Personal Hygiene Five Steps to Function Booklet

Information for parents and carers

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Personal Hygiene Five Steps to Function Booklet – PIAG 338 (448kB)

What are the ‘Five Steps to Function’?

Occupational Therapy is all about function! Through purposeful activities, occupational therapists can support and help children and young people achieve their goals in daily life.

The following five steps are steps to consider when completing any activities with your child:

1. Promote independence – Whenever possible, children should be encouraged to take part in activities, whether it is for the whole activity or part of the activity, so they are taking responsibility for their actions and developing their independence.
2. Develop skills – All activities that your child takes part in will develop their skills. Activities that are familiar can become more fluent or faster, and new activities provide challenges so children can make sense of them, problem solve and learn to adapt to achieve success.
3. Increase confidence and self-esteem – When children try something new and are successful, or gain success through practicing an activity they have been trying for a long time, their confidence increases. This is especially true when children feel that their peers are able to do something that they cannot. This sense of achievement helps children when trying other new activities, as they can reflect and be reminded of their previous achievements.
4. Make activities meaningful – When activities are meaningful to a child they are more motivated to try them. Activities that are themed around your child’s interests can make a big difference to their enthusiasm! If your child is old enough, they can talk with you about what they want to achieve and set goals themselves. This could be making a sandwich, riding a bike, or simply doing an activity without having to ask for help.
5. Have fun! – One of the most important parts of learning something new is that it is fun! Children are much more willing and motivated to take part in activities that are fun. Trying new activities can lead to frustrations, so staying patient and relaxed really does help. Encouraging your child to keep trying even when they make a mistake is really important.

Why is good personal hygiene so important?

Good personal hygiene is an important part of self-care and developing independence. Self-care skills are everyday tasks that are often called Activities of Daily Living (ADL’s).
Good personal hygiene helps children to stay healthy. It keeps them looking and smelling clean and promotes their general health and builds better self-esteem.

Good personal hygiene includes:

• Hand washing
• Bathing and showering
• Hair washing and brushing
• Toileting
• Brushing teeth

Poor hygiene habits can lead to:

• Body odour
• Head lice
• Greasy skin
• Poor dental health
• Stomach viruses from spreading germs from hands to mouth
• Reduced self-esteem and confidence

Depending on the age of your child, their motivation can vary. Some children are very keen to be clean and tidy, whereas others do not see it as a priority and would prefer to spend their time doing something else that they enjoy.

Sometimes this comes from a lack of confidence in their skills and abilities to do the tasks on their own. As your child gets older, they may rather not wash and brush their hair than ask for your help, because their peers are able to do it themselves and they feel embarrassed.

All aspects of personal hygiene are complex and require your child to use various skills at the same time.

• Oral Motor Movement: Your child must be able to move their lips, cheeks, tongue and jaw, to brush their teeth properly.
• Active Movement: Your child must be able to move their muscles voluntarily in order to wash their hair and bodies; brush their hair and teeth; and wash their hands.
• Joint Mobility: Children must be able to move all their joints voluntarily to complete different activities.
• Co-ordination: Your child must be able to co-ordinate and plan their movements in order to move their joints as they need to, and use their body parts together e.g. eyes, hands and mouth when brushing teeth.
• Balance and stability: Your child should be able to maintain sitting and standing balance, and have stability in their core (stomach and back) and pelvis (hips) to sit upright without support (postural control).
• Arm and hand control: Children should be able to use both hands together (bilaterally) and be able to use their hands in a lead-assist way (one hand leads, the other supports) e.g. brushing hair, brushing teeth, squeezing shampoo bottle or shower gel.
• Reach and grasp: Your child must be able to reach and grab items that they need to do the task and be able maintain their grasp whilst moving the item e.g. flannel, hairbrush, and toothbrush.
• Visual perception: Children must be able to see where items are around and in front of them in relation to their hands for them to pick up and use. Being able to identify different items is also important e.g. not use shampoo to wash their body.
• Sensory development: Your child must be able to respond to different sensations, textures, and smells e.g. fragrance of shower gel, taste of toothpaste.
• Body awareness: Children must have an awareness of their own body, and where it is in space. They must be aware of the two sides of their body and an understanding of their midline (middle of their body). These are important when washing their hair or the back of their bodies without being able to see what they are doing.
• Proprioception {pro-pri-o-cep-tion}: Your child must have the ability to judge the force they need when using different items e.g. squeezing toothpaste or shampoo bottle.

