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School Nurse

 

About Me:

Contact details:

Primary Tel: 01454 866944, Secondary Tel: 01454 866756, Email:melanie.coombs@cchp.nhs.uk

You can also communicate with me via your child’s HomeSchool diary or by letter marked ‘School Health Nurse’ and sent in with your child.

My name is Mel Coombs. I have worked as the School Health Nurse for New Siblands since May 2012. I have 27 years children’s nursing experience with a background in Neurosciences at Great Ormond Street, General Paediatrics and NICU at Southmead Hospital in Bristol and in Burns and Neurosciences at Frenchay’s Barbara Russell Children’s Unit.

I work across both of the New Siblands school sites and am based in the School premises. My work days are term times only Monday to Friday, approximately 8.30 am to 2.30 pm. I can be contacted on the numbers above and messages can be left for me outside of these hours. During 2018 I will also be covering for the School Health Nurse at Warmley Park one day per week and extending my working day to 0800 to 1530.

Prior to your child starting school, you may be sent an appointment for a School Health Needs Assessment. At this appointment we can then identify if your child needs a Health Care Plan in school and if you need any other support and advice. Appointments for Nursery children will be sent out during June and July prior to them starting in Reception.

During your child’s journey through school I can help ensure that your child has access to Paediatrician appointments and that you are signposted and referred to the most appropriate place should you need additional help with any health, developmental or behavioural issues.

I am your first point of contact for all continence assessments and toileting issues and liaise closely with the Paediatric Continence Promotion Service for South Gloucestershire. Children are eligible for this service after they enter Reception class at school regardless of age and have undergone six months of toilet training under the care of the School Nurse.

While your child is in Nursery at New Siblands, their Health Care Professional will continue to be their Health Visitor. I will take over from them when they enter Reception. However I do give out general advice and regular information packs about toilet training your child, as it is never too early to start. If you need any further advice regarding this then please contact me or look on the Toilet Training tab on this website.

Paediatricians Clinics in school:

Dr Emma Heckford, Paediatrician, holds a morning clinic most months.

Dr Kim Blackwell, Community Paediatrician, holds a morning clinic every month.

Please contact the School Health Nurse for any queries regarding school clinics or if you feel your child requires an appointment. The clinics take place in school and do not run in the school holidays.

We offer approximately 80 Paediatrician clinic appointments per year at New Siblands. It is very important to attend your appointments in school and if you cannot attend, to let me know in advance so that I can offer that appointment to someone else on the waiting list. You can contact me on melanie.coombs@cchp.nhs.uk or 01454 866944/01454 866756 or via you child’s HomeSchool diary to request an appointment or to make changes to an existing appointment. I send out a slip in advance letting you know of forthcoming appointments. An appointment letter will also be sent from Kingswood Hub with a tear off section at the bottom indicating your availability: this must be returned to me in school.

Community Eye Team

Julie Parker, Senior Orthoptist, holds regular vision checks in school. These are usually on a Tuesday and a slip will be sent to you advising of when this will occur. Please make sure that your child’s glasses are in school daily if they have been prescribed. Staff can support your child increasing and maintaining wear of glasses in school which will have a beneficial affect on their learning ability and sometimes behaviour.

Sue Fraser, Senior Optometrist, holds her eye clinic every term. A consent form is sent out as sometimes drops are used to dilate the pupil as part of the assessment process. This consent needs to be completed and returned to me before your child can be assessed.

Please let me know if you need a referral to the Community Eye Team or if you do not want your child’s vision to be checked regularly in school.

Immunisation clinics

School immunisations occur in school and are delivered by the Immunisations Team throughout the year: You will be sent consent forms which need to be returned to me in school.

  • Seasonal Influenza (‘Flu) Vaccine nasal spray will be available from October 2018 for all pupils. (Previously delivered by Boots, now taken over by Sirona)
  • Meningitis ACWY vaccine for all Year 9 pupils
  • Tetanus, Diphtheria, Polio teenage booster for all Year 9 pupils
  • HPV Preventing Cervical Cancer for all Year 8 and Year 9 girls, first dose in year 8, second in year 9.

Special Needs Dentist

The School Health Nurse can make a referral to the Special Needs Dental Department in Yate if you would like to be seen there. The school does NOT have its own dentist but the Special Needs Dentist will visit once a year to carry out Dental Screening. This is for statistical purposes only and does not include any treatment. The Special Needs Dental Department in Yate do not send out 6 monthly reminders so you need to make a future appointment before you leave the department.

Preparation for toilet training

One of the best things we can do for our children is to teach them to be able to use the toilet appropriately and increase their independence and self-esteem. All staff in our school will fully support toilet training at all stages.

Toilet training is not just about coming out of nappies, pads and continence protection. It includes a wide range of skills a child needs to become reliably clean and dry and acquire reliable control of their bowel and bladder.

