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Bedwetting in children and young people

About

What is covered

This pathway covers the assessment and management of bedwetting in children and young people.
It applies to children and young people up to 19 years with the symptom of bedwetting. There is no minimum age limit to allow consideration of the benefit of interventions in younger children (under 7 years) previously excluded from treatment.
The term bedwetting is used to describe the symptom of involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology.
The causes of bedwetting are not fully understood. There are a number of different disturbances of physiology that may be associated with bedwetting, such as sleep arousal difficulties, polyuria and bladder dysfunction. It often runs in families.
The treatment of bedwetting has a positive effect on the self-esteem of children. Healthcare professionals should persist in offering treatment if the first-choice treatment is not successful.

Updates

Updates to this pathway

13 July 2016 Diabetes in children and young people (NICE quality standard 125) added to this pathway.
17 September 2014 Bedwetting in children and young people (NICE quality standard 70) added to this pathway.
22 July 2014 Link added to constipation pathway.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on assessing and managing bedwetting (nocturnal enuresis) in children and young people under 19 in an interactive flowchart

What is covered

This pathway covers the assessment and management of bedwetting in children and young people.
It applies to children and young people up to 19 years with the symptom of bedwetting. There is no minimum age limit to allow consideration of the benefit of interventions in younger children (under 7 years) previously excluded from treatment.
The term bedwetting is used to describe the symptom of involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology.
The causes of bedwetting are not fully understood. There are a number of different disturbances of physiology that may be associated with bedwetting, such as sleep arousal difficulties, polyuria and bladder dysfunction. It often runs in families.
The treatment of bedwetting has a positive effect on the self-esteem of children. Healthcare professionals should persist in offering treatment if the first-choice treatment is not successful.

Updates

Updates to this pathway

13 July 2016 Diabetes in children and young people (NICE quality standard 125) added to this pathway.
17 September 2014 Bedwetting in children and young people (NICE quality standard 70) added to this pathway.
22 July 2014 Link added to constipation pathway.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Bedwetting in under 19s (2010) NICE guideline CG111
Diabetes in children and young people (2016) NICE quality standard 125
Bedwetting in children and young people (2014) NICE quality standard 70

Quality standards

Bedwetting in children and young people

These quality statements are taken from the bedwetting in children and young people. The quality standard defines clinical best practice in bedwetting in children and young people and should be read in full.

Quality statements

Assessment

This quality statement is taken from the nocturnal enuresis (bedwetting) in children and young people quality standard. The quality standard defines clinical best practice in nocturnal enuresis (bedwetting) in children and young people and should be read in full.

Quality statement

Children and young people who are bedwetting have a comprehensive initial assessment.

Rationale

A number of factors can cause or contribute to bedwetting in children and young people that may affect their treatment and support needs. A comprehensive initial assessment will ensure the plan for managing bedwetting meets the child’s or young person’s needs and helps parents or carers to cope with bedwetting.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people who are bedwetting have a comprehensive initial assessment.
Data source: Local data collection.
Process
Proportion of children and young people who are bedwetting who have a comprehensive initial assessment.
Numerator – the number in the denominator who have a comprehensive initial assessment.
Denominator – the number of children and young people presenting with a new episode of bedwetting.
Data source: Local data collection. Data on the recording of the assessment can be collected using the NICE nocturnal enuresis audit support (criteria 1 and 2).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and NHS trusts) ensure that they have clear policies to train and support healthcare professionals to carry out comprehensive initial assessments for children and young people who are bedwetting.
Healthcare professionals (such as GPs, school nurses and community nurses) undertake a comprehensive initial assessment of children and young people who are bedwetting.
Commissioners (such as clinical commissioning groups, local authorities and NHS England area teams) ensure that the services they commission have sufficient healthcare professionals competent in carrying out comprehensive initial assessments for bedwetting.

What the quality statement means for children, young people, parents and carers

Children and young people who are bedwetting have an assessment in which they (and their parents or carers if appropriate) are asked questions to help work out what is happening, what might be causing it, and to find out more about any other relevant problems they might have.

Source guidance

Definitions of terms used in this quality statement

Comprehensive initial assessment
A comprehensive initial assessment of bedwetting includes the pattern of bedwetting and related factors such as fluid intake, toileting pattern and daytime symptoms, together with possible medical, emotional or physical triggers and individual needs that may have an impact on treatment and support. Physical factors such as constipation, urinary tract infection and diabetes should be identified and treated, and the impact of current medication considered. Other wider social, family, emotional and developmental issues should also be explored to ensure the plan for managing bedwetting meets individual needs and enables the family to cope with bedwetting. Healthcare professionals should consider possible maltreatment if parents or carers are thought to regard the bedwetting as deliberate, there is evidence of punitive treatment or if bedwetting does not resolve in a child or young person who was previously dry, unless a physical or emotional trigger can be identified. [Adapted from NICE clinical guideline 111, recommendations 1.3.1 to 1.3.19]

Equality and diversity considerations

Healthcare professionals should take into consideration the cultural and communication needs of children and young people (and their parents or carers if appropriate) when assessing children and young people with bedwetting.
Healthcare professionals should fully assess bedwetting in children and young people with developmental or learning difficulties or physical disabilities because symptoms can be improved with the correct support and treatment.
The quality statement does not cover children younger than 5 years. The decision about whether to formally manage bedwetting in children younger than 5 years would be a clinical judgement; it would not be appropriate in all cases.

