‘She’s six, fully toilet trained and was well settled in her class this year. But now she’s started to wet her pants at school. She’s very upset about it, yet we can’t get her to go to the toilet regularly. We think she has had kidney infections recently and I wonder if they’re causing the accidents. Or is something worrying her?’
Wetting is a headache for parents who think they have closed the book on toilet training. Why is she still having accidents, even though she’s well out of nappies?
It’s a very common problem, but often misunderstood. In most cases, wetting can be solved with a little motivation and a lot of behaviour therapy. But sometimes it can be a sign of infection.
- Bedwetting isn’t unusual: 15 per cent of five-year-olds still wet their beds.
- If she is toilet trained, ‘holding on’ is the most likely cause of daytime accidents.
- ‘Holding on’ causes urinary tract infections.
- A baby with a urinary tract infection is more likely to have a physical problem.
If you suspect a urinary tract infection, contact your doctor. They are less common in children and need looking into.
Is It a Urinary Tract Infection?
It can be hard to know with small children. Unlike adults, there are no easy clues to an infection. She may be off colour, vomit and have diarrhoea – but there could be other reasons. Her urine won’t usually smell much different from normal. And (especially if she is younger) it may not hurt when she goes.
- The best clue is an unexplained temperature.
- If she’s under two years old and her temperature is 38°C or more (with no other obvious symptom, such as a sore ear), her urine should be tested.
- An older child may be helpful enough to show some of the classic symptoms: back and stomach pains, a temperature, frequent urinating and blood in her urine.
We need to know why she’s infected. Your doctor will send a urine sample for laboratory testing but will also do a dipstick test to get an indirect measure of infection in her urine. If anything shows up, she’ll be started on antibiotics as a precaution.
The Inside Track
Her urinary tract is a complex flushing system. It is a cluster of organs (kidney, bladder and the linking tubes, ureters and urethra) that filter out waste from her blood, store it as urine and expel it when she urinates. She learns how to work the system when she reaches full bladder control, normally some time between her third and fourth birthdays. First, sensing when her bladder is full. Then learning to store urine. Finally, wanting to empty (or hold) her bladder at the right times.
Normally, the urine will be sterile. Bacteria do find their way into the bladder – usually
E.coli bacteria that work their way up from around her anus – but normal peeing flushes most away. Problems start if bacteria have a chance to take hold.
This usually happens if urine gets stored for longer than usual, creating a stagnant reservoir. Bacteria start to grow, her organs fight back, becoming inflamed, and she has a urinary tract infection.
Home Treatment: Urinary Infections
Urinary tract infection is one illness that you cannot treat yourself – the risk of damage is too great. She needs a doctor and antibiotics and she will have an ultrasound test of her kidneys. If she’s under six months old (or the infection is bad) she will be admitted to hospital for treatment and tests. You can, however, help to prevent future urinary tract infections:
Look at her toilet routine. She needs to urinate at least five times a day and to have enough time to fully empty her bladder.
Make sure she doesn’t get constipated. It can encourage her to ‘hold on’.
Let her drink lots of water every day, as routine. It will keep her bladder flushing.
Teach her to wipe herself correctly after using the toilet. From front to back. It is good hygiene.
Cranberry juice is seen as the natural cure-all. It is thought to deter bacteria, by raising acid levels in the urine. It is certainly worth trying, but she may not like the taste. Keep doses small, though. Too much can cause diarrhoea.
Routinely drinking water every day will help your child’s bladder keep flushing
There’s no reason to ban swimming. We know that water (and that includes dirty pool or sea water) does not get into the bladder.
Circumcised boys are less likely to get infected, but before you rush to surgery bear in mind that we would have to circumcise up to 200 boys to prevent one urinary tract infection. It’s a significant operation, with risks. It is usually reserved for boys with severe reflux or foreskin problems.
Is It a Wetting Problem?
It is formally bedwetting (nocturnal enuresis) when she is five and it is all still a problem. She has never been fully dry at night – or she was dry (hallelujah) for six months and has now started bedwetting again.
Daytime wetting is quite different. She starts to have accidents, just when you though she was toilet trained. There is urgency about the toilet with sudden dashes after a long lull. Often too late.
Boys are more likely to wet their beds, while girls are almost exclusively the daytime wetters.
Half of bedwetters will have a parent who did. More recently, researchers have found that a small bladder capacity can also be inherited. In some cases, a stressful event can start her off – an accident, perhaps, or a new baby. But most bedwetting does not have emotional roots.
Normally at night the body increases its levels of an antidiuretic hormone. This makes her kidneys re-absorb more water and so reduces the amount of urine she produces. But some bedwetting children lack this natural circadian rhythm that increases the hormone. And they continue producing daytime amounts of urine. If she wets soon after falling asleep (or if she leaves a large wet area in the bed) this is very likely the problem. She will probably sleep through the whole incident, while a child with a low bladder capacity usually wakes up.
Daytime accidents are usually a problem with toileting routines. Life is too exciting in the playroom or she is not so keen on the school toilet, so she holds on. When she does go, it is a rush and her bladder only gets half emptied. It is quite a serious problem that often goes unnoticed. The big risk is a urinary tract infection.
Home Treatment: Bedwetting
You may decide to do nothing. Most five-year-old bedwetters will eventually solve the problem themselves, but it could be a slow process. If you are more interested in a ‘dry campaign’ than she is, it is likely to fail.
Try a mix of these treatments for a few months. I advise alarms and medication only if nothing else works.
Throw out nappies or training pants as she will only cling to them.
Never punish a bedwetting child unless you want to prolong things. It is not her fault. Better to put her in charge of her ‘dry campaign’ – and to reward results.
Rule out stress. A relapse into bedwetting sometimes starts with a stressful event.
Change her drinking routine. She should take 40 per cent of her liquids in the morning, 40 per cent in the afternoon and only 20 per cent in the evening. Ban drinks with caffeine such as colas; hot chocolate, tea and pure fruit juice can be bladder irritants so avoid them, too. (But don’t ban drinks altogether after 6 p.m. as it does not help.)
Try motivating her. A reward system for dry nights (such as a Star Chart) may help some children over five years old. But keep it going for three to six months.
Light her path. Make sure she can find the bathroom at night.
Bladder training can also help – so that she goes only when the bladder is full. Teach her to hold urine when she wants to go, for increasingly longer intervals. You can even test her progress each week with a measuring jug (this method alone will cure 35 per cent of bedwetters).
An alarm clock can work for some. You wake her after two to three hours of sleep and bring her to the toilet – whether she is wet or dry.
Stay with the new routines until she is fully dry. It will take months, not weeks.
Always use a protective cover on your child’s mattress, until bedwetting stops.
Alternative therapies such as hypnosis, psychotherapy and acupuncture can be tried, though studies have shown limited effects on bedwetting.
This is an extract from When Your Child is Sick by Professor Alf Nicholson, Professor of Paediatrics at Temple Street Children's University Hospital and Grainne Malley.
