Early childhood nutrition is fundamental to how the brain and nervous system develop. Babies’ brains are structurally different, depending on what they eat in the first two years of life. Optimal nutrition enhances and accelerates neurodevelopment, and decreases the risk of bed wetting.

An intriguing July 2006 study from the Robert Wood Johnson Medical Center, published in Pediatrics, showed among other things, that babies who got adequate DHA in the first year of life were about 80 percent less likely than their peers to wet the bed. There are many complicating factors. It is clear, though, that breastfeeding is best.

Beyond this, we want to be sure the other foods we feed babies and toddlers in the first two years (while their brains are growing so rapidly) give them the building blocks they need for optimal neurodevelopment.

In the study in question, the biggest differences were found depending on how children were fed in the first 3 months of life. Children who were breastfed for at least 3 months were dramatically less likely to become bedwetters than those who depended on infant formula without added DHA.

Nursing for longer periods of time, up though the first year, continued to offer significant protection. The authors speculate reasonably that the difference in bed wetting may have been due to the differences in speed of neurodevelopment arising from differences in DHA.

However, there are other nutritional and immune differences between breast milk and formula, and there are physical and psychological differences between breastfeeding and bottle feeding. Whatever the cause or causes of these differences, what and how we feed babies can have a lasting positive effect.

Introduction to tonsillitis:

If you look into your child’s throat, you might see what look like small, dimpled, pink golf balls on either side of the throat. These are the tonsils.
The tonsils are the visible part of the immune system’s ring of protection that surrounds the back of the throat. This immune tissue stands guard to protect your child’s lungs and intestines from foreign invaders. The adenoids, the other famous part of this ring, are hidden out of site above.
Tonsils are normally large during childhood, but they can cause trouble when they become infected or grow too large.

What is tonsillitis?

Tonsillitis is the name given to swollen, red, and tender tonsils. This is usually caused by an infection of the tonsils. The most common causes of tonsillitis are viral infections. Many of the viruses are the same as those that cause the common cold.
Coxsackievirus can cause painful tonsillitis with a high fever and decreased appetite, sometimes with a rash as well. Mononucleosis can also cause severe tonsillitis.
Bacterial infections are important causes of tonsillitis, even though they are less common. Streptococcus is the most common type of bacteria involved.
Tonsillitis overlaps with strep throat and other sore throats. When a child has a sore throat, either the tonsils may be red and swollen, or other parts of the throat may be red and swollen – or both.

Who gets tonsillitis?

Tonsillitis is not common before the first birthday. It tends to peak in the years surrounding kindergarten, but can occur throughout childhood and even in adult life.

What are the symptoms of tonsillitis?

Generally, children with tonsillitis have a sore throat and pain with swallowing. Babies and toddlers may simply refuse to eat or drink because of the throat pain. There may also be some difficulty with swallowing or breathing. You might notice snoring or mouth breathing, accompanied by a dry mouth and mouth odor. Sleep disturbances sometimes result in bed-wetting (enuresis). Decreased appetite, fatigue, and swollen glands in the neck are also common.
The specific symptoms of tonsillitis will depend largely on the underlying cause. Tonsillitis caused by an upper respiratory virus, for instance, may start gradually and be accompanied by nasal congestion. On the other hand, tonsillitis caused by strep might start suddenly with a high fever.

Is tonsillitis contagious?

Most forms of tonsillitis are contagious and are spread by droplet transmission.

How long does tonsillitis last?

The length of tonsillitis depends largely on the underlying cause. Most viral tonsillitis tends to last a matter of days; strep tonsillitis for up to a couple of weeks, and tonsillitis caused by mononucleosis commonly lasts for weeks or months.
Sometimes bacterial tonsillitis will last for months, even with appropriate antibacterial therapy.

How is tonsillitis diagnosed?

Tonsillitis can be diagnosed with a history and physical exam. A throat culture and/or rapid strep test are important to identify the cause, especially if antibiotics are being considered. A mono test, and other specific blood tests, may be indicated if the cause is not clear.

How is tonsillitis treated?