Review after initial advice is given

This quality statement is taken from the nocturnal enuresis (bedwetting) in children and young people quality standard. The quality standard defines clinical best practice in nocturnal enuresis (bedwetting) in children and young people and should be read in full.

Quality statement

Children and young people have an agreed review date if they, or their parents or carers, are given advice about changing their daily routine to help with bedwetting.

Rationale

It may be appropriate to offer initial advice to children and young people, and their parents or carers, about making changes to their daily routine based on the comprehensive initial assessment of bedwetting. This could include advice on fluid intake, diet and toileting patterns, as well as approaches to lifting and waking, and reward systems. It is important to agree a date to review progress to avoid children and young people continuing with the agreed plan indefinitely with no real improvement in their bedwetting.

Quality measures

Structure
Evidence of local arrangements to ensure that a review date is agreed for children and young people if they, or their parents or carers, are given advice about changing their daily routine to help with bedwetting.
Data source: Local data collection.
Process
Proportion of children and young people who have an agreed review date if they, or their parents or carers, are given advice about changing their daily routine to help with bedwetting.
Numerator – the number in the denominator who have an agreed review date.
Denominator – the number of children or young people who are given advice about changing their daily routine to help with bedwetting.
Data source: Local data collection.
Outcome
Detection of unresolved bedwetting in children and young people who are given initial advice.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and NHS trusts) ensure that systems are in place for a review date to be agreed for children and young people if they, or their parents or carers, are given advice about changing their daily routine to help with bedwetting.
Healthcare professionals (such as GPs, school nurses and community nurses) agree a review date for children and young people if they, or their parents or carers, are given advice about changing their daily routine to help with bedwetting.
Commissioners (such as clinical commissioning groups, local authorities and NHS England area teams) ensure that they commission services from providers who agree a review date for children and young people if they, or their parents or carers, are given advice about changing their daily routine to help with bedwetting.

What the quality statement means for children, young people, parents and carers

Children and young people who are bedwetting who are given advice about changing their daily routine to help with bedwetting (or whose parents or carers are given advice) have an agreed date to review how they are getting on and if any other treatment is needed.

Source guidance

  • Nocturnal enuresis (NICE clinical guideline 111), recommendations 1.5.1 to 1.5.7, 1.6.1, and 17.1 to 1.7.3.

Definitions of terms used in this quality statement

Advice about changing their daily routine
This involves providing information and advice on fluid intake, toileting, lifting and waking and the use of reward systems. [Adapted from NICE clinical guideline 111 recommendations 1.5 to 1.7]
Equality and diversity considerations
Healthcare professionals should take into consideration the cultural and communication needs of children and young people (and their parents or carers if appropriate) when carrying out a review.
Healthcare professionals should fully assess bedwetting in children and young people with developmental or learning difficulties or physical disabilities because symptoms can be improved with the correct support and treatment.
The quality statement does not cover children younger than 5 years. The decision about whether to formally manage bedwetting in children younger than 5 years would be a clinical judgement; it would not be appropriate in all cases.

Initial treatment

This quality statement is taken from the nocturnal enuresis (bedwetting) in children and young people quality standard. The quality standard defines clinical best practice in nocturnal enuresis (bedwetting) in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers if appropriate, have a discussion about initial treatment if bedwetting has not improved after changing their daily routine.

Rationale

The choice of initial treatment should be informed by the comprehensive initial assessment, and should take into account the preference of the child or young person and, if appropriate, their parents or carers. Factors such as age, associated functional difficulties and disabilities, financial burdens and living situations may affect their preferences. Discussing the initial treatment options with their healthcare professional will ensure that children and young people, and their parents or carers if appropriate, are able to make an informed decision about which treatment will meet their specific needs.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people, and their parents or carers if appropriate, have a discussion about initial treatment if bedwetting has not improved after changing their daily routine.
Data source: Local data collection.
Process
Proportion of children and young people whose bedwetting has not improved after changing their daily routine who have a recorded discussion (including their parents or carers if appropriate) about initial treatment.
Numerator – the number in the denominator who have a recorded discussion (including their parents or carers if appropriate) about initial treatment.
Denominator – the number of children and young people whose bedwetting has not improved after changing their daily routine.
Data source: Local data collection.
Outcome
Children, young people and their parents or carers are actively involved in decisions about their care.
Data source: Local data collection. The NHS England GP Patient Survey asks how good the GP was in involving people in decisions about their care (this is not specific to bedwetting in children and young people).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and NHS trusts) ensure that systems and policies are in place for healthcare professionals to discuss initial treatment with children and young people, and their parents or carers if appropriate, if bedwetting has not improved after changing their daily routine.
Healthcare professionals (such as GPs, school nurses and community nurses) discuss initial treatment with children and young people, and their parents or carers if appropriate, if bedwetting has not improved after changing their daily routine.
Commissioners (such as clinical commissioning groups, local authorities and NHS England area teams) ensure that the services they commission have policies that include discussion of initial treatment with children and young people, and their parents or carers if appropriate, if bedwetting has not improved after changing their daily routine.

