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To pee or not to pee

Adam is your average 10-year-old - well, almost. He loves playing soccer, he's a whiz at computer games, and he's got a wide circle of friends. But he's never been on a sleepover, and there's a compelling reason.

Adam still wets the bed several times a week and wears nappies every night. It's having an increasingly serious impact on his life. Next week he's supposed to be going on an overnight school camp where he'll have to share a dorm with three other boys, and he's terrified his secret will be exposed.

A Danish research study carried out in the late 1990s examined the level of stress created by bed-wetting, or nocturnal enuresis, and concluded that for children, its impact can be devastating. 'It ranks as the most upsetting after parental divorce,' says paediatrician and nephrologist Mark Chan Kwok-ho. 'It's worse than getting bad results at school, it's worse than being teased for being short. The research showed enuretics [those who wet the bed] were more fearful, anxious and impatient, and had more feelings of inferiority.'

It's extremely distressing for everyone concerned, says Adam's mother, Therese. 'You're constantly having to cover up for your child, make excuses as to why he can't join in on sleepovers or slumber parties,' she says. 'It's also not the sort of thing you can talk about to other mothers. It's humiliating both for you and your child. I always thought he'd grow out of it, but I definitely think we've reached the point where we have to seek medical help. I just don't want to make Adam feel any worse than he already does.'

Bed-wetting is more common than most people think - or talk about - and it's hard to know just what constitutes 'normal'. Is it five-year-old Sean, who has a sodden, heavy nappy five mornings a week? Two-year-old Susie who toilet trained herself, and stopped wearing day and night nappies all at once - she's never wet the bed? Or seven-year-old Katie, who has a couple of accidents a week, but is old enough - and embarrassed enough - to change the bedsheets herself?

The short answer is that there is no 'normal', and all children develop at different rates. But as a rough guide, statistics show that a surprising 15-20 per cent of children still wet the bed at the age of five, and while by 10 years old they should be dry, 5-10 per cent may still be wet. By the age of 15, the incidence rate drops to somewhere between 0.5 per cent and 2.5 per cent. Chan says that being dry at night is the last stage of toilet training, and that a child has to be developmentally ready to achieve it.

He has the following tips: cut down fluid in the evening, go to the toilet with them before going to bed, check every hour to see if they are dry, and keep taking them to the toilet. Use positive reinforcement, and stay neutral if there is an accident. If none of this is working, use a judicious amount of discomfort, that is, get the child to change his own bed. If, after all this, there is still a problem, the child is getting upset, disturbed or embarrassed - or you are upset - then consult a doctor.

The good news for parents who suspect their child may have a bed-wetting issue is that there are prescription medicines that can help, and the bladder can usually be trained to be more accommodating and compliant.

Chan says there is also the option of alarm therapy, where a sensor is placed on the child's mattress, or newer, more portable versions that fit inside underwear and emit noise or vibrations when wet.

Even better news is that groundbreaking research carried out over the past few years is helping experts understand why children - and some adults - wet the bed at night. The new research is slowly debunking some of the traditional concepts and myths surrounding nocturnal enuresis.

One of the pioneers in this field is Professor Yeung Chung-kwong of the Chinese University of Hong Kong, who is also director of the International Children's Continence Society (www.i-c-c-s.org). He says the traditional idea that bed-wetting goes hand in hand with immature or unstable bladder control is incorrect, and that simply waiting for it to go away as the child matures is futile.

The severity of symptoms is key, rather than age, says Yeung. While prevalence does decrease with age, this only applies to those with mild wetting symptoms.

'My team has carried out the biggest epidemiological study ever seen, and the large sample allowed us to split the subjects into different severity groups. Low severity were those who wet less than three times a week, moderate severity were those who wet four to six times a week, and severe were those who wet every night, or more than once a night,' says Yeung.

'For those with severe prevalence, it almost never changes. So while bed-wetting might improve with age, this is only for those who wet sporadically.

'If your child, at age five, is wetting every night, the chances are it will continue.'

Another common misperception, according to Yeung, is that children who wet the bed are deep sleepers. 'We have done hundreds of sleep studies and found these children don't sleep deeply. In fact, they have disturbed or light sleep because they are aroused by bladder activity.

'Their brain is overrun by signals and it stops responding, and refuses to wake up any more. The brain becomes clouded, and cognitive function is impaired because they're not sleeping well. Even if we shout and scream at the child, they don't wake up, and though they have been sleeping for 10 hours they are very tired the next day.'

Yeung calls it the 'discotheque' phenomenon. Just as anyone would find it difficult to solve a complicated maths problem in a noisy club, a child's brain can't function properly when it's clouded with hundreds of messages from the bladder.

Yeung also dismisses the common myth that bed-wetting is often due to psychological disturbances. 'Our research shows that in most children who bed-wet you will find psychological disturbances, but almost 100 per cent are as a result of, rather than a cause of, bed-wetting, including low self-esteem, low confidence, behavioural problems and aggression. It is futile to send children to see a psychologist. The only way to help children is to cure their bed-wetting - their behavioural problems will dramatically improve when the child gets dry.'

These quantum jumps in understanding are also helping experts diagnose and solve the more chronic bed-wetting cases. Causes are diverse and complex, ranging from congenital or acquired problems with the bladder and an inability for the bladder muscle to relax, to overactive, dysfunctional voiding from poor bladder control.

'Nocturnal enuresis should not be treated as a single disease, but as a symptom - you have to find out what is wrong,' says Yeung. 'When we focus on finding the cause, the underlying problem, there is a 96 per cent cure rate.'

So, parents, take heart. Increasingly, there is help and understanding out there for children with nocturnal enuresis, even those who, like Adam, are still miserably wetting their beds at the age of 10.

'It's a vicious cycle, and somewhere along the line we've got to break it,' says Chan. 'Treat the bed-wetting, you feel more confident and you're not bullied. We break the cycle, and the child's self-esteem will improve.'

Yeung agrees. 'It's important we realise children have been misunderstood, it's something beyond their control, and it's almost always a pathological reason which can be cured.'

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