’t remember when they stopped wetting the bed themselves. Most – almost all – of us stopped wetting the bed when we were too young to form a memory of it. An excessively rosy belief in one’s toddling maturity probably colors it back a year or two. I don’t remember when I stopped (although I certainly remember when I started again!), and I would be skeptical of anyone’s memory of being dry before 3. The only memories I would trust would be of people who wet the bed until well into school age, and even they would probably tend to nudge that memory.

The doctors may interpret the survey question as, “At what age can one expect most children to be dry?” Plausible surveys indicate that is about 5.

The right question is, “when should I become concerned”. Current medical wisdom seems to be age 7 or 8, unless the child starts wetting again after being dry (secondary enuresis), or bedwetting is affecting the child’s emotional state, or the child has other symptoms of diabetes, urinary tract infection or other medical problems.

Beyond age 7 or 8, one should test and keep an eye out for more serious causes. But the best approach to bedwetting itself is to keep calm, manage the consequences and wait to outgrow it.

Effects of bedwetting

Medical surveys of children and parents report that bedwettters have a sense of “social difference and isolation“. Wetting the bed causes “distress and low self-esteem“. Bedwetters  have significantly lower self-perception of their scholastic skills, physical appearance and athletic competence, which worsens if bedwetting continues into adolescence and teens. Children in one survey rated parental fighting and divorce as the only things more stressful than bedwetting.

Interestingly, self-esteem improves if bedwetting is managed, even if it isn’t cured.

Parental anger or frustration is strongly correlated with negative emotional and psychological effects.

In my experience, that’s correct: A parent who is tolerant and reassuring and helps manage the physical consequences will also minimize (or even eliminate) shame, isolation, fear and loss of confidence and competence.

I didn’t feel shame or fear or isolation as a teenage bedwetter. It didn’t make me shy or withdrawn or wary. I didn’t feel physically, emotionally, intellectually or socially diminished.

For me, the bad effects were physical: The sodden wretchedness of a wet bed; the bulky discomfort of a diaper; greasy, smelly rash creams; the time and effort of putting on, taking off and laundering diapers.

My first teenage wet bed was a shock. The next few were disheartening, as I realized that it wasn’t a fluke. I didn’t just wet the bed; I was a bedwetter. I was even more unhappy when disposables proved inadequate and I started wearing a cloth diaper.

But within a few weeks, all that had passed. Neither wetting the bed nor wearing a diaper bothered me. After a month, it barely registered on my consciousness. A diaper dealt with wetting, and the washing machine dealt with a diaper. Changing was just another bedtime and morning routine. I could easily hide it on a sleepover or trip.

Perhaps the reason that I wasn’t afraid or ashamed was that my basic personality was already formed. I was already confident and happy.

On the other hand, my siblings were all chronic bedwetters before (and into) their teens, so their personalities were formed under the influence of bedwetting. Although we range from artistic to nerdy to pragmatic, none of us is shy or lacking self-esteem. If my siblings had any shame or fear about wetting the bed, they didn’t show it.

The difference, it seems to me, is family. My parents didn’t treat it as a shameful problem. It wasn’t a big deal. It wasn’t even a small deal. It was what it was, and it was easy to deal with. It was a private matter, and easy to keep private.

My older sisters were as big an influence as my parents. I idolized them. They were smart, outgoing, athletic and confident. They were daredevils. They both wet the bed regularly until they were 16 or 17.

Wetting the bed didn’t seem to affect their personality or outlook. It certainly didn’t hamper their social lives or dampen their enthusiasm for sleepovers or trips. They certainly didn’t seem to fear discovery.

Genetics

Something that came as a surprise to me (although it’s relatively old news): Geneticists claim to have identified the locus of genes that correlate with primary enuresis.

I knew that surveys (dating back to the 1970s) suggest that a child is very likely to wet the bed (about 75% probability) if both parents did. If one parent wet the bed, chances are about even that the child will. If neither parent wet the bed, a child generally will not; a child with no bedwetting in the family tree (parents, grandparents, uncles and aunts) is rarely a bedwetter. Those probabilities are for primary enuresis, that is, for a child over the age of 6 who has never been dry. Secondary enuresis (such as mine), which starts after being dry for some time, is not genetically correlated.

The interesting thing — to me, at any rate — is that geneticists have identified the locus of several genes that appear to be correlated between parents who were bedwetters and their children who wet the bed. Some genes appear to be dominant, some to be recessive.

Some of the genes appear to be sex-linked. That would explain why, as children get older, boys are more likely to still wet the bed than girls are. That’s reversed in my family: My sisters wet the bed to a much later age — 16 or 17 — than my brothers did, and my son was dry while his older sister was still wetting most nights.

A few caveats:

My degrees are in mathematical disciplines. I have a low regard for the rigor of medical studies based on surveys. I doubt that the surveys allow the reported precision of the correlations. I doubt that the samples are large enough or representative enough for the correlations to be very convincing. Still, if one allows a wide margin of error, even at an anecdotal level there is a basis for belief.

While I have a background in statistical methods, I’m no geneticist. My knowledge of biology is limited to 9th-grade public-school frog-chopping (for which I got the worst grade of my academic career) and (like most people with math degrees) I regarded biology as only slightly more respectable than alchemy. On the other hand, geneticists do appear to take science seriously and a pointer to an actual gene is interesting.