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Early intervention for childhood continence problems.

Across the UK, around 900,000 of 8.5 million children and young people aged live to 19 years (equivalent to one in 12 children) have a medical condition affecting their bladder or bowel (National Institute for Health and Care Excellence (NICE), 2010).

Childhood continence difficulties affect children and young people of all demographics and can continue into the teenage years. It is estimated that persistent bedwetting affects about one in seven children aged seven years old; one in 11 nine year olds; and one in 15 children aged 11 years old, with proportional decreases between these age bands (Butler, 1998).

Daytime wetting affects about one in 50 seven year olds and one in 100 11-18 year olds (Hjalmas, 1992). Soiling affects about one in 75 six to 10 year olds and one in 100 11 to 18 year olds (Doleys et al, 1981).

Every year in England alone there are also around 15,000 hospital admissions for chronic constipation and urinary tract infection (UTI) in children--80% of which could be avoided through better care within primary care, community and education settings.

Although many childhood continence problems are not completely preventable, the impact on a child's health and quality of life can be significantly reduced through early intervention. Health professionals working in primary care and community and education settings are, therefore, best placed to deliver firstline treatment and support. This can help to prevent emergency hospital admissions, invasive surgical procedures, repeated referrals and damage to the child's self-esteem, as well as reducing stress within the family.

Bladder and bowel conditions can have a significant, long-term impact on a child's physical, emotional and psychological health and wellbeing. In part, this is due to the huge social stigma associated with wetting or soiling problems, and the general lack of understanding and knowledge about the potential causes and appropriate treatment.

Understanding the causes of wetting and soiling problems

Many people believe that continence difficulties are caused by 'psychological problems'. However, the vast majority of children who are affected experience physical problems, which then lead to the development of psychological issues. Most continence problems are associated with idiopathic constipation or overactive bladders; some are due to developmental delays; and a percentage of children have underlying complex anomalies.

Inevitably, poorly treated symptoms lead to psychological problems, from quiet embarrassment to outbursts of extreme behaviour. This can lead to a culture of shame and isolation among children who are suffering and they may become socially withdrawn (Lottmann and Alova, 2007).

Managing continence problems can be extremely stressful for the family, straining relationships and leading to feelings of helplessness. In addition, the practicalities of caring for children with continence problems can be exhausting and significantly reduce carers' quality of life (Butler et al, 2005). This poor understanding and frustration sometimes leads parents to punish their child, verbally or physically (Meydan et al, 2012).

Nocturnal enuresis (bedwetting)

Nocturnal enuresis, or bedwetting, is involuntary wetting during sleep in a person with no physical disease at an age when they could be expected to be dry (generally considered to be a developmental age of five years or over).

The causes of the problem can include a delay in children developing the right levels of the hormone vasopressin, which helps concentrate urine overnight; not receiving the signal from the bladder to the brain which alerts a child to wake and use the toilet; the muscles of an overactive bladder contracting during sleep; and underlying constipation. The condition also runs in families.

Daytime wetting

One cause of daytime wetting is bladder overactivity, where the bladder muscle contracts as it fills with urine. This makes the child feel like they frequently and urgently need the toilet and if the feeling is ignored urine may leak out. Daytime wetting can also be a sign of a urinary tract infection (UTI), which must be excluded by a doctor before other causes are considered. The problem can also be caused by constipation, as when the bowel is over-full it presses on the bladder causing urine to leak into a child's underwear.

Constipation and soiling

NICE (2010) states that the signs and symptoms of 'idiopathic' constipation include:

* Infrequent bowel activity

* Foul smelling wind and stools

* Irregular stool texture

* Passing occasional enormous stools or frequent small pellets

* Withholding, soiling or overflow

* Abdominal pain

* Poor appetite

* Lack of energy and irritability.

The most common reason for a child soiling is as a result of constipation, leading to an overflow of faeces. Importantly, it may be the first symptom that the child presents with, having suffered from constipation undetected for many months. More rarely, it can be due to an underlying congenital abnormality affecting the bowel--this is then usually labelled as faecal incontinence. In both cases, the soiling happens outside the child's voluntary control and in many cases the child may be unaware that the soiling accident has occurred.
Box 1. Case study

Julia, aged 5, was potty trained at age three and a half, and had
been dry for more than 18 months. However, four months ago she
began wetting during the day and her underwear has needed to be
changed around three times a day at school. Julia's mum Hannah was
getting frustrated about the wetting problem, believing that her
daughter was being 'lazy'. A teaching assistant in Julia's class
was helping to change her after wetting incidents but had not
received any training in relation to continence problems and did
not have personal care written into her job description.

Hannah rang the ERIC Helpline and one of the Helpline specialists
outlined the reasons why daytime wetting occurs, and explained that
a child is usually unable to control what is happening. Hannah was
encouraged to speak to the school nurse or make an appointment with
a GP.

Hannah contacted the school nurse who referred Julia on to a local
paediatric continence advisor. Julia was diagnosed with an
overactive bladder and constipation (which was making the bladder
problem worse) and she is now being treated with two different
medicines. The school has also put in place an individual
healthcare plan for Julia following a meeting with her parents, the
school nurse and teaching staff.


Complex bladder and bowel problems

A small number of children with complex bladder and bowel problems may require intimate care procedures to be carried out, including at school, such as catheterisation of the bladder or changing a stoma bag. Resources from the charity PromoCon (www. disabledliving.co.uk/PromoCon/About) set out guidance for children who require such intimate care in schools.

Psychological stress and continence problems

It is well known that anxiety can lead to frequent urination and, in younger children whose physical control is not completely established, anxiety can lead to wetting accidents. Secondary onset wetting (for example, wetting that occurs after a long period of sustained dryness) should always be investigated, whether daytime or night time. The most common cause is constipation; however, bowel symptoms may be missed as the wetting is the focus of attention. The child's urine should always be tested for UTI even if they appear totally well, as asymptomatic bacteriuria can lead to wetting.

