Ep 188: Why Bedwetting Happens—and What Really Helps: A Conversation with Pediatric Urologist Dr. Andrew Kirsch

Bedwetting is incredibly common—but it’s also often misunderstood, leaving families feeling frustrated, confused, or even ashamed. In this episode, pediatric urologist Dr. Andrew Kirsch joins Dr. Jessica Hochman to demystify nighttime wetting and offer real, evidence-based guidance for parents.

They explore:

• Why bedwetting happens (hint: it’s not your child’s fault)
• When to worry and when to wait
• The truth about bedwetting alarms and medications
• A promising new non-drug device called Soluu that could reshape how we treat bedwetting

Whether you're in the thick of it with your child or just want to be prepared, this episode offers clarity, compassion, and plenty of practical tips.

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

For more content from Dr Jessica Hochman:
Instagram: @AskDrJessica
YouTube channel: Ask Dr Jessica
Website: www.askdrjessicamd.com

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Tiny Health using code: DRJESSICA

Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.

The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hi everyone, and welcome back to your child is normal. I'm Dr Jessica Hochman, and today we're talking about one of the most common and often confusing pediatric concerns, and that is bedwetting. My guest is Dr Andrew Kirsch. He's a pediatric urologist. He's a researcher and the co author of the new book, The Ultimate bedwetting Survival Guide. With over two decades of experience, Dr Kirsch brings both clinical expertise and practical advice to families that are navigating nighttime wetting. We talk about the real causes of bed wetting, how to avoid blame and frustration and what treatments actually help. Dr Kirsch also talks about an exciting new device and development that offers a fresh and hopeful approach to families that are looking for alternatives to medication and traditional bedwetting alarms. If you've ever wondered when to worry or how to help your child stay dry, this conversation is for you, and also as a reminder. If you're enjoying this podcast, I would be so grateful if you could take a moment and leave a five star review wherever it is you listen to podcasts, great reviews help other people find this podcast, which really makes a difference in helping this podcast grow. Now on to my talk about nighttime bedwetting with Dr Andrew Kirsch. Dr Kirsch, thanks so much for being here. I'm looking forward to having this conversation with you. Thank you. It's great to be here. So tell everybody a bit about yourself. What do you do for work, and tell us then about the book that you wrote. I'm a pediatric urologist, so we're a small group. There's only about 400 of us in the country, and I've been a full time urologist at George urology, which is the nation's largest private practice. And I wear several hats, so I at Emory, that's my academic track, where I am professor and chief of Urology. I'm also chief Urology at children's health care of Atlanta, which is the largest children's healthcare system right now in the country, and I am, as I said, also at George urology, where I am the medical director. So those are the hats I wear, but I'm also an entrepreneur, a writer, a parent of three kids and a grandchild, a father of one granddaughter. So clearly, you're a busy man, and there's a lot of things that you could spend your time doing so I'm so curious what inspired you to write a book about bedwetting. It's been something where after practicing for 25 years and seeing literally 1000s of patients, you get to hear all their stories, and a lot of the stories have to do with sleep deprivation or not being able to go to summer camp, anxiety, the feeling that there's got to be a better way of treating these kids. So one of the things I did a couple of years ago was to survey pediatricians how they managed bedwetting. And what we learned in our survey is that about 50% of these families were unaware of the multitude of treatment options that are out there. Not that they're great, but they're also unaware of these options. And so pediatricians were surveyed with a 24 Question voluntary survey, just asking them, is that wedding important? How many patients do you treat how experienced you are? And we learned a lot, and hopefully we'll get to some of those answers as well. It's true that bed wetting is so common, and I think, for myself, as a pediatrician, you're right. It comes up a lot in practice, and I know that most kids grow out of it, so you want to make sure that parents are given the best direction? Yes, it's true that there's biology involved, but also there are options that I think we could make better for families. Yeah, absolutely. And the impetus for writing this book, and my co author, by the way, is ubira jaraborosso, and he's an international leader in treating all kinds of incontinence issues. He's the secretary of the International Children's cotton society, and he's co author of the book, as well as one of my business partners in a company that we developed that I'll talk to you about as well. That's great. I think with Bedwetting, it's an embarrassing topic to discuss freely, and so I hear it in my office. I know how common it is, but I think for parents listening, they may not recognize how prevalent it is and how normal it is. So thanks for having this conversation. I am sure that's gonna help many families. Thank you. So first, what I would like to talk about, and you talk about this in your book, is what