Hand washing

Children should be encouraged to wash their hands from an early age. You can include it day to day even when they are still in nappies – simply wiping their hands when you change their nappy can let your child get used to the sensation.

As children grow and explore through play, their hands touch a lot of different textures and surfaces, including some that are not so pleasant, and this is often followed by putting their hands in their mouths, their ears etc. (especially younger children) so hand washing is an important skill for them to practice.

Getting into a routine with your child and encouraging them to wash their hands at the following times, is a good way to develop their awareness and independence in this skill:

• Before eating
• After using the toilet
• After coughing or sneezing or blowing their nose
• Before preparing food or after touching raw meats, eggs, fish etc.
• After coming in from outside or whenever their hands are dirty from an activity

Helpful tips

• Don’t just splash – When practicing handwashing with your child, encourage them to wet all over their hands, ask them to check and look that all of their hands are wet and not just their fingertips! If your child doesn’t have any skin sensitivities, always use soap. This is a good visual cue for your child to practice covering their hands with soapy suds then washing them away with the water.
• Sing a handwashing song – Sing a song with your child while they wash their hands which they will remember when they are not with you e.g. in nursery, school, grandparents etc. This is a good prompt for them to wash their hands for a certain length of time e.g. as long as the song lasts. There are lots of song ideas available on the internet, or make up your own!
• Picture prompts – You might feel like you are constantly asking your child ‘have you washed your hands?’ and you probably are, especially when they are younger! So, another reminder for your child is to have picture cards where they wash their hands. This could be in the bathroom and by the kitchen sink. Make an activity out of it and have them draw around their own hands on coloured paper and stick them up where they think will help them to remember.
• Hand-drying is important too! – Make sure your child dries their hands properly after washing them, as this makes sure that there aren’t any germs still on their hands and they have cleaned them all away.

Hair washing, brushing and styling

Hair washing

Almost all children go through a stage of not wanting to have their hair washed, this might be because he/she:

• Has previously had shampoo in their eyes or mouth
• Is scared of the water
• Is unhappy about the position they have to be in
• Doesn’t want their hair to be washed, simply because you do, in a classic battle of wills!

Helpful tips

• Don’t wash it as often – Hair washing doesn’t have to be done every time your child has a bath or shower. Once a week is fine for toddlers, as their hair doesn’t get very dirty. A few days’ gap in between hair washes may help your child to forget whatever was bothering them and be open to trying it again. Bath time is a special time for you both, but tension over hair washing may start to ruin it. So, tell your child that it’s not hair-washing night so you can both relax and enjoy your time together.
• Problem-solve together – Don’t just talk about whether or not to wash your child’s hair, talk about how you wash it. Maybe they are happier if it’s done in the shower rather than the bath, or they like it when they can rub the shampoo in themselves. Work together to find the best way.
• Work out what your child dislikes – If your child is old enough you can ask them what bothers them most about hair washing. Maybe they don’t like the water on their face, or the rubbing when you use the shampoo. Once you know which part of hair washing is causing the problem, you can work around it. If your toddler doesn’t like their hair being dampened by the shower, try running the bath so it is very shallow. Suggest that they lie down in the bath, so you can wet their hair more easily.
• Choose together – Take your child to the shops to choose what shampoo they would like to use. This could be their favourite character and is a special bottle just for them. Your child may like the smell of a certain shampoo, so you could choose that one together. When it is hair wash day, your child can then get their shampoo bottle out ready for bath / shower time.
• Dolly does it, too! – Try letting your child wash their doll’s hair in the bath. Seeing how they wash the doll’s hair may give you a clue about why they don’t like having their hair washed. Sometimes you can wash your child’s hair at the same time that they wash their doll’s hair e.g. when they wet the dolls hair you wet your child’s and so on.
• Make it fun – Put a plastic mirror at the end of the bath and help your child to make shapes with their shampoo-covered hair. Horns and halos, curls and twirls – these will all distract them and make them giggle. They may not even notice that their hair is getting washed at the same time.
• Bath together – Have a bath with your toddler, and let them wash your hair and make funny shapes with it. Or bathing with siblings can also be helpful – dependent upon the age of your children. You can take it in turns and make shampoo styles with one child so the other can see what is happening for when it is their turn. They can decide what style their sibling can have e.g. a unicorn, horns etc.
• Change the scene – Try using the kitchen sink to wash your child’s hair. For your toddler – put a thick towel on the draining board them lie down with their head over the sink, leaning back to keep the shampoo out of their eyes. This way your child is safe and secure, and the water is much less likely to go in their eyes. If your child is older, they can sit on a chair with their head back over the sink as they would in the hairdressers.
• Distraction rules! Anything that distracts your child from the hair washing will be helpful and reduce the stress for both you and your child.
  • Put a funny picture or mobile on the ceiling above the bath so that your child has to look up at it.
  • Having toys in the bath, water crayons or letters/numbers that stick to the tiles can keep your child busy whilst you wash their hair.
  • Singing a noisy hair-washing song – so your child knows that the hair washing will last as long as the song.
  • Play a body game where you ask: “Where is your nose? Where is your tummy? Where is your knee?” By the time you have worked all round the body, you will have washed their hair, if you’re quick!
  • Encourage your child to look at the ceiling when you rinse their hair, so the water and shampoo doesn’t drip into their eyes. Consider putting stickers on the ceiling to encourage them. This could be letters or pictures that they have to search for while their head is back.

