by Penny Dobson , Director of the Enuresis Resource and Information Centre (ERIC), a U.K. charity which gives advice and information to children, young people, parents and professionals on bedwetting, day-time wetting and soiling nationally and internationally.

Bedwetting (nocturnal enuresis) is a common childhood problem which can create enormous stress and embarrassment for children and their families. However, something can be done. This article describes a number of ways in which parents can begin to help children improve bladder control and become free of bedwetting. If you would like further information and advice do visit the ERIC website at www.eric.org.uk.

The extent of the problem

It has been estimated that in the United Kingdom over half a million children between the ages of 5 and 16 years regularly wet the bed. Up to the age of 12 years, more of these are girls than boys, but for the older group (12-16 years), there are proportionally more girls. It is very easy for children to feel that they are the only ones with the problem, as it is not something that is easy to reveal and share with friends. It may be of some comfort to an affected child to know that in a school class of 30 children, aged 7-9 years, there is likely to be at least one other who also wets the bed.

"Tuning-in" to the bladder

Children gradually learn to recognise the sensation of a full bladder and begin to "hold-on" until a toilet or potty is found. Most children have gained day-time control by the age of 3 years; night-time control takes a little longer - girls often achieve this earlier than boys. It is quite normal for children as old as 4 years to be still wetting the bed - and accidents may occur from time to time for a number of years.

What might cause bedwetting

It is not always easy to pinpoint the reason why some children acquire night-time control later than others, but it is not due to laziness or lack of willpower. We now believe that bedwetting may be the result of one or more of the following factors:

The body's system to slow down urine production at night is not yet working (this is controlled by a hormone, or chemical messenger called vasopressin which acts on the kidneys). The children concerned therefore have to cope with day-time levels of urine at night.

The bladder holds lower than average amounts of urine before giving a signal that it is full (for most of these children they also pass small amounts frequently during the day). The bladder may also be "overactive" (sometimes called "an irritable" or "unstable" bladder) and gives an urgent signal to empty before it is full. Again this is usually evident during the day.

The signal from bladder to brain to "wake up" and "hold on" at night isn't getting through; something that is not under conscious control.

Anxieties in the child's life, such as the birth of a new baby, the death of a close friend or relative or starting a new school, can also delay learning bladder control, or "trigger" bedwetting incidents in children who were once dry at night. It is also known that children with one or more parents who themselves wet the bed after the age of 5 years, do take longer to be dry at night.

Potty Training

If you as parents are relaxed about potty training, your child is more likely to achieve bladder control. Sitting your child on the potty can provide a peaceful moment to play or read a story. It has been found that praise for using the potty can help your child learn, whilst punishment can have the opposite affect, often making your child tense or anxious. There is no evidence that attempts at potty training earlier than 18 months of age has any affect on the age at which a child obtains bladder control. The general message is that your child will learn at his or her own pace - and that parents can help through giving guidance and encouragement.

The First Steps: Becoming dry at night

If your child is between 3 and 4 years of age and has been dry during the day for a few months, you could find out whether he would like to come out of nappies at night. If he is interested (and many children provide a clue by commenting on wet beds or nappies), put him in ordinary pants, leave a night-light on and a potty beside the bed. You might consider bedding protection, such as disposable absorbent bed mats and washable duvet and mattress protectors. Give plenty of encouragement, even if the number of dry nights are few. The speed at which children achieve night-time dryness does vary, often starting with one or two dry nights a week and building up slowly over a number of months. However, if your child is wet every night for 3 weeks (or any period that causes laundry problems or other difficulties), try not so show your disappointment. Your child is perhaps not yet ready to become dry. You might at this stage wish to consider using absorbent night-time padded pants rather than reverting to nappies - and try again in 3-4 months time.

Five Years Old

Still not dry? What parents can do
The vast majority of children who are not dry at night by the age of 5 years have nothing physically wrong with their urinary system. A small number may have a physical problem, such as an "overactive" bladder or urine infection. If your child's urine has a "fishy" smell, if he or she has difficulty or pain in passing water, is constantly thirsty or is frequently wet during the day as well as the night, it is best to consult your GP. The following suggestions are for younger children (5-7 years) who have not yet learnt either to "hold on" at night or to wake up to the sensation of a full bladder and use the potty or toilet.

Can your child get to the toilet easily?
-If the toilet is downstairs or some distance away, a potty near the bed is helpful
-Use a bottom rather than a top bunk bed
-If your child is afraid of the dark, keep the light on or the switch nearby

Food and drink
Encourage your child to drink a reasonable amount during the whole day (about 6-8 glasses, with 2-3 during the school day). Cutting back on drinks does not help - the bladder tends to adjust to less fluid and therefore holds less before feelings of fullness occur. However, be careful about fizzy drinks and tea or coffee, particularly last thing at night, as these stimulate the kidneys to produce more than average amounts of urine. Do make sure that your child uses the toilet before going to bed. Try to prevent your child becoming constipated as this may "irritate" the bladder at night and result in more frequent urination. A diet with plenty of roughage may help, e.g. wholemeal bread, bran cereal, frozen or tinned peas and baked beans.

Praise
Praise your child for dry nights, or if he wakes by himself to use the toilet during the night. Try not to show your frustration at wet beds, even though you may be feeling this way!

Waking Up (or "lifting")
You may be lucky and reduce the number and extent of wet patches in the bed, but this method does not in itself help your child to react to the sensation that the bladder is full - and wake up or "hold-on". If you do "lift", it is important, where practical, to remember the following:
-Make sure that your child is fully awake
-Wake at a different time each night
-Even if already wet it is helpful for your child to go to the toilet

Use of rewards
With help, your child might design a chart and choose rewards for achievements, such as drinking good levels of fluid during the day, going to the toilet before bed-time, telling you when the bed is wet and helping you to remake the bed. Rewards may be stars or pictures of favourite objects to stick on the chart. Praise and encouragement is important, but if your child is wet, try to be "matter of fact" - don't scold or punish.

A "Dot-To-Dot" surprise bag
A large "dot-to-dot" picture of your child's favourite toy can be drawn and for every achievement the child joins up two dots. Every fifth dot is a larger one and reaching that is rewarded by a "Surprise Bag" which represents a smaller treat. This does not have to be a present - it could be time with a parent, playing a game or reading a story. Completing the "dot-to-dot" could result in a larger reward or the toy itself.

How professionals can help

It is very common for parents and children to reach a state of "deadlock", with feelings of frustration and anger reaching boiling point. Talking it over with a professional can be reassuring and can provide a "fresh start" in tackling the problem. This will enable the most suitable treatment method - or combination of methods - to be chosen to help your child to move towards becoming dry at night.

Further information about treatment methods for bedwetting are available from ERIC. Visit the ERIC website (www.eric.org.uk) for details of ERIC's advice and support services and the books, bedding protection and enuresis alarms available from the charity.