we call primary nocturnal enuresis. Can you describe what that term means? Exactly sure. So what primary nocturnal enuresis refers to are kids that have really never been dry at night. So they've never had a six month period, for example, where they've been dry. Because if there was a six month period, that's when we call it secondary enuresis. Okay, so enuresis can be secondary to other problems, whether it's going to be diabetes or it's going to be bowel and bladder dysfunction or a neurologic problem, those are the ones we get a little bit more concerned about, and we have to work up a little bit more thoroughly, but primary noctulinary system makes up the vast majority of the patients that we see. You. And just to shine some light on this, how common is it? Exactly. So bed wetting is extremely common. So if you just look at the world data, 200 million children suffer from bed wetting. If you look at kids that are around age five, where we start to make the diagnosis, that's probably about 15% a higher incidence in boys than girls, because there is delayed maturity in boys. As kids get older, by the age of seven or eight, that number drops to about five to 10% so the average age of our referrals from people like you, the pediatrician, is probably nine, and there's as they get older, about 3% of 11 or 12 year olds, and then it drops to about 1% and even in adulthood, 1% of adults have bed wedding, something they don't think about a lot, but that's a lot of people, and this is a neurologically normal people. These are primary nocturnal enuresis. They're still waiting for it to go away. And you know when you first saw them, when they were five or six, and you said, Don't worry, it's not much of a problem. It all goes away when it doesn't in the small percentage, you have to start thinking about some other treatments. We'll get to treatments. A lot of them aren't as effective as you may think. And can you comment on family history as well. Sure there is a genetic component to nocturnal neurosis. So if one parent has bed wetting, there's about a 40% chance that their child will have bed wetting, and if both parents have it, it goes up to about 75 or 80% and what is interesting is that you should always ask the parent, how old were you when you stopped wetting your bed, because that correlates with the child's bed wetting cessation as well. So in this situation, the Apple really doesn't fall far from the tree. That's correct. It doesn't. But it could be very helpful, because they bring that experience to their child and they normalize it, and that's very important. I do find it comforts the child when I can talk about it with families in the office, and a mother or father will relate to the child and say, for me, it lasted till 910, years old. And I do think that does provide a lot of comfort for kids. Yeah, everybody's individual, right? So you don't know what they're experiencing. I could tell you that I saw one of my anesthesiologists kids a couple weeks ago, and I saw her in the operating room, and I said, How'd the appointment go for your child? And she said she was kind of covering her face up when she was leaving the office because she was so embarrassed that people would see her because of this problem, not realizing that we see a multitude of other problems, but they don't really know what's in the head of a child, and their experiences, their relationships with their siblings, their parents, their friends, they're all so different, so everybody has to be treated as an individual. Absolutely, I do think, though, it's reassuring to hear that there's a genetic component, because I'm interested in the child being reassured that it's not their fault. Absolutely, that's probably the one kind of myth that will lead to the most damage, if you will. We see a lot of kids that also have psychological issues. They deal with anxiety, depression or they have that problem. In addition to this, what came first certainly doesn't make it better if they started off with anxiety, and it's so important to address that as well. And it's interesting that you point out that you don't typically define primary nocturnal enuresis until five years old. So if I'm understanding correctly, if a kid is four years old and they're wetting their bed at night, parents really shouldn't be alarmed or concerned. You know, as well as I do, you're going to see a four year old whose parents are very concerned because they've had other kids, maybe a daughter that was toilet trained and perfect at age two, and they've dealt with three more years of diapers, and it's not normal for them. So you do have to normalize it, and sometimes you even have to offer treatments to these families, just to give them something to work towards, working towards hope is a reasonable goal when dealing with this problem, absolutely and I completely agree. I do find that comparison in this situation is very prevalent, very often. I hear a family talk about one child, one child was trained at two, two and a half, and why is it taking so long for the other child? And I do think it can be frustrating for family. So this is a good reminder Absolutely. Now, the big question I have is, of course, there are different scenarios for different kids, but do we know the main physiologic reason why bed wetting occurs? Is it because they're deep sleepers? Do they have a small bladder? Do we know in most situations? Why does it actually happen? Yeah, and we talked a little bit about the genetics, but the physiology is multi factorial, for sure. In the most basic sense, there