Symptoms of sleep-disordered breathing in children with nocturnal enuresis

Sleep-Related Breathing Disorders and Lower Urinary Tract Dysfunction in Children and Adolescents: A Scoping Review

AIMS

Sleep disordered breathing (SDB), lower urinary tract dysfunction (LUTD), and enuresis (NE) are common in children and adolescents and have serious consequences, especially on social and emotional development. Even though much is known about the association between SDB and NE among adults, the number of articles in children and adolescents is limited. Therefore, the aim of the present scoping review was to map out the current knowledge about SDB and LUTD in children and adolescents.

METHODS

Four electronic databases (i.e., Embase, PsychInfo, Pubmed, Web of Science) were searched in accordance with the Johanna Briggs Institute (JBI) manual for Evidence Synthesis1 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR).2 The Quality Assessment Tool for Quantitative Studies (QATQS) was used to evaluate the methodological quality of the included studies.63,64 All articles in this scoping review met the following inclusion criteria: (a) the sample included children/adolescents between the ages of 5 and 18; (b) there was a presence of both LUTD and (a clinical manifestation of) SDB, (c) the article was published in English and/or Dutch; (d) the article was available in full text. The following exclusion criteria were used: (a) studies with solely one of the two main concepts (e.g., LUTD or SRBD); (b) studies with a third variable, other than treatment-oriented variables; (c) articles published in a language other than English or Dutch; (d) meta-analyses and reviews.

RESULTS

The search resulted in the inclusion of 17 articles related to SDB and LUTD in children and adolescents. Even though all included articles found a clear association between SDB and NE in children, very limited information was found on SDB and other LUTS and/or how the association impacts children and adolescents with developmental delays (DD's). In addition, limited and/or conflicting results were found related to SDB, NE and other variables (e.g., family history of NE, obstructive sleep apnea (OSA) severity, gender, preoperative ADH/BNP levels, obesity and ADHD). An adenotonsillectomy (T&A) had a significant beneficial therapeutic effect on NE in children and adolescents with SDB.

CONCLUSIONS

This scoping review found a clear association between SDB/OSA and NE, as the arousability and urine production at night are impacted. T&A could be considered as a treatment option for children and adolescents who do not respond to standard NE treatment. However, more research is needed to determine mechanisms involved in responders and non-responders and to examine the possible association between SDB in children and adolescents with other LUTS and/or developmental delays. The need for a multidisciplinary approach and future research is highlighted to provide children and adolescents with comorbid disorders adequate care based on the understanding of underlying conditions and mechanisms involved.

Sleep-Related Urologic Dysfunction

This article reports on the epidemiology, prevalence, and physiopathology of sleep-related urinary dysfunction, a new syndromic category proposed by the recently revised ICSD-3-TR classification. Sleep enuresis, whether primary or secondary, monosymptomatic or plurisymptomatic, will be reviewed in terms of risk factors, comorbidity, and diagnostic and therapeutic indications. A definition of nocturia and its impact on patients' health, quality of life, and mortality will follow. Finally, the impact of urge incontinence on various medical and neurologic disorders will be discussed. Special emphasis will be placed on the possible association of this parasomnia with several sleep disorders and poor, fragmented sleep.

Relationship between nocturnal enuresis and sleep in children and adolescents

BACKGROUND

Nocturnal enuresis (NE) is a multifactorial and complex condition. One less understood factor in its pathophysiology is the enuretic inability to wake up when the bladder is full (impaired arousal).

OBJECTIVE

We aimed to investigate the relationship between sleep and NE in children and adolescents.

METHODS

A systematic review was performed following the PRISMA guidelines, and the electronic databases MEDLINE (via PubMed) and SCOPUS were searched until March 2022. Eligibility criteria were studies that recruited patients aged five-17 years with a diagnosis of NE according to the International Child Continence Society (ICCS), Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5), or International Classification Criteria of Sleep Disorders-Third edition (ICSD-3) who had their sleep assessed using validated questionnaires and/or polysomnography. The tool used to analyze the risk of bias in the included studies was the risk of bias in non-randomized studies of exposure.

RESULTS

Of 1582 citations screened, nine were included, giving 1685 participants, 581 with NE. All studies were observational and half had a low risk of bias. Four studies evaluated sleep by questionnaires only; two used questionnaires and polysomnography; two used only polysomnography, and one used sleep logs and actigraphy. Sleep questionnaires showed that children with enuresis had more sleep problems than controls, especially parasomnias, breathing disorders, and daytime sleepiness. Among the polysomnography parameters, the sleep stage architecture and periodic limb movements during sleep had conflicting data between the two studies.

LIMITATIONS

The studies evaluated sleep through heterogeneous tools. They used different questionnaires; even those considered by polysomnography did not record the same channels.

CONCLUSION

It seems that enuretic children and adolescents sleep differently from those who are non-enuretic. More studies are needed to clarify the best way to assess sleep and better understand this relationship. The review protocol was registered with PROSPERO, CRD42021266338. There was no funding.

