Bedwetting: how chiros can care for a kid with Nocturnal Enuresis
Being a chiropractor will invariably involve caring for kids who wet the bed at night. Often an embarrassing and emotionally upsetting experience for the child, it can be a frustrating experience for the chiro: Sometimes the response is almost instant and complete, other times painfully slow, incomplete or absent.
According to the Royal Children’s Hospital in Melbourne (1) 30% of four-year olds wet the bed. At this age, it is considered normal. A diagnosis of ‘Nocturnal Enuresis’ is given if it affects a child over five years old. 15% of five-year olds wet the bed, 5% of 10 year olds, and 2% of 15 year olds. These statistics are surprisingly similar all over the world (2). It affects twice as many boys as girls (3). 20% of the kids with nocturnal enuresis also have daytime accidents and 15% have bowel accidents (3). There is a strong genetic association, with 75% of children whose parents both wet the bed suffer with enuresis, and 50% if only one parent did (3).
Theories abound for the cause of enuresis. If the child has never been dry at night, he will have what is called primary enuresis, whereas secondary enuresis means the child has had at least six months of being dry at night. Secondary enuresis can be caused by psychological stress such as a new baby in the family, changing schools, moving house or similar. It can also be related to a UTI or constipation, diabetes, sleep apnea or obesity (2). Primary enuresis is thought to be caused by having a smaller bladder, producing more urine at night, bladder muscle (Detrusor) overactivity, poor sleep pattern, global maturation delays and poor brain bladder connection (3). Research has shown that children with ADHD have a higher incidence of bedwetting (4).
Common advice for bedwetting includes sticker charts and prizes and ‘lifting’ – waking the child to go to the bathroom at night. According to one study ‘lifting’ over a six month period improved symptoms significantly in 37% of the kids, whereas the positive reward did nothing (5).
Bedwetting alarms are a popular approach, according to Glazener helping almost half the kids studied to stay dry (6). Another increasingly common medical treatment is the prescription of Desmopressin, a synthetic Anti-Diuretic Hormone mimicking the effect of vasopressin normally increasing at night to decrease urinary output from the kidneys. According to the literature this fixes bedwetting completely in 30% of kids with another 40% experiencing improvement (3). However, there is a 70% recurrence once medication is stopped (3).
Although clinical trials (7), and maybe personal experience have shown that chiropractic is not totally successful in ‘treating bed wetting’, I think there are important thoughts to be had about chiropractic on this topic. Even if it is just that we know from Heidi Haavik’s research that chiropractic adjustments impact the function of the prefrontal cortex (8), and we know that the prefrontal cortex oversees the function of the lower brain functions such as the brainstem which controls micturition (9).
LeBoeuf’s study from 1991 (10) found that the 170 children aged 4-15 years experienced an average decrease in bedwetting (from 7 to 5.6 nights per week), just from showing up in the chiropractic office – no care provided. This number was reduced to four nights per week after receiving chiropractic. I reckon a 43% improvement from a non-invasive approach is not too bad.
Although, as far as I know, all adjustments stimulate the prefrontal cortex equally, I usually pay more attention to the parasympathetic levels when adjusting: Keeping in mind that the individual sacral bones fuse at 18-30 years of age (11), check sacrum, upper cervicals and cranials. Also assess pubic bones and pelvic floor muscles and fascia.
Some things to consider when caring for a bedwetter:
Constipation is an important factor in enuresis and should be discussed in detail. A child over five years will usually take care of all toileting himself. Constipation may cause ‘overflow’ movements, resulting in ‘loose’ stool, faecal material which has squeezed around compacted faecal material. This may cause ‘skiddies’ or accidents, or that the child thinks he has had a bowel movement. A food diary should be kept, and a keen eye kept on the amount of fibre and fluids consumed, as well as potential food intolerances. Lack of physical activity can be involved in constipation and potentially irritate the bladder.
Sometimes parents are very vigilant when it comes to decreasing fluid intake later in the day. Although it makes sense to decrease drinking for an hour or so prior to bedtime, limiting fluids may increase the concentration of the urine, irritating the bladder lining and exacerbating the poor bladder control at night. Point out that coffee, tea and soft drinks are diuretics.
Research has shown that pelvic floor exercises are not effective as a treatment for nocturnal enuresis (12). Overall muscle tone is though, as it stimulates brain function and brain-body connection, and the child should be encouraged to keep physically active in sport and play.
In my experience ‘stressing’ the bladder can be a good way to connect the brain and the bladder. I usually suggest the whole family participates, so as not to single out anyone: Drink a huge amount of water, and then try not to go to the bathroom. Hang on, hang on, curl the toes, squeeze the knees….. Only go when it is impossible to hang on anymore. This will help stretch the detrusor muscle and ‘wake up’ the sensory nerves to sensitize the brain to the sensation of a full bladder. Jumping and running with a full bladder will have a similar effect.