Dr Catherine
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8-15 years

My grandson has short bowel syndrome and is fed via TPN overnight. He is 7 yrs old and is dry during the day. However, he never has a dry night, although he did manage to go 14 nights a while ago, he has now gone back to wetting every night and has to wear a nappy. We have tried an alarm, but he slept through it, and doesn't seem to be bothered by the fact that he is wet and even if he wakes up, he refuses to tell his parents tht he's wet and just sleeps in it. He spent his forst 2 years in hospital and has complex medical needs which reqire strict sterile conditions and sleeping in urine is clearly not good for his condition. His parents have tried everything, positive affirmation, not making a big deal out of things, offering incentives, but to no avail, they're obviously frustrated and worried that he is placing himself in danger by refusing to inform them when he wakes up wet. They cannot check on him through the night, although they try to, but this is tiring and not practical, there are two other children in the home and tired parents who are forced to endure sleepless nights impact on them too. Their medical team is offering little by way of help, telling them that he is lazy and not really trying to solve the problem. I feel that there has to be an underlying psychological reason that causes his lack of concern for his own health, he is only 7 years old but is very aware of his own medical condition and I think knows that neglecting his personal hygeine could be seriously detrimental to his health. Could you offer any insight into how we can approach this and make him realise that he has to help himself to stay well. Thank you.

Coping with a child who wets the bed can be incredibly challenging, particularly when you have to deal with the added pressure of negative attitudes. Unfortunately negative attitudes toward bedwetting stem largely from adults not really understanding the causes. Many adults feel that bedwetting is a consequence of child laziness, which only adds to our feelings of stress and anxiety. Children often wet the bed because their body produces larger than normal amounts of urine overnight and their bladder is unable to store it until morning. This usually continues until the amount of urine produced decreases or children learn to wake-up in response to a full bladder - and being overtired doesn’t necessarily help the situation. The age at which nighttime continence occurs is quite variable – we know that it typically takes longer for boys than girls, with many specialist believing it to be quite normal for boys to experience nighttime wetting up until the age of 8. Research shows that the psychological impact of bedwetting to a child is more significant than its impact on the physical side. Family members reactions can directly impact on children’s ability to cope with the situation so it is important that we try to create as supportive an environment as possible. In the meantime I would certainly request a referral to a paediatric continence specialist. Use the opportunity to discuss treatment options – the most successful outcomes are currently being experienced with conditioning alarms. Their success depends to a large extent on familial commitment as well as correct usage so it is important that you draw on the support of a continence specialist before introducing the alarm. One of the major problems associated with this form of treatment is the fact that many children initially do not wake in response to the alarm - particularly if they are very sound sleepers like your son. Parents usually hear the alarm first, it is important that you respond and wake him so that he learns to turn the alarm off by himself and go to the toilet, even if he has already wet. The principle of conditioning therapy is that repetitively arousing the child at the time of the wetting episode can ultimately condition the child to recognize that urination is about to occur. Gradually, over several months, the child learns to respond to the feeling of a full bladder by going to the bathroom before the alarm goes off. Therefore, it is essential during the first few weeks that you wake him when the alarm sounds. Combining the alarm treatment with reduction in fluids in the evening can also increase success however given your grandson's medical history it would be important to discuss the implications of this before commencing on a course of action.All the best with this tricky situation,