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Taking the pressure off bed-wetters

(ran PT, SP, NP, CI editions)

Punishment doesn't cure bedwetting; it's a physiological, not psychological, problem that yields to medication, alarms and just plain maturation.

There's nothing wrong with school-age kids who wet their beds. Lori knows that. She's a nurse in the Children's Mercy Hospital clinic, which treats bedwetters. Lori wet her bed until she was 12, and her 5-year-old daughter does the same.

Lori knows that bed-wetting wasn't her fault and that it isn't her daughter's fault. She knows bedwetting is thought to be hereditary and isn't a sign of behavioral or emotional problems.

But Lori doesn't want her last name mentioned. It's too embarrassing. She'd rather the whole world not know her "dirty little secret," even though lots of people are former or current bed-wetters.

It's commonly estimated that 5-million to 7-million children and adolescents (girls 5 and older and boys 6 and older) wet their beds, including 15 percent of 5-year-olds.

In the vast majority of those cases, bed-wetting is a symptom of an immature "brain-bladder connection," according to Bradley Warady, a pediatrician who specializes in kidney-related ailments at Children's Mercy Hospital. And in many cases it's just a matter of time until it clears up.

Several factors can contribute to bed-wetting, Warady said. Wetters might have relatively small bladders or might produce unusually large amounts of urine. It's also likely that bed-wetters don't sense when their bladders are full.

Most of the children who don't feel that fullness when they're sleeping do sense it when they're awake, however, Warady noted.

Although bed-wetting isn't generally thought to result from emotional troubles, it can cause emotional troubles in young bed-wetters and their parents.

"There can be some problems with their self-esteem," Warady said. "They won't go to overnight camps, and they won't sleep at friends' houses for fear of wetting the bed. Often if they go to a friend's house, they won't sleep all night for fear of wetting the bed. That's difficult for an 8- or 9-year-old who wants to be like his friends."

Lori remembers that.

"I thought I was abnormal. I had no idea other kids wet the bed," she said.

Parents, too, feel the strain of bed-wetting, or nocturnal enuresis, as it is formally known. They tire of changing and washing sheets, and "some think the children are doing it on purpose as a way to get back at the parents for whatever," Warady said. Nothing could be further from the truth, he said. No kid wishes to urinate on himself or herself.

Lori remembers being accused of being too lazy to get up to go to the bathroom at night. But she doesn't remember feeling the urge.

In years past, many children were sent to mental health professionals for a cure to their bed-wetting, Warady said. Centuries earlier, "extremely traumatic" treatments such as "penile scalding" were employed in an effort to convince children to stop wetting the bed.

Bed-wetters have been and _ in too many cases _ still are punished, Warady said.

"It's totally beyond their control, so punishment has no role at all. That's something we really stress," he said.

There are several approaches recommended by Warady and William Warzak, a clinical psychologist at the University of Nebraska Medical Center in Omaha, who treats bed-wetters and researches the disorder.

Several simple behavioral changes can be helpful, they said, including eliminating or greatly restricting caffeine late in the day. As a diuretic, caffeine contributes to urine production.

Although some parents limit the amount their children drink in the evening, there isn't much evidence that works, according to Warzak.

He is a believer in behavior modification techniques, such as requiring children to help clean up after a bed-wetting episode and having them keep a record of their wet and dry nights. He suggests rewarding children when they comply with the procedures that have been outlined.

"If you do those things, you get pretty good results," Warzak said.

There are more costly interventions, including alarms that awaken children when they begin to wet the bed and drugs that reduce the need to urinate at night.

The alarms have existed for a long time, but in the last decade or so they have been improved and reduced to about the size of a pager, Warady said. The alarm attaches to a waistband and vibrates or rings when the child begins to urinate.

The alarm has the best track record, Warzak said. About 70 percent of the children who try it learn within 12 weeks to awaken themselves in time to get to a bathroom.

A couple of drug treatments are also available. Amipramine, which is an anti-depressant, seems to increase bladder capacity, Warzak said.

Desmopressin acetate, or DDAVP, is a manmade compound very similar to a naturally occurring hormone that enables the kidney to reabsorb water, thereby reducing urine production. The DDAVP is delivered through either a pill or a nasal spray.

The medications have "a fairly high relapse rate," according to Warzak. However, they can be useful in keeping beds dry until children's urinary systems reach maturity.

Parents can take heart in the fact that in the vast majority of cases bed-wetting stops on its own, according to Warzak. Each year about 15 percent of bed-wetters spontaneously stop.

For more information about bedwetting, call the National Kidney Foundation's toll-free hot line, 888-WAKEDRY.