The other day a mother brought her four year-old daughter (let’s call her Sally) into clinic with a severe and painful rash all over her bum and vaginal area. Poor Sally was really suffering.

I had a look at the rash. It reminded me of the diaper rashes I routinely see in newborns.  These rashes are typically caused by chronic exposure of the skin to stool and urine.  Since some newborns can pee and poop hourly (or even more frequently), it can be impossible for parents to keep up with the diaper changes and hence, a bum rash results.  But in this case we’re talking about a 4-year old child! Diaper rash in a 4-year old?

It didn’t take long to figure out what was going on: this poor girl, who attends a local Junior Kindergarten class, was not yet proficient at wiping herself adequately after pooping. Occasionally, she would be a bit late recognizing the ‘need to go’ and would have an accident. Her bum was getting irritated and corroded by prolonged exposure to urine and feces.

I inquired if she asks her teachers for help when she has to go (or is finished going) to the bathroom. The mom quickly interjected and informed me that kids need to be toilet-trained as a prerequisite to attending this particular school.  She went on to explain that the teachers in this school will not help their students with toileting hygiene.

Believe it or not, this is a common school policy in my city/province.

I felt my blood pressure rising.

“So the teachers allow the kids to sit in their soiled underwear all day?” I asked.

“Well, they call me if it’s really bad.  What else can they do?” said the mom.

I felt like vomiting – not at the site of the bum rash, but in reaction to the fact that some schools are OK with letting kids sit in their urine and feces all day!

I won’t even start getting into the psychological consequences of a child spending the day with  her peers smelling of feces and urine.

Unfortunately this is not an uncommon story and I have a well-established strategy to remedy this kind of rash.

I proceeded to write a letter to the school principle:

Dear Mrs. Principle:

Sally has a medical condition that requires adequate and consistent bathroom hygiene. This means facilitating access to a toilet in a timely manner when required, assisting her with wiping after she has finished urinating and/or stooling, and cleaning her adequately/promptly in the event of accidents.  Inadequate bathroom hygiene may result in 1. worsening of her medical condition and 2. an increased risk to others in the school of acquiring fecal-orally spread infectious diseases.

May I suggest that you assist all children in your school with adequate bathroom hygiene when needed as a means to prevent medical conditions from arising in the future for Sally or any other child at risk.

I appreciate your diligence in addressing this matter and trust that you will take the necessary measures to keep Sally and her classmates safe, comfortable, and healthy.

Yours sincerely,

Dr. Flanders

Some cream, a bit of compliance from the school, and a week of healing did the trick.  I saw Sally in follow-up and her bum rash was better.

I have informally spoken to teachers and parents about this issue and it seems that there are three (perhaps related) justifications most commonly given for why teachers will not assist children with bathroom hygiene:

1) The union advises teachers against it

2) Teachers could face allegations of sexual assault

3) It is unsanitary (this is more a justification for refusing admission to children not yet toilet-trained)

The more I encounter stories such as this, the more my blood boils, especially given the fact that daycares around the world help 4-year-olds with bathroom hygiene many times daily.  Using standard universal precautions (and perhaps with a co-worker nearby), daycares routinely and adequately mitigate the risk of spreading infections, and, as far as I know, daycare workers who help kids with bathroom hygiene are not likely to show up in your neighborhood’s list of nearby sexual offenders.

It is entirely feasible for schools to safely help children with and to learn/improve their bathroom hygiene skills.  In fact I argue that it may be a human rights violation to refuse to do so.

If this upsets you too, consider calling your child(ren)’s school(s) to inquire about their policy on this.  If they are one of the ‘we don’t do dirty bums’ violators, consider speaking up and pushing them to change.