PATCHS PROGRAM PUBLIC HEALTH NURSING ADVOCATES TEACHING CHILD HEALTH AND SAFETY HEALTH CARE PROGRAM FOR CHILDREN IN FOSTER CARE (HCPCFC)
Volume 1, Issue 29		OCTOBER 2007

Medical Information Fact Sheet

Enuresis (Bedwetting):

Bedwetting (or nocturnal enuresis or sleepwetting) is involuntary urination while asleep after the age at which bladder control would normally be anticipated.
There are two types of bedwetting:

• A child that has not yet stayed dry on a regular basis is considered to have primary nocturnal enuresis.
• A child or adult who begins wetting again after having stayed dry for 6 months or longer is considered to have secondary nocturnal enuresis.

Many children wet the bed until they are 5 years old, or even older. In most cases, the cause is physical and therefore not the child’s fault. The child’s bladder may be too small or the amount of urine produced overnight is too much for the bladder to hold. As a result, the bladder fills up before the night is over. Some children sleep too deeply or take longer to learn bladder control. Children do not wet the bed on purpose. Bedwetting is a medical problem, not a behavior problem. Scolding and punishment will not help the child to stay dry.
            Bedwetting may run in the family. If both parents wet the bed when they were children, then it is more likely their child will too. If only one parent has a history of wetting the bed then the child has a fifty-fifty chance of having the problem as well. Some children will wet the bed even if neither parent ever did. Bedwetting may be caused by an infection or a nerve disease. Children with a nerve disease often also have daytime wetting.
            Children who have been dry for several months or even years may return to wetting the bed. The cause may be emotional stress, such as the loss of a loved one, problems at school, a new sibling, or even training too early.

What can be done to keep the child dry?

                        The answer is rarely easy. Try skipping drinks before bedtime. Avoid drinks that contain caffeine, like colas and tea. These drinks speed up urine production. Give the child one drink with dinner. Explain that it is the last drink before going to bed. Make sure the child uses the bathroom before going to bed.  Many children may still wet the bed, but these steps are a place to start.
            The child may feel bad about wetting the bed. Let the child know they are not to blame. Let the child help to take off the sheets and put them in the washer, but do not make this a punishment. Be supportive. Praise your child for dry nights. Be patient. Most children grow out of bedwetting. Some children just take more time than others.

Should the child be taken to the doctor?

            If the child is younger than 5, don’t worry about bedwetting. Many children do not stay dry at night until age 7. Most children outgrow bedwetting. A single episode should not cause alarm, even if the child is older. If the child is 7 years old or older and wets the bed more than two or three times in a week, a doctor may be able to help. If both day and night wetting occur after age 5, the child should see a doctor before age 7.
            The doctor will ask questions about the child’s health and the wetting problem. Your child will likely be asked for a urine sample. The doctor uses the sample to look for signs of an infection. By testing the reflexes in the child’s legs and feet, the doctor can check for nerve damage. Sometimes bedwetting is a sign of diabetes, a condition that can cause frequent urination. If the child has an infection, the doctor can prescribe medication. In most cases, the doctor may find that the child is normal and healthy. If the child is basically healthy, a variety of ways are available to help the child stop wetting the bed.

What treatments can help the child stay dry?

            Talk with the doctor to discuss ways to help the child. Many choices exist. Let the child help decide which ones to try.

• Bladder training:

            Bladder training can help the child hold urine longer. Write down what time the child urinates during the day. Then figure out the times between trips to the bathroom. After a day or two, have the child try to wait an extra 15 minutes before using the bathroom. If the child usually goes to the bathroom at 3:30 p.m., have them wait until 3:45. Slowly make the times longer and longer. This method is designed for children with small bladders. It helps stretch the bladder to hold more urine. Be patient. Bladder training can take several weeks, or even months.

• Moisture Alarm:

            A small moisture alarm can be put in the child’s bed or underwear. The alarm triggers a bell or buzzer with the first drops of urine. The sound wakes the child. The child can then stop the flow of urine, get up, and use the bathroom. Waking also teaches the child how a full bladder feels.

• Medication:

            Two kinds of medicine are available for treating bedwetting. One medication slows down how fast the body makes urine. The other medicine helps the bladder relax so that it can hold more urine. These medications often work well. Remember wetting may return when the child stops taking the medicine. If this occurs, keeping the child on the medicine for a longer period of time may help.

Points to remember:

• Normal healthy children may wet the bed.
• Bedwetting may be a sign of infection or other problems.
• Many children are dry at night by the time they are 5 years old. Others take longer to stay dry.
• Scolding and punishment do not help a child stop bedwetting.
• If the child is 7 years old or older and wets the bed more than two to three times a week, a doctor may be able to help.
• Treatments include bladder training, alarms and medications.
• Most children grow out of bedwetting naturally.