What the quality statement means for children, young people, parents and carers

Children and young people with bedwetting that hasn’t improved after changing their daily routine (and their parents or carers if appropriate) discuss possible treatment (such as a bedwetting alarm or medication) with their healthcare professional.

Source guidance

  • Nocturnal enuresis (NICE clinical guideline 111), recommendations 1.4.1 to 1.4.5, 1.8.1, 1.10.1 and 1.10.2.

Definitions of terms used in this quality statement

Changing their daily routine
This involves making changes to the child or young person’s routine based on information and advice provided on fluid intake, toileting, lifting and waking and the use of reward systems. [Adapted from NICE clinical guideline 111 recommendations 1.5 to 1.7]
Initial treatment for bedwetting
An alarm should be offered as first line treatment unless it is considered undesirable or inappropriate (for example, if bedwetting is very infrequent, that is, less than 1 or 2 wet beds per week, or the parents or carers are having emotional difficulty coping with the burden of bedwetting or are expressing anger, negativity or blame towards the child or young person).
Desmopressin may be offered as initial treatment to children and young people older than 7 years if an alarm is undesirable or inappropriate, or if the priority for the child is to achieve a rapid short term improvement in bedwetting.
Consideration of which initial treatment is most appropriate will depend on the child or young person’s age, the frequency of bedwetting and the motivation and needs of the child or young person and their parents or carers.
An alarm or desmopressin may be considered for children aged 5 to 7 years. The decision about suitable treatment for 5 to 7 year olds should take into account the pattern of bedwetting as well as the child’s ability, maturity, motivation and understanding of an alarm, their wider living circumstances and the views of their parents or carers. [Adapted from NICE clinical guideline 111 recommendations 1.4.5, 1.8.1, 1.8.8, 1.10.1 and 1.10.2]

Equality and diversity considerations

When discussing initial treatment of bedwetting in children and young people with developmental or learning difficulties or physical disabilities, healthcare professionals should be aware that symptoms can be improved with the correct support and treatment.
Initial treatment may be considered for children and young people with developmental or learning difficulties or physical disabilities, tailored to their individual needs and abilities.
The quality statement does not cover children younger than 5 years. The decision about whether to formally manage bedwetting in children younger than 5 years would be a clinical judgement; it would not be appropriate in all cases.

Access to treatment

This quality statement is taken from the nocturnal enuresis (bedwetting) in children and young people quality standard. The quality standard defines clinical best practice in nocturnal enuresis (bedwetting) in children and young people and should be read in full.

Quality statement

Children and young people who are bedwetting receive the treatment agreed in their initial treatment plan.

Rationale

Once a child or young person and, if appropriate, their parents or carers, have made an informed choice about using an alarm or desmopressin as the treatment for bedwetting, this should be agreed in their initial treatment plan. They should then receive the treatment in their plan. Bedwetting can put families under considerable pressure and once they have asked for help they need to receive treatment so they can resolve the problem. Any delay in their agreed treatment being available, for example as a result of local waiting lists or treatment policy, may put families under unnecessary pressure and have a negative impact on the outcomes for the child or young person.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people who are bedwetting receive the treatment agreed in their initial treatment plan.
Data source: Local data collection.
Process
a) Proportion of children and young people who are bedwetting who receive the treatment agreed in their initial treatment plan.
Numerator – the number in the denominator who receive the treatment agreed in their initial treatment plan.
Denominator – the number of children and young people who are bedwetting who have an initial treatment plan.
Data source: Local data collection.
b) Waiting times to receive initial treatment for bedwetting.
Data source: Local data collection.
Outcome
Patient satisfaction with the availability of initial treatment for bedwetting.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and NHS trusts) ensure that they have appropriate policies and resources to support healthcare professionals to agree initial treatment plans for bedwetting and to provide the treatment agreed in those plans.
Healthcare professionals (such as GPs, school nurses and community nurses) ensure that children and young people who are bedwetting have an initial treatment plan and receive the treatment agreed in their plan.
Commissioners (such as clinical commissioning groups, local authorities and NHS England area teams) ensure that they commission services with policies and resources to enable children and young people who are bedwetting to have an initial treatment plan and to receive the treatment agreed in their plan. This includes ensuring that services provide enough suitable alarms for bedwetting to meet demand.

What the quality statement means for children, young people, parents and carers

Children and young people who are bedwetting have an agreed plan for their treatment (such as using a bedwetting alarm or taking medication) and are able to get the treatment in their plan.
Source guidance
  • Nocturnal enuresis (NICE clinical guideline 111), recommendations 1.4.5, 1.8.1, 1.10.1 and 1.10.2.

