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  • Steve Hodges, M.D.

Pediatrician Gets Bedwetting Half Right, Half Wrong


In some ways, I was pleased to read pediatrician Howard Bennett’s Washington Post article about bedwetting.

Parents, Dr. Bennett notes, should remember two facts about bedwetting: “First, it is a medical problem. Second, no one wets the bed on purpose.”

Both are absolutely true, and given the number of children punished and abused, and even killed, for wetting the bed, those are messages that need to be hammered home, as I do in Bedwetting and Accidents Aren't Your Fault.

I am also heartened that Dr. Bennett, a Washington, D.C., pediatrician, lists constipation as a cause of bedwetting.

That’s something! But it’s not nearly enough, as Dr. Bennett’s article will lead many parents astray and encourage pediatricians to keep on advocating inadequate treatment.

Dr. Bennett lists constipation fourth on his list of four causes for bedwetting, when evidence shows it’s virtually the only cause of bedwetting.

The top three other “causes” he cites are not actually responsible for bedwetting. In rare cases, bedwetting is caused by two causes he doesn’t mention — type 1 diabetes and sleep apnea — but constipation accounts for at least 95 percent of cases.

Also disconcerting: Dr. Bennett advocates bedwetting alarms as “the most effective treatment for bedwetting.” This is simply wrong. Resolving constipation — ideally through an enema regimen, though laxatives can work — is by far the most effective treatment for bedwetting.

It frustrates me to no end that so many pediatricians and pediatric urologists do not get this. (However, many do! Check out our Find a Provider page for a list of medical specialists who understand that resolving constipation fixes bedwetting.)

Sitting right in front of their noses is an incredibly effective and scientifically proven treatment that requires no middle-of-the-night wake-ups — and that, unlike a bedwetting alarm, actually gets to the root cause of the problem.

“Her Bladder Hasn’t Caught Up to Her Brain”

Dr. Bennett claims most cases of bedwetting are due to a “maturational delay in the way the brain and bladder communicate with each other.”

This is the party line among many pediatricians and, sadly, leads parents to wait around for their child to “outgrow” the bedwetting. Countless parents who end up in my clinic have been told their child’s “bladder hasn’t caught up to her brain.”

This was in fact the explanation given to Betsy Rosso, an Arlington, Virginia, mom whose daughter Zoe was suspended from preschool for having “too many” potty accidents. Zoe, whose story was reported by The Washington Post, eventually became my patient. An X-ray found a mass of stool in her rectum the size of a Nerf basketball.

At first parents are happy to hear their child suffers from a “maturational delay.” They think: It’s normal! All we have to do is wait!

But then months and years go by — years of buying pull-ups, of doing extra laundry, of feeling judged by other parents, of feeling distress because their kids are embarrassed and miss out on sleepovers.

Eventually, many of these folks land in my clinic or find my website and get help for a problem that could have been solved years earlier. But a lot more families don't get help.

3 Unproven “Causes” of Bedwetting

Let’s take a closer look at the three other “causes” of bedwetting that Bennett cites.

•Bladder size. Bennett claims children who wet the bed usually have bladders that are “smaller than their peers.” Well, yes — but not because of any natural “delay” in growth. It’s because the giant lump of poop in their rectums is squishing their bladder! Their bladders are abnormally small only in the way that your waist is abnormally small when you wear tight pants.

Also, the stretched rectum irritates the nerves of the bladder, triggering hiccups; so the bladder is more apt to squeeze when it’s not supposed to, like when the child is sleeping.

Another reason the child's bladder is "small" is that withholding pee can cause the bladder wall to thicken and therefore cause capacity to shrink. Many kids who hold poop also hold pee, exacerbating the bedwetting.

In truth, by about age 4, bedwetting isn’t developmental. Do not wait until your child is 6 or 7 to address bedwetting!

•Deep sleep. This is a wildly popular myth! As I explain in 27 Untruths About Bedwetting, deep sleep can explain why a child would not wake up to pee at night but does not explain why a child would need to pee overnight in the first place.

Again, that reason: a rectal clog is aggravating the bladder. Your 80-year-old grandpa may need to pee overnight (for other reasons), but your 8-year-old should not. Most kids sleep very deeply, but parents don’t notice because most kids don’t have overactive bladders.