Taking out the tonsils for tonsillitis used to be common. Today, most cases of viral tonsillitis are managed by watching and waiting (while treating the pain and fever). Tonsillitis will be treated with antibiotics if bacteria appear to be the cause. The longer that tonsillitis lasts, the more likely that it will require stronger treatment. In some circumstances, steroids are used to reduce tonsil swelling.
The American Academy of Pediatrics recommends removing the tonsils under some conditions:

• Tonsil or adenoid swelling that makes normal breathing difficult (this may or may not include sleep apnea).
• Tonsils that are so swollen that your child has problems swallowing.
• An enlarged adenoid that makes breathing uncomfortable, severely alters speech, and possibly affects normal growth of the face. In this case, surgery to remove only the adenoid may be recommended.
• Your child has repeated ear or sinus infections despite treatment. In this case, surgery to remove only the adenoid may be recommended.
• Your child has an excessive number of severe sore throats each year.
• Your child’s lymph nodes beneath the lower jaw are swollen or tender for at least six months, even with antibiotic treatment.

How can tonsillitis be prevented?

Tonsillectomy can prevent tonsillitis, but is only recommended in select circumstances.
Because most types of tonsillitis are spread by droplet transmission, droplet precautions can be effective means of prevention. Some tonsillitis, such as the kind caused by mono, is spread by body fluid transmission. Body fluid precautions are needed to prevent this type of tonsillitis

Related A-to-Z Information:

Adenovirus, Allergies (Allergic Rhinitis), Body-Fluid Transmission, CMV (Cytomegalovirus), Common Cold, Coxsackievirus, Diphtheria, Droplet Transmission, Enteroviruses, Enuresis (Bedwetting), Fomites, Hand-Foot-Mouth Disease, Mononucleosis (Mono), Scarlet Fever, Sleep Apnea, Strep Throat, Streptococcus (Strep)

Related concepts:

Bed-wetting, Primary nocturnal enuresis, PNE

Introduction to enuresis:

Most children learn how to stay dry during the day before they’re able to stay dry at night. Millions of kids wet the bed long after they feel that they should be dry.
Sadly, most of these children feel that they still wet the bed because there is something wrong with who they are.  Many of them feel that it’s the result of either bad thoughts or bad actions. They feel that somehow bed-wetting is a punishment.
Similarly, many parents feel that their children’s bed-wetting is a result of a defect in their parenting. This feeling is heightened by well-meaning friends and relatives who bring up questions of emotional instability as the cause of bed-wetting.
In one survey of parents, 22 percent stated that they thought the reason their child wet the bed was laziness. This could not be further from the truth! Primary nocturnal enuresis is a common developmental phenomenon related to physical and physiologic factors. It does not come from emotional stress, poor self-esteem, or emotional immaturity.

What is enuresis?

Children who can control their bladders during the day, but who have never been dry at night for at least a six-month period, have what is known as primary nocturnal enuresis (PNE), the most common form of bedwetting.
Secondary nocturnal enuretics are completely dry at night for a period of at least six months and then begin wetting again.
In secondary enuresis, the key is finding out exactly what has changed. There might be a new psychological stress such as a divorce, a move, or a death in the family. It might be something physical: the onset of a urinary tract infection or diabetes, for example. It might be a situational change, such as altered eating, drinking, or sleeping habits. Clearly, something has changed. The first step in solving the problem is identifying any changes in your child’s life.
In any case, children who wet the bed have two things in common. First, they need to urinate at night. Not all children do. During the first months of life, babies urinate around-the-clock. Most adults, however, don’t need to urinate at night (although a small percentage of the population will need to urinate at night throughout life). Sometime in middle childhood, most kids make the transition from urinating around-the-clock to only urinating during waking hours. There are three reasons why some children may still need to urinate at night:

1. There is an imbalance of the bladder muscles. (For example, the muscle that contracts to squeeze the urine out is stronger, at moments, than the sphincter muscle that holds the urine in.)
2. They have bladders that are a little too small to hold the normal amount of urine.
3. They make more urine than their normal-size bladders can hold, for several reasons:
   • They may drink too much. Drinking in the two hours before bed increases nighttime urine production.
   • They may be consuming a diuretic medication, a substance that directly increases urine output. They may also consume diuretic beverages or foods like caffeinated cola drinks or chocolate.
   • They may make more urine in response to a chronic disease, such as diabetes.
   • They may make more urine than average because of their hormonal regulatory systems. Babies make about the same amount of urine around-the-clock. Most adults make less urine while they sleep. The reason for this is thought to be a nighttime surge of a hormone called Antidiuretic Hormone (ADH). Some bed-wetters may make less ADH or have kidneys that are less responsive to ADH.

