Sleepwetting Forum Articles
[ sleepwetting a.k.a. nocturnal enuresis or bedwetting]
from Spontaneous Combustion
Kidney Function and DDAVP
On 12/4/2007, The FDA posted an alert Desmopressin Acetate Information regarding the danger of hypnotremia [water intoxication] and seizures from use of the nasal spray versions of DDAVP. Only the tablet version is now suggested for reduction of sleepwetting with appropriate cautions.
If you call the Bladder Health Council at 800-242-2383, they can send out information on DDAVP (Desmopressin Acetate) a synthetic version of ADH (antidiuretic hormone, vasopressin) which affects kidney function. Think of ADH as a 'control rod' for kidney output. An increase in this hormone causes the kidneys to produce less urine. Infants show little or no variation in production of ADH. They have no need to.
Between the end of infancy and the end of puberty, many children naturally begin to get a little extra burst of ADH every day in the evening. This reduces their kidney output for the next several hours so they then sleep eight or more hours before their bladders get full. Some two-year-olds can sleep dry all night but not through an afternoon nap. Probably close to half of children age six have developed this ADH cycle, though some of those may still sleepwet early in the morning. But only about half of those without the cycle are likely to awaken during the night in time to stay dry. That leaves about 25% of six-year-olds for whom sleepwetting remains a reasonable expectation. Natural development cuts that percentage in half every four years [roughly 12% of ten-year-olds, 6% of fourteen-year-olds, 3% of eighteen-year-olds and adults.]
So if nothing is done about it, 15% (one out of every seven) of school-age children who now sleepwet will get dry in the next year. That leaves six out of seven who won't. Only one of those six seems likely to have significant medical or psychological causes for sleepwetting. The remaining five have a developmental delay which they have not yet learned to compensate for by waking up before sleepwetting.
Waking up dry is a skill that can be learned. Appropriate support from family, friends, mentors, etc. is essential. For most children and teens, understanding how their urinary systems work followed by personalized training programs on how to awaken dry can significantly reduce or end sleepwetting.
If, when, and how the ADH cycle develops seems to have some genetic basis and gender differences. ADH is estrogen-related and girls who reach puberty without developing this hormone cycle seem more likely than boys to get it at that time along with their other hormone and pelvic area changes that may increase bladder capacity as well. Sleep disorders, stress, medications, other hormones, allergies, and schedule or time zone changes may disrupt the ADH cycle temporarily.
To avoid sleepwetting, a person who has normal daytime kidney and bladder function but hasn't developed the ADH cycle may now get a doctor to prescribe a synthetic replacement, DDAVP. This has to be used each evening for it to work that night. DDAVP doesn't help the body develop the real hormone cycle any faster, but it doesn't lose potency over time either. When people regularly using DDAVP stop, about 80% report a return of sleepwetting. Those who do stay dry reflect the expected 15% per year attrition in sleepwetting when nothing is done about it. Families with a history of girls sleepwetting until puberty may want to talk with their doctors about trying DDAVP with their girls beginning around age eight. It is important that children using DDAVP are old enough to have a clear understanding of how it works, the importance of using it correctly, and the ability to do so with relatively little adult intervention.
DDAVP does not work for everyone. The best candidates are those who sleepwet about three hours after bedtime. Those who usually sleep dry for six, seven, or more hours probably have the ADH cycle and may get little benefit from DDAVP. Finding the effective dosage may take a bit of experimentation. For some, even the maximum safe dosage only delays sleepwetting until early morning.
DDAVP only affects kidney output, not bladder size or condition, depth of sleep, bladder-brain communication while sleeping, or environmental factors such as stress or diet. There are other medications that can affect urine quality or output, temporarily extend bladder capacity, or affect sleep patterns in ways that may reduce sleepwetting. Anything that affects kidney function should always be done with careful supervision of the dosage level and regular medical evaluation.
So far, DDAVP seems to comes the closest to replacing the natural control process, but it is reported to have some side effects. The FDA alert Desmopressin Acetate Information says
Certain patients taking desmopressin are at risk for developing severe hyponatremia that can result in seizures and death. Children treated with desmopressin intranasal formulations for primary nocturnal enuresis (PNE) are particularly susceptible to severe hyponatremia and seizures. As such, desmopressin intranasal formulations are no longer indicated for the treatment of primary nocturnal enuresis and should not be used in hyponatremic patients or patients with a history of hyponatremia. PNE treatment with desmopressin tablets should be interrupted during acute illnesses that may lead to fluid and/or electrolyte imbalance. All desmopressin formulations should be used cautiously in patients at risk for water intoxication with hyponatremia.
For such reasons or the cost for daily use, some people prefer to use DDAVP only when travelling or for special events, such as sleep-overs, camp, or visits from nosy grandparents, and continue to rely on other external bladder controls (GoodNites®, diapers, bed pad, etc.) most of the time.
Even if DDAVP can keep someone dry while sleeping, please remember that it is still an external control and should be thought of as temporary. As you get used to waking up dry, try not to let that temporary effectiveness divert attention and effort from understanding and working on true inner control.
disclaimer:
I am not a medical professional and do not offer advice that should be taken as medical or therapeutic in intent. Always consult a doctor for medical diagnoses and treatments. I have researched the area of teaching bladder control and managing bladder disabilities as part of volunteer work with incontinence support organizations and families of children with disabilities. I am a writer, actor, storyteller, children's bookseller, and parent of two young adults. I serve as list-owner of the e-mail lists EnuresisKids [moderated] and EnuresisParents.
Tom Farley
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