Bedwetting in under 19s

Inform children and young people with bedwetting and their parents or carers that bedwetting is not the child or young person's fault and that punitive measures should not be used in the management of bedwetting.

Offer support, assessment and treatment tailored to the circumstances and needs of the child or young person and parents or carers.

Do not exclude younger children (for example, those under 7 years) from the management of bedwetting on the basis of age alone.

Perform regular medication reviews for children and young people on repeated courses of drug treatment for bedwetting.

Offer information tailored to the needs of children and young people being treated for bedwetting and their parents and carers.

Offer information and details of support groups to children and young people being treated for bedwetting and their parents or carers.

Offer information about practical ways to reduce the impact of bedwetting before and during treatment (for example, using bed protection and washable and disposable products).

Ask whether the bedwetting started in the last few days or weeks. If so, consider whether this is a presentation of a systemic illness.

Ask if the child or young person had previously been dry at night without assistance for 6 months. If so, enquire about any possible medical, emotional or physical triggers, and consider whether assessment and treatment is needed for any identified triggers.

Ask about the pattern of bedwetting, including questions such as:

• How many nights a week does bedwetting occur?

• How many times a night does bedwetting occur?

• Does there seem to be a large amount of urine?

• At what times of night does the bedwetting occur?

• Does the child or young person wake up after bedwetting?

Ask about the presence of daytime symptoms in a child or young person with bedwetting, including:

• daytime frequency (that is, passing urine more than seven times a day)

• daytime urgency

• daytime wetting

• passing urine infrequently (fewer than four times a day)

• abdominal straining or poor urinary stream

• pain passing urine.

Ask about daytime toileting patterns in a child or young person with bedwetting, including:

• whether daytime symptoms occur only in some situations

• avoidance of toilets at school or other settings

• whether the child or young person goes to the toilet more or less frequently than his or her peers.

Ask about the child or young person's fluid intake throughout the day. In particular, ask whether the child or young person, or the parents or carers are restricting fluids.

Consider whether a record of the child or young person's fluid intake, daytime symptoms, bedwetting and toileting patterns would be useful in the assessment and management of bedwetting. If so, consider asking the child or young person and parents or carers to record this information.

Do not perform urinalysis routinely in children and young people with bedwetting, unless any of the following apply:

• bedwetting started in the last few days or weeks

• there are daytime symptoms

• there are any signs of ill health

• there is a history, symptoms or signs suggestive of urinary tract infection

• there is a history, symptoms or signs suggestive of diabetes mellitus.

Assess whether the child or young person has any comorbidities or there are other factors to consider, in particular:

• constipation and/or soiling

• developmental, attention or learning difficulties

• diabetes mellitus

• behavioural or emotional problems

• family problems or a vulnerable child or young person or family.

Consider assessment, investigation and/or referral when bedwetting is associated with:

• severe daytime symptoms

• a history of recurrent urinary infections

• known or suspected physical or neurological problems

• comorbidities or other factors (for example, those listed in recommendation 1.3.9).

Investigate and treat children and young people with suspected urinary tract infection in line with NICE's guideline on urinary tract infection in under 16s.

Investigate and treat children and young people with soiling or constipation in line with NICE's guideline on constipation in children and young people.

Refer children and young people with suspected type 1 diabetes immediately (on the same day) to a multidisciplinary paediatric diabetes team with the competencies needed to confirm diagnosis and to provide immediate care.

[This recommendation is from NICE's guideline on diabetes (type 1 and type 2) in children and young people]

Consider investigating and treating daytime symptoms before bedwetting if daytime symptoms predominate.

Consider involving a professional with psychological expertise for children and young people with bedwetting and emotional or behavioural problems.

Discuss factors that might affect treatment and support needs, such as:

• sleeping arrangements (for example, does the child or young person have his or her own bed or bedroom)

• the impact of bedwetting on the child or young person and family

• whether the child or young person and parents or carers have the necessary level of commitment, including time available, to engage in a treatment programme.

Discuss with the parents or carers whether they need support, particularly if they are having difficulty coping with the burden of bedwetting, or if they are expressing anger, negativity or blame towards the child or young person.

