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Case study

Solving soiling problems needs collaboration between family, health and education services

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Faecal soiling can isolate children and leave parents feeling helpless. School nurses can support families and school staff in helping children manage this problem

Keywords Constipation, Laxatives, Soiling, Disimpaction

Introduction

Between 5-30% of children experience constipation and a third of these have chronic symptoms (National Institute for Health and Clinical Excellence, 2010). The problem is usually associated with soiling and accounts for almost half of all calls to the Education and Resources for Improving Childhood Continence (ERIC) helpline. It can be socially isolating and parents often feel helpless. Many blame themselves or their child and this can be compounded by insensitive responses to soiling at school.

Background

Pauline Green (not her real name) rang the ERIC helpline, close to tears, and asked for help coping with her five year old son Jack. He had been soiling on and off for two months and was now having at least one soiling accident at school every day. His teacher had called Mrs Green in for a meeting and told her it was not the school’s responsibility to deal with soiling and she must come in to clean Jack.

Mrs Green had been summoned from work twice that week and felt her job was at risk if this continued. Jack was removed from class after soiling and had to wait for his mother in soiled underwear. She felt this was a negative and punitive measure and raised her concerns with the head teacher who reiterated that toileting issues were not the school’s responsibility. Suggestions were made about inadequate toilet training and bad parenting and Mrs Green felt defensive, irritated and helpless.

Management

When a child soils due to constipation it often indicates faecal impaction. If it has been a long term problem the child will have reduced bowel sensation, and may not notice having soiled or the accompanying odour. Children often deny they have soiled when it is obvious to anyone nearby.

Reassuring parents that constipation is usually not behavioural and providing guidance can empower them to have a role in resolving the problem. Addressing underlying constipation usually resolves the situation and the key to successful management of faecal incontinence is early assessment, treatment with laxatives and a toileting programme.

ERIC suggested Mrs Green contact the school nurse, as they can play a vital role in addressing childhood continence. They can assess the child’s needs and act as an intermediary, working with the parent, child and school to overcome continence problems.

Outcome

The school nurse arranged to meet Jack and Mrs Green. An assessment and full history identified Jack was constipated and the school nurse explained that idiopathic constipation can occur despite a good diet and regular exercise, often for no obvious reason.

Establishing a regular toileting routine is an important step in ensuring regular bowel movements and the school nurse explained to Mrs Green and Jack how and when to sit on the toilet. She explained that laxatives would need to be prescribed to clear the impaction and a maintenance dose would continue for a while (NICE, 2010). Mrs Green was advised to see her GP.

Treatment for soiling requires all parties to recognise their role in resolving the problem. An individualised care plan drawn up in conjunction with the parent, child, class teacher and head teacher ensure the child’s needs and abilities are identified.

Mrs Green agreed to allow the school nurse to discuss Jack’s needs with school staff in preparation for a care planning meeting. At the meeting the nurse provided a full explanation of the problem to enable staff to deal with it sympathetically. Acting as intermediary she was able to diffuse tensions and find a way forward with all parties supporting Jack. His needs became central to the discussion and the cloud of blame and defensiveness dissipated.

Conclusion

After two days off school for disimpaction with laxatives Jack continued to take a maintenance dose combined with a regular toileting routine. Within two weeks he was having fewer soiling accidents and with the school nurse’s continued involvement is moving towards a successful outcome.

Eileen Jacques, MA, BA, DHP, is information and helpline manager, Education and Resources for Improving Childhood Continence, Bristol.

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