is a disconnect between the brain and the bladder, so you should be. Able to sense when your bladder is full, get that message to your brain, get up and go to the bathroom. So kids that have bed wetting are very deep sleepers. Amen, all of them are and so it's a sleep disturbance. Their arousal threshold is elevated compared to otherwise normal children. So that has a lot to do with it. It could also just be that they make more urine at night, so nocturnal polyurea, they may not have enough hormone that's responsible for holding on to urine, anti diuretic hormone, but that doesn't explain all of them. That's why some of the treatments, like medications, are not 100% effective, the way less than that. And so it is multifactorial. It could be related to other stressors in their lives. And we talked a little bit about anxiety, depression, and what these kids are feeling. If those things affect their sleep, the medications they take affect their sleep, well, that's also going to make their bed wetting worse, and that's why a lot of the drugs are ineffective, especially in kids with ADHD, and you have to start looking at other ways of treating it. That was something that I really enjoyed learning in your book, because of my experience when I've given the medication. For some kids, it is very effective, it's very helpful, but for other kids, it's not helpful. So that was an interesting point that you brought up in the book that I appreciated learning about, yeah, one of the examples we give in the book, you might notice that somebody has hyperactivity, or somebody's in a divorced family, and they with the mother, and they're with the Father, and they do different things when they're at different houses. And if you look at that, and you look at what the different treatment options are, it's no wonder that some of these treatment options are ineffective because the scenarios change so often. In your opinion, I know there's a variety of reasons about why bedwetting happens, but would you say that in most situations, it's probably because of a developmental lag that where the brain and the bladder aren't quite synced up yet. I think that makes the most sense. But as I said, if you have treatments and one of them has the highest success, you would think that addresses the main physiology, but the gold standard is a bed wetting alarm, and the bed wetting alarm is about 50 to 70% successful. And some of the success may be on the timing of the kid aging. So it's not always clear what it is. Not everybody understands that you cannot make your bladder contract. So we talk about parents getting frustrated with their child and maybe even blaming their child for being lazy, or you're doing this on purpose, and that, unfortunately, I try to tell people that you could only make your bladder empty by relaxing your sphincter and bedwetting actually has no effect whatsoever on your ability to hold your urine with your pelvic muscle which makes up your sphincter and you can't make your bladder contract, right? So at night when your bladder contracts, your sphincter is relaxing in response to that mechanism. Okay, it's not because you relaxed it. You have no control of it whatsoever. I think that's it helps them understand a little bit about why it's not their child's fault. I like this point because I think it's so important for parents to trust that the kid isn't doing it on purpose in most scenarios, yeah, they're sleeping. So it's kind of hard to blame a child who's sleeping for doing something voluntarily. But this problem also happens in kids that nap during the day, so it is a sleep issue for sure. Now while we're on the subject of myths and bed wetting. Can I also ask you, because this is something that my mom and I talk about. My mom really believes in waking a kid up, having them go pee after they've gone to sleep, to help them get over being a bed wetter. Do you find there's any validity to having a child sleep, waking them up to go to the bathroom and then putting them back to sleep? Does that make them overcome bed wetting any faster. So there's no evidence to support that. And some of these kids wet multiple times a night. So we talked earlier about the brain and bladder connection and sleep deprivation. So you add to this whole process, sleep deprivation, because now the parent and the child are both getting up, it's going to affect their day the next day. So timed awakenings are not really part of the behavioral therapy that we talk about in treating bed wetting. So behavioral therapy would be limit your fluids before you go to sleep and make sure you empty your bladder. That's all you could really do. We do those things. And if you look at the largest study that's ever been published, 6000 patients, a Cochrane Review, it looked at all the different treatments. And if you look at behavioral therapy, it had an 18% success rate. And as a pediatrician that you're telling every single one of your families to do that. We all do it because maybe it'll make the amount of bed wetting a little bit better. But there's really not a lot of strong evidence that actually works. There is evidence from Sweden that if kids have timed voiding during the daytime that they're really conscientious about emptying their bladders, it has no effect whatsoever on bed weight. That's really interesting, because you're right. I've always been taught about the importance of timed voiding, so that means going every two to three hours during the day. And you're telling me that the time voiding actually doesn't make a difference. I mean, if you look at the numbers, it's a placebo effect. 