Behavioural interventions require a behaviour or action by the child that promotes night dryness
Behavioural interventions, including reward strategies, require a behaviour or action by the child that promotes night dryness
The child can achieve simple behavioural interventions without great effort. They include: lifting, waking, reward charts, retention control training, bedwetting alarms and overlearning.
Multiple behavioural (complex) interventions include dry bed training or full-spectrum home training. These interventions require greater effort by the child and parents to achieve, and include enuresis alarm therapy.
Alarm therapy
Alarm therapy can be performed with other interventions. This strategy appears to be the most effective method for stopping bedwetting.
Indication
Children at least five years of age who are unhappy or uncomfortable about their bedwetting.
Daytime bladder control and coordination usually occurs by four years of age, however night time bladder control typically takes longer and is not expected until a child is aged five to seven years old.
While parents may see bedwetting as a problem due to inconvenience or concerns about underlying disease, for most children it is only seen as a problem when it interferes with their ability to socialise with friends.
Most children who wet the bed have no physical or emotional problems.
If the condition is not distressing to the child or parents, treatment is not indicated.
Precautions
Constipation is a common problem in children and can also cause bedwetting. Diabetes and urinary tract infections could contribute to enuresis and should be excluded where indicated.
Adverse effects
Children and parents may become frustrated by lack of response to treatment and relapse. Some of the interventions will cause temporary sleep deprivation for both child and parents.
Availability
Mattress bedwetting alarms are available for hire from The Royal Children’s Hospital in Melbourne, and other children’s hospitals. A referral is required to see a paediatrician before hiring the alarm. (Refer to Consumer resources box). Bedwetting alarms are available to purchase from around $80 to $160 in Australian online stores.
Simple interventions
These include lifting, waking, reward charts and retention control training. Bedwetting alarms and overlearning are also considered simple interventions, however these require purchase of an enuresis alarm and so may be considered second-line interventions.
Lifting
This involves lifting the child from bed while they sleep and taking them to the toilet, without necessarily waking.
Waking
This involves waking the child up and walking them to the toilet. Children can be woken at set times or randomly.
Reward charts
These are calendars with a space for each day, where a sticker can be placed indicating a dry night. These act as visual reminders of progress.
Retention control training (also known as bladder training)
This involves encouraging children to hold voiding urine as long as possible once a day, as a means of expanding bladder capacity and enabling recognition of a full bladder.
Alarms
These are typically reserved for children older than seven years. Alarms work by using a sensor that detects the first drops of urine in the underwear. When the sensor is activated, it sends a signal to an alarm device, which is intended to wake the child with a sound, light or vibration. The alarm helps to train the child to wake up or stop urinating before the alarm goes off.
Children should be in charge of their alarm and should test it every night before sleeping. Parents should give positive reinforcement for dry nights and for successful use of the alarm sequence.
As alarm therapy begins, some children will not awaken when the alarm goes off.
Parents should wake the child initially, although most children will eventually learn to awaken on their own.
It is critical for success of alarm therapy that the child is awake and conscious during the process of going to the bathroom in the middle of the night and not sleepwalking through the experience.
Use the alarm continuously until the child has three to four weeks of consecutively dry nights. This usually takes three to four months but can range between five weeks and six months. The sequence can be restarted if bedwetting recurs.
Overlearning
This also involves use of an enuresis alarm, as described above, until the child is dry for three to four weeks. The child is then allowed to drink three-quarters of a cup (approximately 200 mL) of water in the hour before bedtime. The child then wears the enuresis alarm to sleep. Filling the bladder challenges the child’s ability to awaken before wetting the bed, hence the concept of overlearning.
Complex interventions
These include dry bed training and full-spectrum home training.
Dry bed training
This consists of a strict schedule for waking the child up at night until the child learns to wake up alone when needed. The training is implemented over seven nights.
- Night 1: Wake the child every hour until 1 am and have them go to the toilet. The parent may stay with the child on the first night.
- Nights 2 to 6: Wake child once a night, three hours after falling asleep on the second night and earlier on each subsequent night. On the sixth night, wake child one hour after bedtime.
- Night 7: The child should wake on their own. After training is complete, repeat the steps if the child wets the bed three nights in a row.
Full-spectrum home training
This includes behavioural interventions such as encouraging the child to remove soiled sheets and remake the bed,
overlearning, dry bed training and bladder training.
Complex interventions alone have not been shown to be better than alarms used alone.
Tips and challenges
There does not appear to be one simple behavioural therapy that is more effective than another. Simple treatments do not have any side effects or safety concerns. Therefore, simple methods could be tried as first-line therapy before considering alarms or drugs for this common childhood condition. Treatment should be delayed until the child is able and willing to adhere to the treatment program. Parents also need to be highly motivated before starting behavioural interventions.
If the enuresis persists despite use of the options listed above, there are enuresis clinics at major hospitals in each state and territory which can help.
© The Royal College of General Practitioners. Originally published RACGP’s Handbook of Non-Drug Interventions (HANDI), May 2014
