Helping children with enuresis and encopresis: school children who are bedwetters or those who soil their pants often receive little sympathy and less understanding. A public health nurse wants to change such attitudes.

IN 1998 NELSON public health nurse Shirley Reid wrote and illustrated a book, Tim's Problem, the story of a little boy with the "embarrassing problem" of soiling his pants. "We had nothing to give children who were bedwetters or soilers, so I decided to write a book based on a child I had known." Little Treasures magazine reviewed it and Reid was overwhelmed with letters she received from people "absolutely desperate" for information and support.

She realised the need for an organisation to provide information, education and support for children with wetting and soiling problems--enuresis and encopresis--and their parents/caregivers. True to her pragmatic nature and commitment to public health, Reid established a committee, including two parents of children with wetting and soiling problems. The committee began with the princely sum of $200, donated by a local church group. Its initial work was to establish a data base and produce a newsletter. In July 2001, the Kiwi Enuresis Encopresis Association (KEEA) became a trust and in September that year produced the first newsletter. Again, the response was enormous. "So many people contacted us, extremely relieved they were not alone in having a child who was a bedwetter or who soiled their pants," Reid, who is KEEA chair, said.

From those humble beginnings, the trust has grown into an organisation which, since March this year, has employed Reid one day a week. Funding comes mostly from charitable trusts but KEEA is now seeking Ministry of Health funding to employ Reid for three days a week.

The trust has produced eight newsletters, each dealing with an aspect of bedwetting or soiling--the physiology of enuresis and encopresis, bladder retraining, bowel regimes, ways of helping children cope, helpful hints from parents about how to deal with school camps or sleepovers.

Reid is passionate about disseminating information on enuresis and encopresis and would like nurses to become an integral part of that process. "I don't think nurses know any more about bedwetting and soiling than Jo Bloggs. Certainly we didn't get any training about it and I don't think that's changed. But because of our contact with children we are in an ideal position to help them and their families."

She would like to get information on enuresis and encopresis into nursing schools and training colleges. Often teachers have to deal with the problem, about which they have little understanding

Reid has a box full of letters from parents/caregivers of children with enuresis or encopresis and some make heart-wrenching reading. They tell of families and children struggling with shame and embarrassment, ignorance and misunderstanding; of children's plummeting self esteem and growing anxiety; of frustration and a sense of isolation and social withdrawal.

Reid says services for children with enuresis or encopresis vary. "Each district health board has a different system and services are very much dependent on the personnel. There are areas with almost no service."

Taranaki is well served by a doctor Pat Boulton who runs wetting and soiling clinics in New Plymouth and who provided the impetus to establish KEEA. Ideally, Reid would like nurse-led clinics throughout the country for enuresis and encopresis. "These would provide a much more effective service than a child visiting a paediatrician every six months, as is the case in some areas."

She would also like national best practice guidelines for constipation and soiling. There is group, led by the Paediatric Society, and with Reid as a nursing representative, developing guidelines for nocturnal enuresis.

Enuresis is relatively common: 15 to 20 percent of five years; seven percent of seven year olds; five percent often year olds; and up to two percent of young adults have the problem. Encopresis is estimated to affect one to three percent of children. Reid said one third of children seen by paediatricians at gastroenterology clinics are seen because of constipation. "But there is no real data on soiling," Reid said.

Toileting accidents are thought to be a significant factor in child abuse. "These problems need to be far more widely acknowledged, not just for the child's self esteem but for the actual physical safety of a number of children," Reid said.

Enuresis and encopresis are often considered to be psychological problems but in almost all cases the cause is physical. "There is a lot of misinformation in the health sector and generally about both wetting and soiling. Some parents think if their child just concentrated harder they could be dry overnight. But bedwetting is usually a physical problem--the bladder may have a small capacity and when it is full that doesn't wake the child. To explain this to parents and the child can be very helpful," Reid said.

Bed alarms are the most effective way of training a child to become dry, but not all parts of the country have a bed alarm service. A nasal spray is also available which can make school camps and sleepovers easier for a child. "Children with daytime wetting problems often get very little sympathy from home or school. Telling parents and children that it is a condition that needs treatment helps enormously. Children who soil have the most unacceptable problem of all and, again, understanding of what's happening and appropriate treatment can alter families' lives."

It is playing a part in altering children's and families' lives in this way that drives Reid in what one colleague described as "not a glamorous cause but a noble one".

For further information on KEEA contact Shirley Reid, KEEA, PO Box 1123, Nelson; ph 0800 533 269; email: [e-mail]; web site: www.keea.org.nz