18. Interesting, yeah. But we definitely all do it. And I think avoiding habits is good for other reasons. I may not stop bedwetting. It might make it a little bit less in terms of quantity, but it's not really a very effective treatment. Just explain to me that you want to think about the bladder as a rubber band, and if it's stretched too much during the day, then it might not work as well at night. So just like a rubber band, if it's continually stretched, it loses its elasticity, and it might not respond as well to the stretch, but if there's not the evidence to back it, I can see that that's interesting. I think what you're saying is true for daytime problems or secondary enuresis. So we see a lot of kids with bowel and bladder dysfunction. Remember, the pelvic floor in the front makes up your sphincter, which you can't control in your sleep, and it also makes up your your rectal sphincter as well. So kids that have pelvic floor problems tend to hold their urine and hold their stool, and the treatment of that is full on, bowel clean out timed, time voiding, like you described. And if you don't do that, then you get bladder instability. So bladder instability will cause some of the secondary enuresis, or what we call polysyptomatic poly means they have daytime problems, urgency, frequency, constipation, sometimes fecal incontinence, if they have other issues. And those all could be managed pretty well during the daytime. And so what you talk about is overdistent of the bladder, you know, that could certainly cause problems. And we do see some kids where they have such bad, overactive bladder that might actually make their nighttime worse if they're having bladder contraction. So you talk about using first line therapy, which would include something like DDAVP or vasopressin. If that's not working, or maybe it works a little bit, you could always throw on a medication like an anticholinergic, like oxybutyn or ditropan, which will then relax the bladder, and that has been shown to improve the results with kind of polytherapy, and those two together, DDAVP and oxybutyn or ditropan, are the ones that we may use in combination in cases where one is not effective. The problem with ditropan, of course, is side effects, and that includes constipation. So now you're in this vicious cycle of having bowel and bladder dysfunction during the day that you treat with something that makes it worse, making the constipation harder to treat. And that's why I mentioned that we very aggressively treat constipation these children, because our therapy sometimes leads to it. I really appreciate that distinction. That makes sense, that the timed voiding the bladder exercises helps with the daytime urination when your brain is working and alert and you can tell when you have to go the bathroom, as opposed to being in a deep sleep when you're not aware. That makes total sense. And we also did a survey of parents asking them about their school bathroom policies, because one of my colleagues, years ago wrote an article in the Journal of Urology that was picked up by the New York Times that basically says schools are creating bowel and bladder dysfunction, and if you think about it, they're lining up all these kids when they're little. The kids may or may not need to go to the bathroom. That's your time to go, and then they have certain times where you can use the restroom. So what we've learned is that in doing a survey of the parents, and we've surveyed probably three or 400 of them now, and we found out that you have a certain number of times where you could use the bathroom, if you overuse that, then that could be used against you. And what is really shocking, and this happened probably less than 5% of the time, but they were actually rewarding kids for not using the restroom. And so think about what we tell them to do, like you mentioned earlier, the time, voiding and making sure they drink and do everything else to treat their daytime issues. The schools are reversing that circumstances. You can understand why, because I think it's hard for teachers, right? If they're managing a classroom of 30 kids, and if they're all going to the bathroom at different times, it's just not practical. So but I can also understand that if a kid doesn't have to go and they're being told to go, that can be confusing to the body. Yeah, yep. Absolutely. The other thing that I hear a lot from kids is that they don't like going to the school restrooms because of the way it smells, or just because of the general atmosphere. They don't want to go while they're at school. And I think that's another issue as well for little kids. Yeah, the other thing is, a lot of bathrooms are dirty. They don't want to use them, and they will just hold the entire day. A lot of these kids are running back, either from the bus stop or out of their parents car, at pickup, running back to their house, holding themselves, trying not to urinate, because they just held all day. It's true. There are so many kids they do not go all day at school. When I ask them about it, they don't like anything about their school bathroom the way it smells. They don't want to go number two in public, or maybe their friend might find out they don't want anything to do with their school bathroom. So I don't know how to fix this problem, but I do agree it's a problem. Yeah, it's a big problem. I'm on the board of the American Academy of Pediatrics in Georgia, and one of my projects has been school policy. So it's up to interest, and hopefully