About incontinence in children
Incontinence refers to the involuntary loss of urine or faeces after the age of 5 years. Children who have congenital problems (e.g. spina bifida) or who have acquired conditions which affect their anatomy or nervous system, can be expected to have difficulties with achieving continence (dryness), and should be managed by a team of medical specialists.
However, incontinence is not uncommon in otherwise well children. 3-12% of children have day wetting or daytime incontinence and 1-3% have faecal incontinence or soiling. About one in every five children in Australia experience bed wetting or nocturnal enuresis.
These are medical conditions and although there is a tendency for them to improve with age, not all do. Just waiting for this to happen is not advisable as there can be long term effects on bladder, bowel and kidney function, as well as emotional, social and psychological consequences which impact on the child’s quality of life.
What causes these problems?
Day wetting
Most children achieve day dryness by the age of 4 years. If a school age child has not done so, there are several bladder problems that may be present and day wetting tends to be more common in girls. The most common problem is bladder overactivity which leads to the child experiencing urinary urgency (busting), frequency (going often) and wetting (ranging from damp underwear to wetting of outer clothing). An underactive bladder, incomplete bladder emptying, urinary infections and postponing toileting can also lead to wetting.
As a teacher you may recognise some of the signs such as wriggling, squatting and heel sitting to control the bladder. Wet patches, smell and the need to leave class often are some of the signs.
Faecal incontinence/soiling
This condition is usually associated with underlying constipation which may be unrecognised. The sequence of events often starts with painful defecation (bowel motion) leading to avoidance of bowel emptying and in turn over-distension of the bowel causing loss of sensation and decreased bowel movement. Soft faecal matter may leak around retained stools leading to soiling. It is likely that the child will be unaware of the need to go to the toilet, or of the soiling occurring. You may notice staining of clothing and odour.
Nocturnal enuresis/bedwetting
This refers to children aged 6 years or over who wet the bed while asleep. It occurs more in boys than girls. There is a strong genetic predisposition to this condition. Other possible causes include reduced bladder storage capacity at night, kidney overproduction of urine and the inability to wake up to the sensation of a full bladder. Teachers are not necessarily aware of this problem unless the child’s morning hygiene is inadequate and the odour of urine is noticeable, or the issue arises in relation to school camp.
None of these problems are caused by laziness, attention seeking or naughtiness. All are medical problems and as such should be assessed and treated by a health professional. This should initially be a GP or Continence Advisor who may refer to a Paediatrician or specialist centre.
Incontinence and psychological issues
Previously it was believed that emotional difficulties lead to incontinence. Evidence suggests that in most instances this is not so. Loss of self-esteem, embarrassment, anxiety, poor behaviour and even denial are usually understandable responses to the incontinence and improve with treatment. Sometimes children do need psychological support to assist them and their family to deal with their experiences and help them comply with treatment.
Children with Attention-Deficit/Hyperactivity Disorder (ADHD) have higher rates of both urinary and bowel control problems and take longer to treat. They need extra support to carry out toileting regimes and have difficulty “tuning in” to bladder and bowel sensation.
Management
There are a range of treatments depending on the underlying type and cause of incontinence including medication, laxatives, bed wetting alarms and other specialist treatments. Fundamental to all is a toileting programme designed for each child. This will usually involve regular fluid intake (not too much) and toileting regimes for the day-wetting child and regular “sits” on the toilet after meals for the child with faecal incontinence.
What can you do to help?
- Allow free access to the toilet – the child cannot hold on.
- Familiarise yourself with the key messages for teachers to promote healthy bladder and bowel health in your students.
- Reinforce toileting programs. See how you can get involved in Toilet Tactics.
- Ensure there is someone the child can turn to if assistance is needed.
- Provide a private place where clothes, wipes etc. can be left and the child can change.
- Have a school protocol in place to deal with classroom continence accidents which minimises attention and the child’s distress.
- Deal with any bullying arising from the continence problem.
- Communicate with parents should you notice a child who leaves class frequently, appears to crouch or wriggle to control the bladder, or if any odour of urine or faeces is detectable.
- Document any observations or episodes of incontinence.
- Ask for a Continence Care Plan to assist your understanding of the child’s condition and needs.