The Impact of Adenotonsillectomy on Sleep and Behavior of Children with Obstructive Sleep Apnea

Adenotonsillar hypertrophy (ATHt) is a common cause of chronic airway obstruction (UAO) in children and may cause obstructive sleep apnea syndrome (OSAS). Surgical correction in the form of Adenotonsillectomy (AdTyb) may significantly improve the sleep and behavior patterns of children, and enhance their quality of life. To test the effect of adenotonsillectomy on sleep and behavioral disorders in children with adenotonsillar hypertrophy. Prospective observational study; children ≤ 14 years diagnosed with symptomatic adenotonsillar hypertrophy planned for surgery were included. Parents were asked to complete Connor's revised parent rating scale and Children's sleep habit questionnaire pre-operatively and 3 months after surgery. This was done to evaluate the children's sleep habits, disturbances and behavior. A total of 77 children were included in the study. The age range was 4 - 14 years. Fifty-two were male and rest, female. There was a significant reduction in Sleep score after surgery (mean pre-operative sleep score 51.3 ± 8.9 vs. post-operative 37.29 ± 7.1; p value < 0.001). Similarly, there was a statistically significant improvement in the behaviour score also after surgery (mean pre-operative behavior score 28.96 ± 9.8 vs. post-operative 23.13 ± 7.9; p value < 0.001). The sleep and behaviour scores were not related to the age or gender of the participants. Adenotonsillar hypertrophy causes documentable sleep disturbances and obstructive sleep apnea leading to neurobehavioral issues in children. The standard of care is surgery which leads to significant improvement in these aspects and quality of life.

The impact of adenotonsillectomy on monosymptomatic primary nocturnal enuresis in children with obstructive sleep apnea syndrome

Objectives:

To analyze the outcome of monosymptomatic primary nocturnal enuresis (MPNE) after adenotonsillectomy in children with obstructive sleep apnea syndrome (OSAS).

Methods:

The study included 74 MPNE children with OSAS qualified for an adenotonsillectomy procedure. MPNE was assessed prior to surgical procedure as well as 3 and 6 months after surgery. In addition to polysomnographic parameters, serum antidiuretic hormone (ADH) and brain natriuretic peptide (BNP) levels were measured preoperatively and 3 months postoperatively.

Results:

The mean age was 9.8 years and the mean number of nocturnal wetting weekly was 4.1. Thirty-eight percent of patients had family history of MPNE. All the patients underwent a successful adenotonsillectomy. Nocturnal enuresis was still reported in 18% of children 6 months after adenotonsillectomy. An increased risk of MPNE was significantly demonstrated in children with high obstructive apnea-hypopnea index (O-AHI), high oxygen desaturation index (ODI), high frequent nocturnal enuresis and family history. After surgery, ADH levels were significantly lower, whereas BNP levels were significantly higher in non-resolution children. Univariate analysis showed that higher O-AHI, higher ODI, severe enuresis, low serum ADH and higher serum BNP levels were indicative of persistent nocturnal enuresis. Multivariate analysis showed that higher ODI and higher BNP levels are independent prognostic markers for MPNE.

Conclusions:

Adenotonsillectomy in MPNE children with OSAS is an effective treatment for resolution of MPNE. Also, higher ODI caused by apnea and elevated serum BNP levels are the most important factors affecting the outcome of MPNE patients.

Level of evidence:

Not applicable for this multicentre audit.

Nocturnal enuresis in children is associated with differences in autonomic control

Study Objectives

To assess the relationship between urine osmolality, cardiovascular parameters, and nocturnal enuresis in a population of children undergoing polysomnographic assessment.

Methods

This prospective observational study included consecutive children aged 5–17 years presenting for overnight polysomnography. Children were evaluated using continuous ambulatory blood pressure monitoring to assess heart rate and blood pressure. Urine samples were collected throughout the night to determine urine sodium excretion and osmolality. Comparisons of results were made between children with and without a history of nocturnal enuresis.

Results

A total of 61 children were included for analysis; 13 had a history of nocturnal enuresis. Children with nocturnal enuresis had greater disruption in respiratory parameters including higher apnea–hypopnea index (mean difference 12.2 ± 8.8 events/h, p < 0.05), attributable to more central respiratory events (mean difference 5.4 ± 4.9, p < 0.05), and higher variability in both oxygen and carbon dioxide parameters compared to those without nocturnal enuresis. Sleep parameters, urine osmolality, and blood pressure did not differ between groups. Children with nocturnal enuresis showed an increase, rather than a decrease, in heart rate across the night (+5.4 ± 19.1 vs. −6.0 ± 14.8 beats/min, p < 0.05).

Conclusions

Children with a history of nocturnal enuresis have greater respiratory abnormalities, no differences in urine osmolality or blood pressure, and loss of normal heart rate decrease across the night. This pattern suggests that autonomic control, rather than renal or hemodynamic abnormalities, may contribute to the pathophysiology of nocturnal enuresis.

How Does Adenotonsillectomy Affect the Olfactory Threshold in Children?