Definitions of terms used in this quality statement

Initial treatment for bedwetting
An alarm should be offered as first line treatment unless it is considered undesirable or inappropriate (for example, if bedwetting is very infrequent, that is, less than 1 or 2 wet beds per week, or the parents or carers are having emotional difficulty coping with the burden of bedwetting or are expressing anger, negativity or blame towards the child or young person).
Desmopressin may be offered to children and young people older than 7 years if an alarm is undesirable or inappropriate, or if the priority for the child is to achieve a quick short term improvement in bedwetting.
Consideration of which initial treatment is most appropriate will depend on the child or young person’s age, the frequency of bedwetting and the motivation and needs of the child or young person and their parents or carers.
An alarm or desmopressin may be considered for children aged 5 to 7 years. The decision about suitable treatment for 5- to 7 year olds should take into account the pattern of bedwetting as well as the child’s ability, maturity, motivation and understanding of an alarm, their wider living circumstances and the views of their parents or carers. [Adapted from NICE clinical guideline 111 recommendations 1.4.5, 1.8.1, 1.8.8, 1.10.1 and 1.10.2]
Equality and diversity considerations
Although some parents and carers may be willing and able to buy an alarm for their child, this should not be assumed. Children and young people whose parents or carers cannot afford to buy an alarm should not be disadvantaged by having to wait before they can get access to this treatment.
The type of alarm should be selected to meet the specific needs of children and young people with developmental or learning difficulties or physical disabilities.
The quality statement does not cover children younger than 5 years. The decision about whether to formally manage bedwetting in children younger than 5 years would be a clinical judgement; it would not be appropriate in all cases.

Access to specialist review

This quality statement is taken from the nocturnal enuresis (bedwetting) in children and young people quality standard. The quality standard defines clinical best practice in nocturnal enuresis (bedwetting) in children and young people and should be read in full.

Quality statement

Children and young people whose bedwetting has not responded to courses of initial treatments are referred for a specialist review.

Rationale

If bedwetting in children and young people does not respond to courses of initial treatments, referral should be made for a specialist review so that the factors associated with a poor response (for example, overactive bladder, underlying disease, or social and/or emotional issues) can be assessed. Services that provide specialist reviews after courses of initial treatments have been tried for bedwetting may help to reduce the number of inappropriate hospital referrals, which will benefit the child or young person and may reduce costs.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people whose bedwetting has not responded to courses of initial treatments can access a specialist review.
Data source: Local data collection.
Process
Proportion of children and young people whose bedwetting has not responded to courses of initial treatments who are referred for a specialist review.
Numerator – the number in the denominator referred for a specialist review.
Denominator – the number of children and young people whose bedwetting has not responded to courses of initial treatments.
Data source: Local data collection.
Outcome
Reduction in inappropriate hospital referrals.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and NHS trusts) ensure that healthcare professionals are aware of agreed referral pathways to access a specialist review for bedwetting.
Healthcare professionals (such as GPs, school nurses and community nurses) refer children and young people who are bedwetting for specialist review if their bedwetting does not respond to courses of initial treatments.
Commissioners (such as clinical commissioning groups, local authorities and NHS England area teams) ensure that they commission services to provide specialist reviews for bedwetting with agreed referral pathways from primary care.

What the quality statement means for children, young people, parents and carers

Children and young people with bedwetting that hasn’t improved after trying initial treatments (such as a bedwetting alarm and/or medication) are referred to a specialist who can provide extra support.

Source guidance

Definitions of terms used in this quality statement

Bedwetting that has not responded
Bedwetting has not responded to treatment if the child has not achieved 14 consecutive dry nights or a 90% improvement in the number of wet nights per week. The response to treatment should be assessed as follows:
  • The response to an alarm or desmopressin should be assessed at 4 weeks. If there are no early signs of response (smaller wet patches, fewer wetting episodes per night or fewer wet nights), treatment should be reviewed.
  • Children and young people should continue treatment for 3 months if there are early signs of a response at 4 weeks. If complete dryness is not achieved after 3 months, treatment should be reviewed.
  • Treatment with an alarm should only continue after 3 months if the bedwetting is still improving and the child or young person, and their parents or carers if appropriate, are motivated to continue. Bedwetting may continue to improve for up to 6 months with desmopressin but treatment should be withdrawn for 1 week after 3 months to check if dryness has been achieved.
[Adapted from NICE clinical guideline 111, recommendations 1.8.2, 1.8.4, 1.10.6, 1.10.11 and 1.11.3]
Courses of initial treatments
An alarm should be offered as first line treatment unless it is considered undesirable or inappropriate (for example, if bedwetting is very infrequent, that is, less than 1 or 2 wet beds per week, or the parents or carers are having emotional difficulty coping with the burden of bedwetting or are expressing anger, negativity or blame towards the child or young person).
Desmopressin may be offered to children and young people older than 7 years if an alarm is undesirable or inappropriate, or if the priority for the child is to achieve a quick short term improvement in bedwetting.
Consideration of which initial treatment is most appropriate will depend on the child or young person’s age, the frequency of bedwetting and the motivation and needs of the child or young person and their parents or carers.
An alarm or desmopressin may be considered for children aged 5 to 7 years. The decision about suitable treatment for 5- to 7 year olds should take into account the pattern of bedwetting as well as the child’s ability, maturity, motivation and understanding of an alarm, their wider living circumstances and the views of their parents or carers.
If bedwetting does not respond to initial alarm treatment, courses of treatment with a combination of alarm and desmopressin and/or desmopressin alone may be offered depending on the response achieved and whether an alarm remains acceptable.
[Adapted from NICE clinical guideline 111 recommendations 1.4.5, 1.8.1, 1.8.8, 1.10.1, 1.10.2, 1.9.1 and 1.9.2]
Specialist review
Children and young people whose bedwetting has not responded to courses of initial treatments should be referred to the next step up in service that provides specialist continence reviews for children and young people (for example, from Level 1 in primary care, which provides basic advice and support, to a Level 2 specialist service that assesses and treats children and young people with more complex needs). The characteristics and setting for this service will depend on local arrangements.
An example of this type of service would be an integrated community paediatric service that treats bladder and/or bowel problems, and is delivered by a multidisciplinary team trained in managing continence problems in children and young people. [Adapted from Paediatric continence commissioning guide – Paediatric Continence Forum (2014)]
Equality and diversity considerations
When referring children and young people for a specialist review, any potential difficulties in accessing services, which may include distance, disability and financial barriers, should be taken into account.
When discussing treatment for bedwetting in children and young people with developmental or learning difficulties or physical disabilities, the healthcare professional should be aware that symptoms can be improved with the correct support and treatment.
The quality statement does not cover children younger than 5 years. The decision about whether to formally manage bedwetting in children younger than 5 years would be a clinical judgement; it would not be appropriate in all cases.

