By Steve Hodges, M.D.
I don’t usually comment on kooky advice posted on social media. But when the topic bedwetting — a condition I know something about! — and when the advice ventures into harmful territory or steers families in the wrong direction, I feel compelled to weigh in.
A Facebook page with a large following recently posted this question from a parent:
My child is 8 years old and still wets his bed at least 4 nights a week. I have tried limiting drinks/liquid intake after 4 p.m., waking him up regularly, etc. Are there any other methods out there I can try?
Last I checked, 584 commenters had held forth! I was heartened that most of the comments urged compassion for the child. That’s huge, as many children are shamed and blamed for bedwetting. Some are physically abused or murdered.
However, compassion won’t resolve enuresis. Appropriate medical treatment is needed. Based on this cache of comments, the public misunderstands what causes bedwetting and the consequences of overlooking or undertreating this condition.
Below, I have filtered out the advice from left field — “a teaspoon of honey before bed," “consider the fabric softener you use” — and have addressed the most common misunderstandings reflected in the 500+ comments.
1. Bedwetting is caused by a “deep sleep pattern.” ACTUALLY: Children with healthy bladders, whether deep sleepers or not, simply do not need to pee overnight. It’s not as if light-sleeping kids are awakened overnight by the urge to pee, whereas deep sleepers fail to heed the signal and therefore wet the bed. When a child wets the bed, it's because their rectum, enlarged by chronic constipation, is aggravating the badder nerves. The bladder contracts forcefully and empties suddenly, so the child has no chance of waking up and sprinting to the toilet. READ: Nope, "Deep Sleep" Doesn't Cause Bedwetting (It's Impossible)
2 Bedwetting is “not a big deal.” ACTUALLY: Countless children suffer because their bedwetting has gone untreated. Many kids avoid sleepovers, feel ashamed and alone, blame themselves, and become withdrawn or depressed. READ: Kids Shoulder Shame and Blame for Bedwetting and Accidents.
3. “He will eventually grow out of it.” ACTUALLY: Hundreds of thousands of children do not spontaneously stop bedwetting. Among teens, enuresis is more common than autism. The children least likely to "outgrow" this condition are children who wet the bed nightly and those who also have daytime pee or poop accidents (encopresis). I have a large caseload of teenage enuresis patients who were promised they would outgrow it and did not. I also run a private Facebook support group for parents of teens and tweens with enuresis. READ; Don’t Assume Your Child Will Outgrow Bedwetting.
4. “Sometimes there’s just nothing you can do. It may be something he has to live with.” ACTUALLY: Bedwetting can always be resolved. No child should just have to “live with” it. In most cases, accidents will stop when the rectum has been fully emptied and remains clear for several months, so it can shrink back to normal size and stop bothering the bladder. An enema-based regimen such as the Modified O'Regan Protocol (M.O.P.) will accomplish this more effectively than Miralax. In the most challenging cases, bladder Botox will halt accidents. READ: Better Bedwetting Treatment — and How to Stop Encopresis and Pee Accidents, Too
5. “She has an underdeveloped bladder.” ACTUALLY: Bedwetting isn’t developmental. By toilet-training age, a child's bladder is plenty developed enough to hold urine all night. If a child’s bladder is too “small,” it’s being squished — sometimes even flattened — by the clogged, enlarged rectum. However, this "small bladder" theory is common and was cited by "Frozen" actress Kristen Bell to explain her daughter's bedwetting. She tweeted that it's “pretty normal for a 5 yr old whose tiny bladder cant take the 10 hr challenge yet." It's not! I recommend treating bedwetting at age 4. READ: A Doctor Weighs in on Kristen Bell and Celebrity Potty Shaming.