Consider maltreatment if:

• a child or young person is reported to be deliberately bedwetting

• parents or carers are seen or reported to punish a child or young person for bedwetting despite professional advice that the symptom is involuntary

• a child or young person has secondary daytime wetting or secondary bedwetting that persists despite adequate assessment and management unless there is a medical explanation (for example, urinary tract infection) or clearly identified stressful situation that is not part of maltreatment (for example, bereavement, parental separation).
  
  [This recommendation is adapted from NICE's guideline on child maltreatment: when to suspect child maltreatment in under 18s]

Use the findings of the history to inform the diagnosis (according to table 1) and management of bedwetting.

Explain the condition, the effect and aims of treatment, and the advantages and disadvantages of the possible treatments to the child or young person and parents or carers (see recommendations 1.8.13 and 1.10.9).

Clarify what the child or young person and parents or carers hope the treatment will achieve. Ask whether short‑term dryness is a priority for family or recreational reasons (for example, for a sleep‑over).

Explore the child or young person's views about their bedwetting, including:

• what they think the main problem is

• whether they think the problem needs treatment.

Explore and assess the ability of the family to cope with using an alarm for the treatment of bedwetting.

Consider whether or not it is appropriate to offer alarm or drug treatment, depending on the age of the child or young person, the frequency of bedwetting and the motivation and needs of the child or young person and their family.

Advise children and young people with bedwetting and their parents or carers that:

• adequate daily fluid intake is important in the management of bedwetting

• daily fluid intake varies according to ambient temperature, dietary intake and physical activity. A suggested intake of drinks is given in table 2:

Advise the child or young person and parents or carers that the consumption of caffeine‑based drinks should be avoided in children and young people with bedwetting.

Advise the child or young person and parents or carers to eat a healthy diet and not to restrict diet as a form of treatment for bedwetting.

Advise the child or young person of the importance of using the toilet at regular intervals throughout the day.

Advise parents or carers to encourage the child or young person to use the toilet to pass urine at regular intervals during the day and before sleep (typically between four and seven times in total). This should be continued alongside the chosen treatment for bedwetting.

Address excessive or insufficient fluid intake or abnormal toileting patterns before starting other treatment for bedwetting in children and young people.

Suggest a trial without nappies or pull‑ups for a child or young person with bedwetting who is toilet trained by day and is wearing nappies or pull‑ups at night. Offer advice on alternative bed protection to parents and carers.

Offer advice on waking and lifting during the night as follows:

• Neither waking nor lifting children and young people with bedwetting, at regular times or randomly, will promote long‑term dryness.

• Waking of children and young people by parents or carers, either at regular times or randomly, should be used only as a practical measure in the short‑term management of bedwetting.

• Young people with bedwetting that has not responded to treatment may find self‑instigated waking (for example, using a mobile phone alarm or alarm clock) a useful management strategy.

Explain that reward systems with positive rewards for agreed behaviour rather than dry nights should be used either alone or in conjunction with other treatments for bedwetting. For example, rewards may be given for:

• drinking recommended levels of fluid during the day

• using the toilet to pass urine before sleep

• engaging in management (for example, taking medication or helping to change sheets).

Inform parents or carers that they should not use systems that penalise or remove previously gained rewards.

Advise parents or carers to try a reward system alone (as described in recommendation 1.7.1) for the initial treatment of bedwetting in young children who have some dry nights.

Offer an alarm as the first‑line treatment to children and young people whose bedwetting has not responded to advice on fluids, toileting or an appropriate reward system, unless:

• an alarm is considered undesirable to the child or young person or their parents or carers or

• an alarm is considered inappropriate, particularly if:

  • bedwetting is very infrequent (that is, less than 1 to 2 wet beds per week)

  • the parents or carers are having emotional difficulty coping with the burden of bedwetting

  • the parents or carers are expressing anger, negativity or blame towards the child or young person.

Assess the response to an alarm by 4 weeks and continue with treatment if the child or young person is showing early signs of response. Stop treatment only if there are no early signs of response.

Continue alarm treatment in children and young people with bedwetting who are showing signs of response until a minimum of 2 weeks' uninterrupted dry nights has been achieved.