The earlier you start teaching your child to sit (nothing more at this stage) and feel comfortable sitting on the toilet or potty as part of their regular bedtime and morning routine, the better. It does not matter at this stage if they cannot use it to do a wee or a poo, just that they can start to sit on it without a nappy for a minute or two at a regular time, two or three times a day.

Once this routine is being accepted happily, toilet training can gradually begin. Please try to start introducing this routine as early as you can. It is never too early to start and you may need to think about simple adaptations to the environment to help your child, such as a small step, a more secure toilet seat, a bag of toys to help occupy the time spent sitting and some visuals and maybe even a timer to measure the time. Always consistently use the phrase “toilet time” during this routine and do not expect any appropriate use of the toilet or to see signs that your child is aware of the process. If they do have an awareness, that will speed up the toilet training process but it is not unusual for this to come much late.

The most important thing at this stage is the routine of sitting. Any delay in starting them to sit regularly as part of a routine (like teeth cleaning and bathing) will delay the toilet training process. Give plenty of praise for just sitting on the toilet.

Toilet training

Toilet training is an important milestone for your child, but learning to gain control of the bowel and bladder is a complex process and your child needs to be emotionally and physically ready to start formal toilet training. To help our children become emotionally and physically ready it is important to remember that the earlier toilet preparation is started, the easier the skill will be acquired. Any delay in the preparation will delay formal toilet training. Remember the Mantra: “All things toilet, stay in the toilet” for example only changing a nappy in the toilet (and not in the bedroom or anywhere else) can help the child register that this is where wee and poo should go.

Another thing that helps your child to understand is to always allow them to see that the contents of a dirty nappy (not the actual nappy) are put down the toilet and flushed away. It can also help for your child to be able to see you use the toilet too.

During this time it is also important to ensure that your child has plenty of fluids during the day time and try to keep bedtime drinks to a minimum. If you notice that your child suffers from constipation, now is a good time to obtain some treatment from your GP. Constipation will also delay toilet training and impede any progress. Please see further advice regarding constipation later in this article.

Formal toilet training begins as a gradual process of increasing the sitting times that your child has already become used to as part of their normal bedtime and morning routine. This will include a mixture of starting to introduce sitting on the toilet after meals. The sitting times should be increased gradually from a couple of minutes to 5 minutes at a time. You may need toys, timers, social stories etc to occupy them help and focus the mind. Get your child used to this new routine and let everyone involved in the process know what words or signs your child makes if they want the toilet..

Raising Awareness.

If your child uses disposable nappies, they may never feel wet or uncomfortable. Feeling wet and uncomfortable is an important part of the toilet training process. It helps children connect weeing with feeling wet.

If your child is happy so far with the toileting process and will happily sit on the toilet as part of their normal routine, it is time to introduce some discomfort. This is normally achieved by firstly putting kitchen roll inside the nappy. You can regularly check if they are wet and ask them to tell you when they are wet. You only need to do this during the daytime for the moment. If it does not seem to be having much effect then try this for one week out of every month. If it does seem to be having an effect, then continue for a period of two weeks at a time.

This may be the time to involve your child in buying some pants of their own and putting these on underneath their nappy instead of the kitchen roll. Continue to change them standing up if possible as this enables them to take an active part in the process: pulling pants up and down and learning to wipe their bottom themselves. Encourage them to wash and dry their hands and dress themselves. It is helpful to regularly read stories to them about using the toilet. Make sure that boys are always taught to sit down for both wees and poos and not encouraged to wee standing up. This can lead to delayed use of the toilet for poos and constipation in some cases.

Make a note of when your child is regularly weeing and pooing by checking the nappy every hour for a few days. Based on this pattern, you can take you child to the toilet at scheduled times. Blowing bubbles can help your child stay busy while on the toilet and also may help them to have a bowel movement too.

Once your child has a regular sitting routine in place and can stay dry for two hours they can stop using nappies. You can use washable training pants if required, or their own underwear with waterproof pants over the top.You will need to keep a bag handy with a change of clothes, some wet-wipes for cleaning and seat protectors for school transport to send into school. Accidents are a normal part of the toilet training process so it is best to be prepared in advance.

Your child will gradually start to understand and know how to react and respond to the feeling that they need to empty their bladder or bowel. They will also need to understand what you want them to do and how to do it. It can take a long time but with regular routine and patience it can be achieved.

Constipation

Constipation must always be treated before any formal toilet training is started. It is very difficult for a child to have any control over his or her bladder if they are at all constipated. Constipation is very common in children and for many there is no known reason why it happens (this is known as idiopathic constipation). Research has shown that 29% of 4½ year olds and 27.5% of 9½ year olds in the UK suffer with constipation.