Adenotonsillectomy is one of the main operations on the head and neck surgery quality in children. This study aimed to compare the olfactory threshold changes in adenotonsillectomy patients. This comparative study was done on 152 children whom candidate for adenotonsillectomy before and 3 weeks after the operation referred to the Dr. Kermanshahi Hospital, Kermanshah, Iran during 2015-2016. The olfactory threshold was determined by olfactory test using phenyl butyl alcohol in propylene glycol. The orthonasal test was done by a strip and the lowest propylene glycol detection used as olfactory threshold. The mean age was 6.81 ± 3.83 of patients were boys and 69 of them were girls. The allergic rhinitis was detected in 83.6% of the patients before the adenotonsillectomy while it was only in 16.4% after adenotonsillectomy. Also, nocturia was higher before the adenotonsillectomy 104 (68.4%) compared to post-adenotonsillectomy 48 (31.6%). In 73 (48%) patients, the sleep quality score was 10 after the surgery while there was a patient with score 10 before the operation. The positive allergic rhinitis was higher in male 70 (84.3%) compared to female 57 (82.6%). Also, no significant difference detected on nocturia (P = 0.531). Also, significant difference detected between 2 groups in sleep quality score before and after the adenotonsillectomy (P = 0.001). The olfactory threshold significantly improved after surgery compared to previous (P = 0.034). These results suggest olfactory threshold improves after adenotonsillectomy in children.

Nocturnal enuresis and sleep disordered breathing in primary school children: Potential implications

INTRODUCTION

The association between nocturnal enuresis (NE) and sleep disordered breathing (SDB) has been repeatedly reported, but has primarily been focused on clinical cohorts. The purpose of this study, was to assess whether SDB-related symptoms such as snoring and unrefreshing sleep in the morning are associated with NE in a large-scale community school-based survey.

METHODS

A cross-sectional assessment using a standard questionnaire was conducted on nearly 20 000 primary school children (5-12 years old) in Matsuyama, Japan. Associations between NE and the frequencies of snoring and unrefreshing sleep were evaluated using multivariate logistic and regression analyses.

RESULTS

Multivariate adjusted odds ratios (95% confidence intervals) for enuresis were 1.21 (1.04 to 1.40) and 1.36 (1.07 to 1.73) in boys who snored 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Those for enuresis were 1.67 (1.41 to 1.99) and 1.96 (1.63 to 2.36) in boys who showed unrefreshing sleep 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Significant associations between NE and snoring frequency emerged among children who did not report unrefreshing sleep (P-trend for boys and girls were <0.0001 and <0.01, respectively), while significant associations between NE and frequency of unrefreshing sleep were detected among children who snored ≥1 nights per week (P for trend >0.1).

CONCLUSIONS

The pathogenic mechanisms linking snoring and unrefreshing sleep to increased risk of NE are unknown. However, snoring, a surrogate reporter of SDB, is associated with increased urine production, while unrefreshing sleep may result from disrupted sleep facilitating increased sleep pressure and elevated arousal thresholds. Thus, both SDB and unrefreshing sleep are potential independent risk factors of NE in school age children.

Pre- and post-operative evaluation of the frequency of nocturnal enuresis and Modified Pediatric Epworth Scale in pediatric obstructive sleep apnea patients

OBJECTIVE

To investigate the beneficial effect of adenotonsillectomy (AT) on nocturnal enuresis (NE) in children with adenotonsillar hypertrophy and evaluate the Modified Pediatric Epworth Scale (MPES).

METHODS

This was a prospective study comparing preoperative and postoperative evaluation of the frequency of NE and MPES in pediatric obstructive sleep apnea (OSA). A questionnaire on NE history was prepared based on the Turkish Enuresis Guidelines. NE histories were evaluated pre- and postoperatively on the first month and third month, respectively. MPES questions were asked to the parents of all the OSA patients pre- and postoperatively, and scores were noted.

RESULTS

Eighty-four (84) pediatric OSA patients were involved in the study. Preoperatively, 19 patients (27%) complained about nocturnal enuresis. After the surgery, 52% of the patients with NE had complete resolution of NE (p < 0.001). Postoperatively, the average Epworth scores of both groups significantly decreased (p < 0.001).

CONCLUSION

There is a strong correlation between OSA and NE. In the present study, enuresis in pediatric OSA patients significantly decreased after surgery. Also, Epworth scores decreased significantly after surgery. In children with nocturnal enuresis, the presence of OSA symptoms should be questioned.

Sleep disordered breathing in enuretic children and controls

INTRODUCTION

Nocturnal enuresis and sleep disordered breathing are common childhood problems that are reported to be associated with each other. Sleep disordered breathing is often found in children with upper airway obstruction and, according to some studies, its presence is associated with an increased risk of nocturnal enuresis. Respiration during sleep in children with therapy-resistant enuresis, but no history of snoring or sleep apneas, has previously been investigated, and subclinical signs of disordered respiration were found in this group. However, sleep disordered breathing in enuretic children without a history of snoring or sleep apneas has not been thoroughly studied before.

