Absenteeism, educational plans, and anxiety among children with incontinence and their parents

Anorectal malformation and Hirschsprung's disease: a cross-sectional multicentre comparison of quality of life and bowel function to a healthy population

PURPOSE

Children with anorectal malformation (ARM) and Hirschsprung's disease (HD) often experience bowel symptoms into adulthood, despite definitive surgery. This study evaluates the quality of life (QOL) and bowel functional outcome of children treated for ARM and HD in comparison to healthy controls.

METHODS

Between December 2020 and February 2023, we recruited patients with ARM and HD aged 3-17 years at four tertiary referral centres, who had primary corrective surgery done >12 months prior. Healthy controls were age-matched and sex-matched. All participants completed the Pediatric Quality of Life Inventory Generic Core Scales 4.0, General Well-Being (GWB) Scale 3.0 and Family Impact (FI) Module 2.0 Questionnaires. Bowel Function Score (BFS) Questionnaires were also administered. We also performed subgroup analysis according to age categories. Appropriate statistical analysis was performed with p<0.05 significance. Ethical approval was obtained.

RESULTS

There were 306 participants: 101 ARM, 87 HD, 118 controls. Patients with ARM and HD had significantly worse Core and FI Scores compared with controls overall and in all age categories. In the GWB Scale, only ARM and HD adolescents (13-17 years) had worse scores than controls. ARM and HD had significantly worse BFSs compared with controls overall and in all age categories. There was significant positive correlation between BFS and Core Scores, GWB Scores and FI Scores.

CONCLUSION

Patients with ARM and HD had worse QOL than controls. Lower GWB Scores in adolescents suggests targeted interventions are necessary. Bowel function influences QOL, indicating the need for continuous support into adulthood.

Experiences of children's self-wetting (including urinary incontinence) in Cox's Bazar's Rohingya refugee camps, Bangladesh

Self-wetting is the leakage of urine, either due to the medical condition of urinary incontinence (UI), or because a person does not want to, or cannot, access a toileting facility in time. This study explored the attitudes towards self-wetting and experiences of children (aged five to 11), their caregivers, community leaders and humanitarian practitioners in the Rohingya refugee camps in Cox's Bazar, Bangladesh. We particularly focused on how water, sanitation and hygiene (WASH) and protection interventions might assist in improving these experiences. We purposively selected participants from two camps where our partner organisation works. We conducted Key Informant Interviews (KIIs) with community leaders and camp officials, Story Book (SB) sessions with Rohingya children and in-depth Interviews (IDIs) with caregivers of children who participated in the SB sessions, as well as surveying communal toilets. Self-wetting by children was common and resulted in them feeling embarrassed, upset and uncomfortable, and frightened to use the toilet at night; many children also indicated that they would be punished by their caregivers for self-wetting. Key informants indicated that caregivers have difficulty handling children's self-wetting due to a limited amount of clothing, pillows, and blankets, and difficulty cleaning these items. It was evident that the available toilets are often not appropriate and/or accessible for children. Children in the Rohingya camps appear to self-wet due to both the medical condition of UI and because the sanitation facilities are inappropriate. They are teased by their peers and punished by their caregivers. Although WASH and protection practitioners are unable to drastically alter camp conditions or treat UI, the lives of children who self-wet in these camps could likely be improved by increasing awareness on self-wetting to decrease stigma and ease the concerns of caregivers, increasing the number of child-friendly toilets and increasing the provision of continence management materials.

Clinical features and outcomes of adult idiopathic megarectum

OBJECTIVE

Idiopathic megarectum is characterized by abnormal, pronounced rectal dilatation in the absence of identifiable organic pathology. Idiopathic megarectum is uncommon and under-recognized. This study aims to describe the clinical features and management of idiopathic megarectum.

METHODS

A retrospective review was undertaken on patients diagnosed with idiopathic megarectum with or without idiopathic megacolon over a 14-year period until 2021. Patients were identified from the hospital's International Classification of Diseases codes, and pre-existing clinic patient databases. Patient demographics, disease characteristics, healthcare utilization and treatment history data were collected.

RESULTS

Eight patients with idiopathic megarectum were identified; half of the patients were female, with the median age of symptom onset being 14 years (interquartile range [IQR] 9-24). The median rectal diameter measured was 11.5 cm (IQR 9.4-12.1). The most common presenting symptom was constipation, bloating and faecal incontinence. All patients required prior sustained periods of regular phosphate enemas and 88% were using ongoing oral aperients. Concomitant anxiety and or depression were found in 63% of patients and 25% were diagnosed with an intellectual disability. Healthcare utilization was high with a median of three emergency department presentations or ward admissions related to idiopathic megarectum per patient over the follow-up period; 38% of patients required surgical intervention during the period of follow-up.