6. “Try prunes and All Bran Buds.” ACTUALLY: While a fiber-rich, whole-food diet can help prevent constipation by keeping stool soft and mushy, many children with stellar eating habits nonetheless become severely constipated. Constipation is strongly influenced by genetics and temperament. At any rate, once a child is constipated to the point of developing enuresis, all the prunes in California won’t dislodge the large, hard lump of clogging the rectum. Enemas and/or laxatives are needed. READ: Why Is Your Child Constipated? Because We Live in the 21st Century
7. “Stop all drinks around 6:30.” ACTUALLY: Bedwetting isn’t caused by an excess of fluids. A child with a healthy, stable bladder will be able to drink water before bed and not need to pee overnight. In a child with enuresis, restricting fluids can actually backfire, contributing to constipation, the very condition we’re trying to prevent, and aggravating the bladder. READ: 4 Bedwetting Treatments That Backfire.
8. “Boys’ bladders typically don't catch up to their brains until later.” ACTUALLY: Boys are no more prone to enuresis that girls, and anyway, enuresis has nothing to do with a child's bladder "catching up" to their brain. READ: To the American Academy of Pediatrics: Please Update Your Bedwetting Advice.
9. “See a chiropractor. When even a tiny part of the spine is misaligned, a child can lose bladder control.” ACTUALLY: In my entire career I’ve never seen a spine misaligned from everyday life to a degree that it can impinge on the bladder nerves and alter their function. Unless your child has suffered a spinal trauma or has a neurological condition such as spina bifida, this should not be a concern. I do x-ray my enuresis patients to rule out one of the rare medical conditions that can caused bedwetting in the absence of constipation. READ: Outlier Cases and Medical Conditions to Rule Out, page 40, The M.O.P. Anthology.
10. “Consider emotional and mental stressors.” ACTUALLY: There is zero legitimate evidence showing enuresis is caused by stress, anxiety, attention seeking, defiant behavior, chaotic family life, or parental depression or divorce. None. Yet these explanations are basically a given in our culture. In the movies, in books, and on TV, bedwetting signals emotional distress. Even in our political discourse, "bedwetting" is shorthand for "excessive worry." As a result, children are referred for psychological counseling when all they need is treatment for constipation. READ: Enuresis and Encopresis Are Not “Mental Disorders.” Let’s Remove Them from the DSM-5.
11. “Try bribery. When my sister had this problem, mum rewarded her with a toy if she made it a whole week without an accident.” ACTUALLY: Praise and rewards are totally inappropriate for bedwetting and can do more harm than good by implying to the child that staying dry is within the child’s control. It's not! READ: 4 Bedwetting Remedies That Backfire.
12. “It could be a UTI.” ACTUALLY: Many children with chronic urinary tract infections also wet the bed, but it's not the UTI that is triggering the bedwetting; it's the underlying constipation, which also leads to UTIs. The Modified O'Regan Protocol resolves UTIs as well as enursis. READ: Why 1 Million Girls a Year Get UTIs.
13. “Perhaps the bathroom is too far or too scary at night. Leave a light on or put a potty in his room.” ACTUALLY: While some kids may indeed be afraid of the dark, this fear won't cause bedwetting because a child with a healthy bladder won't need to wake up and pee in the middle of the night.
14. "Ask your doctor for desmopressin. Fantastic stuff.” ACTUALLY: Desmopressin, a common bedwetting medication, has a dismal long-term success record because it does not address the root cause of enuresis: constipation. Desmopressin tricks the brain into telling the kidneys to make less urine than they should., and that does help some kids stay dry, especially those who are also on a bowel program such as M.O.P. I will prescribe desmopressin for sleepaway camp and when a child on M.O.P. needs the psychological boost of dry nights. But it's of limited value, and there are more effective bladder medications. READ: Bladder Medication, pp. 114-116, The M.O.P. Anthology.
15. “Put him in underwear overnight, so he will get tired of waking up wet at night.” ACTUALLY: While many adults perceive pull-ups as a “crutch,” children don't wet their sheets out of convenience or laziness. So, making them uncomfortable won't solve anything. I do not advise removing pull-ups overnight until a child is reliably dry. Simply taking them away will not accelerate dryness. READ: Nighttime Potty Training Is Not a Thing.