AIM

To evaluate sleep disordered breathing in enuretic children and compare them with healthy control children.

SUBJECTS AND METHODS

Children aged 8-13 years with nocturnal enuresis were included. Exclusion criteria were: daytime incontinence, on-going anti-enuretic treatment, and concomitant urological, endocrinological, nephrological or psychiatric disorders. Twenty children (19 boys and 1 girl) suffering from therapy-resistant nocturnal enuresis, and 21 healthy controls (18 boys and 3 girls) underwent one night of polygraphic sleep registration focused on respiratory variables. The registration included electroencephalography as well as assessment of respiratory movements, nasal airflow and oxygen saturation; it was performed with a portable sleep device at the subjects' homes. In addition to this, OSA 18, a health-related quality of life instrument, was used to evaluate subjective issues related to sleep and breathing.

RESULTS

The mean apnea hypopnea index values were 0.96 ± 0.8 for the patient group and 0.46 ± 0.4 for the control group. The oxygen desaturation index was slightly higher for the children with nocturnal enuresis compared with the healthy controls (P = 0.05). No other differences were found in the respiratory variables. Both groups of children showed low levels of arousals (Summary Table). The enuretic children reported significantly more subjective sleep disturbances and a lower quality of life than their healthy peers.

DISCUSSION

This was the first controlled study of sleep disordered breathing in children with nocturnal enuresis. One limitation of the study was that some variables were known to be underestimated when scoring polygraphic data. The apnea hypopnea index was such a variable and was indeed lower than in a previous study.

CONCLUSION

No major differences in respiration during sleep were found between enuretic children and controls.

Primary nocturnal enuresis is associated with lower intelligence quotient scores in boys from poorer socioeconomic status families

OBJECTIVES

To explore intelligence quotient in boys with primary nocturnal enuresis compared with normal boys considering their socioeconomic status.

METHODS

A total of 152 school-aged boys (including 55 boys with primary nocturnal enuresis and 97 matched normal controls) were assessed. Boys with a history of any neurological or urological disease were excluded. Two different districts of Tehran: Khani-Abad (a poor district) and Pirouzi (a middle class district) districts were enrolled according to socioeconomic status data reported by the World Health Organization. Intelligence tests were carried out using a validated Iranian translation of the Wechsler Intelligence Scale for Children Revised. Total, as well as performance intelligence quotient and verbal intelligence quotient scores and verbal-performance discrepancy (the difference between verbal and performance intelligence quotient scores for each individual) were compared using a t-test between boys with primary nocturnal enuresis in each district and their matched controls.

RESULTS

Considering each district separately, the total intelligence quotient score was lower in primary nocturnal enuresis cases than controls only in the lower income district (90.7 ± 23.3 vs 104.8 ± 14.7, P = 0.002). Similarly, boys with primary nocturnal enuresis ranked lower in verbal intelligence quotient (P = 0.002) and performance intelligence quotient (P = 0.004) compared with their matched normal controls only in lower income district, whereas in the higher income district, boys with primary nocturnal enuresis ranked similar in total intelligence quotient to their matched controls.

CONCLUSIONS

Boys with primary nocturnal enuresis had a lower intelligence quotient compared with the control participants only in low-income district. It seems important to adjust the results of the intelligence quotient assessment in these children according to their socioeconomic status.

Indications for tonsillectomy stratified by the level of evidence

Background: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of evidence-based medicine. Material and methods: A systematic Medline research was performed using the key word of "tonsillectomy" in combination with different filters such as "systematic reviews", "meta-analysis", "English", "German", and "from 1984/01/01 to 2015/05/31". Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the "Trip Database" were researched for "tonsillectomy" and "indication" and "from: 1984 to: 2015" in combination with either "systematic review" or "meta-analysis" or "metaanalysis". Results: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. Conclusions: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research is required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.

Enuresis and sleep disordered breathing: An old and new link

The causes of nocturnal enuresis (NE) are likely multifactorial. It has been related to several (urological-nephrological-hormonal) reasons but clear and univocal pathogenesis remains mostly undetermined. Sleep disordered breathing (SDB) is a syndrome of upper airway dysfunction that occurs during sleep and is characterized by snoring and/or increased respiratory effort secondary to increased upper airway resistance and pharyngeal collapsibility. Adenotonsillar hypertrophy is the main cause of SDB in children. To date, several studies have associated childhood NE with coexistent SDB. Adenotonsillectomy was successful for both SDB and NE in about half of patients. Unfortunately, practical consensus guidelines for the management of primary NE do not mention, or marginally concern, SDB in these children, particularly in those who have treatment resistance and comorbidities. The concerns regard the concomitant presence of two relatively frequent sleep disorders, raising the question whether they are really coincidental problems of childhood.

Adenoidectomy for Obstructive Sleep Apnea in Children

STUDY OBJECTIVE

Adenotonsillectomy is the recommended treatment for children with obstructive sleep apnea (OSA). Since adenoidectomy alone may be associated with significantly lower morbidity, mortality, and cost, we aimed to investigate whether adenoidectomy alone is a reasonable and appropriate treatment for children with OSA.