Sometimes an additional gadget may be needed to help with hair washing:

• Shampoo rinsing cups – these prevent water from going into your child’s eyes and over their face.
• Shampoo shields – fit on your child’s head like a cap or sun visor and prevent water from running into their eyes. Or you can use a clean flannel or small towel, which your child can hold over their eyes as you rinse out the shampoo.
• Swimming goggles – these will keep the water out and allow your child to put their head under the running water when rinsing while their eyes are still open.

Hair brushing and styling

Hair brushing and styling is another complex task for your child to achieve. Many boys and girls take great pride in their hair, and often want it to be styled in a certain way, which can increase the demand on your styling expertise and theirs. The longer your child’s hair, the less manageable it can be to brush and style it independently.

With a vast amount of hair products available for your child to use, it can be frustrating for them if they are not able to use them how they want to, to make their hair look like their favourite celebrity or how their peers are wearing their hair. Again, this can lead to lots of frustration and affect your child’s confidence and self-esteem, if they start to worry about how they look.

Helpful tips

• Choose the right brush or comb – There are lots of different brushes and combs available and choosing the right one might make all the difference for your child. If holding a hairbrush is difficult – try using one with a strap across it so it stays in your child’s hand. Tangle Teezer brushes don’t have a handle so can be easier for your child to control. A comb may be easier for using on short hair. If your child is sensitive to touch, use a soft-bristled brush or bristles with a rounded head for more comfort. Your child may be more interested in brushing and styling their hair if they can help to choose brushes, or combs, that feel best for them.
• Reach – Long-handled combs and brushes are available if your child has difficulty reaching behind their head, however, organising their movements for its use may be difficult if your child has motor planning difficulties
• Crossing midline – If your child has difficulty with crossing their midline (the middle of their body) sometimes brushing the opposite side of their head is avoided. Try encouraging your child to look in the mirror to check that they have completely brushed their hair, or give a verbal prompt to brush the whole of the head.
• Follow my lead – Using a mirror can sometimes be more confusing for your child as it shows the opposite of what they are doing. It may be more helpful if you sit next to your child and brush your hair at the same time so they can copy your actions. Or sitting behind them in front of the mirror, physical prompting by holding their hand as you brush their hair may help.
• Style dolly’s hair – Practicing brushing and styling dolls hair can be a good way for your child to learn how to coordinate their actions.
• Allow lots of time – Hair brushing and styling takes time and even the simplest of styles won’t be achieved overnight. They all need practice. Encourage independence by letting your child practice brushing and styling their hair during weekends initially, to allow more time and reduces time pressures that can increase stress before school.

