A pilot project is training health professionals to recognise continence problems in children during routine appointments, to ensure they receive early intervention
One in 12 children and young people in the UK are affected by continence problems, but it is estimated that only a third of families seek treatment. Ineffective or delayed treatment can lead to longer-term physical, psychological and emotional problems. A pilot project trained health professionals to spot the early signs and symptoms of childhood continence problems, then signpost families for support. It also used literature targeted at parents to better recognise early signs of childhood bladder and bowel dysfunction.
Citation: Cheer B (2015) Increasing recognition of childhood incontinence. Nursing Times; 111: 5, 21-22.
Author: Brenda Cheer is paediatric specialist continence nurse, University Hospital of Wales, and dedicated ERIC nurse.
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There are 900,000 young people under the age of 19 living with bladder and bowel problems in the UK, including daytime wetting, bed-wetting, soiling and constipation (National Institute for Health and Care Excellence, 2010). It is estimated that only a third of families seek treatment for their child’s problems due, in large part, to a lack of knowledge of where to go for treatment and the social stigma associated with incontinence (Sureshkumar et al, 2000).
In some cases problems may not be recognised; for example, parents may attribute their child’s soiling to behavioural issues rather than constipation, while it is estimated that 30% of families punish their children for wetting accidents (Sureshkumar et al, 2000). There is also a lack of understanding within the medical profession about how to recognise and treat childhood continence problems.
Delayed or ineffective treatment can lead to physical, psychological and emotional problems and can adversely affect learning (Joinson et al, 2007). A pilot project in Bristol and South Gloucestershire led by Education and Resources for Improving Childhood Continence (ERIC) has trained health professionals to spot the early signs and symptoms of childhood continence problems and to know where to signpost families for support.
Childhood continence services
Services to support children with continence problems are often fragmented, inconsistent and underfunded, and there is a shortage of specialist paediatric nurses working in community settings. The Paediatric Continence Forum, of which ERIC is a member, recently conducted Freedom of Information requests that revealed:
- Only 32% of responding clinical commissioning groups commissioned all four main continence services (for bed-wetting, daytime wetting, toilet training and constipation/soiling);
- Only 22% commissioned services that were fully “joined up” (PCF, 2014).
There are around 14,500 hospital admissions every year for those aged under 19 experiencing problems including constipation and urinary tract infections; an estimated 80% of these could be avoided if continence issues were treated effectively in primary care (NICE, 2010). As well as saving resources, avoiding admissions would cut the emotional burden associated with continence problems.
The ERIC nurse project
Providing good children’s continence care is not difficult, but is hampered by:
- Professionals’ lack of knowledge;
- Many people’s reluctance to discuss continence problems;
- Not knowing where to go for help.
The ERIC nurse project was devised to address this and has been piloted in Bristol and South Gloucestershire. It aims to increase the awareness of children’s bladder and bowel health in families and professionals working with children to improve recognition of early signs of problems and promote early intervention.
The project has used targeted information leaflets to raise awareness of healthy bladders and bowels, along with training for professionals to help them spot the early signs and symptoms of childhood continence problems and to know where to signpost families for support. The aim was to reach every child in the pilot area to make the biggest difference possible.
ERIC secured three years’ funding for a clinical post from the Department for Health as part of an initiative to improve the health, wellbeing and care of vulnerable groups in the community. I joined ERIC to lead on the project in May 2013. We have sought to create a best-practice example of paediatric continence management in the hope of influencing national service development and policy.
I designed two information leaflets aimed at parents, to spread the messages about healthy bladders and bowels:
- Thinking About Wee and Poo Now You’ve Reached the Age of 2 (attached) is now given out by health visitor teams in the newly reintroduced two-year health and development checks;
- Thinking About Wee and Poo Now You’re on Your Way to School (attached) is added to the information packs given to all children starting reception by the school health nurse service.