Same-day referral and appointments

This quality statement is taken from the diabetes in children and young people quality standard. The quality standard defines clinical best practice in diabetes in children and young people and should be read in full.

Quality statement

Children and young people presenting in primary care with suspected diabetes are referred to and seen by a multidisciplinary paediatric diabetes team on the same day.

Rationale

Multidisciplinary paediatric diabetes teams can confirm a diagnosis of diabetes and provide immediate care. Children and young people whose diagnosis and care are delayed are at higher risk of diabetic ketoacidosis (DKA), which is life-threatening but preventable.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that children and young people presenting in primary care with suspected diabetes are referred to and seen by a multidisciplinary paediatric diabetes team on the same day.
Data source: Local data collection.
Process
Proportion of children and young people presenting in primary care with suspected diabetes who are referred to and seen by a multidisciplinary paediatric diabetes team on the same day.
Numerator – the number in the denominator who are referred to and seen by a multidisciplinary paediatric diabetes team on the same day.
Denominator – the number of children and young people presenting in primary care with suspected diabetes.
Data source: Local data collection.
Outcome
Presentations of DKA.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care services) ensure that systems are in place for children and young people presenting in primary care with suspected diabetes to be referred to and seen by a multidisciplinary paediatric diabetes team on the same day.
Healthcare professionals (such as GPs) immediately refer children and young people presenting in primary care with suspected diabetes to a multidisciplinary paediatric diabetes team, to be seen on the same day.
Commissioners (NHS England regional teams and clinical commissioning groups) commission services that make sure children and young people presenting in primary care with suspected diabetes are immediately referred to and seen by a multidisciplinary paediatric diabetes team.

What the quality statement means for children and young people and their parents and carers

Children and young people who see their GP with suspected diabetes are immediately referred to and seen by a team that specialises in caring for children and young people with diabetes. The symptoms of diabetes include feeling very thirsty or tired, needing to urinate more often than usual, or recently losing weight without trying to.

Source guidance

Definition of terms used in this quality statement

Suspected diabetes
Recognised symptoms of diabetes in children and young people include one of more of the following: increased thirst, increased urination, excessive tiredness and recent unexplained weight loss. A plasma glucose level above 11 mmol/litre indicates the presence of diabetes.
[Expert consensus and Diabetes UK]

Equality and diversity considerations

Particular care should be taken when communicating with children and young people with diabetes and their family members or carers (as appropriate) if they have, for example:
  • physical, cognitive or sensory disabilities
  • difficulties speaking or reading English.

Education and information

This quality statement is taken from the diabetes in children and young people quality standard. The quality standard defines clinical best practice in diabetes in children and young people and should be read in full.

Quality statement

Children and young people with type 1 or type 2 diabetes are offered a programme of diabetes education from diagnosis that is updated at least annually.

Rationale

Education is essential in enabling self-management of diabetes and reducing the chance of complications. It should start at diagnosis and continue throughout a person’s life. It is important to focus education on core topics and tailor it to the individual needs and learning styles of the child or young person and their family members or carers (as appropriate).

Quality measures

Structure
a) Evidence of local arrangements and written protocols to ensure that children and young people with type 1 diabetes are offered a programme of diabetes education from diagnosis that is updated at least annually.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
b) Evidence of local arrangements and written protocols to ensure that children and young people with type 2 diabetes are offered a programme of diabetes education from diagnosis that is updated at least annually.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
Process
a) Proportion of children and young people with type 1 diabetes who are offered a programme of diabetes education from diagnosis that is updated at least annually.
Numerator – the number in the denominator who receive a programme of diabetes education from diagnosis that is updated at least annually.
Denominator – the number of children and young people with type 1 diabetes.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
b) Proportion of children and young people with type 2 diabetes who are offered a programme of diabetes education from diagnosis that is updated at least annually.
Numerator – the number in the denominator who receive a programme of diabetes education from diagnosis that is updated at least annually.
Denominator – the number of children and young people with type 2 diabetes.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
Outcome
a) Quality of life.
Data source: Local data collection.
b) HbA1c level of 48 mmol/mol or lower.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
c) Satisfaction of children, young people and their family members or carers (as appropriate) with the education intervention.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care diabetes services for children and young people) ensure that systems are in place to offer children and young people with type 1 or type 2 diabetes and their family members or carers (as appropriate) a programme of diabetes education from diagnosis that is tailored to their individual needs and learning styles and updated at least annually.
Healthcare professionals (such as those providing diabetes services for children and young people) offer children and young people with type 1 or type 2 diabetes and their family members or carers (as appropriate) a programme of diabetes education from diagnosis that is tailored to their individual needs and learning styles and updated at least annually.
Commissioners (NHS England regional teams and clinical commissioning groups) commission services that offer children and young people with type 1 or type 2 diabetes and their family members or carers (as appropriate) a programme of diabetes education from diagnosis that is updated at least annually.