• Knots and tangles – Encourage your child to section their hair into more manageable parts and brush out the knots at the end first before brushing from the roots. If this is too tricky for them, you can separate the hair and they can brush it. Use a de-tangle spray for hair that gets knots in easily. When washing hair, use a conditioner, or to minimise length of time washing use a 2 in 1 shampoo and conditioner.
• Bobbles and hair ties – To tie hair up use a large bobble or a hair tie that does not need lots of twists to secure style in place. A fabric bobble such as a scrunchie will reduce your child’s hair getting tangled and twisted in the bobble. Any thin elastic bands are more likely to get twisted in your child’s hair and be painful getting them out.
• Hair products – If your child really wants to use gels, or styling crème’s….advise them that less is more! They can always add more to their hair, but once it’s on they can’t take it out and may mean washing their hair again! So practice with them putting a little bit on then add more until they get the look they want.
• Hair drying – Your child may not like the noise or feeling of the hair dryer on their hair, so try towel-drying it as much as possible to reduce the need for a hair dryer. Your child may want to hold the hair dryer themselves as they have more control over it being near their head. Or if it is the sound they that dislike, have your child wear ear phones whilst you dry their hair. They can listen to a story or watch a video or a song that they like to distract them.

Brushing teeth

Brushing teeth is an important part of personal hygiene but it can be a difficult task for some children to master as they can only see their hand moving up to their mouth then rely on their body awareness to complete the task fully.

Sometimes children don’t brush their teeth properly or avoid it altogether for different reasons:

• They find it hard putting enough toothpaste on their toothbrush
• They find it hard to coordinate their movements to move the toothbrush around their mouth.
• They might not like the feeling of the toothbrush in their mouth.
• They might not like the taste or texture of the toothpaste.
• They forget to do it unless they are prompted to

You may need to assist your child until they are around 7 years old, when they have developed the coordination needed to reach all of their teeth.

Helpful tips

• Choosing a toothbrush – Using an electric toothbrush may help with brushing teeth rather than a regular one as it can help to clean teeth more thoroughly. Musical toothbrushes are also available and fun to use. Or a toothbrush of their favourite colour or character can help to motivate them to use it.
• Choosing toothpaste – If your child struggles to put the right amount of toothpaste on their brush because they squeeze too hard or not hard enough, a pump toothpaste dispenser may be easier to use. If your child dislikes the flavour of the toothpaste try choosing different flavours or non-flavoured toothpaste. These will still clean your child’s teeth as well.
• Coordination – This may need different amounts of support from you for your child to be successful.

• If putting toothpaste onto the toothpaste is tricky:
  • Ask your child to put toothpaste on their finger first then wipe it across their teeth then start brushing.
  • Put the toothpaste on your child’s toothbrush for them then they only have to move it to their mouth and brush.
• If moving the toothbrush to their mouth is tricky:
  • Try hand-over-hand with your child standing behind them and moving the toothbrush to their mouth with them. Then, move the toothbrush around their mouth so they can feel what they need to do themselves.
  • Have a mirror for your child to see their mouth during brushing.
  • Ask them to do some gentle tapping with their fingertips on their cheeks and lips before they use the toothbrush. This will help to increase their awareness of where their mouth is.
  • You may need to assist your child until they are around 7 years old, when they have developed the coordination needed to reach all of their teeth.

• Routine – Have a set time each day for your child to brush their teeth so it becomes part of their daily routine e.g. after breakfast and before bed when they have their pyjamas on.

• • Follow my lead – Demonstrate how to brush teeth by letting your child copy you.
• Timers – Use a timer to make sure that your child brushes their teeth for the correct amount of time. This could be a kitchen timer, a timer on a mobile phone, or there are different apps you can download. Electric and musical toothbrushes often have a timer setting on them which buzzes or the music stops after 2 minutes, so that your child knows how long to brush their teeth for.
• Stick to the same place – Keep your child’s toothbrush and toothpaste in the same place for them to easily find and reach each time they need it. Don’t keep them in cupboards or drawers. Encourage your child to put the toothpaste and toothbrush back in the same place once they have used it.
• Checklists – Checklists can be a great visual prompt for your child. Have one in the bathroom by the sink with basic instructions to follow or pictures, where your child brushes their teeth to remind them of what they need to do.
• Reward charts – Using a reward chart may be a good motivator for your child, particularly if they are reluctant to brush their teeth.
• Food and drink – Encourage good dental health by the food and drinks you and your child have. Especially if your child is a fussy eater, playing games where they try different textures or guess the food can help to build up their tolerance for different tastes and textures in their mouths.