16. “Bedwetting alarms work wonders!” ACTUALLY: A bedwetting alarm can prevent wet sheets in some children, by priming children to wake up before they wet the bed. However, that isn’t the same thing as resolving an overactive bladder. I’m certainly in favor of dry sheets, but cleaning out and healing the rectum is a better way to permanently resolve enuresis. Incidentally, alarms are a useful tool to monitor a child’s progress on M.O.P. READ: Bedwetting Alarms, page 112, The M.O.P. Anthology.
17. “It could be hereditary.” ACTUALLY: It’s true that bedwetting runs in families, but children simply won’t have accidents in the absence of constipation. There's clearly a genetic propensity toward constipation, and in some families, the children's bladders are more sensitive to rectal stretching than in others. In other words, in some families, a rectum stretched to 5 cm in diameter, while abnormal, may have no effect on the bladder, whereas in another family, a rectum stretched
to 4 cm, only slightly enlarged, may cause bladder hiccups. But ultimately it doesn't matter whether a child's bedwetting has a genetic component because all children need treatment. READ: About That "Bedwetting Gene."
18. “Hold in his urine during the day to strengthen the bladder.” ACTUALLY: Holding pee is unhealthy for the bladder, especially in a children with enuresis. A child who ignores the urge to pee develops a thickened bladder that is more prone to irritation and accidents. READ: 4 Bedwetting Remedies That Backfire.
20. “Require him to wash his bedding.” ACTUALLY: Punishment has no place in the treatment of bedwetting. I'm all for kids doing their own laundry, but since child with enuresis cannot stop accidents, sentencing the child to manual labor will accomplish nothing good and only serve to shame the child. READ: Why Threats and Bribes Won't Stop Bedwetting (And What Will)
21. “Children will stop wetting the bed when their body secretes the proper hormones and not one day before.” ACTUALLY: Numerous studies have considered hormonal production in relation bedwetting. I have read them all and have served as a peer reviewer for several. Not one has demonstrated that a hormonal imbalance or deficit causes bedwetting. READ: To the American Academy of Pediatrics: Please Update Your Bedwetting Advice.
22. "Try cutting out dairy in the evening." ACTUALLY: While intolerance to dairy does predispose some children to constipation, once a child is clogged to the point of developing enuresis, simply avoiding dairy will not resolve the accidents, though it certainly will help prevent a recurrence. If you suspect your child has an intolerance to milk, see if eliminating dairy helps. If you don’t notice a difference within a few weeks, I wouldn’t maintain the restriction.READ: Is Dairy a Culprit? page 50, The M.O.P. Anthology.
23. “See if he can remember anything about dreaming. When I was young I would dream I was ‘going’ out in the woods, in a toilet, on the floor, etc. and had to learn to wake up when I felt the urge. A lot of the time, the answer is in our own head.” ACTUALLY: Dreams like these are the brain explaining to the body that the child is voiding. but dreaming does not cause the child to pee overnight. In other words, the dream is a response to the bladder spasm, not the other way around.
24. “Limit chocolate and soda because of the caffeine.” ACTUALLY: There are plenty of good reasons for a child to go easy on caffeine, but resolving enuresis is not among them. This advice is commonly given to teenagers and only serves to frustrate them. READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable.
25. “He might not be able to feel his bladder, so have him sleep on his stomach, and tape a tennis ball to the back of his PJ shirt to reduce rolling over.” ACTUALLY: I had never heard this piece of advice before but can assure you it won't resolve enuresis. Interestingly, a child's sleep position and particular anatomy can affect whether they wet the bed. This explains why some children with daytime wetting are able to stay dry overnight, a scenario that baffles parents. However, the root cause, as always, remains a clogged rectum.