CONCLUSION

Idiopathic megarectum is uncommon and associated with significant physical and psychiatric morbidity and high healthcare utilization.

Effectiveness of standard urotherapy (basic bladder advice) and combination therapies in managing bladder dysfunction in children with treated behavioral disorders: Results of a prospective cohort (DABBED) study

AIMS

We evaluated the efficacy of standard urotherapy and combination therapies in treatment of bladder dysfunction in children with treated behavioral disorders.

METHODS

Prospective study of children (6-16 years) with bladder dysfunction and behavioral disorders was conducted between March 2018-2020. Eligible children were initially offered standard urotherapy and those with no response at 3 months were offered combination therapies. Symptomatic response, changes in Akbal score and PinQ score were reported at 6 months and outcomes were correlated to behavioral diagnoses and medications.

RESULTS

Thirty-nine consecutive children (male = 27, mean age [SD] 10.3 [±2.0] years) were recruited, of whom 29 completed the study (five lost to follow-up, three non-compliant to treatment, two excluded). Thirty-four (87%) children had attention deficit/hyperactivity disorder. Monosymptomatic nocturnal enuresis (n = 11) and non-monosymptomatic enuresis (n = 17) were the commonest diagnoses. Following 3-month review, 14 (38%) children continued to receive standard urotherapy, while 15 (41%) children were transitioned to combination therapy. At 6-month review, complete/partial response was seen in 62% (23/37) and no response in 16% (6/37); with 32% (12/37) responding to standard urotherapy alone. Akbal symptom scores (15.9-11.5; P < 0.01) and PinQ scores (26.0-19.5; P = 0.008) improved significantly at 6-month follow-up. Type of underlying behavioral disorder(s) or medications for behavioral disorder did not influence the outcomes.

CONCLUSION

This study confirms that children with underlying behavioral disorders are able to have a good response to the appropriate therapy for their bladder dysfunction with a third of children responding to standard urotherapy alone.

The relationship between school-basic psychological need satisfaction and frustration, academic engagement and academic achievement

The main purpose of this study is to investigate how students’ perceptions of need satisfaction and need frustration at school are indirectly associated with academic achievement through academic engagement. A modified version of the Basic Psychological Need Satisfaction and Frustration Scale was used to assess these needs in a school-based context. The study sample consisted of 551 students, comprising 299 males (54.3%) and 252 females (45.7%), with an average age of 16.19 years (SD = 1.49). The results suggested autonomy satisfaction and relatedness satisfaction are positively correlated with academic engagement, autonomy frustration is negatively correlated with academic engagement, and, moreover, academic engagement is associated with increased academic achievement. The results of this study highlight the importance of developing specific training programs to promote a school environment that pays attention to students’ psychological needs.

Long-term results of dynamic graciloplasty for severe fecal incontinence

BACKGROUND

Fecal incontinence is a common complaint. In the presence of extensive sphincter deterioration, after anorectal trauma, or failure of non-invasive surgical procedures, a sphincter reconstruction with dynamic graciloplasty can be proposed. The aim of our study was to evaluate the long-term results of dynamic graciloplasty.

METHODS

A retrospective study was conducted on all the patients who underwent dynamic graciloplasty between 1997 and 2019 in one French tertiary referral center for severe fecal incontinence after previous unsuccessful treatments. Only patients with available long-term results (≥ 1 year) were included.

RESULTS

Among 40 patients who underwent dynamic graciloplasty, 31 patients [77% women, median age = 57 years (range 17-74 years)] were included with a mean long-term follow-up of 11 ± 6 years. The mean duration of fecal incontinence was 8 ± 7.9 years and the mean Wexner score was 16 ± 3. Fecal incontinence was adult-acquired in 88% of patients. 74% of patients underwent previously unsuccessful surgical procedures. A diverting colostomy was present in 7 patients (23%). Postoperative overall, surgical and major morbidity occurred in 20 (64%), 17 (55%) and 7 (23%) patients, respectively. At the end of follow-up, 18 patients still used their stimulation device (58%), and 4 patients required a permanent colostomy (12.5%). Long-term efficacy of dynamic graciloplasty was reported by 17 patients (55%).

CONCLUSION

The efficacy of dynamic graciloplasty is conserved in 55% of patients after a mean follow-up of 11 years. This procedure needs to be kept in the surgical armamentarium for persistent and severe fecal incontinence after previous surgical interventions or in the presence of large perineal defects, before the ultimate step of permanent stoma.