Toileting

Your child may have difficulty with becoming independent using the toilet for various reasons, including:

• Poor body awareness – being able to reach behind them, being able to turn their hand, and knowing where to wipe, all without being able to actually see what they are doing!
• Poor stability – difficulty staying balanced whilst sitting on the toilet
• Coordination difficulties – reaching behind themselves and knowing where to wipe whilst holding onto toilet roll and staying balanced!
• Sequencing problems – remembering which order to do things
• Less sensation that they need to go to the toilet or they have been – frequent accidents
• Avoidance of smells (toilet) and noises (flushing, hand dryer)

Helpful tips

• Easy access – Make sure that your child is able to access the toilet easily:
  • Step: Having a step in front of the toilet is not only useful to help your child get up to the toilet, but also for them to place their feet on and provide stability whilst sitting on the toilet.
  • Seat insert: Sometimes children are scared and think they might ‘fall down the toilet’ so they avoid using it. If necessary, a toilet seat insert can be placed on the toilet seat, so it reduces the size of the hole for your child’s bottom to sit on, and can be easily removed for others in the house.
  • Toilet roll / wipes: Place the toilet roll/wipes within easy reach for your child to use.

• Standing allowed! – If your child finds it too challenging to wipe their bottom whilst sitting, practice standing up. They will be more stable as their feet are on the ground and may find it easier to twist and turn their body as needed. Placing one foot on the step may be easier for your child to wipe their bottom.
• Check again – practicing with your child to check that the tissue is clean when they have wiped their bottom after a bowel movement is important. Not only will this stop any unwanted smells it is also important for comfort that your child is clean properly to reduce the risk of any unwanted germs.
• Clothing – Have your child wear clothing that is easy for them to take off when going the toilet. Fastenings or tight fighting clothing can add unnecessary stress, particularly if your child tends to leave it until the last minute to rush to the toilet.
• Boys – Once boys have worked out the different feeling of needing a bladder or a bowel movement they may want to stand up to have a wee. This can come with its own difficulties and getting them to aim into the toilet bowl. Putting cereal or ping pong balls in the toilet for him to aim at can be a good prompt, or alternatively you can buy stickers that change colour when urine hits them.
• Encourage routine – Encourage your child to go to the toilet throughout the day but it can help if these are at set times to begin with, such as before bed, when they first get up, after breakfast, before/after tea.
• Drink up – it is important for your child to drink throughout the day. Not only is this good for their bladder movements it will also help with their bowel movements and reduce constipation.
• Step-by-step – Have a step-by-step picture card in the bathroom for your child to remember what order they need to do things and check what they need to do next. This is useful if your child sometimes forgets to wipe their bottom, flush the chain, or wash their hands (or all 3) after using the toilet!
• Books and more – There are lots of books available on toileting and apps for tablets or mobile phones that you can download and look at with your child.

• Play games – Play different action games with your child so that they develop more awareness of their different body parts:
  • Standing in front of a long mirror ask your child to touch and name different parts of their body (front and back) whilst they look in the mirror. This will help to visually reinforce the physical feedback of touching.
  • Have your child pass a small object (beanbag or soft toy) around their body at waist level. First move the object in one direction then the other. If your child is able to do this without dropping the object, progress to passing the object in a figure of eight – round and between the legs. Do this activity in standing or in sitting position with their knees bent and back supported if necessary or sitting on the edge of a chair or low bench.
  • Ask your child to sit on the floor and place one object at a time behind them. Ask them to find the object by feeling for it behind them without looking or eyes closed if possible. To increase the challenge, ask them to identify what they have found by touch alone.
  • Stick light weight objects to the back of your child’s trousers for them to feel for and pull off, using sticky tape or masking tape doubled back on itself with make-up pads, scrunched up tissue or cotton wool stuck to the tape. Reduce the size of the objects, finally using small stickers or pieces of sticky labels for your child to find.
  • Tuck a scarf or handkerchief into the back of their waistband and ask your child to get it using either hand. To progress, ask your child to tuck back in again, partially then fully. If this is difficult, using a full length mirror may help.

Bathing and showering

Bathing and showering is an important skill for your child to learn to increase their independence. Children are first introduced to a bath as a baby, but as they get older they may prefer a shower. Some children however do not like either, and it can make this one of the most stressful times of the week for you and your child.

A lot of children go through a phase of not wanting to bath or shower, and don’t appear to be bothered by their poor hygiene habits. However this can be frustrating as a parent knowing how to support your child in the best way.

