"Mom, dad? I'm wet."

Parents quickly spring into action when they hear these words. Changing wet sheets and comforting an upset or embarrassed child isn't fun for anyone in the middle of the night.

Many families struggle with bed-wetting. It's a normal part of child development. It isn't anyone's fault, but that doesn't mean it can't be stressful, especially for older kids. Here's what you need to know about this common condition.

Types of bed-wetting

Bed-wetting, also known as nocturnal incontinence or nocturnal enuresis, is the involuntary release of urine while asleep. It happens after the age at which staying dry at night is reasonably expected. Bed-wetting up to age 7 is common and not a concern. Most kids outgrow bed-wetting on their own by the time they are 12.

There are two general types of bed-wetting:

• Primary bed-wetting
  This is when a child has not been able to stay dry through the night. This usually happens in younger children. For example, the child may be able to remain dry during the day, but needs to wear a pull-up while asleep.
• Secondary bed-wetting
  This is a reoccurrence of bed-wetting. The child has been able to stay dry at night for a long period, six months or longer, but then starts having trouble again at an older age. For example, a child that has been dry at night since age 4, but then starts wetting the bed again at age 6.

Causes of bed-wetting

When a child starts to experience bed-wetting, especially secondary bed-wetting, we work with parents to figure out why it is happening. There is a strong family connection with bed-wetting. About 40% to 50% of kids with nocturnal bed-wetting had a parent who struggled with bed-wetting as a child.

Other possible causes include:

• Diabetes
• Urinary tract infection
• Vaginitis
• Deep sleeper
• Small bladder or bladder nerves slow to mature
• Chronic constipation

Tips for helping a child stay dry

Treatment usually isn't necessary for primary bed-wetting or children under 7. A watch-and-see approach is usually the best option, as we can expect an 8% to 10% improvement every year the child grows. Most children outgrow bed-wetting on their own.

There are things that parents can do to help a child with secondary bed-wetting or who is older than 7, including:

• Restrict fluids in the evening.
  Encourage the child to drink plenty of fluids during the day to remain hydrated and reduce thirst in the evening. Avoid high-sugar or caffeinated drinks during the evening. Restrict drinks within two hours of bedtime.
• Build voiding into the bedtime routine.
  Start the bedtime routine by urinating and then encourage the child to go again before falling asleep.
• Set alarm for overnight voiding.
  Some children can stay dry by voiding in the middle of the night. For example, a parent can set the alarm to wake the child at midnight, the child uses the bathroom and then returns to bed.
• Use a moisture alarm.
  These over-the-counter pads, also called bed-wetting alarms, are connected to a battery-operated alarm. This approach takes time, motivation and patience. It can take one to three months to see results, but this option is low-risk and may be a better long-term solution than medications.
• Try prescription medications.
  Occasionally, a child could be prescribed desmopressin as a short-term solution for bed-wetting. This medication retains water in the body, so the child's bladder does not get too full overnight. There are a few possible side effects with medication, which should be discussed with your child's health care team. The medication is more effective in older children, and the overall success rate is about 30%. Usually, other strategies, including time, are tried before medications.

What not to do

Bed-wetting can be frustrating and embarrassing for children. It can cause anxiety, especially for children planning sleepovers with friends. Children look to their parents for their response to the situation and for acceptance regardless of their struggles.

If your child is experiencing secondary bed-wetting, here are four things you should not do:

• Reprimand or scold.
  Children don't wet the bed because of laziness or spite. Yelling or expressing your disappointment does not help children's bed-wetting and can hurt their confidence.
• Withhold liquids all day.
  Depending on age, children need between 4 and 8 cups of water each day to remain hydrated. This improves mood, memory, energy and attention while decreasing the risk of constipation. Consider restricting liquids in the evenings, but encourage fluids during the day.
• Purposely embarrass your child.
  Discussing children's bed-wetting with peers or family can increase anxiety and embarrassment. It doesn't motivate and can create lasting emotional scars.
• Compare children.
  All children are different and develop at their own rates. They can't control how quickly the nerves in their bladders mature or their bladder sizes. Don't compare children to siblings or peers, as this will only increase stress and lower self-esteem.
• Expect instant results.
  Sometimes, all a child needs is time and a supportive parent. There are no quick fixes for solving bed-wetting. Be patient, kind and compassionate.

Remember, bed-wetting isn't anyone's fault. Your child isn't lazy and isn't doing it on purpose. Most likely, it's a familial gift passed down by one of the parents.

Talk with your child's health care team about weight loss, burning or cloudy urine, daytime incontinence, or increased thirst, as they could be a sign of a different, treatable condition.

Manjunatha, M.D., is a pediatrician in Pediatric & Adolescent Medicine in Eau Claire, Wisconsin.

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