How to manage nocturnal enuresis (bedwetting) in a 6-year-old child?

Management of Nocturnal Enuresis in a 6-Year-Old Child

For a 6-year-old child with nocturnal enuresis, begin with behavioral interventions and education, as active treatment is appropriate at this age but should start with non-pharmacological approaches. 1, 2

Initial Assessment

• Perform urinalysis (dipstick test) to rule out diabetes mellitus, urinary tract infection, or kidney disease 3, 1
• Complete a frequency-volume chart or bladder diary for at least 1 week to establish baseline patterns and detect underlying issues 3, 2
• Assess for constipation, as treating it can lead to resolution of urinary symptoms in many cases 2
• Physical examination is usually normal in monosymptomatic enuresis but should include examination of the back and external genitals 3

Education and Reassurance

• Educate parents about the prevalence (15-20% of 5-year-olds) and high spontaneous remission rate (approximately 14% per year) 1, 4
• Reassure the family that bedwetting is not the child's fault and is a common condition 1
• Avoid punishment or shaming, as this can worsen the situation and create psychological distress 1, 2

Behavioral Interventions

• Implement a reward system (sticker chart) for dry nights to increase motivation and awareness 1, 5
• Establish regular daytime voiding schedule: morning, at least twice during school, after school, dinner time, and before bedtime 3, 1
• Minimize evening fluid intake while ensuring adequate hydration earlier in the day 3, 2
• Address constipation if present, using polyethylene glycol if needed 3, 2
• Involve the child in changing wet bedding to raise awareness (not as punishment) 1, 2
• Encourage physical activity during the day 3, 1
• Keep a calendar of dry and wet nights to track progress 3

Treatment Progression

• If behavioral interventions are insufficient after 1-2 months of consistent implementation, consider alarm therapy 1, 2

  • Enuresis alarm therapy has success rates of approximately 66% and is more likely to produce long-term success 1, 4
  • Provide written instructions and establish a contract to enhance success 2
  • Treatment should continue for at least 2-3 months before attempting to wean 2

• Consider desmopressin for children with nocturnal polyuria when alarm therapy has failed or is unlikely to be successful 2, 6

  • Typical oral dose is 0.2 to 0.4 mg tablets or 120 to 240 mg melt formulation, taken 1 hour before bedtime 2
  • Limit fluid intake to 200 ml (6 ounces) or less in the evening and no drinking until morning to prevent hyponatremia 2
  • Expect approximately 30% full response and 40% partial response rates 1, 2

Important Considerations and Pitfalls

• Waking the child during the night to void is allowed but only helps for that specific night 3, 1
• Simple behavioral methods may be superior to no active treatment but appear to be inferior to enuresis alarm therapy and some drug therapies 5
• Imipramine should only be considered as third-line therapy at tertiary care facilities due to safety concerns, despite its FDA approval for enuresis in children aged 6 years and older 2, 7
• Schedule monthly follow-up appointments to sustain motivation and assess treatment response 3, 2
• Referral to a pediatric urologist is indicated for children with primary enuresis refractory to standard and combination therapies 8, 4