If an individual regularly needs to urinate at night, one or more of the three reasons listed above is the cause.
The second thing children who wet the bed have in common is that they don’t wake up when they need to urinate. When infants need to urinate, there is no signal that goes from the bladder to the brain to wake them up. This is wonderful, since they are not yet able to walk to the bathroom and use the toilet. On the other hand, when an adult’s bladder is full at night, there is a signal that goes from the bladder, through the nervous system, up to the brain. This initiates a dream about water, or more specifically, about going to the bathroom. The dream alerts our reticular activating system, which either awakens us or causes us to tighten our sphincter muscles to hold the urine. This signaling mechanism comes into play sometime in childhood.
Children who wet the bed are dramatically more difficult to wake up than their peers, which confirms what parents have known for years!
Children who wet the bed at night both need to urinate at night and do not wake up when their bladders are full. These are the only children who wet the bed.

Who gets enuresis?

Research has shown that primary nocturnal enuresis is often inherited. If both parents were bedwetters, 77 percent of their children will be. If only one parent wet the bed, 44 percent of their offspring will. If neither parent wet the bed, only about 15 percent of their children will wet the bed. With primary nocturnal enuresis, one almost always finds another relative who was a bed-wetter. This corresponds to what is called an autosomal dominant inheritance pattern.
Bed-wetting is more common in boys.

What are the symptoms of enuresis?

In primary nocturnal enuresis, children have never achieved complete nighttime control. They have always wet the bed at least two times a month.
As a result, these children may suffer significant psychological stress and develop feelings of low self-esteem (including feelings of shame, inferiority, and fear of being discovered by others). These are the result, not the cause, of PNE.
Families of bedwetters can experience disturbed sleep, turmoil, and a drain on energy and resources.

Is enuresis contagious?

No

How long does enuresis last?

At age 5, about 15 percent of children have PNE.
Among those who still have PNE after age 6, only about 15 percent of them will achieve dryness over the course of the next year (without treatment).
At age 15, one to two percent of adolescents still have PNE. If left untreated, some will wet the bed for life.

How is enuresis diagnosed?

When bedwetting continues to age 5 or 6 (or at any age if it is troublesome to the child) it is time to discuss it with the child’s doctor or with a doctor skilled in treating bed-wetting. A careful history, physical exam, and urine test can usually determine the type of bed-wetting and the best treatment approaches. Sometimes it is important to measure the child’s bladder size. This is often done at home with a measuring cup.
It is also important to identify any constipation or encopresis (uncontrolled passing of stools). If one of these conditions is present, it should be treated first. The bed-wetting will often disappear when these conditions are treated.

How is enuresis treated?

A variety of effective solutions are available, alone or in combination. Different solutions work better for different children. Behavioral therapies include motivational programs, guided imagery, and hypnosis. Conditioning therapies involve one of several bedwetting alarms. Specific exercises can be done to strengthen the nighttime resting tone of the sphincter muscles.
Your doctor may recommend a medication such as the DDAVP tablet. The DDAVP tablet can help achieve dryness in some children with PNE. However, it also has the potential for serious side effects and should be used with caution and only under close supervision by a physician. The FDA has recently placed a ban on treating PNE with DDAVP in the nasal spray form.
Behavioral treatments are most effective and with the right approach for the right child, most school-age children can be dry within 12 weeks.
Treatment can improve a child’s self-concept, even if total dryness is not achieved.

How can enuresis be prevented?

Not much can be done to prevent bed-wetting, but adequate sleep may help. Some children will stop wetting the bed with as little as 30 extra minutes of sleep per night.

Related A-to-Z Information:

Constipation, Night Terrors, Sleep Apnea, Tonsillitis

Parents are quick to mention some things to their pediatrician: fevers, seizures, bleeding. Snoring is another important symptom that your child’s doctor needs to know about, though it often goes unreported. Snoring can be the sign of obstructive sleep apnea syndrome (OSAS), where there is prolonged partial blocking, or intermittent blocking, of breathing during sleep.

OSAS can cause growth problems. It has also been linked to ADHD, poor school performance, learning difficulties, bedwetting, high blood pressures, and even death.

OSAS is different from primary snoring (PS), the name given to snoring that doesn’t cause sleep disruption or breathing problems. Primary snoring is more common than OSAS, which occurs in about 2 percent of children.

The American Academy of Pediatrics has issued important April 2002 guidelines for diagnosing and managing OSAS. They state that OSAS and PS cannot be distinguished from each other based on the history and physical examination alone. Other tests must be used.

A sleep study is the gold standard test for telling the difference. Thus, snoring needs to be reported to the doctor, and when snoring lasts longer than a brief respiratory infection, it deserves thorough evaluation.