METHODS

Five-hundred fifteen consecutive children diagnosed with moderate-to-severe OSA (apnea-hypopnea index > 5) based on polysomnography and who underwent adenoidectomy or adenotonsillectomy were reevaluated after 17-73 months (mean 41) for residual or recurrent OSA using a validated questionnaire (Pediatric Sleep Questionnaire, PSQ). Failure of OSA resolution was defined as a positive mean PSQ score ≥ 0.33. Contribution of age, obesity, tonsil size, and OSA severity at baseline to adenoidectomy or adenotonsillectomy failure was examined.

RESULTS

Positive PSQ score occurred in 15% of the entire sample and was not influenced by age or gender. No difference in failure rate was observed between adenoidectomy and adenotonsillectomy for children who were not obese with apnea-hypopnea index < 10 and had small tonsils (< 3). Children with apnea-hypopnea index ≥ 10 and/or tonsil size ≥ 3 showed a higher failure rate after adenoidectomy compared to adenotonsillectomy (20% versus 9.8%, p = 0.028).

CONCLUSIONS

We suggest that subjective, long term outcomes of adenoidectomy are comparable to those of adenotonsillectomy in non-obese children under 7 years old with moderately OSA and small tonsils. Hence, adenoidectomy alone is a reasonable option in some children. Future prospective randomized studies are warranted to define children who may benefit from adenoidectomy alone and those children in whom adenoidectomy alone is unlikely to succeed.

Efficacy of a Mandibular Advancement Appliance on Sleep Disordered Breathing in Children: A Study Protocol of a Crossover Randomized Controlled Trial

BACKGROUND

Sleep-Disordered Breathing (SDB) varies from habitual snoring to partial or complete obstruction of the upper airway and can be found in up to 10% of children. SDB can significantly affect children's wellbeing, as it can cause growth disorders, educational and behavioral problems, and even life-threatening conditions, such as cardiorespiratory failure. Adenotonsillectomy represents the primary treatment for pediatric SDB where adeno-tonsillar hypertrophy is indicated. For those with craniofacial anomalies, or for whom adenotonsillectomy or other treatment modalities have failed, or surgery is contra-indicated, mandibular advancement splints (MAS) may represent a viable treatment option. Whilst the efficacy of these appliances has been consistently demonstrated in adults, there is little information about their effectiveness in children.

AIMS

To determine the efficacy of mandibular advancement appliances for the management of SDB and related health problems in children.

METHODS/DESIGN

The study will be designed as a single-blind crossover randomized controlled trial with administration of both an "Active MAS" (Twin-block) and a "Sham MAS." Eligible participants will be children aged 8-12 years whose parents report they snore ≥3 nights per week. Sixteen children will enter the full study after confirming other inclusion criteria, particularly Skeletal class I or class II confirmed by lateral cephalometric radiograph. Each child will be randomly assigned to either a treatment sequence starting with the Active or the Sham MAS. Participants will wear the appliances for 3 weeks separated by a 2-week washout period. For each participant, home-based polysomnographic data will be collected four times; once before and once after each treatment period. The Apnea Hypopnea Index (AHI) will represent the main outcome variable. Secondary outcomes will include, snoring frequency, masseter muscle activity, sleep symptoms, quality of life, daytime sleepiness, children behavior, and nocturnal enuresis. In addition, blood samples will be collected to assess growth hormone changes.

TRIAL REGISTRATION

This study was registered in the Australian New Zealand Clinical Trials Registry (ANZCTR): [ACTRN12614001013651].

The Relationship Between Child Anxiety Related Disorders and Primary Nocturnal Enuresis

BACKGROUND

Nocturnal enuresis, often called bedwetting or sleep wetting, is a common problem in children after the age of five and may lead to symptoms such as infection, incontinence and frequent urination. This problem refers to a state in which children after the age of five have no control of their urine for six continuous months and it cannot be attributed to any organic factors or drug use.

OBJECTIVES

In this study we aimed to study generalized anxiety disorder as one of the possible causes of primary nocturnal enuresis.

MATERIALS AND METHODS

In this case-control study 180 children with primary nocturnal enuresis and same number of healthy children with a mean age of 7 - 17 years old with the same demographic characteristics were selected. The study took place at Amir Kabir hospital of Arak, Iran during year 2014. After collecting the information, diagnosis was verified based on the diagnostic and statistical manual of mental disorders (DSM) IV-TR criteria. Results were analyzed using the SPSS software (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, version 20.0. Armonk, NY: IBM Corp.).

RESULTS

Frequency of generalized anxiety disorder, panic disorder, school phobia, social anxiety, separation anxiety, history of anxiety in mother, history of primary nocturnal enuresis in parent's family and body mass index had a significant difference between the two groups (P = 0.005).

CONCLUSIONS

With the results obtained from this study we could say that there was a clear significant difference between the two control and patient groups for all subgroups of anxiety disorders such as generalized anxiety disorder and their relationship with primary nocturnal enuresis. Given the higher prevalence of generalized anxiety disorder, panic disorder, school phobia, social anxiety, separation anxiety and comparison with healthy children, it is recommended for all children with primary nocturnal enuresis to be investigated and treated for generalized anxiety disorder.

