By Steve Hodges, M.D.
Diaper companies spend massive amounts of money to normalize bedwetting.
After all, if parents perceive their child’s bedwetting as no big deal — simply an inconvenient part of child development — they won’t question the need to buy ever-larger pull-ups for years on end.
Previously, I wrote about Goodnites’ campaign for “Bedwetting Underwear,” designed to provide “a dry night’s sleep” for children up to age 17.
Now comes the Pampers Ninjamas Bedwetting Series, three appealing, upbeat videos designed to assure families in the UK and Ireland that bedwetting is of no concern.
A smiling doctor says: “Don’t worry, it’s fine,” and “Don’t fret. It’ll stop eventually.”
In the meantime? “Ninjamas are here — they’re saving the day,” the doctor says, cheerfully.
Certainly, I’m in favor of bolstering the self-esteem of children with enuresis — but not in a way that misleads or steers them away from treatment that will halt the wetting.
Super-absorbent disposable underwear is not “saving the day.” Ninjamas are just saving the family from extra laundry and providing comfort for the child overnight. Helpful, sure, but no solution for enuresis.
The Ninjamas campaign is slick but highly inaccurate. The cheerful doctor offers four explanations for enuresis, all of them erroneous. What’s more, his suggested remedies (besides purchasing Ninjamas) are useless.
In this post, I will highlight the video series’ most significant errors and explain that the way to resolve bedwetting is to address its root cause: chronic constipation. Unsurprisingly, constipation is never even mentioned in the Ninjamas videos. Perhaps this is because Pampers doesn't know constipation causes virtually all cases of enuresis. Or maybe it's because if more children were properly treated, diaper sales would suffer.
Ninjamas’ claim: Bedwetting will “stop eventually.”
Reality: You cannot assume a child will outgrow bedwetting.
At my clinic, I treat loads of teenagers who were assured, year after year, “Don’t worry, you’ll outgrow it.” But they never did. Many are terrified at the prospect of heading off to college with pull-ups in their duffel bag. This is a legitimate fear, at least for children who are not undergoing appropriate treatment. I explain to my patients that bedwetting is entirely fixable, though it’s often a slow process.
READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable
Research shows that the children least likely to outgrow bedwetting are those who wet the bed every night and those who also have daytime accidents. Left untreated, most kids wetting in middle school or high school will not spontaneously stop wetting.
I treat patients for bedwetting starting at age 4. I do not believe children benefit from waiting for years to find out if they are among the unlucky ones. The anxiety, the embarrassment, the missed sleepovers and overnight camps — why put children through all that? And why should parents have to purchase Ninjamas or similar products for years and years? Given that enuresis is highly treatable and not guaranteed to resolve on its own, I don’t think it makes sense to sit back and wait. As I often tell families, you wouldn't wait around for a clogged bathroom pipe to spontaneously unclog itself. Same goes for a clogged rectum.
Ninjamas’ claim: In some children, bedwetting occurs because the bladder “hasn’t fully developed yet, and it contains more wee than it can hold. So, it needs to get rid of some.”
Reality: Though young children have a somewhat smaller bladders than adults, they also produce less urine. The bladder of a 4- or 5-year-old is plenty large enough to hold pee all night. The “underdeveloped bladder” theory of enuresis has no scientific basis.
The actual cause of bedwetting, in almost all cases, is an overactive bladder due to chronic constipation. A stool pile-up causes the rectum to stretch to the point where it presses against the nearby bladder, aggravating the bladder nerves. The bladder goes haywire, emptying suddenly, randomly, and before it’s even full.
In some cases, the rectum is so enlarged that it practically flattens the bladder. You can see this on an x-ray. When a child’s bladder capacity is compromised, it’s because the bladder is being squished by the stretched rectum, not because it’s underdeveloped. Waiting for a child’s bladder to reach its full size won’t resolve accidents.
Ninjamas’ claim: Sometimes bedwetting happens because the “bladder and brain need time to talk to each other. And they need time to connect. As you grow up, they will speak to each other more, which means you’ll be better at knowing when you need to go.”