Several of the nation’s leading bedwetting experts gathered earlier this year to candidly discuss the issues surrounding the millions of school-age children who wet the bed. I participated in what proved to be a very stimulating conversation. I learned things (about red dyes, for instance) that I had not seen in the literature or in practice. Transcripts of the lively discussion were published in the October 17, 2001 issue of Infectious Diseases in Children.

The older children get, the more their bedwetting threatens self-esteem and interferes with family life. But safe and effective solutions are available. With proper use of a conditioning alarm, desmopressin (DDAVP) tablets, or other options, most children can wake up dry within 12 weeks. Without treatment, though, 85% of bedwetters will still be wet a year from now.

Nevertheless, most families don’t bring up the issue with their doctors. The bottom line? Ask your doctor for help. If your doctor is not able to help your child get dry, ask for a visit to someone especially knowledgeable about bedwetting.

Sleep terrors, sleepwalking, and bedwetting all fit into the category of “partial-arousal parasomnias”. Although there is a genetic predisposition to each of these conditions, a report at the 2001 annual meeting of the Associated Professional Sleep Societies suggests that some children with these conditions respond dramatically to a small increase in total sleep time –sometimes as little as 1/2 an hour a day.

Children with sleep terrors and sleepwalking experienced rapid and impressive improvement after adding a short daily nap, moving bedtime ahead, or delaying wake-up time in the morning. The average increase in total sleep was 1 hour, 25 minutes. With this change even children who had needed medicines to control these conditions were able to sleep without disturbance.

I suspect that children who are bedwetting would have similar experiences, and have seen evidence of this again and again in children I know.

Children who can control their bladders during the day, but who have never been dry at night for at least a six-month period, have what is medically known as primary nocturnal enuresis (PNE), the most common form of bed-wetting. Over five million school-age children in the US alone have PNE.

Sadly, most of these children feel that there is something wrong with who they are that causes their problem. Many of them feel that it’s the result of either bad thoughts or bad actions. They feel that somehow bed-wetting is a punishment.

Similarly, many parents feel that their children’s bed-wetting is a result of a defect in their parenting. This feeling is heightened by well-meaning friends and relatives who bring up questions of emotional instability as the cause of bed-wetting.

I am happy to tell you that this could not be further from the truth! Primary nocturnal enuresis is a common developmental phenomenon related to physical and physiologic factors. It does not come from emotional stress, poor self-esteem, or emotional immaturity.

Dr. Greene’s Answer:

Bed-wetting alarms are among the safest and most effective of all therapies for bedwetting. The alarms have a simple moisture-sensor that snaps into your child’s pajamas. A small speaker attaches up on the shoulder with Velcro. At the first drop of urine, a piercing alarm goes off, that sounds similar to a smoke alarm. Instantly, the child reflexively stops urinating. Next, the household awakes, EXCEPT for the deep sleeper who wets the bed. Precisely those children who sleep through the alarm are most likely to be helped by it.

For the alarm to be effective, someone else must wake your child up (most likely you), walk him to the bathroom, and get him to finish urinating in the toilet — all before resetting that annoying alarm. If this ritual is continued, the alarm will likely begin to wake him up directly within 4 to 6 weeks. Within twelve weeks, your child will very likely master nighttime bladder control, and no longer need the alarm. Relapses after alarm therapy are uncommon.

I participated in a conference on enuresis where one of the speakers described the use in Africa of frogs strapped to the child as a ‘natural’ alarm. Today’s electronic alarms are more effective, and I dare say, more comfortable (for the frog as well as the child). Many good alarms are available. I like SleepDry, produced by StarChild/Labs (in which I have no interest whatsoever). It may be obtained for approximately $55.00 by calling 1.800.346.7283. or ordering online at www.sleepdryalarm.com.

Almost 7 million school-age children (in the United States alone) go to bed dry and wake up wet. Most of them feel like they are alone. They often feel guilty, inadequate, and ashamed. And their parents feel ashamed — they think they are doing something wrong as parents.

How fabulous that baseball legend Mark McGwire has stepped up to the plate and said “Bedwetting is not your fault!” McGwire is working with the non-profit National Kidney Foundation (NKF) to get the word out that bedwetting is nothing to be ashamed of and that good treatments are available.

You can find one version of his 30-second public service announcement at www.kidney.org/general/news/newsitem.cfm?id=140

Dr. Greene’s Answer:

Children who can control their bladders during the day, but who have never been dry at night for at least a six month period, have what is known medically as primary nocturnal enuresis (PNE), the most common form of bed-wetting. Over five million school-age children in the US alone have PNE.