Social-Emotional Development and Associated Risk Factors in Chinese Toddlers with Cerebral Palsy

OBJECTIVE

This study aimed to analyze the social-emotional behaviors of Chinese toddlers with cerebral palsy and to identify the risk factors associated with these behaviors.

METHODS

A total of 300 Chinese toddlers and their parents were recruited in this study. A Chinese version of the Infant-Toddler Social-Emotional Assessment was used to assess the children and basic information and clinical data were collected using an author-designed questionnaire. The patients were also assessed using a coping style questionnaire and the hospital anxiety and depression scale. Multiple logistic regression analysis was performed to identify risk factors.

RESULTS

The scores of the externalizing and competence domains for Chinese toddlers with cerebral palsy at different ages were lower compared to healthy children of the same age and gender (p<0.05). For the boys with cerebral palsy aged between 12-17 and 18-23 months, the scores of the internalizing and dysregulation domains were significantly lower compared to the national normal (p<0.01). The effect of perinatal factors on the externalizing and competence domains was more significant compared to other domains, whilst the coping style of the parents significantly affected the dysregulation domain (p=0.001). Multivariate analysis showed that the parental emotional state, education level, coping style and perinatal factors were closely associated with the social-emotional problems of children with cerebral palsy.

CONCLUSION

Children with cerebral palsy are more likely to have behavioral, emotional, and psychiatric issues that are mostly ignored. These children may benefit from early screening and intervention for risk factors to improve rehabilitation and long-term prognosis.

Parental experiences of their child's vulvovaginitis: a qualitative interview study

INTRODUCTION

Vulvovaginitis is described as a common self-limiting paediatric gynaecological condition. Parents' experiences of their child being diagnosed with this condition and subsequent treatment have not previously been described.

AIM

The aim of this study was to explore parents' experiences of their child's diagnosis and management of vulvovaginitis.

STUDY DESIGN

The study was conducted in the north west of England over a two-year period. Qualitative data were generated by semistructured in-depth interviews. Mothers of nine children with vulvovaginitis consented to participate. Data were analysed using thematic analysis.

RESULTS

The analysis of the data resulted in four themes: trauma and uncertainty of initial symptoms, seeking a diagnosis; an uncertain journey, managing the symptoms; a process of trial and error and managing the impact; keeping it private. Parents experienced a difficult and protracted journey to their child's diagnosis and were involved in a process of trial and error to try and monitor and manage what can be a difficult ongoing condition.

DISCUSSION

Clinical reports suggest that vulvovaginitis is a minor childhood condition; this is not necessarily the perceptions and experiences of parents, who can experience uncertainty and ongoing difficulty after their child's diagnosis.

CONCLUSION

The diagnosis of vulvovaginitis can have a major and ongoing impact on children's and their family's lives.

Conservative interventions for treating functional daytime urinary incontinence in children

BACKGROUND

In children, functional daytime urinary incontinence is the term used to describe any leakage of urine while awake that is not the result of a known underlying neurological or congenital anatomic cause (such as conditions or injuries that affect the nerves that control the bladder or problems with the way the urinary system is formed). It can result in practical difficulties for both the child and their family and can have detrimental effects on a child's well-being, education and social engagement.

OBJECTIVES

To assess the effects of conservative interventions for treating functional daytime urinary incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains studies identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 11 September 2018). We also searched Chinese language bibliographic databases: Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang. No language restrictions were imposed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised, multi-arm studies, cross-over studies and cluster-randomised studies that included children aged between 5 and 18 years with functional daytime urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened records and determined the eligibility of studies for inclusion according to predefined criteria. Where data from the study were not provided, we contacted the study authors to request further information. Two review authors assessed risk of bias and processed included study data as described in the Cochrane Handbook for Systematic Reviews of Interventions. Where meta-analysis was possible, we applied random-effects meta-analysis using the Mantel-Haenszel method for dichotomous outcomes.