we'll get some traction on it. That's great. That's great. Okay, so for parents that are listening, and maybe they have a child themselves who is wedding at night, I want to go through the list of practical advice to give them and practical things to think about. So we talked about limiting fluids before bed. What does that look like? Yeah, limiting fluids is probably something you do like right after dinner. It really depends on bedtime. And you could talk about limiting fluids, but you also have to talk about sleep hygiene and how you wind down before you go to bed. If these kids are drinking and they're playing video games right up to the time they go to sleep, they're getting over stimulated, that's also not good for them, so that will affect their sleep cycle. You should limit fluids, but there are other things that you need to do in conjunction with that all surrounded around that concept of sleep hygiene. Okay, I completely agree. So, a good bedtime routine, offering sips of fluids before bed if they request it, but trying to limit guzzling large quantities of fluid, I think that would be helpful. There are situations where you really shouldn't limit fluids, and it may be that you're doing sports that end at seven to eight o'clock at night, and there's no way you're going to be able to limit fluids after you just drank a gallon of water during practice. We'll get to that in a little more detail. We talked about the medical therapies that kind of is the category of fluid limitation. Yes, it's true. If a child is telling you they're thirsty, it'd be oppressed as a parent not to let them drink fluids. Okay. Now, bed wetting alarms are a big topic of conversation. A lot of parents are interested in using a bed wetting alarm because it's not a medication. It feels more natural, but there's a lot of questions that come up. So I guess my first question to you is, do you have a favorite type of bed wetting alarm? And what would using a bed wetting alarm look like for a family? Part of the frustration as a specialist is that I do see a lot of kids that have already failed bedwetting alarms. If you ask me, Is there a favorite? There's really isn't, because they all kind of work with the same concept. It's going to be a loud noise, it might be vibration, it might be flashing lights, it may be all of those. And the success is not that different between them. And so think about what happens now that we talked about the physiology and sleep, and how this is a sleep disturbance. The child wets completely. An alarm goes off. There's nothing stopping that child from finishing so if the alarm goes off most of the time, they're going to sleep through it. And in the ones that don't, they are awakened to a wet bed. So what do they learn? They learn that the bed is a cold place to be, and now they have to go to the bathroom to finish urinating, which they most of the time, have already finished. They're taught, and this is how I was trained. This is the opportunity for them to clean their sheets, and that's supposed to change the brain bladder connection. It does not do that. It does nothing to neuro modulate. So neuromodulation is when the brain can sense a full bladder, and then that sense of a full bladder awakens you to use the restroom. It's true, that's what I've been taught, is that you're supposed to involve the child in the cleanup process. But you're right. That doesn't make any sense, that it's how would this speed up their learning process, to not wet their beds? It's just more frustration. They're extremely frustrated already. There is one alarm that is not available in the United States that involves a vibrating orb. It goes under your pillow, and it also has an industrial speaker next to your bed, and it shakes your head, and it is very loud. And they claim to have a 90% success, but I don't know it still. There's really no reason why it would work based on the whole process of neuromodulation. So is there a time when you would most likely recommend it? So for example, I find that kids that have never been dry, it's not worth recommending a bed wetting alarm, but for the kids that are dry a couple days a week, I find that there's a higher success rate. Would you agree with that? It's probably worth trying out everybody, because what's your alternative? The alternative is to limit fluids, which we talked about. And then there's bedwetting alarms, which is the gold standard. And the gold standard is pretty tarnished, because the success is 30 to 60% you have to use bed wetting alarms for four to six months. So the child is alarmed by the alarm. The siblings wake up, the parents get frustrated because the child is pretty much already wet. They're basically taking a kid that is spending very little time with good quality sleep. They're zombies. They're taking these kids to the bathroom, pretty much dragging them there with them to sleep, and then that process is supposed to go on for four to six months, no wonder that the dropout rate with bed wetting alarms is up to 80% okay, so what I'd like to talk about is a new device that my partner, Dr Barroso and I have been developing for the last five years, and it's currently under FDA review and hopefully will be available With the next year or so, and it's a product called Solu s, o, l, u, u. Our company is called Global continence, and we developed this device because of everything we just talked about. And so how does it work? So it's a wearable, which means that you have electrodes or stickers that go on the bottom. It has a little moisture sensing area and a