What I need to know about My Child’s Bedwetting. (2006, April). National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. Retrieved October 1, 2007, from http://kidney.niddk.nih.gov/kudiseases/pubs/bedwetting_ez/index.htm

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Encopresis:

            Encopresis is involuntary “fecal soiling” in children who have usually already been toilet trained. Children with encopresis often leak stool into their underwear.

• Causes:

            Encopresis is commonly caused by constipation, by deliberate withholding of the stool, by various physiological, psychological or neurological disorders, or from surgery (a rare occurrence).
            The colon normally removes excess water from feces. If the feces or stool remains in the colon too long due to deliberate or incidental constipation, so much water is removed that the stool becomes hard, and becomes painful for the child to expel in an ordinary bowel movement. A vicious cycle can develop, where the child may avoid moving his/her bowels in order to avoid the "expected" painful toilet episode. The hardened stool continues to build up and stretches the colon or rectum to the point where the normal sensations associated with impending bowel movements do not occur. Eventually, softer stool leaks around the blockage and cannot be withheld by the anus, resulting in soiling. The child typically has no control over these leakage accidents, and may not be able to feel that they have occurred or are about to occur due to the loss of sensation in the rectum.
            Encopresis may also be due to psychological problems, such as oppositional defiant disorder or conduct disorder which are often viewed as a kind of "parental control" attempt by the child. Encopresis may be the result of a fear of the commode and its flushing action, or by simple reluctance to "let go" of the stool into the toilet. Health practitioners, however, typically think of encopresis as mainly a physical problem with a psychological component (but not cause).

• Diagnosis:

A diagnosis can be made for encopresis using the psychiatric (DSM-IV) diagnostic criteria, which includes:

1. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether voluntary or unintentional
2. At least one such event a month for at least 3 months
3. Chronological age of at least 4 years (or equivalent developmental level)
4. The behavior is not exclusively due to a physiological effect of a substance (e.g., laxatives) or a general medical condition, except through a mechanism involving constipation.

The DSM-IV recognizes two subtypes: with constipation and overflow incontinence, and without constipation and overflow incontinence. In the subtype with constipation, the feces are usually poorly formed and leakage is continuous, and occurs both during sleep and waking hours. In the type without constipation, the feces are usually well-formed, soiling is intermittent, and feces are usually deposited in a prominent location. This form may be associated with oppositional defiant disorder or conduct disorder.

• Treatment:

There is a 3-pronged approach to the treatment of encopresis associated with constipation:

1. cleaning out
2. using stool softening agents
3. scheduled sitting times, typically after meals

The initial clean-out is achieved with enemas, laxatives, or both. Following that, enemas and laxatives are used daily to keep the stools soft and allow the stretched bowel to return to its normal size.
Next, the child must be taught to use the toilet regularly to retrain his/her body. It is recommended that a child be required to sit on the toilet at a regular time each day and 'try' to go for 10-15 minutes, usually soon (or immediately) after eating. Children are more likely to be able to expel a bowel movement right after eating. It is thought that creating a regular schedule of bathroom time will allow the child to achieve a proper elimination pattern.
Dietary changes are an important management element. Recommended changes to the diet in the case of constipation-caused encopresis include:

1. reduction in the intake of constipating foods such as dairy, peanuts, cooked carrots, and bananas;
2. increase in high-fiber foods such as bran, whole wheat products, and fruits and vegetables; and
3. higher intake of liquids, such as juices. (Although, an increased risk of diabetes and/or tooth decay has been attributed to excess intake of sweetened juices.)

Unless there are immediate, satisfactory results from the above, some practitioners recommend keeping the child on a program of daily laxative use with an over-the-counter laxative.     Use of laxatives, however, often results in unexpected and/or uncontrollable bowel movements for the child, wherein the child cannot "avoid" soiling. Other practitioners recommend that the child be kept on a regular program of simple, water-based enemas, which can be scheduled for appropriate times when the child is comfortably at home or in other private quarters. One benefit of the enema therapy is that it keeps the child from any attempts at "parent control" by preventing the child from withholding stool. An enema usually results in a fairly timely expulsion at a time and place more convenient to family members.

Encopresis. (2007, October 1). In Wikipedia, The Free Encyclopedia. Retrieved 14:54, October 1, 2007, from http://en.wikipedia.org/w/index.php?title=Encopresis&oldid=161546244

HCPCFC PROGRAM UPDATES and ANNOUNCEMENTS!!! Congratulations to Cherry Macalino on her promotion to Nurse Manager of Public Health Nursing. This is great news to the staff of Public Health Nursing. Cherry is an asset to the Department and to the County.  Happy Bosses Day to all the great supervisors in Public Health Nursing who provide us with great leadership each and every day.

Editor: Kristen Thompson, PHN
Contributors: Nicole Boyd, PHN, Assistant Nurse Manager, Cherry Macalino, PHN, Nurse Manager and Hermia Parks, MA, Director of Public Health Nursing.