Some children have anatomically small bladders and others don't release enough of an anti-diuretic hormone called ADH, a substance released during sleep that prompts the kidneys to make less urine. Here is a nine-step method for stopping bedwetting that I have used in my practice for nearly 30 years with an 80 percent success rate:

1. Show and tell your child about bladder training. Here's how I explain it to the bedwetters in my pediatric practice: "The bladder is like a balloon the size of a baseball. Inside the balloon are tiny nerves that tell you when your bladder is full of urine. When you're awake, you can feel this pressure and you can hold it because there is a big doughnut-shaped muscle at the end of your bladder that you squeeze to keep your pee inside. So, if you're standing in line or in the middle of a game, you can hold it awhile. Yet, at night, your brain is sleeping so deeply that it says to the bladder: 'Don't bother me, I'm sleeping.' The bladder may say: 'I'm too full, I've got to go,' so out into the sheets comes the pee. Now we're going to do some exercises that teach your bladder and brain to talk to one another at night."
   
   
2. Use reinforcement charts. Put a chart next to his bed, have him mark a "D" for dry and a "W" for wet. After five straight "D's" he gets a social reward, such as a night out with mom and dad at a place of his choice. Soon waking up dry becomes its own reward.
   
   
3. Teach your child triple voiding. Many children go to bed with a half-full bladder. So, just before bedtime, encourage your son to "go pee three times." Have him stand in front of the toilet and grunt, grunt, grunt while "pushing all the pee out."
   
   
4. Do the before-bed bladder and brain talk. Because bedwetting is primarily a sleep problem -- children sleep too deeply to pay attention to the bladder signals -- you want to teach the brain and the bladder to communicate with one another at night. Just before going to bed, program your child to get up when his bladder is too full. Have him repeat phrases that imprint on his brain what to do: "I will get up and go to the bathroom when I feel my bladder get big" and "I will splash water on my face and go three times."
   
   
5. Do the shake and wake. Just before you go to bed, awaken your child fully (encourage him to splash water on his face) and have him empty his bladder by going three times into the toilet. Be sure your child is awake enough to hold onto you, yet walk to the bathroom.
   
   
6. Increase bladder capacity. Since some children have an anatomically small bladder, encourage your child to drink lots of water during the day (at least six 8-ounce glasses) and voluntarily hold onto his urine for longer periods of time, even when he has the urge to go. Eventually, his bladder will stretch, much like a balloon that is repeatedly inflated. However, children -- especially girls -- should never hold onto their urine if they have a past history of bladder infections.
   
   
7. Overhaul your child's diet. Certain foods can cause bedwetting, such as beverages containing high amounts of caffeine and/or artificial food colorings, such as in colas and punches. Also, be sure your child is not constipated. Full bowels can squeeze a full bladder. Add lots of fiber to your child's diet, such as prunes, prune juice and bran flakes. Give your child a daily smoothie containing yogurt, fresh fruit and high fiber supplements (such as a tablespoon of psyllium or flax meal). Also, give your child 8 ounces of nectar (prune or pear) daily.
   
   
8. Use a bladder-conditioning device. Sounds like you've already tried this alarm system, yet you may not have used it correctly. In our experience, these devices work about 80 percent of the time. You can purchase these bladder-conditioning devices out of most child-product catalogs. Basically, they consist of a moisture-sensitive pad your child wears inside his underwear. When a drop of urine strikes the pad, it sets off a buzzer or vibrator, alerting the child to get up and go to the toilet. The bladder-conditioning device operates on the principle of conditioned response. It's not as effective if you simply put the pad and device on the child without first going through the following drills: 1) Have your child empty his bladder completely by triple-voiding just before he goes to bed. 2) Tell him to "imagine waking up and taking a trip to the toilet. Pretend your bladder is full and starting to stretch and it's time to get up and go." 3) Practice. Set-off the alarm manually and have your child hop out of bed as soon as he hears the alarm. He then walks to the bathroom, splashes water on his face, and urinates. Explain to him that the aim of the game is to "beat the beeper," so that he gets up and goes before the alarm goes off.
   
   
9. Try medications. If the above steps are not working after several weeks, consult your child's doctor about the use of a medication called Desmopressin (DDAVP). This medication, available by tablet or nasal spray, decreases the production of urine at night, similar to the action of your child's natural anti-diuretic hormones. Your child takes a spray or tablet before bedtime. Minimal side effects, such as an occasional nosebleed or burning of the nasal passages, may occur with the spray. This medication is expensive (a 30-day supply costs around $100). When used in conjunction with the entire program mentioned above, this medication is very effective and can be tapered off as your child's bedwetting subsides.

If you have tried all the above steps and your child is still wetting his bed, it would be best to consult a urologist and do some tests of your child's bladder function. Some children do have an anatomically small bladder or other structural problems, which make it more difficult to retain a bladder full of urine all night. Also, your child should be a partner in this program, taking responsibility for doing his own laundry -- not as a punitive task, but as a way to motivate him to learn about and control his bodily functions. Finally, turn a developmental problem into an opportunity to increase the strength of the trust relationship between you and your child. Work with your child in an encouraging and sympathetic way to "help his brain learn to listen to his bladder at night." For further motivation, encourage your child to spend overnights at his friends' houses, and point out the fact that bedwetting is so common that probably some of his friends have bladders that have not grown up either. Once your child learns the joy of waking up in a dry bed, he will thank you for putting forth all this effort.