Sadly, most children with PNE feel that there is something wrong with who they are that causes their problem. Many of them feel that it’s the result of either bad thoughts or bad actions. They feel that somehow bed-wetting is a punishment.

Similarly, many parents feel that their children’s bed-wetting is a result of a defect in their parenting. This feeling is heightened by well-meaning friends and relatives who bring up questions of emotional instability as the cause of bed-wetting.

In a recent survey of 9,000 parents of kids ages 6 – 17, 22% stated that they thought the reason their child wet the bed was laziness (survey conducted by ICR Survey Group from July 10, 1996, through August 6, 1996). I am happy to tell you that this could not be further from the truth! Primary nocturnal enuresis is a common developmental phenomenon related to physical and physiologic factors. It does not come from emotional stress, poor self-esteem, or emotional immaturity.

Children with PNE have two things in common. First, they need to urinate at night. Not all children do. During the first months of life, babies urinate around-the-clock. Most adults, however, don’t need to urinate at night (although a small percentage of the population will need to urinate at night throughout life). Sometime in middle childhood, most individuals make the transition from urinating around-the-clock to only urinating during waking hours. There are three reasons why individuals continue to need to urinate at night:

1. There is an imbalance of the bladder muscles. For example, the muscle that contracts to squeeze the urine out is stronger, at moments, than the sphincter muscle that holds the urine in.
2. They have bladders that are a little too small to hold the normal amount of urine.
3. They make more urine than their normal-size bladders can hold, for several reasons:
   • They may drink too much. Drinking in the two hours before bed increases nighttime urine production.
   • They may be consuming a diuretic medication, a substance that directly increases urine output. Usually these are not prescribed medications, but caffeinated cola drinks or chocolate.
   • They may make more urine in response to a chronic disease such as diabetes or a chronic urinary tract infection.
   • They may make more urine than average because of their hormonal regulatory systems. Babies make about the same amount of urine around-the-clock. Most adults make less urine while they sleep. The reason for this is thought to be a nighttime surge of a hormone called Antidiuretic Hormone (ADH). The levels of ADH found in the blood are higher beginning in the evening. One study looking at ADH levels in bed wetters, compared to controls, found that there was a constant low level of ADH in the bed wetters. The nighttime surge did not happen. Perhaps this is a reason bed wetters tend to make more urine at night.

If an individual consistently has to urinate at night, one or more of the above three reasons is the cause. The second thing children with PNE have in common is that they don’t wake up when they need to urinate. When infants need to urinate, there is no signal that goes from the bladder to the brain to wake them up. This is wonderful, since they are not yet able to walk to the bathroom and use the toilet! On the other hand, when an adult’s bladder is full at night, there is a signal that goes from the bladder, through the nervous system, up to the brain. This initiates a dream about water, or more specifically, about going to the bathroom. The dream alerts our reticular activating system, which awakens us. We can then get out of bed, walk to the bathroom, and use the toilet. This signaling mechanism comes into play sometime in middle childhood.

For many years, parents of bed-wetting children have claimed that their children were deep sleepers. Physicians have usually disagreed with this, citing evidence from sleep EEGs showing that bed-wetting children went through the same stages of sleep as other children, at the same frequency, and that bed-wetting can occur at any stage of sleep.

I have never heard a parent come in and say, “My child spends too much time in stage four sleep.” They just say that their children are deep sleepers and are difficult to wake up. About a decade ago, researchers in Canada performed a simple, but powerful, study where they put headphones on children in a sleep lab. They began the study by allowing the children to get used to sleeping with the headphones on. Then they began introducing tones through the headphones. They measured the minimum volume it took to wake each child. The study showed that the children in the bed-wetting group were dramatically more difficult to wake up than normal controls — confirming what parents have known for years!

Children who wet the bed at night both need to urinate at night and do not wake up when their bladders are full. These are the only children who wet the bed.

Understanding the causes of bed-wetting can help remove its stigma. You are also now better equipped to evaluate the suggestions people make to you. Effective therapy is aimed at the underlying causes. Most children can be completely dry within 12 weeks.

N.B. As I stated in my earlier answer titled, “Is bed-wetting genetic?”, there is help for children who wet the bed! The biggest hindrances to getting help are the absence of a skilled, empathetic physician, and shame — parents and children are ashamed to bring the subject up with someone who can help. It is up to you to take the first step! Talk with your doctor. If you find that for some reason she or he is not able to get your child dry quickly and effectively, I would call the closest Children’s Hospital to find out who treats bed-wetting issues.