•Nighttime urine production. Bennett states: “The brain produces a hormone at night that reduces the amount of urine the kidneys make. Some children who wet the bed produce less of this hormone and thereby produce more urine while they sleep.”

The hormone he’s talking about is ADH (anti duretic hormone), and in most bedwetting studies where patients’ ADH levels were actually checked, their levels were normal.

Fact is, the human body manages fluid balance very well. If your child’s body produced abnormal ADH levels, you would know it. Your child would have uncontrollable thirst and pee incessantly, among other symptoms, and you’d be seeing a doctor for it (trust me).

If you doctor says your child has abnormal ADH levels, insist on a test.

What Actually Fixes Bedwetting

Bennett provides no evidence for his claim that bedwetting alarms are “the most effective treatment.” I have plenty of experience with alarms and have read the scientific studies, and I can tell you that alarms are not the most effective treatment.

Alarms can help, and for tough cases I sometimes recommend them in conjunction with aggressive treatment for constipation. However, like bedwetting drugs, alarms don’t solve the problem. They just teach the brain to wake the child up to pee before he wets the bed. The child still needs to pee at night, which is not normal. A young, healthy bladder should be able to hold whatever urine is produce at night.

What’s more, the number of families who successfully use the alarm for the necessary three months is small. The sleep disruption and havoc they cause at night is difficult for families to handle, especially during the school year.

It is strange that while Bennett lists constipation as a cause of bedwetting, he does not make the connection that resolving constipation fixes bedwetting. It does.

This was demonstrated in an impressive series of studies conducted by Dr. Sean O’Regan, a pediatric nephrologist practicing at the University of Montreal Hôpital Sainte-Justine back in the 1980s.

I discuss his research in depth in It’s No Accident (I also interviewed him for the book), and I have posted the full text of his studies on my website.

In one study, Dr. O’Regan tracked 22 boys and girls with daytime wetting, nighttime wetting, or both. Parents of 17 of these children agreed to follow Dr. O’Regan’s favored enema therapy: nightly enemas for a month, followed by a month of enemas every other day, followed by a month of twice-weekly enemas.

(This is the basis for the regimen I recommend in our free download, How to Give a Child an Enema in 5 Easy Steps: A Reluctant Parent’s Guide.)

All 17 children in Dr. O'Regan's study improved dramatically — on average they went from wet to dry in 16 days, with a range of three days to six weeks.

And the results lasted. Nine months later, 14 of the 17 (82%) were still entirely accident free. The other three had gone from having daily accidents before the therapy to wetting once a week. In my experience, extending the daily enema regimen an extra month or two fixes the problem for virtually all children.

In another investigation with similarly impressive results, Dr. O’Regan tracked 47 young girls who had recurrent urinary tract infections (another condition caused by constipation) and, in most cases, daytime or nighttime wetting. All of his subjects had lost so much rectal tone and sensation due to constipation that they could not detect an air balloon that was inserted in their bottoms and inflated to the size of a tangerine. (This is a test called anal manometry.)

It’s nuts that doctors are recommending bedwetting alarms (or worse, bedwetting medication) as the go-to treatment. I don’t know Dr. Bennett’s opinion on enemas, but I do know that most of my patients have been told by their pediatricians that enemas are an “overly aggressive” treatment for constipation and bedwetting.

(Enemas, by the way, are safe for children are far more effective than MiraLAX.)

Next time your pediatrician tells you that your child’s bedwetting is caused by deep sleep, a hormonal imbalance, or a delay in bladder growth, ask the doctor to prove it. And if pediatrician recommends a bedwetting alarm as the “best” treatment, ask whether he or she has used Dr. O’Regan’s enema protocol or read his studies.

Constipation is easily proven with an abdominal X-ray, and the results of enema therapy are available for anyone to see.a

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Must-read books for kids by Steve Hodges, M.D.

• Bedwetting and Accidents Aren't Your Fault

• Jane and the Giant Poop

CONTACT​ US

Feel free to contact Dr. Hodges or Suzanne directly:
shodges@wakehealth.edu
suzanne@bedwettingandaccidents.com

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