Sleep Disorders

Daughter sleeps too deeply

09/20/2006

Question:

My daughter turned 6 in July and continues to have problems with bed wetting. My husband and I will wake her up during the night to use the bathroom and this helps, but she has never awoke on her own to go. If we don`t get her up, she will almost always wet the bed.
We thought that getting her up around the same time every night would cause her to habitually start waking up around this time on her own to use the bathroom, but it`s been a year and that hasn`t happened.
We notice when we wake her up, she`s a "zombie", has no idea where she is, what time it is, what`s going on, nothing. We literally have to steer her into the bathroom or else she`ll start walking down the stairs or into our bedroom without a clue as to where she`s supposed to go or what she`s supposed to be doing.
Last night I got her up, told her it was time to go potty, and steered her into the bathroom, then had to duck out for a second to take care of something. When I came back, she had her pants and underwear down but was sitting on the step stool 3 feet from the toilet and had urinated on the step stool. She really didn`t have a clue at all what she was doing.
In the morning, she usually doesn`t remember being awakened the night before to use the bathroom. Sometimes she will mumble a jumble of words that doesn`t make any sense when we get her up, or pull away from us and make sounds like an animal growling or shrieking.
It`s like once she`s asleep, she`s totally dead to the world, I sometimes think a bomb could go off outside and she wouldn`t wake up. She doesn`t even wake up when she`s wet, she`ll come in shortly before our alarm goes off in the morning to tell us she`s wet and we have no idea how long she has been as the wetness is cold already by that time. If she doesn`t wet the bed, even after 10-11 hours sleep she still has a hard time waking up in the morning for school.
Once we get her out of bed and dressed she seems to perk up and be fine, but getting her awake and out of bed in the morning is a struggle no matter how many hours of sleep she`s had. We put her to bed at 8 p.m. and we get her up around 7 a.m. for school. Could the bedwetting be caused by a sleep disorder that`s not allowing her to wake up to use the bathroom? She just seems to sleep so soundly it`s like she can`t wake up to go, she`s so sound asleep she doesn`t feel her body`s signal that it needs to wake up and use the bathroom. We also restrict her drink intake after 6 p.m. and that doesn`t seem to have helped either.
Any information or advice you could give would be appreciated.

Answer:

The bedwetting that you describe is formally called "Sleep Related Enuresis (SRE)" which is usually described as bedwetting occurring during sleep at any time, not just at night.

Sleep related enuresis has an incidence of about 30% of 4 yr olds, 15% of 5 yr olds and 10% of 6 yr olds. It gets better by itself as children get older with only 3% of 12 yr olds and 1% of 15 yr olds remaining affected. There is a clear genetic predisposition with an incidence of 75% in children whose parents were both enuretic during childhood.

Sleep related enuresis is termed primary when the child has not had a period of more than 3 months of sleep continence (or being dry at night) since birth. This is the most common form. It is termed secondary when it redevelops in a child who formerly was continuously dry during sleep for at least 3 months. The secondary form is less common and is a cause for more concern

I assume that your daughter hasn't had frequent urinary tract infections that might indicate an underlying renal (kidney) cause of enuresis. I would also want to be sure that your daughter doesn't snore at night, since obstructive sleep apnea (OSA) may cause SRE in some children. Treating the OSA will improve the enuresis in these children

The second concern you express is your difficulty in attempting to awaken your daughter at night ie. she seems like "a zombie". This is due to the known difficulty awakening children your daughter's age from slow wave sleep which is more common in the 1st 3 hours after falling asleep. Part of the problem is due to what is called sleep inertia or a cognitive and motor deficit (i.e. being groggy and confused) that occurs immediately upon awakening people from slow wave sleep. The fact that your daughter has deep slow wave sleep is actually a very healthy thing. But trying to awaken her during this time leads to only partial arousal which causes behavior like her urinating on her stepstool and not in the toilet. She is not completely awake. This is shown by the fact that she does not remember anything happening the next morning.

The good news is that your daughter is likely to "outgrow" bedwetting as she gets older. I know that this may be of little condolence to you right now. Waking her at night is not likely to help her and will only frustrate you. We generally suggest that children wear commercially available extra absorbant underpants during the night to reduce laundry concerns. While medications such as DDAVP are sometimes used in older children, they are usually avoided in this age group, since so many children normally have this problem and will get better in the next few years. I would suggest you talk about this issue with your child's pediatrician or family practitioner.

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Response by:

Mark Splaingard, MD
Professor, Clinical Pediatrics
Pulmonary Medicine
Nationwide Children’s Hospital
College of Medicine
The Ohio State University