By Steve Hodges, M.D.
Over the decades, I have witnessed the unfortunate normalization of bedwetting.
But I’m now seeing something more worrisome: the monetization of bedwetting by the diaper industry, abetted by well-meaning doctors and child advocates, including the Autism Society.
It’s bad enough when families are told, “Don’t worry, she’ll outgrow it” or “Bedwetting is just a normal part of child development.” Due to this nonchalance, children are deprived of timely, effective treatment, and many are left to suffer shame, social isolation, and a crushing loss of self-esteem — even, in some cases, verbal and physical abuse.
In reality, bedwetting is not a stage of child development but rather a highly treatable condition caused by chronic constipation. The rectum, enlarged by a pile-up of stool, aggravates the nearby bladder nerves, causing the bladder to contract forcefully and empty without warning. When the constipation is resolved, the rectum shrinks back to size, and accidents stop. (Anyone skeptical their child is constipated can confirm with a plain abdominal x-ray.)
But left unresolved, chronic constipation, and the resulting bedwetting, can persist into the teen years and beyond.
READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable
The diaper industry seems fine with this. In fact, the Goodnites brand refers to its pull-ups as “Bedwetting Underwear” and sells its product in sizes “up to XL” and “fitting up to 140 lbs.”
As if it is no big deal for a 140-pound kid to be wearing pull-ups to bed!
In fact, the company literally advises parents, “Don’t make a big deal about it” and asserts that bedwetting is “not even considered to be an issue until after age seven.”
More concerning, this advice to ignore bedwetting comes not from a traditional advertisement but from an ad disguised as informational journalism — an article Goodnites paid to be published in PureWow.com, a “woman’s lifestyle destination.”
To bolster its case, Goodnites enlisted a pediatrician to help normalize bedwetting. This pediatrician says the most common cause of bedwetting is “maturational delay” — the child’s “bladder and brain need time to connect.”
This is actually not even a cause of bedwetting, let alone the most common.
The pediatrician does mention that bedwetting can be triggered by constipation but characterizes this cause as far less common than a "delay in maturation."
There are, in fact, precious few causes of enuresis besides garden-variety constipation. These include posterior urethral valves, tethered cord syndrome, and a few other conditions I discuss in the M.O.P. Anthology.
The Pure Wow article concludes: “It is good to know that most bedwetting is normal and have a reminder that it will most likely resolve on its own.”
Certainly, it is a relief for parents to hear that most bedwetting is “normal,” except that . . . it's not true. Plenty of parents have told me, "It's what I wanted to hear, so I believed it."
Many doctors won’t even consider bedwetting treatment until at least age 7. Many doctors ignore the condition even longer. One mom in our private Facebook support group posted: “A pediatrician told my 7-year-old not to be concerned until age 11 or 12 because there are such great pull-up-type products available nowadays.”
This is a disservice to families. I treat enuresis starting at age 4, usually with the Modified O'Regan Protocol (M.O.P.), an enema-based regimen far more effective than Miralax. The longer you wait, I've learned, the more stretched and stubbornly clogged the child’s rectum becomes and the more deeply ingrained the child’s tendency to delay pooping.
Enuresis can be resolved at any age, but it’s far more challenging to treat at age 14 than at age 4. I have never heard a parent say, “I’m so glad we didn’t treat our child’s bedwetting earlier!” or “Good thing we purchased an extra 10 years’ worth of pull-ups!”
What does Goodnites recommend for treatment? Well, the pediatrician quoted in Pure Wow advises parents to decide whether the family wants "short-term dryness (such as using a medication) for things like sleepovers" or whether they want a "long-term solution."
She's right that medication is a short-term solution at best. That's because drugs do not address the root cause of enuresis, chronic constipation. But this doctor does not offer any "long-term solution." The next paragraph simply advises parents to use Goodnites Bedwetting Underwear to keep children "comfortable and dry."
Now, it’s true that most bedwetting resolves without treatment. But this fact is irrelevant to the unlucky kids whose bedwetting persists — the hundreds of thousands of U.S. kids (and millions around the world) who miss out on sleepovers and suffer severe distress due to enuresis. I have a large caseload of teenagers who were assured, year after year, that their bedwetting would stop or that it was “hereditary,” so they were never treated. Among teens, enuresis is more common than autism, but you'd never know it.
As research shows, you cannot assume a child will outgrow bedwetting. The idea that enuresis will stop without treatment “probably applies only to those with mild enuretic symptoms,” Hong Kong researchers concluded in a survey of 16,000 children. In other words, kids who wet the bed infrequently and never have daytime accidents. The researchers found children with nightly wetting and daytime accidents have a “significantly greater chance of persistent [bedwetting] in adult life.”
It’s terrific for the Goodnites bottom line when 140-pound kids need to wear pull-ups. It’s terrifying for 140-pound kids heading off to summer camp or college.
In addition to normalizing bedwetting in neurotypical children, Goodnites has launched a campaign to normalize enuresis in autistic children and kids with ADHD.
Earlier this year, Goodnites announced a partnership with the Autism Society of America “to Raise Awareness and Provide Solutions for Bedwetting Needs of Families with Neurodivergent Children.”
In a news release, Goodnites notes that its “bedwetting underwear” is designed to provide “a dry night’s sleep” for children up to age 17.
Again, as if it’s fine for 17-year-olds to need pull-ups to stay dry!
Goodnites asserts that while bedwetting is common among neurotypical children, those with autism and/or ADHD “may face a longer experience with nocturnal enuresis.”
Yes, but do you know why these kids often need pull-ups longer? Because they are even less likely than their peers to receive timely, effective treatment!
Doctors mistakenly consider enuresis “part of the deal” with autism and ADHD, as I explain in this article for Autism Advocate Parenting Magazine.
I implement the same treatment regimen (M.O.P.) for autistic patients as for my neurotypical patients. When you aggressively treat constipation in a child with enuresis — whether that child has been diagnosed with autism, ADHD, or the common cold — accidents will stop, and their lives will improve.
But many doctors either dismiss enuresis altogether in autistic patients or vastly undertreat the condition.
As the mom of an autistic child who overcame bedwetting with M.O.P. recently emailed:
My youngest son is now 16. He has been free of enuresis and encopresis for years now thanks adherence to M.O.P. starting when he was about 5. He has autism, and when he started having accidents at around 4 years, his pediatrician told us airily, “It’s because he’s autistic.”
We promptly found a new pediatrician. I did my own research and came across M.O.P., got buy-in from our son (who met the whole experience with a maturity beyond his years) and convinced my husband, who was reluctant at first.
We were on M.O.P. for over a year. It is a quality-of-life issue, to live free of the fear of accidents and experience all the simple joys that one can never recapture once childhood is in the rear-view mirror.
Goodnites recognizes that bedwetting causes distress. The company unveiled “new propriety research” — a survey of 1,000 parents — illustrating the impact of enuresis on families of kids with ADHD and/or autism. The survey found 60% of these parents felt anxious or helpless, 50% said their children’s bedwetting made them feel like a failure as a parent, and 40% reported enuresis lowered their child’s self-esteem.
I assure you, these statistics also apply to parents of neurotypical kids! I talk to these parents all day long at my clinic. I know how enuresis affects the entire family.
The solution is not super-absorbent pull-ups for 17-year-olds.
The solution is to treat enuresis early and aggressively so that children can get a good night's sleep in plain old underwear.