A child is considered to be constipated if they poo less than 3 times a week. However, every child’s pooing pattern is different and some children will need to poo twice a day whilst others will go only every other day.

Coping with constipation and soiling

In 2009 100,000 children in the UK were treated by their GPs for constipation and soiling problems.  For most children, constipation can be successfully resolved.  It can be a long journey, needing ongoing support from health professionals and much patience and encouragement from parents and carers. The quicker a child has an assessment by their GP, the easier it will be to manage and resolve the problem.

Causes of constipation

  • Withholding poo/ stool withholding (avoiding going to the toilet) – see more below
  • Fear of the toilet (sometimes associated with pain or discomfort)
  • Lack of a toilet routine (some children have such busy lives that it can be difficult to find time to sit and relax on the toilet each day)
  • Resistance to toilet training and an insistence that a nappy be put on to poo in
  • A diet that is not fully balanced
  • Low fluid intake
  • A change in routine
  • Anxiety and emotional upset
  • Some medications may cause constipation
  • Illness

Withholding poo/ stool withholding 

Stool withholding is when a child feels the need to use the toilet but resists it. Resisting the need might involve crossing the legs, sitting on the back of the heels, clenching the buttocks and being fidgety. The stool gets bigger the longer the child holds on to it and eventually when they absolutely have to go it is very painful and difficult to pass. This can lead to a vicious cycle of holding on and pain.

A child might start withholding stools for several reasons – they may have experienced passing a painful or difficult stool; they may have a sore or anal fissure which makes pooing painful; or they might not want to use strange or smelly toilets and prefer to hold on until they get home.  

Recognising the signs of constipation

  • Pooing less than three times a week
  • Regular and foul smelling wind
  • Foul smelling poo
  • Painful tummy
  • Distended tummy
  • Poo looks like hard pellets
  • Pain when pooing
  • Straining
  • Withholding poo
  • Poor appetite
  • Lack of energy
  • Unhappy, angry or irritable mood
  • Soiling

The Bristol Stool Form Scale can help you identify whether poo is becoming constipated.  The ideal poo is number 4 on the scale – a soft, smooth sausage shape.

Establishing a routine

The pace of life can be so busy that it is easy to neglect the need to ensure there is time in the day for children to have a relaxed sit on the toilet for a poo.

Putting a toilet routine in place will ensure that sitting on the toilet for a poo is a regular part of a child’s day and will encourage the complete emptying of the bowel on a regular basis, helping to lessen pooing accidents and avoid constipation.

A toilet routine is especially important for boys who, once they begin to stand up to wee, have to make a special effort to sit on the toilet for a poo and pooing can become rushed or simply forgotten.

Tips for successful pooing on the toilet

The correct way to sit on the toilet to have a poo

Tips on what to do when a child prefers to poo in a nappy

 What is soiling?

Children soil when they poo in their pants, on the floor or in other inappropriate places.  Some children have a more regular and persistent difficulty.

Why soiling happens

Constipation is the most common cause of soiling.  When children don’t poo regularly, the bowel can become loaded with large poos that are hard to pass. This is sometimes called faecal impaction.

Poo can appear runny (like diarrhoea), in small lumps or can be visible around the bottom and difficult to wipe away.  Soiling occurs when runny poo leaks around the hard lump that is blocking the way; or if there has been a longstanding problem of constipation the lower bowel and rectum may have become overstretched.  Soiling can happen several times a day as the child does not always receive the message that they need a poo or is not always aware that the poo has come out.

Treatment for constipation and soiling

Most parents seek help initially from their health visitor, school nurse or GP. Keeping a record of how often pants are soiled, poo is passed in the toilet and the type of poo passed will help health professionals assess the problem and offer appropriate intervention.

Treatment is likely to include:

  • Medication to relieve constipation and clear faecal impaction (this is likely to be Movicolbut could be a stool softener, stimulant laxative or bulking agent). The medicine is then continued to ensure that the poo remains regular and easy to pass, stopping the medication too soon can result in the constipation building up again
  • Suggestions for appropriate changes to the diet and fluid intake
  • Establishing a regular routine of sitting on the toilet for a few minutes at least once a day, 15-20 minutes after a meal
  • Checking that your child is positioned comfortably and securely on the toilet (using a child seat if necessary), and ensuring that feet are firmly on the floor or supported on a step will help your child push poo out
  • Teaching your child the technique of gently rocking forwards and back when sitting on the toilet
  • Motivating your child by involving them and offering simple rewards for achieving targets
  • Occasionally psychological help is useful to explore anxieties or stress that may be associated with, or aggravating the problem

Always consult your GP if your child is showing signs of constipation or there are changes in bowel patterns.

There is a lot of advice available and I would recommend ERIC at http://www.eric.org.uk/ and Promocon at http://www.disabledliving.co.uk/Promocon/Publications/Children/Toilet-Training