There are many reasons why your child may not like bathing or showering, including:

• Not understanding why it is necessary, especially if there is no visible dirt
• They might not like the feeling of the water on their skin, especially in the shower.
• They might find the smells of the soaps, shampoos, body washes too overpowering.
• They might be unsure of how long to stay in the bath or shower or forget everything they need to do, and then keep getting asked to go back and do it again.
• They simply just don’t want to and they would much rather spend time doing something else that they enjoy.

Helpful tips

• Talk to your child – Ask your child why they don’t want to shower or bath. It may be something quite simple, such as they don’t like the soap in the bathroom. Talk through ideas on how you might be able to help your child and listen to their suggestions on what they think would help. If your child is going through puberty, it may be helpful to talk to them about changes going on with their body and why personal hygiene is so important at this stage. Personal hygiene can be quite a delicate issue, and your child may be quite sensitive or embarrassed about it.
• Don’t force it – As much as you may get to a point where you want to, don’t try to physically force your child to bathe or shower, because ultimately it won’t work and it will just add to the battle. It is more effective to focus on things that will motivate your child, and ways to encourage them to do it themselves without any prompting such as reward or behaviour charts. Depending on the age of your child, the reward will be varied. You can discuss what rewards your child would think are important to them, along with consequences if they don’t bath or shower e.g. reduced time on their games console or simply a lack of reward. Rewards could include a sticker on the chart and a small reward at the end of the week, or for an older child extra time at night if they complete 5 out of 7 days.
• Soaps, shower gels and shampoos – If your child struggles with different smells and finds them overpowering, use soaps, shower gels and shampoos that have no or minimal scent. Your child may like a certain smell, so going on a shopping trip to buy soaps or shower gels that smell good to them may motivate them to use in the bathroom. There are also lots of varieties of bath bombs and bubble baths that make exciting colours in the bath, which may be more inviting for your child to try.
• Water worries – If your child does not like the feeling of the water on their skin, it may be that you need to support them to gradually increase the amount of time they spend in the bath or shower. This may be as short as 30 seconds at a time initially.

Sometimes the pressure of the shower can feel too hard against your child’s skin, so they are happier getting a bath. If a shower is their only option, sometimes having hold of the shower head means that your child has more control over the water on their body. Ask them to see where it feels best to hold the shower head, closer or further away from their body as each way will feel different.

Washing at a basin may be the best option for your child. This is a good way for them to practice washing themselves one body part at a time using a flannel or sponge. Your child may then move into a shallow bath whilst standing following the same method, then introduce sitting in the bath then increase the water in the bath and so on.

• Checklist – If your child forgets what to do, and you need to keep sending them back into the bathroom after their shower or bath to wash out the shampoo from their hair or to rub their dirty knees, a checklist or cue card might be helpful. This could be something that you create with your child, talking about all the things they need to do, and have them write a list to take in the bathroom with them.

• Make sure they have what they need – Have a basket or place in the bathroom where your child can find all the items that they need to get a bath or shower. You can start this with your younger child, so that they get used to getting items out for bath/shower time and putting them back in the same place. For an older child who is able to bath/shower alone it might be helpful to number the bottles so that your child knows they have used all the items they need to.

• Practice with toys – Practice the bath time routine with your child’s toys from start to finish. Running the water, getting the items ready, and then ask your child to bath their toy, including all aspects of washing and then drying them with a towel and putting pyjamas on. This may just be the motivation that your child needs to try it themselves, or at least have a bath with their toy next time.

• Be patient – sometimes it just takes time for your child to make the choice to bath or shower. Remain positive and encouraging of your child.

Contact details

If you require any further advice on the information provided in this booklet, please do not hesitate to contact the Children’s Occupational Therapy team in your area.

North Sefton Children’s Community Occupational Therapy
Hoghton Street Clinic
52 Hoghton Street
Southport
PR9 0PN
Tel: 01704 395895
(Areas covered – L37, PR8, PR9)

South Sefton Children’s Community Occupational Therapy
2nd Floor
Sefton Carers Centre
27-37 South Road
Waterloo
L22 5PE
Tel: 0151 252 5836
(Areas covered – L20, L21, L22, L23, L30, L31, L38, Sefton parts of L10)

This leaflet only gives general information. You must always discuss the individual treatment of your child with the appropriate member of staff. Do not rely on this leaflet alone for information about your child’s treatment.

This information can be made available in other languages and formats if requested.

PIAG: 338