Assess whether it is appropriate to continue with alarm treatment if complete dryness is not achieved after 3 months. Only continue with alarm treatment if the bedwetting is still improving and the child or young person and parents or carers are motivated to continue.

Do not exclude alarm treatment as an option for bedwetting in children and young people with:

• daytime symptoms as well as bedwetting

• secondary bedwetting.

Consider an alternative type of alarm (for example, a vibrating alarm) for the treatment of bedwetting in children and young people who have a hearing impairment.

Consider an alarm for the treatment of bedwetting in children and young people with learning difficulties and/or physical disabilities. Tailor the type of alarm to each individual's needs and abilities.

Consider an alarm for the treatment of bedwetting in children under 7 years, depending on their ability, maturity, motivation and understanding of the alarm.

If bedwetting does not respond to initial alarm treatment, offer:

• combination treatment with an alarm and desmopressin or

• desmopressin alone if continued use of an alarm is no longer acceptable to the child or young person or their parents and carers.

Offer desmopressin alone to children and young people with bedwetting if there has been a partial response to a combination of an alarm and desmopressin following initial treatment with an alarm.

Offer desmopressin to children and young people over 7 years, if:

• rapid‑onset and/or short‑term improvement in bedwetting is the priority of treatment or

• an alarm is inappropriate or undesirable (see recommendation 1.8.1).

Consider desmopressin for children aged 5 to 7 years if treatment is required and:

• rapid‑onset and/or short‑term improvement in bedwetting is the priority of treatment or

• an alarm is inappropriate or undesirable (see recommendation 1.8.1).

Do not exclude desmopressin as an option for the management of bedwetting in children and young people who also have daytime symptoms. However, do not use desmopressin in the treatment of children and young people who only have daytime wetting.

In children and young people who are not completely dry after 1 to 2 weeks of the initial dose of desmopressin, consider increasing the dose.

Assess the response to desmopressin at 4 weeks and continue treatment for 3 months if there are signs of a response. Consider stopping if there are no signs of response. Signs of response include:

• smaller wet patches

• fewer wetting episodes per night

• fewer wet nights.

Do not exclude desmopressin as an option for the treatment of bedwetting in children and young people with sickle cell disease if an alarm is inappropriate or undesirable and they can comply with night‑time fluid restriction. Provide advice about withdrawal of desmopressin at times of sickle cell crisis.

Do not exclude desmopressin as an option for the treatment of bedwetting in children and young people with emotional, attention or behavioural problems or developmental and learning difficulties if an alarm is inappropriate or undesirable and they can comply with night‑time fluid restriction.

Do not routinely measure weight, serum electrolytes, blood pressure and urine osmolality in children and young people being treated with desmopressin for bedwetting.

If offering desmopressin for bedwetting, inform the child or young person and their parents or carers:

• that many children and young people, but not all, will experience a reduction in wetness

• that many children and young people, but not all, will relapse when treatment is withdrawn

• how desmopressin works

• of the importance of fluid restriction from 1 hour before until 8 hours after taking desmopressin

• that it should be taken at bedtime

• if appropriate, how to increase the dose if there is an inadequate response to the starting dose

• to continue treatment with desmopressin for 3 months

• that repeated courses of desmopressin can be used.

Consider advising that desmopressin should be taken 1 to 2 hours before bedtime in children and young people with bedwetting that has either partially responded or not responded to desmopressin taken at bedtime. Ensure that the child or young person can comply with fluid restriction starting from 1 hour before the drug is taken.

Consider continuing treatment with desmopressin for children and young people with bedwetting that has partially responded, as bedwetting may improve for up to 6 months after starting treatment.

Consider alarm treatment again if a child or young person who was previously dry with an alarm has started regularly bedwetting again.

Offer combination treatment with an alarm and desmopressin to children and young people who have more than one recurrence of bedwetting following successful treatment with an alarm.

Consider using repeated courses of desmopressin for children and young people with bedwetting that has responded to desmopressin treatment but who experience repeated recurrences. Withdraw desmopressin treatment at regular intervals (for 1 week every 3 months) to check if dryness has been achieved when using it for the long‑term treatment of bedwetting.

Gradually withdraw desmopressin rather than suddenly stopping it if a child or young person has had a recurrence of bedwetting following response to previous desmopressin treatment courses.

