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Discreet products for children and teenagers with continence problems.

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VOL: 101, ISSUE: 12, PAGE NO: 50

Debra Evans is information co-ordinator, PromoCon, Disabled Living, Manchester

Carvet (1998) - in a study commissioned by the Joseph Rowntree Foundation into the experiences of families with a child with faecal incontinence - identified that 'some children and young people feared ridicule if their impairment became known beyond their immediate family circle'.

Carvet (1998) - in a study commissioned by the Joseph Rowntree Foundation into the experiences of families with a child with faecal incontinence - identified that 'some children and young people feared ridicule if their impairment became known beyond their immediate family circle'.

Breaking down the stigma attached to bladder and bowel problems is the ultimate goal, but as this has not been achieved, it is essential that health and social care professionals who work with young people are aware of the many discreet product options available to manage incontinence, boost confidence and enhance quality of life.

Failure to manage faecal and urinary incontinence can restrict educational, leisure and employment opportunities (DoH, 2000). It is a young person's inability to participate fully in activities - such as gym classes, football, attending cub scouts or brownies, or going on school trips or holidays - that may set them apart from their peers. Any activity that involves their getting undressed in front of friends can cause problems.

Good Practice in Paediatric Continence Services - benchmarking in action (DoH, 2004b) suggests indicators of best practice that ensure that health care personnel are proactive in anticipating the needs and preferences of children, their family and or carers, and that the choice of products is not restricted.

Budgetary constraints may make it impossible to supply certain products free of charge, but providing information about these products or directing people to services such as PromoCon (see Footnote, below left) where they can obtain information, does not incur a charge.

Bedding protection
Williams (1996) interviewed 2,962 children from primary schools in Sheffield, and found a strong association between bedwetting and bullying. Children with continence problems may be reluctant to stay overnight at a friend's house, or indeed have a friend to stay at their house, for fear that their peers will find out about their continence problem. It is therefore essential when recommending bedding protection that consideration is given to its appearance.

Mattress, duvet and pillow protection - A range of bedding protection is available in various sizes, from bunk beds to pressure-relieving mattresses to king-size beds. There is no correlation between quality and cost, but there are product solutions to fit all budgets.

Protective covers that are breathable and do not wrinkle and crinkle when the child moves should be recommended.

Coloured protectors (Shiloh, EMS Medical) are particularly suitable, as they are not instantly recognisable as waterproof covers because they have the appearance of a mattress. Duvet protectors and pillow protectors are also available.

If cost is a deciding factor, there is an extremely cost-effective bedding protection set available from Argos, comprising a mattress, duvet and pillow protectors.

Several companies, such as Vernacare, Shiloh Healthcare and Sylvan Corporation, have recently introduced 'no launder' duvets to their product range. The duvets are breathable, completely waterproof and can be wiped clean with a mild solution of disinfectant and water.

The cost of these products varies depending on the company, but the time saved by parents should be taken into account.

Absorbent washable bed pads - Absorbent washable bed pads may be suggested as a means of managing incontinence at night. The pads are placed over the sheet, and the child lies directly on the pad wearing nothing below the waist, which allows the pad to absorb the urine, while at the same time keeping the child's skin dry.

The pads are available in various sizes and colours including white, blue and pink, and some are designed specifically for children with colourful cartoon prints (EMS Medical, Fledglings) (Fig 1).

The latter may be more appealing to younger children; for those who are older, or who are teenagers, it may be more appropriate to recommend a pad that is the same colour as the sheet on the bed, as this would be a more discreet option.

Disposable continence pads
It is important that no assumptions are made about a child's ability to become toilet trained (Rogers, 2003). Regular reassessment is therefore required, which may influence the product provided or suggested.

It is generally acknowledged that there is a gap in the range of disposable pads that are specifically designed for children.

For example, when children are too big for products designed for toddlers they are offered extra-small adult nappies, the design of which is not suitable for this group's requirements.

One pad manufacturer, Ontex (Euron), is currently evaluating a product that fits the criteria for children. There has been very positive feedback about the product from parents and it will be commercially available later in the year.

Many parents prefer to use pull-ups as an alternative to the traditional nappy-type product. Fader et al (2003), in their study of absorbent products for children, found that 40 per cent of parents/guardians preferred pull-ups for their child for day use, but that only 29 per cent preferred them during the night.

However, the continence services are reluctant to provide such products because of the cost implications. However, it should be noted that these products have a 'cotton-feel' backing, which may reduce the rustling noise when the child moves, and that this, combined with their appearance and their similarity to conventional underwear, may have a positive influence on a young person's self-esteem and confidence.

Although there are no shaped pads specifically designed for children, there are many that have been designed for men or women that may be appropriate. Pads vary in length, shape, and width in the crotch area, and in thickness and absorbency, which may mean that a pad from one company may be more suitable than one from another.