Association of Sleep Disordered Breathing with Mono-Symptomatic Nocturnal Enuresis: A Study among School Children of Central India

OBJECTIVE

To study the prevalence of primary monosymptopomatic nocturnal enuresis (PMNE) in children aged 5-10 year and to find its association with sleep disordered breathing (SDB) by using a 22 item pediatric sleep related breathing disorder (SRBD) scale.

METHODS

This was a school based cross sectional epidemiological study from July 2015 to November 2015. A questionnaire seeking information on socio-demographic variables, nocturnal enuresis (NE) frequency, school performance and a validated 22 item pediatric sleep related breathing disorder scale (SRBDs) was distributed to 1820 pupils in three primary schools.

RESULTS

A total of 1528(83.95%) questionnaires were retrieved. Out of 1528 forms, 182(11.9%) forms were incomplete for requested information and hence 1346 (73.9%) questionnaires were finally analyzed. The prevalence of NE was found to be 12.7% (95% CI; 11-14.6), whereas prevalence of primary nocturnal enuresis (PMNE) was 8.2% (95% CI; 7.1-10.1). SRBD scale score >0.33 (adjusted OR: 2.87; 95%CI: 1.67-4.92), paternal history of enuresis in childhood (adjusted OR:4.96; 95% CI: 2.36-10.45), and inappropriate toilet training (adjusted OR: 1.64; 95% CI: 1.01-2.66) were independently associated with PMNE.

CONCLUSION

Sleep disordered breathing, inappropriate toilet training and a history of childhood NE in father were found to be significant risk factors for PMNE in the present study. Thus, these findings suggest that it is imperative to rule out SDB in PMNE patients as they may require different therapeutic interventions.

Adenotonsillectomy improves quality of life in children with sleep-disordered breathing regardless of nocturnal enuresis outcome

BACKGROUND

Nocturnal enuresis (NE) and sleep-disordered breathing (SDB) have both been associated with impaired health-related quality of life (HRQoL). The following were investigated: (1) whether tonsillectomy and/or adenoidectomy (T&A) significantly affect the HRQoL in children with NE and SDB, and 2) differences in HRQoL between children with NE persistence versus resolution post-T&A.

METHODS

This was a prospective study comparing the HRQoL of children with SDB and NE (study group) pre- and 4 weeks post-T&A, and the HRQoL of children with SDB without NE (control group) (independent t-tests). HRQol was assessed using the Obstructive Sleep Apnea Quality of Life 18 questionnaire (OSAS-18), a validated measure containing five subscales that combine to create a total score. Individual items were scored on a Likert-type scale ranging from 1 (none of the time) to 7 (all of the time). Symptoms of SDB were evaluated using the validated Pediatric Sleep Questionnaire (PSQ). Mixed ANOVA was conducted to evaluate changes in the measures between the wet and dry children post-T&A. Pre- and post-T&A change scores were calculated for both the PSQ and the OSAS-18.

RESULTS

There were 30 children in the study group (18 male, mean age 9.07 years, SD 2.19), and 30 age-matched controls (16 male). There were no statistically significant differences between the two groups in regards to OSAS-18 total, PSQ total, BMI, diagnosis of snoring or OSAS on sleep study, or race. Overall, OSAS-18 and PSQ scores significantly improved in all children post-surgery (p < 0.001; p < 0.001, respectively), with no significant differences between dry and wet children post-T&A. The correlation between the pre- and post-T&A change scores on the OSAS-18 and PSQ was significant (r(29) = 0.58, p = 0.001), suggesting that a reduction in SDB symptoms post T&A is related to improved HRQoL.

CONCLUSIONS

T&A significantly improved HRQoL in all children with SDB and NE, regardless of NE outcomes. These findings support recommendations for T&A in children with SDB with or without NE.

Why does adenotonsillectomy not correct enuresis in all children with sleep disordered breathing?

PURPOSE

We analyzed the outcome of nocturnal enuresis after adenotonsillectomy in children with sleep disordered breathing. We also evaluated differences in demographic, clinical, laboratory and polysomnography parameters between responders and nonresponders after adenotonsillectomy.

MATERIALS AND METHODS

We prospectively evaluated children 5 to 18 years old diagnosed with sleep disordered breathing (snoring or obstructive sleep apnea syndrome) on polysomnography and monosymptomatic primary nocturnal enuresis requiring adenotonsillectomy to release upper airway obstruction. Plasma antidiuretic hormone and brain natriuretic peptide were measured preoperatively and 1 month postoperatively.