neuromodulation device or a nerve stimulator attached to it, so as soon as one drop of urine hits this, the nerve stimulator will make the sphincter close. And we talked before about how you can't make your sphincter close. You can only relax it in response to the bladder emptying. What this device does is it makes the sphincter close for five seconds, and it's painless, and the guarding reflex that allows your bladder to relax as your sphincter closes happens at the same time. So you get closure of the sphincter, relaxation of the bladder, and then we have a built in app that will send a message to the parents that it went off, so now they could go in the kid is dry, and then they will bring that child to the bathroom, where they actually will complete voiding. And after using this device for two months, in our first study in Brazil, we found that 83% of our children were cured within two months, and at one year, everybody that was cured was still cured. So we're about to start a multi institutional, multinational study looking at Vanderbilt Children's Hospital of Philadelphia, where I trained, as well as two sites in Brazil, and we're going to compare our device to a placebo device that will alarm but it won't have the 10s unit stimulation or the app. So we're really excited about this product, and if your listeners want to hear more about it, they could go to our website@globalcontinence.com or look up Salou and get more information on it. So this is something that I think will be a game changer in the treatment of bed wetting. If you ask pediatricians, we'll get back to the survey, is it important to treat bed wetting? 70% says Absolutely. But if you ask them, when do you use bed wetting alarms and medications in our survey, 2% less than age eight, were offered any medications or bed wetting alarms. And what it tells you is that even though everybody thinks it's important to treat, the reason they don't treat, when we ask this direct question, 70% of pediatricians say finding effective treatments is the biggest problem. And so I don't blame pediatricians for not using these things. I think there are certainly frustration involved with better waiting alarms and there are side effects. That's probably the number one reason why pediatricians don't like to prescribe medications and parents don't like to give their kids medications. Having this device salute will hopefully change the whole paradigm in treating bedwetting. I'm so excited to see what the rest of your research shows, because this could be a game changer for a lot of families. I could tell you, device development takes years, and so I told you, I've been doing this for five years. I have families that I told it's coming three years ago, they're all on waiting lists. So if they go to the website@globalcontinence.com, we have a way of getting on on the list as well. Can you explain to me a little more about the nerve modulation? What does it feel like to kids? Is it painful? What will they experience? So right now, neuromodulation devices are over the counter, and so you use them mostly for pain, and you use them for muscle conditioning, and those people put on their bodies for multiple minutes. Our device delivers five seconds of stimulation. So. Sure that kids don't really sense it that much. It does wake some of them up, though, and it's not because they had pain. They just felt maybe a little bit jolted by it. And the reason why it's only five seconds is the you can't contract your sphincter muscle for more than about five to 10 seconds. So the device makes the sphincter contract. The bladder relaxation comes free, because that's a reflex, and so we don't have to really do anything to the bladder with this therapy. How many participants were in the study in Brazil? That was about 30 patients in Brazil, and our study will be 70 patients that will be randomized, controlled, double blinded, multi institutional, and so it's going to be a good study. We're really looking forward to those results. But the one thing that the Salou device offers is that you may not even need an alarm, okay, you just need the stimulation. The parents may not need to get up, because if those wake the child up, they could go and so it gives you all the benefits of not waking up the entire household, one of the reasons why people drop out. So is it the idea that it re establishes that brain bladder connection? Exactly your neuromodulation is re establishing the connection between the brain and the bladder. I wish you all the best, because this is such an issue for so many families, and if there was a way that was successful, I do agree that a lot of pediatricians would be behind recommending it. Yeah. So we're gonna be doing a lot of education, obviously, you know, our bed wedding, and participate in a lot of meetings at the American Academy of Pediatrics, and a lot of meetings around the country, and truly trying to get in front of as many pediatricians as we can I'd also love to just talk with you about the pros and cons of the medication that we prescribe for bed wetting, because I practice pediatrics with my dad, so he's been in practice for 45 years as a pediatrician, and he tells me that many years ago, we used to get a lot of pharmaceutical Sales Reps coming around, and there was a lot more emphasis about using the medication, the DDAVP for Bedwetting, and we don't really hear about it as much anymore, which I find interesting. It's fallen out of popularity. Yeah, and I talk a lot with one of our senior nephrologists, and he said that pediatricians gave a lot