Don't Scold Him

When I first saw Nandan in my clinic he had the usual viral fever so commonly seen by paediatricians. After the routine check-up, I was chatting with his mother when I came to know that Nandan was a regular bedwetter. He was seven and both he and his parents were upset because of this habit.

Nandan was enuretic. Which means that he would pass urine in his sleep involuntarily. This condition, called Enuresis, though common among children, needs attention if the child is over five years of age. There are two types of bedwetters : primary enuretics are those children who have been wetting the bed right from the beginning. And children of five years and older, who were not bedwetters for at least six months, but have now started wetting their bed fall in the secondary category.

Nandan is not alone. He has company. In fact, enuresis is a very common chronic problem of childhood. In a survey of 1500 children in Mumbai. 15-18 per cent was found to be enuretic. Every year 15 per cent of the enuretic children automatically become dry. Yet, 0.5 per cent would still continue to wet their bed for life, if left untreated. Even though most of the enuretics wet their bed during night, a few are even day-enuretics also. Boys face this problem more commonly than girls.

Why are some children bed-wetters? As most children automatically stop wetting their bed when they grow up, medical professionals haven't shown too keen an interest in this problem. For many years this was branded as a psychological problem and was considered to be associated with personally traits, life stresses, family disorders, social problems and improper toilet training.

However, in the last decade, there has been a dramatic change in the understanding of bedwetting. There are a whole lot of factors involved in enuresis. It has been proved that it is mainly related to biological factors like sleep pattern and an inability to wake up in response to a full bladder in sleep. At night the levels of anti-diuretic hormones (ADH) are low and, therefore, the volume of urine produced at night is in excess of bladder's capacity. Enuretic children are twice as likely to have a positive family history of this disorder than dry children.

Bedwetting affects the child himself badly. By a conservative estimate, there are at least 10 crore bedwetters in the world and even though such children remain otherwise healthy, this disorder can create tremendous anxiety and depression for both children and parents. This problem prevents children from participating in normal school activities such as picnics, overnight stay at cousin's house, summer camps, holidays with friends and relatives etc.. which are extremely important for their normal development and growing up process.

Parents, on the other hand, frustrated with the day-to-day cleaning and laundry problems, routinely scold or punish the child for wetting the bed because they believe that bedwetting is a result of the child's bad behaviour. All this makes the child lose his self-esteem - so crucial for a growing child. So, although it is most often a benign condition which resolves itself spontaneously, it will, if left untreated, lead to serious psychological and social disturbances.

Simple enuretics can be helped and cured by proper history and minimum investigations. The only investigation that is needed is a standard physical examination and urinalysis to rule out urinary tract infection or diabetes. But if the child has problems while passing urine, the parents need to consult a doctor to rule out any major abnormality.

The first and most important point is that the child must be motivated for treatment. He needs regular counselling about how it will help him in the long run and a reassurance about how he can enjoy things which he could not because of his problem. Besides, he needs full support from his family. The child should not be given liquids at least two to three hours before sleep.

Though the key to managing enuresis is counselling and reassurance, the main treatment may involve either enuresis alarms and/or desmopressin spray.

Alarms are buzzers, which need to be set at the approximate time when the child may wet his bed. When it goes off, the child himself will go to the lavatory. Most of the children wet their bed in the first 2-4 hours of sleep. It is, therefore, easy to imagine the disturbance tha tthis technique may cause to both the child and parents. They are, however, not available in India.

As for drug therapy, desmopressin reduces the volume of urine produced during the night and is effective for six to eight hours. It's effect is usually immediate, enabling it to be used at short notice.

Desmopressin in the form of nasal spray is also a simple and effective way to treat night bedwetting. It has been used for immediate relief and effective control of enuresis for more than 15 years. It has proved tobe very well tolerated with no side effect. However, if any of these treatments fail, it may be necessary to do a further investigation into the bladder function of the child.

Despite a high awareness in the developed world, in our country only 1.5 per cent of families with an enuretic child consult a physician. In a large Indian survey, it has been observed that both parents and patients have preconceived ideas about the cause of enuresis, which often conflict with the physician's view. The parents also feel that most doctors have little to offer them in the way of treatment and the problem is increased by the lack of certainly amongst doctors about the cause and appropriate treatment for enuresis. Therefore, there is a need to create awareness amongst parents of school-going children, teachers, school physicians and also practitioners about the psychological problems created by untreated enuresis and the effective and safe treatment now available for it.

Today, Nandan is completely free from his bedwetting problem and is enjoying his life like any other healthy seven-year-old. For the parents and relatives, who have a `Nandan' at home, there is an enuresis helpline available in Mumbai at the following email address : ferring@bom3.vsnl.net.in