RESULTS

Sleep studies were done in 46 children and 32 also underwent blood testing preoperatively and postoperatively. Mean ± SD patient age was 8.79 ± 2.41 years and the mean number of wet nights weekly was 6.39 ± 1.26. Polysomnography revealed obstructive sleep apnea syndrome in 71.7% of patients and snoring in 28.3%. After adenotonsillectomy 43.5% of patients became dry. Preoperative polysomnography findings indicated that responders, who were dry, had significantly more arousals and obstructive apnea episodes but fewer awakenings than nonresponders, who were wet. Significant increases in plasma antidiuretic hormone and significant decreases in plasma brain natriuretic peptide were seen in all children with no difference between responders and nonresponders. No difference between the groups was noted in age, gender, race, body mass index, constipation, preoperative number of wet nights weekly or type of sleep disordered breathing.

CONCLUSIONS

Nocturnal enuresis resolved after adenotonsillectomy in almost half of the children with sleep disordered breathing. Those who became dry had more frequent arousal episodes caused by apnea events than those who remained wet.

Sleep apnea in children with refractory monosymptomatic nocturnal enuresis

BACKGROUND

Children with nocturnal enuresis (NE) are believed to have deep sleep with high arousal threshold. Studies suggest that obstructive sleep apnea-hypopnea syndrome (OSAHS) and NE are common problems during childhood. We sought to assess the prevalence of OSAHS in children with refractory NE and whether its severity is associated with the frequency of bedwetting.

METHODS

The study group comprised 43 children with refractory monosymptomatic NE and a control group of 30 children, both aged 6-12 years. All subjects underwent thorough neurological examination, one night of polysomnography only for the patient group, and a lumbosacral plain X-ray to exclude spina bifida.

RESULTS

The groups were well matched. Two subjects of the control group had mild OSAHS. The mean age of the patients was (9.19±2.4 years), 26 were boys, and 67% showed frequent NE (>3 days bedwetting/week). Patients with NE had significantly higher rates of OSAHS (P<0.0001); three patients had mild, 12 had moderate, and eleven showed severe OSAHS. There was no significant statistical difference among patients having OSAHS in relation to age, sex, or family history of NE. The frequency of bedwetting was statistically significantly higher in patients with severe OSAHS (P=0.003).

CONCLUSION

Patients with refractory NE had a significantly higher prevalence of OSAHS with no sex difference. The frequency of bedwetting was higher in patients with severe OSAHS.

Primary nocturnal enuresis as a risk factor for sleep disorders: an observational questionnaire-based multicenter study

INTRODUCTION

Primary nocturnal enuresis (PNE) is a common problem in developmental age with an estimated overall prevalence ranging from 1.6% to 15%, and possible persistence during adolescence. There is a growing interest in the sleep habits of children affected by PNE, which is derived from the contradictory data present in clinical literature. The aim of the present study was to evaluate the presence of sleep disturbances in a population of children affected by PNE, and to identify whether PNE could be considered as a risk factor for sleep disturbances among children.

MATERIALS AND METHODS

A total of 190 PNE children (97 males, 93 females) aged 7-15 years, (mean 9.64 ± 1.35 years), and 766 typically developing children matched for age (P = 0.131) and gender (P = 0.963) were enrolled. To evaluate the presence of sleep habits and disturbances, all of the subjects' mothers filled out the Sleep Disturbances Scale for Children (SDSC), a questionnaire consisting of six subscales: Disorders in Initiating and Maintaining Sleep (DIMS), Sleep Breathing Disorders (SBD), Disorders of Arousal (DA), Sleep-Wake Transition Disorders (SWTD), Disorders of Excessive Somnolence (DOES), and Nocturnal Hyperhidrosis (SHY). The results were divided into "pathological" and "normal" scores using a cut-off value (pathological score = at least three episodes per week), according to the validation criteria of the test. Then, the Chi-square test was used to calculate the statistical difference and a univariate logistic regression analysis was applied to determine the role of PNE as a risk factor for the development of each category of sleep disorders and to calculate the odds ratio (OR).

RESULTS

PNE children show a higher prevalence of all sleep disturbances (41.03% DIMS; 85.12% SBD; 63.29% DA; 67.53% SWTD; 31.28% DOES; 37.92% SHY; 25.33% SDSC total score), and according to OR results (SDSC total score OR = 8.293, 95% confidence interval [CI] = 5.079-13.540; DIMS OR = 7.639, 95% CI = 5.192-11.238; SBD OR = 35.633, 95% CI = 22.717-55.893; DA OR = 13.734, 95% CI = 9.476-19.906; SWTD OR = 14.238, 95% CI = 9.829-20.625; DOES OR = 5.602, 95% CI = 3.721-8.432; SHY OR = 6.808, 95% CI = 4.608-10.059), PNE could be considered as a risk factor for the development of sleep disorders.

CONCLUSION

Among PNE children, sleep could be strongly altered, thus helping to affirm the hypothesis that PNE tends to alter sleep architecture, or it could itself be the consequence of an abnormal sleep structure. The findings also point to the existence of a potential increase in the risk of developing sleep disorders in the presence of PNE.

Enuresis associated with sleep disordered breathing in children with sickle cell anemia

PURPOSE

Enuresis and sleep disordered breathing are common among children with sickle cell anemia. We evaluated whether enuresis is associated with sleep disordered breathing in children with sickle cell anemia.

