Wetting and soiling are common in childhood and affect looked after children more than children living with their own families. According to NICE (National Institute for Health and Clinical Excellence) (1) clinical guidelines (2010a), nocturnal enuresis (defined as bedwetting more than two nights each week) has a prevalence of eight per cent for children of four-and-a-half years, diminishing to 1.9 per cent at nine years and seven months. Bedwetting can have a deep impact on the child or young person's behaviour as well as their emotional and social life. It is also particularly stressful for parents and carers. Constipation is prevalent in five to 30 per cent of children, depending on the criteria used for diagnosis (NICE, 2010b). Symptoms become chronic in more than one-third of children and morbidity may be under-reported as people may not seek advice out of embarrassment. Many do not recognise the signs and symptoms of constipation in children and few relate this to the presence of soiling. Although it is rarely life threatening, soiling is debilitating with social, psychological and educational consequences (NICE, 2010b).
Bedwetting is more common in looked after children. For example, a case-controlled study in South Wales found it to be more prevalent in those in the care of local authorities (Williams et al, 2001); it was also one of the most commonly reported physical complaints reported in a national survey of children and young people, aged five to 17 years, looked after by local authorities in England (Meltzer et al, 2002). Thirteen per cent of those surveyed were reported to wet the bed and children with hyperkinetic disorders were more likely to do so (29% compared with 10%) than children with no mental health disorder. Foster carers can find caring for a child who wets or soils frustrating, distressing and embarrassing, as can be seen from the number of requests for help posted on online parenting sites (eg Answerbag, 2006; Mumsnet, 2008).
Supervising social workers and specialist nurses for looked after children need to have the knowledge and skills to advise foster carers on the best ways to manage these difficulties. Recent NICE (2010a, b) guidance on nocturnal enuresis and constipation in children and young people has significantly added to the knowledge base.
Most children grow out of bedwetting, but it can take many years and have considerable impact on the child and his or her family. The causes are not fully understood; a number of factors may be involved, from difficulty waking to a full bladder to needing to pass a larger than normal volume of urine at night and having a small bladder capacity. The problem often runs in families.
In order to identify the most appropriate treatment, NICE guidance recommends that the nurse or doctor first should ascertain the child's history. This should include questions regarding how long the bedwetting has been a problem, how often it occurs, whether the child wets more than once a night, whether it is a large or small volume of urine and if the child ever wakes at night to pass urine. Further questions need to be asked about daytime frequency (more than seven times a day)...