Once constipation and UTI have been ruled out, the possibility of psychological stress should then be considered as a cause of the wetting. Wetting can in some cases be indicative of abuse.

Similarly, secondary onset faecal soiling in the absence of constipation is likely to be behavioural. Such behaviour may be the result of stress, anxiety or abuse.

The role of the community practitioner

A survey of 72 primary care trusts (PCTs) in 2011 revealed that three quarters did not deliver a dedicated paediatric service and half did not class their paediatric continence services as joined up (Paediatric Continence Forum, 2011). Five PCTs failed to offer any service covering daytime wetting, bedwetting, constipation/soiling and toilet training, and four PCTs only offered a service covering one of these issues.

Data and anecdotal feedback that have been collected since 2011 highlight that service provision remains inadequate and that many children are not receiving the support they need to resolve problems promptly and effectively.

Community practitioners have an important firstline role in identifying and treating childhood continence problems, and promoting messages on how to maintain healthy childhood bladders and bowels. If children do not respond to treatment, they should be referred on to specialist continence services for secondary care, where these services exist.

Information for professionals and parents on all aspects of childhood continence is available online at the ERIC website (www. eric.org.uk) and features a comprehensive range of leaflets highlighting how to support healthy bladders and bowels in children, how to recognise the onset of any problems and where to go for further support.

ERIC also delivers a rolling programme of training courses for community practitioners and will be holding an International Paediatric Continence Care conference on 5 November 2014 to share knowledge and best practice.

Health professionals should make themselves aware of the NICE guidance for commissioning a paediatric continence service, plus specific guidelines covering bedwetting, constipation and UTI (ERIC, 2010). Treatment can involve a variety of interventions, ranging from simple drinking and toileting programmes, to drug treatments or wetting alarms which require more complex and comprehensive treatment plans.

ERIC also runs a campaign called The Right to Go, which aims to improve understanding and support for childhood continence problems in early years and school settings. A campaign toolkit is available for health professionals, education staff and parents to access and use to start a dialogue about a child's bladder or bowel problems, and how best to support them. This could include developing a continence policy and individual healthcare plans.

Conclusion

Poorly managed or untreated childhood continence problems can have a devastating effect on a child's health and wellbeing; however, through appropriate commissioning of local health services and effective partnership working, we can ensure children receive the support they need, in the right way, as early as possible.

References

Butler RJ. (1998) Night wetting in children: Psychological aspects. J Child Psychol Psychiatry 39(4): 453-63.

ERIC. (2010) NICE Guidelines. Available from: www. eric.org.uk/Parents/guidelines [Accessed June 2014].

Hjalmas K. (1992) Functional day-time incontinence: definitions and epidemiology. Scand J Urol Nephrol Suppl 141: 39-4.

Doleys et al. (1981) Elimination problems: Enuresis and encopresis. In: Marsh GR, Terdal LG (eds). Behavioural Assessment of Childhood Disorders. London: Wiley.

Lottmann HB, Alova I. (2007) Primary monosymptomatic nocturnal enuresis in children and adolescents. Int J Clin Pract Suppl 155: 8-16.

Butler RJ, Golding J, Heron J, ALSPAC Study Team. (2005) Nocturnal enuresis: a survey of parental coping strategies at 7 1/2 years. Child: Care, Health Dev 31: 659-7.

Meydan EA, Civilibal M, Elevli M et al. (2012) The quality of life of mothers of children with monosymptomatic enuresis nocturna. International Urology and Nephrology 44: 655-9.

National Institute for Health and Care Excellence (NICE). (2010) Paediatric Continence Service Guidance. Available from: www.nice.org.uk/media/0 A3/93PaediatricContinenceCommissioningGuide.pdf [Accessed June 2014].

Paediatric Continence Forum. (2011) Freedom of Information Report, 2011. Available from: http:// www.paediatriccontinenceforum.org/wp-content/ uploads/2013/09/PCF-FOI-Report.pdf [Accessed June 2014].

CPD questions (please visit www.communitypractitioner.com/CPD to submit your answers)

1. How many children and young people aged five to 19 years in the UK have a medical condition affecting their bladder or bowel?

A. 500,000

B. 600,000

C. 800,000

D. 900,000

2. Daytime wetting affects approximately what proportion of seven year olds?

A. 1 in 20

B. 1 in 40

C. 1 in 50

D. 1 in 60

3. Soiling affects approximately what proportion of 11-18 year olds?

A. 1 in 100

B. 2 in 100

C. 3 in 100

D. 4 in 100

4. How many hospital admissions for chronic constipation and urinary tract infection are there in children each year in England?

A. 15,000

B. 16,000

C. 17,000

D. 18,000

5. How many of these hospital admissions could be prevented through better care?

A. 50%

B. 60%

C. 70%

D. 80%

6. Most continence difficulties are caused by psychological problems--true or false?

A. True

B. False

7. From about what age is it considered a child should remain dry at night?

A. 2

B. 3

C. 4

D. 5

8. The most common reason for a child soiling is constipation true or false?

A. True

B. False

9. A survey of 72 primary care trusts in 2011 revealed that how many did not deliver a dedicated paediatric service?

A. A quarter

B. Three quarters

C. Half

D. Two thirds

10. How many of these trusts failed to offer any service covering daytime wetting, bedwetting, constipation/soiling and toilet training?

A. 5

B. 6

C. 7

D. 8

Jenny Perez

Chief Executive, ERIC (Education and Resources for Improving Childhood Continence)
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Title Annotation:PRACTICE: CPD
Author:Perez, Jenny
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Jul 1, 2014
Words:2135
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