What the quality statement means for children and young people and their parents and carers

Children and young people with type 1 or type 2 diabetes and their family members or carers are offered a programme of diabetes education when they are diagnosed with diabetes. This education should continue throughout their life, and be updated every year.
The programme should teach them what they need to know about their condition and what changes they might need to make now that they have diabetes. This includes clear advice (designed specifically for each child or young person) on what to do when they are ill or have high blood glucose levels.

Source guidance

Definitions of terms used in this quality statement

Programme of diabetes education (type 1 diabetes)
A continuing programme of education that is age appropriate, tailored to need and revisited at least annually. The following core topics should be included from diagnosis:
  • insulin therapy, including its aims, how it works, its mode of delivery and dosage adjustment
  • blood glucose monitoring, including targets for blood glucose control (blood glucose and HbA1c levels)
  • the effects of diet, physical activity and intercurrent illness on blood glucose control
  • managing intercurrent illness (‘sick-day rules’, including monitoring of blood ketones [beta-hydroxybutyrate])
  • detecting and managing hypoglycaemia, hyperglycaemia and ketosis.
[Adapted from Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015) NICE guideline NG18, recommendation 1.2.1 and expert opinion]
Programme of diabetes education (type 2 diabetes)
A continuing programme of education that is age appropriate, tailored to need and revisited at least annually. The following core topics should be included from diagnosis:
  • HbA1c monitoring and targets
  • the effects of diet, physical activity, body weight and intercurrent illness on blood glucose control
  • the aims of metformin therapy and possible adverse effects
  • the complications of type 2 diabetes and how to prevent them.
[Adapted from Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015) NICE guideline NG18, recommendation 1.3.1 and expert opinion]

Equality and diversity considerations

Particular care should be taken when communicating with children and young people with type 1 or type 2 diabetes and their family members or carers (as appropriate) if they have, for example:
  • physical, cognitive or sensory disabilities
  • difficulties speaking or reading English.

Intensive insulin therapy and level 3 carbohydrate-counting education for type 1 diabetes

This quality statement is taken from the diabetes in children and young people quality standard. The quality standard defines clinical best practice in diabetes in children and young people and should be read in full.

Quality statement

Children and young people with type 1 diabetes are offered intensive insulin therapy and level 3 carbohydrate-counting education at diagnosis.

Rationale

The aim of intensive insulin therapy is to reach near-normal blood glucose levels, to reduce the risk of long-term complications and improve quality of life. Dietary management can also improve control of blood glucose and HbA1c levels. When using intensive insulin therapy it is important to match the insulin dose to carbohydrate intake, in line with individualised insulin-to-carbohydrate ratios (level 3 carbohydrate-counting). Children and young people and their family members or carers (as appropriate) should be taught how to do this at diagnosis.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that children and young people with type 1 diabetes are offered intensive insulin therapy and level 3 carbohydrate-counting education at diagnosis.
Data source: Local data collection.
Process
Proportion of children and young people with type 1 diabetes who are offered intensive insulin therapy and level 3 carbohydrate-counting education at diagnosis.
Numerator – the number in the denominator who receive intensive insulin therapy and level 3 carbohydrate-counting education at diagnosis.
Denominator – the number of children and young people with type 1 diabetes.
Data source: Local data collection.
Outcome
a) HbA1c level of 48 mmol/mol or lower.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
b) Quality of life.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care diabetes services for children and young people) ensure that systems are in place to offer intensive insulin therapy and level 3 carbohydrate-counting education at diagnosis to children and young people with type 1 diabetes.
Healthcare professionals (those providing diabetes services for children and young people) offer intensive insulin therapy and level 3 carbohydrate-counting education at diagnosis to children and young people with type 1 diabetes.
Commissioners (NHS England regional teams and clinical commissioning groups) commission services that offer intensive insulin therapy and level 3 carbohydrate-counting education at diagnosis to children and young people with type 1 diabetes.

What the quality statement means for children and young people and their parents and carers

Children and young people with type 1 diabetes are offered intensive insulin therapy (either multiple daily injections or an insulin pump) and level 3 carbohydrate-counting education at diagnosis.
‘Multiple daily injections’ means injecting a long-acting (slow) insulin once or twice a day, and a rapid-acting (fast) insulin before eating. An insulin pump is a small machine connected to your body that gives you insulin throughout the day, so you don't need to inject yourself.
‘Level 3 carbohydrate counting’ means counting the carbohydrates in your food and drink, so you can make sure you are injecting the right amount of insulin.