MAIN RESULTS

The review included 27 RCTs involving 1803 children. Of these, six were multi-arm and one was also a cross-over study. Most studies were small, with numbers randomised ranging from 16 to 202. A total of 19 studies were at high risk of bias for at least one domain. Few studies reported data suitable for pooling due to heterogeneity in interventions, outcomes and measurements.Individual conservative interventions (lifestyle, behavioural or physical) versus no treatmentTranscutaneous electrical nerve stimulation (TENS) versus sham (placebo) TENS. More children receiving active TENS may achieve continence (risk ratio (RR) 4.89, 95% confidence interval (CI) 1.68 to 14.21; 3 studies; n = 93; low-certainty evidence).One individual conservative intervention versus another individual or combined conservative interventionPelvic floor muscle training (PFMT) with urotherapy versus urotherapy alone. We are uncertain whether more children receiving PFMT with urotherapy achieve continence (RR 2.36, 95% CI 0.65 to 8.53, 95% CI 25 to 100; 3 studies; n = 91; very low-certainty evidence).Voiding education with uroflowmetry feedback and urotherapy versus urotherapy alone. Slightly more children receiving voiding education with uroflow feedback and urotherapy may achieve continence (RR 1.13, 95% CI 0.87 to 1.45; 3 studies; n = 151; low-certainty evidence).Urotherapy with timer watch versus urotherapy alone. We are uncertain whether urotherapy plus timer watch increases the number of children achieving continence compared to urotherapy alone (RR 1.42, 95% CI 1.12 to 1.80; 1 study; n = 58; very low-certainty evidence).Combined conservative interventions versus other combined conservative interventionsTENS and standard urotherapy versus PFMT with electromyographic biofeedback and standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.11, 95% CI 0.73 to 1.68; 1 study; n = 78; very low-certainty evidence).PFMT with electromyography biofeedback and standard urotherapy versus PFMT without feedback but with standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.05, 95% CI 0.72 to 1.52; 1 study; n = 41; very low-certainty evidence).Individual conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)PFMT versus anticholinergics. We are uncertain whether more children receiving PFMT than anticholinergics achieve continence (RR 1.92, 95% CI 1.17 to 3.15; equivalent to an increase from 33 to 64 per 100 children; 2 studies; n = 86; very low-certainty evidence).TENS versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 0.81, 95% CI 0.05 to 12.50; 2 studies; n = 72; very low-certainty evidence).Combined conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)Voiding education with uroflowmetry feedback versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportion of children achieving continence (RR 1.02, 95% CI 0.58 to 1.78; 1 study; n = 64; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The review found little reliable evidence that can help affected children, their carers and the clinicians working with them to make evidence-based treatment decisions. In this scenario, the clinical experience of individual clinicians and the support of carers may be the most valuable resources. More well-designed research, with well-defined interventions and consistent outcome measurement, is needed.

Prevalence of urinary incontinence and other lower urinary tract symptoms in children in the Netherlands

INTRODUCTION

The International Children's Continence Society (ICCS) defines urinary incontinence (UI) as 'involuntary leakage of urine' [1], a condition that can have a negative impact on a child's life. Although UI is common among children, the reported prevalences worldwide vary. Regarding children in the Netherlands, only a few studies report on the prevalence of UI and other lower urinary tract symptoms (LUTSs).

OBJECTIVE

The aim was to investigate the prevalence of episodes of UI and other LUTSs along with associated 'risk factors' in children in the Netherlands.

STUDY DESIGN

In a cross-sectional study, 240 children (8- to 17-year-olds) were included, who completed the Groningen Pediatric Defecation and Fecal Continence Questionnaire. UI was defined in accordance with the ICCS's definition of involuntary leakage of urine. To define a timeframe of episodes of UI, the situation during the past 6 months was specifically asked. The other LUTSs included were intermittency, straining, urinary tract infections, nocturia, and frequency.

RESULTS

The prevalence of episodes of UI in the total group was 21.7%. Girls experienced UI significantly more often than boys (30.1% versus 14.2%, P = 0.003). Prevalence did not differ between the 8- to 12-year-olds and the 13- to 17-year-olds. The most prevalent form of UI was stress UI (8.8%). After excluding six children with a medical history that could influence bladder function, UI in 20.9% of the remaining 'healthy' children was found. Intermittency was experienced by 18.3% of the children, and 15% strained during micturition. Univariate analysis showed that the presence of straining, intermittency, nocturia, or fecal incontinence was significantly associated with UI.

DISCUSSION

Of the children studied, episodes of UI occurred in 21.7%, and the condition did not decrease with age. It was found that UI is not limited to 'sick' children because it occurred in 20.9% of the 'healthy' subgroup. Although children with urge UI in daily practice were mainly seen, in this study, it was found that on average, stress UI was the most common form of UI among Dutch children. The prevalence of other LUTSs was also high, with intermittency and straining as the most frequent symptoms (18.3% and 15.0%, respectively). Intermittency and straining are significantly associated with UI, as are nightly nocturia and fecal incontinence.

CONCLUSION

Episodes of UI and other LUTSs are common conditions among children in the Netherlands, even in the 'healthy' group. It is important that medical practitioners are aware of these phenomena, and they should be alert to the associated symptoms as they may be considered as 'risk factors'.

