Tag Archives: incontinence

Bedwetting in the Older Child:

5 Oct

Punishable by death?

In August of this year, the Dallas Morning News reported that a 10-year old boy died in late July of dehydration after his parents deprived him of water to discipline him for wetting the bed. The boy’s father, Michael Ray James, 42, and his wife, stepmother Tina Maria Alberson, also 42, were arrested and charged with injury to a child causing serious bodily injury. Depending on the outcome of trial, sentencing and punishment, they could be imprisoned for up to 99 years for the crime.

The charge stems from the death of the boy after an autopsy revealed the child died from dehydration while being punished. Alberson’s bond is set at $150,000; James is $100,000. According to online reports, both are currently being held at the Lew Sterrett Justice Center. While the two had previously encountered problems with the child custody authorities, nothing had been proven to warrant removal of their children from them, according to reports.

Their son, Johnathan James, died on July 25. He wasn’t tied up or beaten as we often hear in child abuse stories. Instead, it seems the boy was forced to stand still for long periods of time, and not allowed anything to drink—not even a teaspoon of water, for five long days during the intense heat wave gripping Texas and The South throughout the summer. The James’ home does not have central air conditioning. And the child was forced to eat peanut butter, found stuck in his throat because of insufficient beverages upon his death and discovery by health care personnel upon autopsy.

At the time, Alberson told police the boy had complained of being hot and she had tried to cool him by putting him into a tub of cold water. Authorities initially thought the boy had died from heat exhaustion, but his death went unexplained until his autopsy revealed foul play. The boy’s grandmother is very concerned for the twin brother who saw his brother collapse and now wishes he had been able to sneak him a drink.

It’s not the first time we at the National Association For Continence (NAFC) have heard of a grandmother’s concern. In fact, I have personally spoken to grandmothers who telephoned our headquarters expressing serious concern about the physical and emotional abuse their grandchildren were being subjected to because of bedwetting. I have referred them, on occasion, to social services and other local authorities including the police.

It happens to be the #1 search term that brings people to our website, not for babies but for unresolved problems in older children and even young adults. Read what we have to offer in the way of guidance and information. Most parents are ill-informed and react with frustration, anger, or acceptance, none of which are helpful to the child.

Nocturnal enuresis, or bedwetting while sleeping at night, affects over 5 million children in the United States. In population-based cross-sectional studies on children between 6 and 12 years of age, a prevalence of 0.2-9.0% (daytime incontinence), 1.5-2.8% (combined daytime and nighttime incontinence), and 1.5-8.9% nocturnal enuresis, respectively, have been reported in published research. It is well known that nocturnal enuresis resolves over time. Every year 15% of those suffering from bedwetting become dry without treatment. But bedwetting also appears to run in families, and young people who suffer from bedwetting as children are more likely than others to have problems with incontinence later in life as adults.

Before discussing the treatment of nocturnal enuresis, there are two important things to keep in mind. First, children do not wet the bed on purpose. Second, most pediatricians do not consider bedwetting to be a problem until a child is at least six years of age. A recent study showed a significant communication breakdown between parents and doctors on this issue. While 80% of parents want healthcare providers to discuss bedwetting, most feel uncomfortable initiating the discussion themselves. Furthermore, 68% of parents said their children’s doctor has never asked about bedwetting at routine visits. Therefore, parents need to be more proactive by asking for help if they have a child who is wet at night. And they MUST be involved in the remedy. The most successful intervention strategies, with or without sophisticated bed alarms, require the parent’s involvement and positive reinforcement.

Bedwetting by the older child is a common and embarrassing problem that can greatly affect children and families. Life at summer camp, for the camper and the counselors, can be a disaster and is major problem summer camps are forced to address. It is neither the fault of the child nor the parent. Despite the frustrations that families have to endure, many parents do not raise the issue with their health care providers. The most important thing to remember is that with care and perseverance, nocturnal enuresis is a problem that can be successfully treated.

Nancy Muller, Ph.D.
Executive Director,
National Association for Continence


New CDC Guide to Infection Prevention in Outpatient Settings

14 Jun

The Centers for Disease Control and Prevention (CDC) released in May its Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care.  Specific sections of the publication, with links to full guidelines and source documents, are devoted to needed resources including staff education and training as well as standards for the monitoring and reporting of infections.  Existing standard precautions are, of course, included, such as hand hygiene, personal protective equipment, injection safety, and cleaning and disinfection of environment and medical equipment.

Outpatient settings are the CDC’s focus because of the rapid shift from inpatient to ambulatory care settings.  Three-quarters of all surgeries in the U.S. are now performed on an outpatient basis, and more than a million cancer patients receive outpatient chemotherapy, radiation therapy or both.  Kidney dialysis is outpatient and so is a significant portion of all diagnostic procedures across service lines.

One such section is a separate guideline for prevention of catheter-associated urinary tract infections (CAUTI).  The document updates and expands the original CDC Guideline published in 1981.  To evaluate the evidence in the intervening 28 years on preventing CAUTI, the authors examined data addressing three key questions and related sub-questions:

  1. Who should receive urinary catheters?  When is catheterization necessary and who is at risk for CAUTI?
  2. For those who may require urinary catheters, what are the best practices in terms of approaches, types of catheters and collection systems, management techniques, and quality improvement programs?
  3. What are the best practices for preventing CAUTI associated with obstructed urinary catheters?