Source guidance

Definitions of terms used in this quality statement

Intensive insulin therapy
Insulin therapy is aimed at reaching near-normal blood glucose levels. There are 2 types of intensive insulin therapy:
Multiple daily injection basal–bolus insulin regimens
An intermediate or long-acting insulin that is usually injected once or twice a day (basal), and a rapid-acting insulin that is injected as needed before each meal and snack.
[Adapted from Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015) NICE guideline NG18 (full guideline) and expert opinion]
Continuous subcutaneous insulin infusion (insulin pump therapy)
A programmable pump and insulin storage device that delivers a background or basal supply of insulin (either a rapid-acting analogue or a short-acting insulin) and boluses of insulin as needed, through a subcutaneous needle or cannula.
[Adapted from Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015) NICE guideline NG18 (full guideline) and expert opinion]
Level 3 carbohydrate counting
Carbohydrate counting for people with type 1 diabetes who are using intensive insulin regimens (multiple daily injections or insulin pump) involves calculating insulin-to-carbohydrate ratios that are individualised according to age, sex, pubertal status, duration of diabetes, time of day and activity. Pre-meal insulin is adjusted according to the estimated carbohydrate content of meals and snacks using the specified insulin-to-carbohydrate ratios.
[Adapted from Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015) NICE guideline NG18 (full guideline) and expert opinion]

Equality and diversity considerations

Particular care should be taken when communicating with children and young people with type 1 diabetes and their family members or carers (as appropriate) if they have, for example:
  • physical, cognitive or sensory disabilities
  • different cultural, ethnic or family traditions to the healthcare professional
  • difficulties speaking or reading English.

Continuous glucose monitoring in type 1 diabetes

This quality statement is taken from the diabetes in children and young people quality standard. The quality standard defines clinical best practice in diabetes in children and young people and should be read in full.

Quality statement

Children and young people with type 1 diabetes who have frequent severe hypoglycaemia are offered ongoing real-time continuous glucose monitoring with alarms.

Rationale

Continuous glucose monitoring helps children and young people with type 1 diabetes and their family members or carers (as appropriate) to respond more quickly to changes in blood glucose levels throughout the day. For children and young people with frequent severe hypoglycaemia (particularly those who have difficulty recognising or reporting it), continuous glucose monitoring can help to improve their control of blood glucose and HbA1c levels.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that children and young people with type 1 diabetes who have frequent severe hypoglycaemia are offered ongoing real-time continuous glucose monitoring with alarms.
Data source: Local data collection.
Process
Proportion of children and young people with type 1 diabetes with frequent severe hypoglycaemia who are offered ongoing real-time continuous glucose monitoring with alarms.
Numerator – the number in the denominator who receive ongoing real-time continuous glucose monitoring with alarms.
Denominator – the number of children and young people with type 1 diabetes who have frequent severe hypoglycaemia.
Data source: Local data collection.
Outcome
a) HbA1c level of 48 mmol/mol or lower.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
b) Quality of life.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care providers) ensure that systems are in place to offer ongoing real-time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have frequent severe hypoglycaemia.
Healthcare professionals (such as consultants) offer ongoing real-time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have frequent severe hypoglycaemia.
Commissioners (NHS England regional teams) commission services that offer ongoing real-time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have frequent severe hypoglycaemia.

What the quality statement means for children and young people and their parents and carers

Children and young people with type 1 diabetes who have frequent severe hypoglycaemia (a hypo that they need help from someone else to treat) are offered ongoing real-time continuous glucose monitoring with alarms. This is special equipment that checks the person’s blood glucose all the time, without them having to do finger-prick tests. It sounds an alarm if blood glucose levels fall too low.

Source guidance

Definitions of terms used in this quality statement

Frequent severe hypoglycaemia
Having low blood glucose levels that require assistance from another person to treat. ‘Frequent’ is when this is happening often enough to have a significant impact on school, work or quality of life.
[Expert opinion and Diabetes.co.uk]
Ongoing real-time continuous glucose monitoring with alarms
A type of system for continually monitoring glucose. ‘Ongoing’ means the device is used for weeks, months or longer. ‘Real-time continuous’ means the device takes real-time measurements for as long as it is worn.

Blood ketone monitoring in type 1 diabetes

This quality statement is taken from the diabetes in children and young people quality standard. The quality standard defines clinical best practice in diabetes in children and young people and should be read in full.

Quality statement

Children and young people with type 1 diabetes are offered blood ketone testing strips and a blood ketone meter.

Rationale

Insufficient insulin can lead to increased ketone levels which, if untreated, can lead to progressive dehydration and diabetic ketoacidosis (DKA). The risk of DKA is increased if a child or young person with type 1 diabetes has an illness such as flu or a urinary tract infection, or has missed some insulin doses. NICE’s guideline on diabetes in children and young people suggests that blood ketone testing is more cost effective than urine ketone testing for preventing hospital admission during intercurrent illness. It is important not to use out-of-date testing strips because the result might not be accurate. Education on how to prevent, detect and manage increased ketone levels is also vital.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with type 1 diabetes are offered blood ketone testing strips and a blood ketone meter.
Data source: Local data collection.
Process
Proportion of children and young people with type 1 diabetes who receive blood ketone testing strips and a blood ketone meter.
Numerator – the number in the denominator who receive blood ketone testing strips and a blood ketone meter.
Denominator – the number of children and young people with type 1 diabetes.
Data source: Local data collection.
Outcome
a) DKA.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
b) Hospital admission rates.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
c) Mortality.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
d) Satisfaction of children and young people with type 1 diabetes and their family members or carers (as appropriate) with blood ketone testing strips and blood ketone meters.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary and secondary care providers) ensure that systems are in place to offer children and young people with type 1 diabetes blood ketone testing strips and a blood ketone meter.
Healthcare professionals (such as GPs and consultants) offer children and young people with type 1 diabetes blood ketone testing strips and a blood ketone meter, and advise them and their parents or carers on how to prevent, detect and manage increased ketone levels.
Commissioners (clinical commissioning groups) commission services that offer children and young people with type 1 diabetes blood ketone testing strips and a blood ketone meter.