I aimed to make the leaflets eye-catching, small and concise so they are not off-putting to parents. They contain basic information about healthy bladder and bowel care, including what to drink and how to spot constipation. They do not aim to provide all the answers but do highlight sources of further information, including more specific ERIC leaflets such as Bed Wetting - ERIC’s Guide for Parents. They also feature ERIC’s “wee” and “poo” characters to improve recognition and continuity.
The professionals distributing the leaflets have to be able to answer queries parents may have so training has been a key element of the project. The aim has been to reach a cross-section of all staff working with children, not just health professionals. So far, I have trained over 450 people, including local school nurses, health visitors, learning disability nurses, children’s centre staff and childminders. We believe this is the first time a project has tried to coordinate training on childhood continence for such a wide range of professionals.
Most participants have never received training on childhood continence but look after children every day, supervise potty training and advise on children’s health and wellbeing, to which good bladder and bowel care is so vital. The training is delivered at no cost to participants.
Arranging training with GPs has been complicated as they find it difficult to take time out to attend training sessions and I cannot travel to every GP surgery in the area to give in-house training. The current plan is to target some GPs and learn from them how best to advise other GPs of ERIC’s work. We know from parents that this is vital, as GP appointment slots do not allow time for an assessment and a full explanation. Signposting to ERIC and providing leaflets to support GPs’ advice would save GPs’ time and, crucially, provide a better experience for both children and their parents.
The challenge with schools is that staff may not be aware of the benefits they can get from continence training. It is vital that teachers and school staff are more aware of how to support bladder and bowel health, for example by: allowing, or even encouraging, children to drink; allowing them to go to the toilet when they need to; and providing acceptable toilet facilities. ERIC runs the Right to Go campaign to overcome the lack of awareness of continence problems and how to manage them in schools.
Informal responses from health professionals participating in the training to date have been positive. For example, one health visitor said:
“I’ve never received any training before on childhood continence problems but it’s been a really useful, helpful session, and it would be great to have refresher sessions in the future. It’s so important for us to be able to give the right support and information to families and know where to signpost them to.”
To gain more objective information on outcomes I am gathering feedback from the pilot study. This will include conducting questionnaires to measure health professionals’ knowledge before and after training. I also plan to collect feedback from mini-pilot studies elsewhere in the UK.
Each health visiting team has also been asked to persuade 20 families to complete a questionnaire, which would give us a total of approximately 500 responses; to date I have received about 200. The questionnaires assess parents’ existing knowledge of ERIC and of basic bladder and bowel health. I will also obtain feedback from parents about how useful the leaflets have been.
In the longer term, I will look at the effect of the project on families in Bristol and South Gloucestershire by comparing the experiences of those who did not receive information through the pilot with those of the people who did.
We will use the data from the questionnaires to refine the leaflets and training, and to broaden the project’s remit with the aim of covering the entire UK. To achieve this, health professionals distributing the leaflets will need training to ensure they have the necessary knowledge. I intend to work with local services to do this. Some already have children’s continence services in place that train health professionals in their areas but, despite NICE (2010) guidance on commissioning paediatric continence services, many areas do not have dedicated services. I need to identify key people in each area, who will then be trained as trainers. I also plan to develop refresher sessions and online training so I can reach as many professionals as possible.
- One in 12 children in the UK has continence problems
- Only about a third of clinical commissioning groups commission the full range of children’s continence services
- 80% of hospital admissions linked to childhood continence could be avoided with effective treatment in primary care
- Parents are unlikely to seek help without a basic understanding of continence problem
- Continence training for professionals who work with children may lead to early intervention and prevent long-term psychological and physical problems
Joinson C et al (2007) Psychological problems in children with bedwetting and combined (day and night) wetting: a UK population based study. Journal of Paediatric Psychology; 32: 5, 605-616.
National Institute for Health and Care Excellence (2010) Paediatric Continence Service: Commissioning Guide.
Paediatric Continence Forum (2014) Launch of the Paediatric Continence Commissioning Guide and the NICE Quality Standard on Nocturnal Enuresis.
Sureshkumar P et al (2000) Daytime urinary incontinence in primary school children: a population-based survey. Journal of Pediatrics; 137: 6, 814-818.