Flowchart - Daytime Bladders Every child must be fully assessed using the appropriate Continence Assessment Form. If daytime bladder problems are identified, follow the flowchart below to ensure the child receives the correct assessment, treatment and management. The ‘pop-up’ information boxes suggest who might deliver each intervention. In England the local CCG (Clinical Commissioning Group) can clarify who is commissioned to do so. Information to support the commissioning of children’s continence services can be found in the PCF’s Paediatric Continence Commissioning Guide. In Scotland and Wales, ask your GP, Health Visitor or School Health Nurse for advice on who provides local continence care. Back to the Children's General Continence Flowchart Daytime bladder problems identified by GP If symptoms of constipation present follow Flowchart for Constipation before addressing daytime bladder problems GP to inform/refer to School Health Nursing / Health Visiting / Children's Community Nursing / Learning Disability Team Daytime bladder problems identified by School Health Nursing / Health Visiting / Children's Community Nursing / Learning Disability Team If symptoms of constipation present follow Flowchart for Constipation before addressing daytime bladder problems Child to be referred to GP DEMYSTIFICATION Discuss causes Explain symptoms Discuss treatments Explain prognosis CHILD TO BE ASSESSED for underlying organic cause: Perform urinalysis to exclude Urinary Tract Infection (UTI) / Diabetes mellitus Check lower limb neurology and appearance of spine to exclude neurological link e.g. spinal anomaly Constant dribbling of urine is never functional Check for abdominal mass/large bladder Check for faltering growth WHO DOES THIS?Physical examinations are usually performed by doctors – this might be your GP, school doctor or paediatrician. Some nurse specialists/practitioners also do physical examinations If present refer or treat as appropriate No concerns If confirmed UTI may need renal ultrasound scan (USS) – include post void residual INITIAL ADVICE: Demystify, reassure, educate Provide leaflet ERIC’s Guide to Children's Daytime Bladder Problems Fluid optimisation – 6-8 drinks/day – offer Drinking Reward Chart Promote water, milk in moderation, well diluted fruit juice/squash Avoid caffeinated drinks Limit carbonated drinks, artificial colourings/flavourings Observe effect of blackcurrant/orange Toileting advice – 4-7 voids/day – offer Toileting Reward Chart Advise on rewards for compliance Signpost to ERIC for further information/reassurance and advice on absorbent pants, children’s disposable pads etc WHO DOES THIS?The information may be provided by the School Health Nurse / Health Visiting / Children’s Community Nursing / Learning Disability Team and/or ERIC NICE Guidelines: Urinary Tract Infection in Children Pre-school age School age Reassure that functional daytime bladder problems are common in young children. Most spontaneously resolves as the bladder matures. Advise to continue to follow above advice and to liaise with Health Visitor No progress after implementation of initial advice Symptoms improved Provide information and leaflets as appropriate and discharge Refer to School Health Nurse if not yet seen Ask family to complete Intake/Output Chart over three days Discuss, explain and offer treatment options Consider prescribing anti-cholinergic e.g. Oxybutynin IF no suspicion of incomplete bladder emptying Use Lyrinel XL if child can swallow tablets WHO DOES THIS?Anti-cholinergics are usually prescribed by the GP or paediatrician. Some nurses prescribe too. The information may be provided by them but may be supplemented by the School Health Nurse / Health Visiting / Children’s Community Nursing / Learning Disability Team and/or ERIC Symptoms improved Symptoms ongoing Provide information and leaflets as appropriate and discharge. If child is commenced on an anti-cholinergic GP to review every six months. Refer to Paediatric Continence Service or equivalent local service using Referral Form