Reality: Accidents don’t occur because children with enuresis aren’t good at “knowing” when they need to pee. Accidents happen because the child’s signaling mechanism is on the fritz.
As I explain here, there are two patterns of urination: the "baby pattern" and the "adult pattern." As a baby, you can’t control urination. When your bladder fills, a reflex travels from your bladder to your spinal cord and back to your bladder, which empties automatically. You don’t receive a signal to pee that you, in turn, must react to by finding a toilet.
Eventually, by around age 3, your body transitions to the "adult pattern." The filling of your bladder transmits a signal to your brain. If you have a healthy, stable bladder, you initially feel a subtle urge, which gradually intensifies until you absolutely must heed the signal.
Kids with enuresis are, to varying degrees, stuck in the "baby pattern." Their urination signal has gone awry, bypassing their brain. Because the enlarged rectum has aggravated the bladder nerves, the bladder spasms more frequently, including overnight, and the child does not get "notified." The kid has no opportunity to wake up and get to a toilet. In many cases, the bladder contracts during the daytime, too, but it happens so quickly the child has no chance to react.
The solution is not to wait around for the bladder and brain to “connect.” It’s to clean out the rectum and keep it clear for several months so it can shrink back to size and stop aggravating the bladder nerves. Only then will the urination signal be fully restored. In my experience, an enema-based bowel-clearing regimen, such as the Modified O’Regan Protocol (M.O.P.), achieves this goal more effectively than a laxative-only program. Many doctors prescribe a PEG 3350 (Miralax or Restoralax) clean-out, followed by daily "maintenance" MIralax. This works for some children, but usually falls short, for reasons I detail in the M.O.P. Anthology.
Ninjamas’ claim: Some kids wet the bed because they “drink too much too close to bedtime.” The cheerful doctor urges children with enuresis to “try finishing your drinks before 6 p.m. if you can and make sure you go for a wee before you snuggle down.”
Reality: Pretty much every parent of a bedwetting child has tried restricting their child’s liquid intake at night, and guess what? This approach always fails, because enuresis is not caused by urine overproduction. In a child with enuresis, the aggravated bladder spasms and empties before the bladder is full.
A child with a healthy, stable bladder can drink a glass of water right before bed and still sleep all night without needing to pee. Restricting a child’s fluid intake can actually worsen enuresis by further aggravating the bladder. It’s important for a child’s bladder to continually fill and empty, so I do not advise restricting fluids.
Ninjamas’ claim: Sometimes accidents happen because “children can go into such a deep sleep that their bodies don’t wake up in time for a wee.”
Reality: Deep sleep does not cause bedwetting. An overactive bladder does. It’s not as if light-sleeping children wake up at 2 a.m. every night to pee, whereas their deep-sleeping siblings wet the bed. Children with a stable bladder simply don’t need to pee overnight.
Most children are deep sleepers. Most children don’t wet the bed. The “deep sleep” theory is a red herring.
Ninjamas’ claim: “Feeling worried or anxious can make your bladder nervous, too.”
The smiling doctor advises: “When you’re a little nervous, take a big, deep breath. Lift up your shoulders. Breathe into your chest. Don’t you worry. You’re going to do just fine. Relax your body, and get ready for bedtime. When you feel nervous, your body may jitter, which can upset your bladder. But you’re not a quitter.”
Reality: There is zero evidence that stress or anxiety causes urinary accidents. Certainly, plenty of children with enuresis feel anxiety when faced with the prospective of a sleepover, but it’s not anxiety that makes the bladder spasm. Taking deep breaths will not stop bladder contractions.
I’m guessing the Ninjamas video writer used the word “quitter” because it rhymes with “jitter” (there's lots of rhyming in the videos!). But this is an ill-advised word choice. Suggesting that some children with enuresis may be“quitters” only adds to the blame and shame these children feel every day.
At the end of the video series, the cheerful doctor says to children, “Before you go to bed, put your Ninjamas pants on, and you’ll wake up in the morning and want to burst into song.”
I assure you no child who wakes up with wet pull-ups feels compelelled to “burst into song” over it. What does brighten the day of a child with enuresis is to sleep in plain old underwear and wake up dry.