Section 2 - Child health checks

Health check recommendations

• All children from birth to 6 months, then 4 and 7 years of age

1. Procedure

• Ask the parent or child the age appropriate questions. See Table 1.
• Children from birth to 6 months are checked for elimination issues. 4 and 7 year olds are checked for continence
• Children 6 months–3 years are developing bladder and bowel control; incontinence is normal. Only assessed if parent has concerns
• Provide brief intervention and resources
• If a child requires follow-up place on a recall register and refer as necessary

2. Results

• Be mindful that incontinence in children can also be attributed to urinary tract infections or sexual abuse
• If a continence issue is identified provide brief intervention and make a referral to an appropriate source

3. Brief intervention

1. Birth to < 6 months of age ^1–4
   • Breastfed children will have one or more dirty nappies every 7–10 days
   • Bottle-fed children should have a dirty nappy daily to every few days
   • < 6 months of age babies have 5 wet nappies per day, 8 for cloth nappies:
     • the urine should be a pale straw colour
     • the smell should not be offensive
   • Provide Resource 1. See Diet and nutrition
2. Children 6 months–3 years ^1–4
   • Provide toilet training resources. See Resources 2–9.
3. Children 4 years and 7 years old ^1–4
   • Main parental concerns are the social-emotional impacts on their child including embarrassment and low self esteem. Reassure parents:
     • bedwetting or soiling is not a child’s fault
     • night time bed wetting (nocturnal enuresis) is common including:
       • 20% of 5 year olds; 1–3% of children will have faecal soiling
       • 10% of 10 year olds
       • 3% of 15–17 year olds
     • most incontinence is due to developmental, environmental or emotional factors; rarely anatomical defects
     • continence improves with age
     • daytime wetting is more common in girls, night time more common in boys
     • most children will gain daytime bladder control by 4 years old
   • Provide support Resources 2–7.
   • Provide Resource 7. to parents of children with disabilities not toileting independently

4. Referral^1–4

• See Child safety reporting for a toilet trained child who suddenly starts to soil or bedwet again
• If the child has painful urination, chronic diarrhoea, acute gastroenteritis, dehydration or constipation refer to the Primary Clinical Care Manual
• For children < 6 months of age, refer to the MO/NP or child health nurse if:
  • urine colour is dark yellow or the baby is having < 5 wet nappies a day despite encouraging more fluids or breastfeeding
  • faeces are foul smelling, watery, discoloured (white, green, or bloodstained) or hard
  • any parental concerns
• Refer children < 6 years of age with elimination or behaviour related continence concerns to:
  • a child health nurse or
  • local continence program
• Refer children < 6 years of age with a disability or autism where toilet training difficulties are anticipated to:
  • continence services (Resource 9.) or
  • the local child development unit or allied health service
• Refer children > 4 years of age to continence services if child:
  • suddenly starts bedwetting, who has normally been dry
  • is impacted socially, makes them upset or angry, or they want to become dry
  • > 4 years of age regularly wets during the day
  • > 4 years has regular faecal soiling (skid marks or larger amounts of faeces)
  • is successfully toilet trained then starts to soil again
• If the parent has any concerns refer to the MO/NP

5. Follow-up

• Place the child on a recall register to monitor continence if required
• Ensure all referrals are actioned
• Provide the parent with details for the next scheduled follow-up appointment

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. Australian Breastfeeding Association
2. The Continence Foundation of Australia
3. Australian Government Bladder and Bowel website
4. Bedwetting in children
5. Faecal soiling in children
6. Tips for bedwetting children who want to enjoy a sleep over
7. eric: The Children’s Bowel and Bladder Charity
8. One Step at a Time - A parent’s guide to toilet skills for children with disability
9. Child continence advisory service