of talks for the companies that basically sold DDAVP, so it was used a lot, but you talk about kind of side effects of that medication. Fortunately, rare. If you take DDAVP and you drink, okay, so you're taking a medication that makes you hold water, and now you're drinking water that could lead to low sodium levels, and that could lead to seizures, lethargy and other issues. So a lot of the folks, like the nephrologist that we work with, they're not very into DDAVP at all for that reason. And I find that it's a band aid. I think it's fine in the short term. So for kids that are going on a sleepover or to sleep away camp, I think people like knowing that there's something that they can use. But I will also tell you there's a number of kids, whereas medication is not effective, yeah, and that's exactly correct again, 30 to 50% and it loses its effect over time, and it's expensive in some countries that have where people have to pay for it on their own. When they get referred to me, I'm always giving DDAVP because they've already failed so many other things, and I just want to see if it's effective. And so I usually tell people, you know what, let's try this stop fluids an hour before you go to sleep. And I say after three months, if it's working, stop it. Let's see if you still need it. And we go through that because nobody likes to put their kids on medications long term, at least that gives them a little bit of hope. But you mentioned camps, and I used to think exactly like you. Let's give DDAVP for situational things like sleepovers, which is fine, you'll get to speak to a parent and you'll say, maybe you'll tell them that they're taking the medication if they're old enough, they probably don't need to. It's a small pill. And then why should the child miss out on some fun for something that isn't their fault Exactly? Some people say we don't have to treat bed wetting. It's not a medical problem. It's a social problem, but it's associated with anxiety and mental health issues, and why wouldn't we treat it? When we ask the question to pediatricians, if you knew of a device that was non medical and it gave you a cure within two months? What age would you treat? And that went from less than 2% to almost everybody before age six, of course. Because why wouldn't you, of course, an opportunity to change a kid's life? Yeah, not a medical problem. I don't think so. I think it is a potential medical issue. If it's psychological anxiety provoking, those are reasons to do something that's minimally invasive. Of course, no. Parents can't wait to get their kids out of diapers, that's for sure. Yeah. So not to mention the cost. It costs up to$1,200 a year to deal with bed wetting, so it's a very expensive problem to me, when you're describing waking up with your child with bed wetting alarms, that sounds. Exhausting, and my kids are older now, but thinking about getting up in the middle of the night with them every once in a while, okay, but to get up with them every night for months on end, that just doesn't sound sustainable, and that sounds very stressful on families. Yeah, agree 100% a couple more questions about salute, because I find this really interesting. When do you envision it being available to families. So we have to complete a trial. The good thing about our trial is it's two month trial, because we think we're going to get a lot of people care within that time period, compared to an alarm only, and we already know the alarm is 30 to 50% so that's what our control group is. So after that it gets done, we expect it'll take several months to go through the FDA process, and then we hope to launch probably in early 2026 hopefully I'll come back on your podcast and we could talk more about it. Absolutely. Just appreciate this message of hope, because the saying is, when parents ask, Will this ever go away? And our answer is yes, it will go away by the time they walked on the aisle. Don't worry they won't be in diapers, or by the time they're at graduation from high school, don't worry they'll be out of diapers. But, boy, it'd be a lot nicer to reassure them that it'd be solved a lot sooner than that. Yeah, absolutely. And the reassurance is important. I think it's important also when you tell them they're gonna outgrow it, that it's about 15% each year, with the greatest chance, probably in your first couple of years. So when you get to be seven or eight and you still have the problem, you should be a little more aggressive at that time about treatment options. Yes, and just to bring it back to the DDAVP, I'm just curious. Have you ever seen a kid have seizures from hyponatremia, from having too low sodium? I haven't. Yeah, I've only heard about it. I personally, I told you I put, like everybody, on DDAVP, and I have not seen it, but I also read them the riot act about how to manage fluids during it same so it's important to understand, yes, the side effect is significant, but it's rare. But I think another point to get through that we didn't talk about. We talked about sleep deprivation when we talked about sleep hygiene. But deep sleep does not always equate to good sleep, and kids that sleep deeply are not always in REM sleep, and it's the amount of time in REM sleep where they're dreaming, where they're having that deficiency, and that was what leads to the bed wetting and another problem that they get an offshoot, which I have seen are parasomnias, and you may have seen these as well. These are kids that are having night terrors and sleep walking. These are really bizarre things that happen, so anything