Consider alarm treatment as an alternative to continuing drug treatment for children and young people who have recurrences of bedwetting, if an alarm is now considered appropriate and desirable.

Refer children and young people with bedwetting that has not responded to courses of treatment with an alarm and/or desmopressin for further review and assessment of factors that may be associated with a poor response, such as an overactive bladder, an underlying disease or social and emotional factors.

Do not use an anticholinergic alone for the management of bedwetting in children and young people without daytime symptoms.

Consider an anticholinergic combined with desmopressin for bedwetting in children and young people who also have daytime symptoms and have been assessed by a healthcare professional with expertise in prescribing the combination of an anticholinergic and desmopressin.

Consider an anticholinergic combined with desmopressin for children and young people who have been assessed by a healthcare professional with expertise in the management of bedwetting that has not responded to an alarm and/or desmopressin and have any of the following:

• bedwetting that has partially responded to desmopressin alone

• bedwetting that has not responded to desmopressin alone

• bedwetting that has not responded to a combination of alarm and desmopressin.

Consider continuing treatment for children and young people with bedwetting that has partially responded to desmopressin combined with an anticholinergic, as bedwetting may continue to improve for up to 6 months after starting treatment.

Consider using repeated courses of desmopressin combined with an anticholinergic in children and young people who have responded to this combination but experience repeated recurrences of bedwetting following previous response to treatment.

If offering an anticholinergic combined with desmopressin for bedwetting, inform the child or young person and their parents or carers:

• that success rates are difficult to predict, but more children and young people are drier with this combination than with desmopressin alone

• that desmopressin and an anticholinergic can be taken together at bedtime

• to continue treatment for 3 months

• that repeated courses can be used.

Do not offer an anticholinergic combined with imipramine for the treatment of bedwetting in children and young people.

Do not use tricyclics as the first‑line treatment for bedwetting in children and young people.

If offering a tricyclic, imipramine should be used for the treatment of bedwetting in children and young people.

Consider imipramine for children and young people with bedwetting who:

• have not responded to all other treatments and

• have been assessed by a healthcare professional with expertise in the management of bedwetting that has not responded to an alarm and/or desmopressin.

If offering imipramine for bedwetting, inform the child or young person and their parents or carers:

• that many children and young people, but not all, will experience a reduction in wetness

• how imipramine works

• that it should be taken at bedtime

• that the dose should be increased gradually

• about relapse rates (for example, more than two out of three children and young people will relapse after a 3‑month course of imipramine)

• that the initial treatment course is for 3 months and further courses may be considered

• about the particular dangers of imipramine overdose, and the importance of taking only the prescribed amount and storing it safely.

Perform a medical review every 3 months in children and young people who are using repeated courses of imipramine for the management of bedwetting.

Withdraw imipramine gradually when stopping treatment for bedwetting in children and young people.

Do not use strategies that recommend the interruption of urinary stream or encourage infrequent passing of urine during the day.

Do not use dry\u2011\bed training with or without an alarm for the treatment of bedwetting in children and young people.

Reassure parents or carers that many children under 5 years wet the bed, for example, approximately one in five children of 4 and a half years wets the bed at least once a week.

Ask whether toilet training has been attempted, and if not, ask about the reasons for this and offer support and advice. If there are no reasons why toilet training should not be attempted, advise parents or carers to toilet train their child.

Suggest a trial of at least 2 nights in a row without nappies or pull‑ups for a child with bedwetting who is under 5 years and has been toilet trained by day for longer than 6 months. Offer advice on alternative bed protection to parents and carers. Consider a longer trial in children:

• who are older

• who achieve a reduction in wetness

• whose family circumstances allow the trial to continue.

Advise the parents or carers of a child under 5 years with bedwetting that if the child wakes at night, they should take him or her to the toilet.

Consider further assessment and investigation to exclude a specific medical problem for children over 2 years who, despite awareness of toileting needs and showing appropriate toileting behaviour, are struggling to not wet themselves during the day as well as the night.

Assess children under 5 years with bedwetting for constipation, in line with NICE's guideline on constipation in children and young people, as undiagnosed chronic constipation is a common cause of wetting and soiling in younger children.