What the quality statement means for children and young people and their parents and carers

Children and young people with type 1 diabetes are offered blood ketone testing strips and a blood ketone meter to measure ketones in their blood. When people need more insulin (because they are ill or have missed some insulin doses) their body makes ketones, and too many ketones can make people very ill – this is called diabetic ketoacidosis, or DKA for short.

Source guidance

Equality and diversity considerations

Particular care should be taken when communicating with children and young people with type 1 diabetes and their family members or carers (as appropriate) if they have, for example:
  • physical, cognitive or sensory disabilities
  • difficulties speaking or reading English.

Access to mental health professionals with an understanding of type 1 or type 2 diabetes

This quality statement is taken from the diabetes in children and young people quality standard. The quality standard defines clinical best practice in diabetes in children and young people and should be read in full.

Quality statement

Children and young people with type 1 or type 2 diabetes are offered access to mental health professionals with an understanding of diabetes.

Rationale

Psychological issues (such as anxiety, depression, behavioural problems, eating disorders, conduct disorders and family conflict) and psychosocial issues have a significant and adverse impact on the management of type 1 and type 2 diabetes, and on the general wellbeing of children and young people and their family members or carers.
Children and young people with diabetes are at high risk of anxiety and depression, and it is important that they have early access to mental health professionals when they need it. Mental health professionals who have an understanding of diabetes and the particular problems it causes are essential for delivering psychological interventions and engaging with children, young people and their families.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with type 1 or type 2 diabetes are offered access to mental health professionals with an understanding of diabetes.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
Process
a) Proportion of children and young people with type 1 diabetes who are offered access to mental health professionals with an understanding of diabetes.
Numerator – the number in the denominator who have access to mental health professionals with an understanding of diabetes.
Denominator – the number of children and young people with type 1 diabetes.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
b) Proportion of children and young people with type 2 diabetes who are offered access to mental health professionals with an understanding of diabetes.
Numerator – the number in the denominator who have access to mental health professionals with an understanding of diabetes.
Denominator – the number of children and young people with type 2 diabetes.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
Outcome
a) Self-management of type 1 and type 2 diabetes.
Data source: Local data collection.
b) Adverse events (for example, severe hypoglycaemic episodes, diabetic ketoacidosis [DKA] or self-harm).
Data source: Local data collection.
c) Quality of life.
Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.
d) Satisfaction of children, young people and their family members or carers (as appropriate) with the intervention.
Data source: Local data collection.
e) Anxiety or depression.
Data source: Local data collection.
f) School performance or attendance.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care providers) ensure that systems are in place to offer children and young people with type 1 or type 2 diabetes access to mental health professionals with an understanding of diabetes.
Healthcare professionals (such as consultants) offer children and young people with type 1 or type 2 diabetes access to mental health professionals who have an understanding of diabetes and the particular problems it causes and can deliver psychological interventions and engage with children, young people and their families.
Commissioners (NHS England regional teams and clinical commissioning groups) commission services that offer children and young people with type 1 or type 2 diabetes access to mental health professionals with an understanding of diabetes.

What the quality statement means for children and young people and their parents and carers

Children and young people with type 1 or type 2 diabetes are able to see mental health professionals who understand the types of problems people with diabetes can have. The mental health professional should be one of the main members of the diabetes team.

Source guidance

Definition of terms used in this quality statement

Access
Multidisciplinary paediatric diabetes teams should include a psychologist, and provide access to them in an appropriate timeframe. Each child and young person with type 1 or type 2 diabetes should have an annual assessment by their multidisciplinary team to decide whether they need support from the psychologist.
[Adapted from Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015) NICE guideline NG18 (full guideline) and expert opinion]

Equality and diversity considerations

Particular care should be taken when communicating with children and young people with type 1 or type 2 diabetes and their family members or carers (as appropriate) if they have, for example:
  • physical, cognitive or sensory disabilities
  • difficulties speaking or reading English
  • an increased risk of psychological difficulties.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Consider alarm treatment as an alternative to continuing drug treatment for children and young people who have recurrences of bedwetting, if an alarm is now appropriate and desirable.
Perform regular medication reviews for children and young people on repeated courses of drug treatment for bedwetting.

Glossary

daytime urinary symptoms such as wetting, urinary frequency or urgency
a training programme that may include combinations of a number of different behavioural interventions, and that may include rewards, punishment, training routines and waking routines, and may be undertaken with or without an alarm
carrying or walking a child to the toilet. Lifting without waking means that effort is not made to ensure the child is fully woken
the child's bedwetting has improved but 14 consecutive dry nights or a 90% improvement in the number of wet nights per week has not been achieved
the child has achieved 14 consecutive dry nights or a 90% improvement in the number of wet nights per week
the child or young person has previously been dry at night without assistance for 6 months or more
waking a child from sleep to take them to the toilet

Paths in this pathway

Pathway created: January 2013 Last updated: April 2017

© NICE 2017

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