Potty training is a rite of passage not only for children, but also for parents. Once you’re past the days of diapers, those times can make for fun stories.
The same is not true for nighttime training. The journey to dry nights can be a long and frustrating one for parents and kids.
Parents don’t discuss nighttime training as much; it comes with a stigma that daytime training doesn’t have. I would slink away from the diaper aisle with my extra-large pull-ups hidden under my arm when my second child failed to stay dry through the night at age 5 and then 6.
We tried bedwetting alarms that clip to her underwear at night. We tried showering in the morning, banning drinks at night and waking up at midnight every night to use the potty. We talked to the pediatrician and ruled out physical problems. But six months into her sixth year, it was still a nightly occurrence.
Obioma Nwobi, M.D., a pediatric nephrologist with Nicklaus Children’s Hospital, encourages parents to be patient until their children reach age 6.
“Kids become potty-trained at night, most, by 5 years of age,” so in children younger than 5, bedwetting is normal, he said. Generally by 5 or 6, a child’s bladder capacity is big enough to accommodate nighttime urine, he said.
But not always.
Studies indicate that about 13 percent of 6-year-olds wet the bed, Nwobi said, and about 5 percent of 10-year-olds do, too.
The reasons vary.
Bladder infections and constipation can be to blame. “The control of both the bladder and bowel, they are interrelated,” Nwobi said, “so kids who are constipated tend to have more bladder issues.” If infection or constipation is present and parents can clear up those issues, the problem may resolve on its own.
If a child starts bedwetting after being dry at night for six or more months, stressors such as a change in the family, a new home or problems at school might play a part, Nwobi said, and those issues would need to be addressed first.
Family history is also important, as bedwetting can be hereditary. If one or both parents wet the bed as children, the chance of their child dealing with the same issue increases substantially, Nwobi said.
Such was the case with Tal Sagie and his father, Jacob Sagie, a certified family psychotherapist. Bedwetting, or enuresis, runs in their family, and Jacob Sagie’s struggle to train the 6-year-old Tal motivated him to get his doctorate in psychophysiology so he could help other children overcome bedwetting.
Jacob Sagie and his son Tal, now a therapist and doctoral student, have decades of clinical experience with bedwetting. They spent four years crafting an online program called TheraPee that mimics the personalized support program of their enuresis clinics in Israel, Tal Sagie said.
The cognitive behavioral program works because of the flexibility of the online format and its personalization to each user.
“This program is tailor-made to the child’s condition,” Tal Sagie said. “We take into consideration the age, the frequency of the bedwetting, the time of the bedwetting and the size of the urine spot.”
You cannot treat every child the same, Tal Sagie said, which explains why many bedwetting alarms fail.
“If you treat a child who is wetting the bed every single night with an alarm, it is effective. … It’s not enough, but it’s effective,” he said. “If you use the same alarm with a child who wets the bed once a week, there won’t be any learning process because the gap between one incident and the next is too big.”
TheraPee has an alarm pad that’s placed under the bed sheet, but the bulk of the program is its online support for parents and children. TheraPee uses algorithms to customize its support program, which includes interactive videos with Tal Sagie, a visual reward system and exercises custom-matched with each patient.
“We have hundreds of video clips … and each one of our patients is exposed to 10 percent, maybe 15 percent,” depending on their age and situation, Tal Sagie said. “We continue developing it all the time and adding more features.”
Through the software, Sagie and his father can treat thousands of patients simultaneously. “But we’re always here to support,” Sagie said. “Customer service is very important.”
Families start the program with a video tutorial on how to use the TheraPee pad and the online tracking system. They report progress daily, and every two weeks, a video report is generated with advice, quizzes and further instruction for parents and children.
Families with questions can get answers on the TheraPee website at bedwettingclinics.com or the TheraPee Facebook page, which is a dynamic and informative resource for parents, Sagie said. Parents can also chat with a therapist or even arrange Skype sessions for more challenging issues.
A parent’s role
Parent involvement is key to the TheraPee system. “We found there are a lot of misconceptions about bedwetting, a lot of parent mistakes,” Sagie said.
One of those is waking the child up to go to the bathroom in the middle of the night, he said.
Bedwetting is characterized by extremely deep sleep, so the first challenge of therapy is training the body to recognize the signals the bladder is sending out in the middle of the night.
When parents wake their children, they block that learning. “You’re not letting the system get used to handling the problem,” Sagie said.
Another common mistake is fluid restriction before bedtime.
Doing so is “not really training the bladder to cope with normal liquids,” Sagie said. “Even if it is successful, as soon as the child has another cup of water before bedtime, there is a high chance he is going to wet the bed.”
The idea is to teach the body to deal with any circumstances. “We need to train the brain. We also need to address the bladder, strengthen the sphincter muscles, expand the bladder capacity.”
The first two weeks of TheraPee can be challenging as parents turn away from coping methods and rely on Sagie’s system to begin training the child. The alarm pad may wake them up several times a night, he said, but after the first two weeks, it gets much easier.
The combination of daily reporting, a star chart, exercises and feedback to address elements at the right time to the right patient helps the child succeed faster, Sagie said. “Every tiny element in this program is based on decades of clinical experience with more than 40,000 children.”
Most children begin responding to the TheraPee system in two to six weeks. Complete dryness takes three to five months on average, he said.
If parents don’t see progress, Sagie encourages them to contact him personally to evaluate the issue. But “in four months, we should expect to see at least 50 to 70 percent success,” he said.
Sagie said TheraPee works because “we have managed to imitate what we are doing in our walk-in clinics, but in a computer program. So the therapist can ask a question, and he’ll just answer by clicking the mouse on the screen and get immediate feedback.
“So it’s the closest you can get to interacting with a therapist in the clinic, and you’ll get the exact same elements, the exact same feedback, everything exactly the same as it’s done in the clinic,” he said. “It’s not as easy as preparing some kind of CD with a couple of videos and sending them to everyone, ‘Just do these exercises. It will work.’ It wouldn’t work.”
Dry at last
With my daughter, the interactive videos and continuous encouragement made all the difference.
Yes, those first few weeks were tough, but once she started recognizing the feeling of a full bladder at night, her progress was amazing. On week six, she had her first solid week of dryness, and at week nine, she started a run of dry nights that lasted more than a month.
I went from waking every night at midnight to getting a full night of sleep, and by now, we’ve said goodbye to her “peepee pad” forever. We’re dry at last.