Promocon Special Interest Group meeting: Paediatric Continence Promotion 2016

Note: Promocon is now known as Bladder and Bowel UK 

I recently attended the Promocon paediatric continence group meeting in Manchester. Promocon is part of the wider Disabled Living Group and has recently re-branded to become Bladder and Bowel UK.

Presentations ranged from what is happening at the national level to raise awareness of continence as a significant health issue among children and young people and develop standards for treatment and care including the provisioning of containment products, to a practical demonstration of how to analyse and identify the causes of dysfunctional voiding in children using an electronic uroflow metre (subject of a separate blog). It was an interesting and instructive day!

June Rogers MBE discussed the development of the 2016 Consensus Guideline for the provision of containment products for children and young people which hitherto has been an ad hoc affair: In some areas, there is no ‘free nappy’ service and in others, expensive and wasteful provisioning. For example, the cost of providing a child with 4 disposable pull-ups per day is estimated at around ₤335pa whereas the cost of providing 12 washable trainer pants would be around ₤65 pa. With an overarching theme of the NHS 5-year plan to achieve significant cost savings, any protocols must be consistent with this.

Guidance for the provision of continence containment products to children and young people.

A consensus document.

The 2016 Guidance document recommends, inter alia:

  • Products would not normally be supplied before a child has reached their fourth birthday and then only after the child or young person has undergone a comprehensive bladder & bowel assessment and, where appropriate, a trial of toilet training for at least three months;
  • Where it is known or anticipated, there may be difficulties with toilet training e.g. due to learning disabilities or autism, children should have the opportunity for early intervention (at around 2 years of age) to facilitate the development of the necessary toileting skills;
  • The use of two-piece system (pad & pants) should be considered wherever possible instead of an all-in-one (nappy) or disposable pant-style product;
  • Consideration should always be made regarding the provision of washable products rather than disposable – clinical experience has shown that they are effective in supporting toilet training and help ‘normalise’ the process;
  • Containment products should not be supplied for treatable medical conditions, such as bedwetting and constipation with overflow. These children should be offered assessment and treatment;
  • Clear plans and pathways need to be in place to ensure the smooth transition from paediatric to adult continence services for those young people requiring ongoing support and product provision.

 

Davina Richardson followed up with a discussion of the UK Continence Society (UKCS) Minimum Standards to improve continence care across the board. She noted that continence is moving up the political agenda due to increased understanding of the cost of incontinence to individuals, families and society.

The main issues for continence are:

 

  • it currently does not feature in nurse training;
  • the recent transfer of school nursing from public health to local authority funding has reduced the number of school nurses whose role includes the early identification of child continence issues, which has increased the pressure on continence services;
  • fragmentation of service provision with attendant cost and service inefficiencies: only 27% of Clinical Commissioning Groups (CCGs) have commissioned integrated children’s continence services (bed wetting, daytime wetting, constipation/soiling, & toilet training);
  • ignorance about the solutions to bedwetting and the reluctance of families to seek help;
  • the impacts on a child of a failure to toilet train.

Minimum Standards for Paediatric Continence Care in the U.K.

A document produced by the Paediatric Continence Forum on behalf of the United Kingdom Continence Society. (March 2016)

In terms of the UKCS minimum standards, it is recommended that:

Level 1 (Nursery Nurses, Health Visitors, School Nurses) Professionals should:

  • Have a knowledge of developmental milestones in relation to attainment of continence
  • Be able to gain a basic history about continence status from the child, where appropriate, as well as from their parents/carers and assess:
    • the impact of symptoms on the child and their family
    • their desire for advice
  • Be able to identify concerns, including safeguarding, and know when and how to refer appropriately to other professionals for assessment
  • Be able to provide support and lifestyle advice
  • Promote toilet training, including in children with additional needs
  • Recognise ‘red flags’ and refer as appropriate

 

Level 2 (Community paediatric continence nurse specialists and some school nurses and health visitors who provide “one community-based service for children and young people with all wetting (daytime and bedwetting), constipation and soiling problems”). Professional should:

  • Be able to take a full history to identify bladder and bowel dysfunction
  • Be able to administer and interpret toileting charts, frequency-volume charts and bowel diaries 
  • Understand the significance of co-morbidities and safeguarding issues 
  • Recognise ‘red flags’
  • Be able to recognise the need to investigate for possible urinary tract infection including the use of urinalysis
  • Be able to perform bladder ultrasound scan investigations
  • Advise on lifestyle interventions
  • Advise on the use of enuresis alarms, desmopressin, anticholinergics and laxatives
  • Be able to advise about continence containment products
  • Be able to suggest modifications to treatment and offer advice on how to avoid relapse
  • Provide advice, information, support and training to Level 1 and other professionals including educational and care staff, about support of children with bladder and bowel problems
  • Be able to liaise with GPs, community staff and professionals in secondary and tertiary care 
  • Make appropriate onward referrals when treatment outcomes are not achieved.

What Continence professionals can do now

It is encouraging that coherent and consistent protocols for Continence management and treatment are being developed in the UK, particularly for children and young people. Widespread adoption and implementation will require the commitment of professionals who work in the area and a fair share of funding. To this end practitioners can raise awareness of the issues at their local level, lobby their managers for cost-saving equipment and treatment plans, monitor and report any unmet demands and provide families with the best care they can with the resources at their disposal including advising families who want to raise concerns about how best this can be done.

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Disclaimer:
This blog is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professionals regarding any medical questions or conditions.

Lydia and her girls

My daughter loves the alarm. She’s told me to ‘sell my pull-ups on eBay mommy’. She just loves that she doesn’t have to wear pull-ups…

- Lydia Du Buisson