Childhood Disability and Educational Outcomes: A Systematic Review

PROBLEM

Graduation from high school is an important milestone for all adolescents and affects future health in adulthood. Children with chronic illnesses have additional challenges that affect school attendance, grade retention and graduation. If children with chronic conditions are not able to participate fully in education, this may limit their opportunities for future health. The aim of this study was to integrate the evidence in the past 28 years about educational outcomes of children and adolescents with chronic conditions causing disability.

ELIGIBILITY CRITERIA

Quantitative studies reporting on a chronic condition and attendance, grade retention, or high school graduation, from a peer-reviewed journal in the English language, data collection since 1990, and research conducted with a population in the United States were eligible for review.

SAMPLE

Forty-three studies from a literature search of CINAHL, MEDLINE, ERIC, Teacher Reference Center, Psychology & Behavioral Science Collection, and Academic Search Elite databases, followed by ancestry searches, were included in this review.

RESULTS

In general, chronic conditions are significantly associated with increased absenteeism, grade repetition and not completing high school within four years, although hemophilia does not follow this pattern. Additionally, increased severity of the condition is associated with poorer educational outcomes.

CONCLUSIONS

Nurses and other healthcare providers should include an educational assessment as part of psychosocial assessment of children and adolescents to identify risk, intervene early and limit risk.

Chronic School Absenteeism of Children with Chronic Kidney Disease

We evaluated the frequency of chronic school absenteeism (≥18 missed school days per year) among children with mild-to-moderate chronic kidney disease. Chronic absenteeism was present in 17.3% of children with chronic kidney disease, compared with 2.7% of children in the US National Health and Nutrition Examination Survey.

Left behind and left out: The impact of the school environment on young people with continence problems

Objectives

To explore the impact of the secondary school environment on young people with continence problems.

Design

In‐depth qualitative semi‐structured interviews.

Methods

We interviewed 20 young people aged 11–19 years (11 female and nine male) with continence problems (daytime wetting, bedwetting, and/or soiling). Interviews were conducted by Skype (n = 11) and telephone (n = 9). Transcripts were analysed using inductive thematic analysis.

Results

We generated five main themes: (1) Boundaries of disclosure: friends and teachers; (2) Social consequences of avoidance and deceit; (3) Strict and oblivious gatekeepers; (4) Intimate actions in public spaces; and (5) Interrupted learning.

Conclusion

Disclosure of continence problems at school to both friends and teachers was rare, due to the perceived stigma and fears of bullying and social isolation. The lack of disclosure to teachers and other school staff, such as pastoral care staff, creates challenges in how best to support these young people. Young people with continence problems require unrestricted access to private and adequate toilet facilities during the school day. There is a need for inclusive toilet access policies and improved toilet standards in schools. Addressing the challenges faced by young people with continence problems at school could help to remove the barriers to successful self‐management of their symptoms. It is particularly concerning that young people with continence problems are at higher risk of academic underachievement. Increased support at school is needed to enable young people with continence problems to achieve their academic potential.

'What does that mean?': a qualitative exploration of the primary and secondary clinical care experiences of young people with continence problems in the UK

OBJECTIVES

To explore the clinical care experiences of young people with continence problems.

DESIGN

In-depth semistructured qualitative interviews were conducted by Skype and telephone, with the addition of art-based participatory research techniques. Transcripts were analysed using inductive thematic analysis.

SETTING

Primary and secondary care in the UK.

PARTICIPANTS

We interviewed 20 participants (9 females, 11 males) aged 11-20 years. There were six participants with bedwetting alone, five with daytime wetting alone, five with combined (day and night) wetting and four with soiling.

RESULTS

We identified four themes: appointment experiences, treatment experiences, engagement with treatment and internalisation and externalisation of the continence problem. Patient-focused appointments using age-appropriate language were highly desirable. Continuity of care was highlighted as an important aspect of positive clinical experiences; however, this was found to be rare with many participants seeing a different person on each visit. Participants had tried a wide range of treatments for their continence problems with varying degrees of success. Relapse and treatment failure were common. Experiencing relapse was distressing and diminished participants' belief in the success of future treatments and undermined adherence. Participants would be seen to adopt two opposing coping strategies for dealing with their continence problem- internalisation and externalisation.

CONCLUSION

Incontinence in young people is challenging to manage. Young people may need to try a range of treatments before their symptoms improve. Due to challenges in treatment, there is an increased risk of poor adherence. During patient-focused appointments, clinicians should work to build rapport with patients and use age-appropriate language. Involving young people in their own care decisions is important. The way in which young people understand their continence problem can influence their coping strategies and adherence to treatment regimes.