you could do to improve their sleep is potentially helpful. Interesting. Yeah, that was something brand new to me that I learned from reading your book, even though we label these kids, these kids as deep sleepers and we think of them as deep sleepers, they're not actually getting as quality sleep as they could be getting. Yeah, absolutely Okay, so before we wrap up, is there any advice that you'd like parents to learn from you, especially if their kids feeling embarrassed or shamed because they're bed wetting? Yeah, I think the most important thing is to normalize it as much as you can. And as we discussed at the beginning, that's sometimes easier said than done. Avoid blame. The book describes a lot of misconceptions and myths around bed wetting, and I think it's important that people understand that it's really not the child's fault. It's important to be supportive. It's important to praise them for the dry nights, but not to use bribes. And I say, if you're dry tonight, I will get you whatever you want. That doesn't work, but giving them praise and rewards does potentially work. So I would stress that. And I think after doing this for a long time, and this applies to other diseases that I see. Sometimes it's better to have an acute problem than to have a chronic problem. And this book, which is about 130 pages, and you got your copy there, we wrote this with parents in mind, and I tried to get as much information to the parents as I can about what's in this book. And I think the other thing say at this point is that there are published guidelines to treat bedwetting. There's the American Academy of Pediatrics, there's the International Children's continent society, there's one from the United Kingdom, from Canada, and they all say that it's important to treat Bedwetting, and that if you have four months of failure, starting at age five or six, you should step it up to either medications or alarms. And we talked about my survey that I don't think that's happening, and I think the reason it's not happening is because people know that these treatment options always are not always effective, but it doesn't mean we shouldn't try them, and I think it's important to try some of these things for all the benefits that we had discussed earlier. Are there any times when parents should think to take their kids to the doctor about nighttime bedwetting? Yeah. So yeah. Very important question is about, when should you be concerned about bed wetting? So I would say if it's if it's sudden, like my kid was fine for three years. And then they're wet in the bed. The things that are really the most concern, it could be child abuse. Could be sexual abuse. It could be your child has type one diabetes. We ask these questions, and we do a urinalysis, which is quick and easy, just to check their glucose. We ask questions about the social support, what's going on in the family. And then you may also want to understand that there could be neurologic problems, which sometimes are more obvious, but sometimes they're not. So when you're running out of reasons why this child is having day and nighttime wedding physical exam, sometimes you'll see a hair tuft on their back. That's something that indicates that there's a nerve problem, potentially. So it's important to do a physical exam, get a urinalysis screening, address social issues, abuse, very important. And then some of these medical issues that you know that you absolutely need to make every effort to diagnose. Yeah. So just to conclude, if you're a parent out there whose child doesn't have a family history of bed wetting. It's a sudden onset. Something just doesn't feel right to you. Definitely talk to your doctor about it. Yeah, absolutely. So starts off with the pediatrician, the primary care doctor, and then from there, if there's difficulty managing it, use your local pediatric urologist. There's only 400 of us, but we're in most places. The other thing that we do a lot since COVID is telehealth. So at George urology, I see a lot of patients through telehealth from all over the country. Other problems that I treat, such as urinary reflux, I see from all over the world. I'm in California. Can people make a telehealth visit with you? I see a lot of people from California and from a lot of different states. So yeah, so I'm available to talk about really any problem in pediatric urology and telehealth has really changed things, and it just makes it so much easier. I think it's in a lot of situations. It's very practical and very helpful for families. I also want to tell everybody, in your book, there's a lot of helpful resources for families. So thanks for writing this book. I think a lot of families will get a lot out of it. Thank you. I appreciate that, and spread the word. The book is available on every major place to buy books, including Amazon and Barnes and Noble and I think it'll be helpful, not only for parents, but for primary care providers, and I hope it's going to be useful to all the families that you see. Thank you so much. I wish you so much luck with your book sales, with your device. I think you're going to help a lot of families, and I really applaud you for what you're doing. Thank you very much. I appreciate you. It was great talking to you. Good talking to you. Take care. Thank you for listening, and I hope you enjoyed this week's episode of your child is normal. Also, if you could take a moment and leave a five star review, wherever it is you listen to podcasts, I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr Jessica, see you next Monday. You.