A young girl with 2 episodes of nocturnal enuresis (bedwetting) over the last week, recent birth of a new baby in the family, no underlying medical issues, normal physical examination, and no daytime urinary symptoms, what is the most appropriate next step in management?

Reassurance and Behavioral Interventions

The most appropriate next step is reassurance and implementing simple behavioral interventions (reward system/sticker chart), as this represents secondary nocturnal enuresis triggered by a significant family stressor (new sibling) that typically resolves spontaneously with supportive management. 1

Why Reassurance is the Correct Initial Approach

• The American Academy of Child and Adolescent Psychiatry emphasizes that secondary enuretics who have experienced stress (such as the birth of a new sibling) represent a common psychological regression that often resolves spontaneously with reassurance, behavioral interventions, and watchful waiting. 1

• The timing is critical here: only 2 episodes over one week coinciding with a major family event (new baby) strongly suggests a transient stress-related regression rather than true pathological enuresis. 1

• The American Academy of Pediatrics recommends reassuring parents that secondary enuresis is common, affecting 15-20% of 5-year-olds, with a 14% spontaneous remission rate per year, and emphasizing that bedwetting is not the child's fault. 1

Specific Behavioral Interventions to Implement Now

• Implement a reward system (sticker chart) for dry nights to increase motivation and awareness, which has an independent therapeutic effect. 1

• Establish regular daytime voiding schedules and encourage the child to void at bedtime and on awakening. 1

• Minimize evening fluid and solute intake while ensuring adequate daytime hydration. 1

• Involve the child in changing wet bedding to raise awareness (not as punishment). 1

Why Other Options Are Inappropriate at This Stage

Fluid restriction alone (Option A) is insufficient as a standalone intervention and should be part of a broader behavioral approach, not the primary management strategy. 1

Referral to child psychologist (Option B) is premature after only 2 episodes and would be considered only if the enuresis persists despite behavioral interventions or if there are other concerning psychological symptoms. 1

Desmopressin (Option C) is second-line therapy reserved for children age 6 and older with persistent monosymptomatic enuresis after behavioral interventions have failed, not for acute secondary enuresis with only 2 episodes. 1, 2

Essential Diagnostic Steps to Complete

• Perform a urinalysis (urine dipstick test) to rule out diabetes mellitus, urinary tract infection, or kidney disease. 1

• Screen for constipation by asking about bowel movement frequency and stool consistency, as constipation can contribute to enuresis. 1

• Complete a frequency-volume chart or bladder diary for at least 1 week to confirm monosymptomatic pattern if episodes continue. 1

When to Escalate Treatment

• If enuresis persists beyond age 6 years despite behavioral interventions, enuresis alarm therapy becomes first-line treatment with approximately 66% success rates. 1

• Desmopressin can be considered as second-line therapy if alarm therapy fails, with 30% full response and 40% partial response rates. 1

Critical Pitfalls to Avoid

• Do not punish, shame, or create control struggles around bedwetting, as this worsens the situation and creates psychological distress. 3

• Do not rush to pharmacological treatment for what is likely a transient stress-related regression in a young child with only 2 episodes. 1

• Do not overlook the need for urinalysis to exclude organic causes, even when psychological factors seem obvious. 1