Reuseable products
Until recently, manufacturers of reuseable products offered little choice in style and colour - there were white Y-fronts for boys and full briefs with a motif design for girls (see Case Study One, p52).

Currently there are several manufacturers that sell boxer shorts with wide elastic around the waist, in dark colours and with discreetly concealed pads (P&S Healthcare, Hi-Line) (Fig 2).

For girls, a range of knickers is available (Fig 3), the suitability of which will depend on the age of the girl. Products designed for women, for example, with a high-cut leg or even a thong (Hi Line), may be more appealing to the older teenager.

The appearance of garments for teenagers is important: the style must be the same as those worn by their friends, and it is essential that the stitching that holds the absorbent pad in place is not noticeable on the outside of the garment.

Sheaths, body-worn urinals and leg bags
Penile sheaths are available for boys. The smallest sheath is in the Manfred Sauer product range - 18mm diameter, increasing by 2mm sizes to 40mm. Body-worn urinals are also available in paediatric sizes (S G & P Payne, Jade Euro Med).

These consist of a cone that fits over the penis (it is similar to a sheath but does not adhere to the penis), a flange, a drainage bag, and a belt or pant system that secures the urinal to the body.

When a child or teenager uses a urethral catheter or sheath to manage incontinence, it is usually connected to a drainage bag and secured to the leg by the use of Velcro straps.

Manfred Sauer offer a range of Discreet Bags (Fig 4) that have a capacity of 400-450ml that can be worn on the thigh, allowing the child to wear shorts or girls to wear a skirt. A recent addition to their product range, the Discreet Mini, holds 210ml of urine and is useful for children.

For young people who manage their bladder problems with an indwelling catheter, consideration should be given to using a catheter valve instead of a leg bag. Young people need an adequate bladder capacity, the ability to empty their bladder regularly and the dexterity to open the tap on the valve (see Case Study Two).

Intermittent catheters
A wide range of catheters is available, some requiring water to be added to lubricate them, while others are pre-lubricated.

Most companies that manufacture such products also produce catheter kits (Fig 5), which allow sterile intermittent catheterisation where there is no easy access to toilets. These products can be extremely useful on holiday.

Swimwear
Children who have continence problems are not allowed into public swimming baths (or hydrotherapy pools), unless they wear a suitable containment garment.

A variety of products is available that are worn under conventional swimwear: Hydrobrief (Concept Care); Freestyle Swimmer (PHP); Pool Pants (Samsolutions); and plastic pants from various suppliers.

These products may be considered functional but there is a need for a more discreet solution. Hi Line has taken a different approach by launching a range of swimwear for 'special children' (adult sizes are also available), the swimwear having an integral waterproof pant liner (Figs 6 and 7).

Conclusion
White (2001) suggests that 'the burden of unhappiness and despair that children with incontinence and their families carry should never be underestimated'. Health care professionals should not assume their colleagues have already provided information relating to a range of product options.

Each child is an individual, whose priorities and needs change with age. Manufacturers are investing heavily to develop new products; it is therefore essential that health care professionals continually update their knowledge base.

Footnote
PromoCon: an integral service of Disabled Living, Manchester, which provide impartial and unbiased information relating to continence products and services.

Postal address: 4 St Chad's Street, Cheetham, Manchester M8 8QA

Helpline: 0161 834 2001

E-mail: promocon@disabledliving.co.uk

Website: www.promocon.co.uk

Case Study one: Hannah
Hannah, an eight-year-old girl with spina bifida, primarily manages her incontinence by intermittent self-catheterisation, although she requires the added protection of a pant with a built-in pad. It was important to Hannah that when she changed for PE she wore underwear that was similar to that of her friends, which meant that she wanted to wear Barbie or Tweenie knickers. The continence adviser suggested that Sarah's mother purchase reusable shaped pads (EMS Healthcare) that could be sewn into these 'off the shelf' garments. The pads have proved to be a cost-effective method of providing protection, and have ensured that Hannah appears no different from her friends when changing around them. Case Study two: Sarah
Sarah is 15 years old and for many years had managed her bladder problems with an indwelling catheter and leg bag. However, she had become depressed, withdrawn and very self-conscious about her image because she wanted to wear fashionable clothing like her friends, but tended to wear dark-coloured baggy pants to hide the leg bag. On the advice of a continence adviser, Sarah tried using a catheter valve, and this has transformed Sarah into a fun-loving 'normal' teenager, who can wear fashionable clothes like those of her friends. Sarah's mother said the transformation in Sarah is unbelievable, but commented that she felt disappointed she had not been made aware earlier of this management option.

Related article in nursing times

Evans, D. (2005) Lifestyle solutions for men with continence problems. Nursing Times; 101: 2, 61-64. In the next issue of the continence supplement

'Product solutions for women with continence problems' will be published in the 3 May issue.

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