Providers in the acute care hospital setting are strictly instructed to insert urinary catheters using aseptic technique and sterile equipment.  Routine use of antiseptic lubricants is not necessary.  However, in the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is considered an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization, although the CDC recommendations state that further research is needed on optimal cleaning and storage methods for catheters re-used for clean intermittent catheterization.  This recommendation is based on category level IA evidence (p. 12).  Hydrophilic catheters are considered preferable to standard catheters for patients requiring intermittent catheterization, although this was based on very low level evidence.  Silicone might be preferable to other catheter materials, although this statement is not definitive.

Although there is not a cross reference found in the CDC’s publication to the 2009 policy change announced by the Centers for Medicare and Medicaid (CMS) commencing coverage for single use, sterile catheters, it is this patient advocate’s opinion that those at highest risk of infection and those already witnessing recurrent UTIs (four or more a year) should be provided access with insurance coverage to sterile devices regardless of the CDC’s recommendations.

Practical instructions are included as well.  Unobstructed urine flow is to be maintained by keeping the catheter and collecting tube free from kinking and keeping the collecting bag below the level of the bladder at all times.  The bag should not be rested on the floor to avoid contamination.  The collection bag should be emptied regularly using a separate, clean collecting container for each patient and splashing should be avoided.  The drainage spigot should not be put in contact with the non-sterile collection container.

The CDC publication also attempts to dispel myths and unsupported actions.  For example, routine irrigation of the bladder with antimicrobials is not recommended, nor is routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags (p. 14). Nor should the periurethral area be cleaned with antiseptics with the goal of preventing CAUTI while the catheter is in place.  Routine hygiene during daily bathing or showering, including cleansing of the meatal surface, is appropriate and considered standard care (p. 13).

Particularly for men with serious urine retention resulting from a distended bladder caused by an enlarged prostate gland blocking urine flow through the urethra, these latest guidelines are worthy of study so that advice and product guidance from providers is consistent with these recommendations.  Those facing catheterization while hospitalized should be sure the facility’s practices are compliant with this CDC publication.  Every provider should practice with quality improvement programs that include a system of alerts and reminders to patients assessing the need for continued catheterization, guidelines and protocols for nurses to remove unnecessary urinary catheters, education and performance feedback on hygienic practices, and guidelines in place for catheter management after placement.

Price’s Passing for HC

22 Feb

In January 2011, Reynolds Price, distinguished James B. Duke Professor of English at Duke University and longtime member of the American Academy of Arts and Letters, passed away at age 77. He had authored dozens of books, inspired thousands of students as well as colleagues and others on and beyond the Duke campus, and was revered as a highly skilled novelist, memorable Southern storyteller, and unmatched creative writer. A North Carolina native, Price graduated summa cum laude from Duke in 1955 and returned in 1958 after studying in Oxford as a Rhodes Scholar, with peers as notable as W. H. Auden, as a Duke University faculty member for the next 53 years.
Duke President Richard H. Brodhead commented upon his passing, “Reynolds was a part of the soul of Duke; he loved this university and always wanted to make it better. We can scarcely imagine Duke without Reynolds Price.”1
Price became confined to a wheelchair in 1984 when a cancerous tumor in his spinal cord left him paralyzed from the waist down. “The fact that my legs were subsequently paralyzed by 25 X-ray treatments … was a mere complexity in the ongoing narrative which God intended me to make of my life,” he was quoted as saying in an interview with a local newspaper reporter years later. Price’s account of cancer survival is captured poignantly in his 2003 book, “A Whole New Life: An Illness and a Healing.” Having read this book shortly after it was published, I retrieved it from my bookshelf when I heard the announcement of his death on NPR morning news because I wanted to reread Price’s account of his “mid-life collision with cancer and paralysis”. It is one man’s record – through a ten-year recollection – of how a person confronts a life-altering trial of unimaginable proportions and comes out of the experience transformed, with a new but very different life. He offers the book to those facing their own trials, those caring for someone who is undergoing such turmoil and stress, and those of us awaiting our own, yet unknown “devastation”. I highly recommend it to anyone.
Some people who lose control over their bladder or bowels may have found themselves in such circumstances because of a single event, such as in the immediate aftermath from surgical removal of a cancerous prostate. One day, you feel fairly normal as you’re getting along with life, and the next day you’re soiling your clothes because of the surgical trauma inflicted upon tissue, vessels, and nerves. For many others, it is not so sudden. The symptoms come on gradually, almost invisibly, until one day you realize that the symptoms of urgency or leakage are taking over your life instead of you controlling it. Knowing how others have maneuvered the road to wellness and mastery over symptoms, even if it’s just to be able to manage the symptoms rather than eliminate them, requires patience and perseverance. But it also takes the coaching and encouragement of others. In this book, Price writes of his friendships tenderly because they comfort him, they energize him, and they uplift him.
Online forums do that too. Find one that works for you. Let NAFC connect you. On the NAFC web site, there is a group just for men and another one for women. There’s even one just for those concerned with bowel control issues. It’s a private meeting place where you can get and give advice to comfort, energize, and uplift others. Working together, you can discover a whole new life, just as Reynolds Price did.
Nancy Muller, PhD

1 http://news.duke.edu/reynoldsprice/, accessed online 27 January 2010