MATERIALS AND METHODS

Baseline data were used from a multicenter prospective cohort study of 221 unselected children with sickle cell anemia. A questionnaire was used to evaluate, by parental report during the previous month, the presence of enuresis and its severity. Overnight polysomnography was used to determine the presence of sleep disordered breathing by the number of obstructive apneas and/or hypopneas per hour of sleep. Logistic and ordinal regression models were used to evaluate the association of sleep disordered breathing and enuresis.

RESULTS

The mean age of participants was 10.1 years (median 10.0, range 4 to 19). Enuresis occurred in 38.9% of participants and was significantly associated with an obstructive apnea-hypopnea index of 2 or more per hour after adjusting for age and gender (OR 2.19; 95% CI 1.09, 4.40; p = 0.03). Enuresis severity was associated with obstructive apneas and hypopneas with 3% or more desaturation 2 or more times per hour with and without habitual snoring (OR 3.23; 95% CI 1.53, 6.81; p = 0.001 and OR 2.07; 95% CI 1.09, 3.92; p = 0.03, respectively).

CONCLUSIONS

In this unselected group of children with sickle cell anemia, sleep disordered breathing was associated with enuresis. Results of this study support that children with sickle cell anemia who present with enuresis should be evaluated by a pulmonologist for sleep disordered breathing.

[Voiding disorders in childhood: from symptoms to diagnosis]

The new definitions of voiding disorders in children should be used in clinical practice. Two major kinds of voiding disorders are identified: 1) isolated primary enuresis as a disorder occurring exclusively during sleep with no daytime leakage; 2) urinary dysfunctions that include uninhibited detrusor contraction, sphincter hypertonicity, and urethral instability. These dysfunctions may be primary or secondary. Constipation as an underlying cause is frequent and usually underestimated. The diagnostic process requires one (or more) long consultations. After ruling out a urine leak without a voiding disorder and secondary causes (constipation, inadequate hydration, poor voiding hygiene, crystalluria, etc.), the aim is to distinguish isolated sleep-time disorders (primary enuresis) from daytime ± sleep-time symptoms (primary urinary dysfunctions). Anamnesis, long and accurate, can be sensitized by a questionnaire completed at home. The physical examination focuses on the exclusion of anatomic abnormalities and local inflammation (vulvitis, balanitis, etc.). Diagnostic tests are rarely required at the beginning. Urodynamic exploration may be indicated, never at the first consultation, in case of primary urinary dysfunction. This diagnostic approach provides an appropriate therapeutic decision.

Association between primary nocturnal enuresis and habitual snoring in children with obstructive sleep apnoea-hypopnoea syndrome

INTRODUCTION

Nocturnal enuresis (NE) and obstructive sleep apnoea-hypopnoea syndrome (OSAHS) are common problems during childhood, and population studies have reported a significant correlation between them. This study aimed to assess whether habitual snoring, mouth breathing and daytime sleepiness are associated with increased incidence of NE in children with OSAHS.

MATERIAL AND METHODS

Polysomnography was performed in 42 children (66.7% males), 3.5-14.5 years old, who were evaluated for sleep-disordered breathing (SDB).

RESULTS

Fourteen out of 42 children (33.3%) presented mild, 16 out of 42 (38.1%) moderate and 12 out of 42 (28.6%) severe degree of OSAHS. Apnea hypopnea index (AHI) ranged between 1.30-94.20 (10.54 ±15.67) events per hour of sleep. Nocturnal enuresis was reported in 7/42 (16.7%) of them. The main observed symptoms were snoring (90.5%), restless sleep (81%), mouth breathing (71.4%), nasal congestion (76.2%), and difficulty in arousal (52.4%). A statistically significant association was found between NE and mouth breathing (p = 0.014) or nasal congestion (p = 0.005). Children with OSAHS and NE had a higher arousal index (8.14 ±8.05) compared with OSAHS children without NE (4.61 ±7.95) (p = 0.19, z = -1.28). Snorers had higher levels of AHI (11.02 ±16.37) compared with non-snorers (6.05 ±4.81) (p = 0.33, z = -0.96), and habitually snorers (23/42, 54.76%) were at greater risk of having NE (4/23) than were non-snorers (0/4, p = 0.36). However, the prevalence of enuresis was not related to the severity of OSAHS, expressed as AHI (p = 0.70).

CONCLUSIONS

Mouth breathing, nasal congestion and high threshold of arousal during sleep should be more carefully evaluated in cases of children with NE who do not respond to standard treatment and present SDB.

Diagnostic value of functional bladder capacity, urine osmolality, and daytime storage symptoms for severity of nocturnal enuresis

Purpose

To investigate the correlation between functional bladder capacity, first morning urine osmolality, daytime voiding symptoms, and severity of nocturnal enuresis.

Materials and Methods

We assessed a total of 101 children with nocturnal enuresis (mean age, 7.7±2.3 years). Patients were divided into three groups according to the severity of enuresis: (1) one to six episodes per week (46 cases, 45.5%), (2) one episode every day (29 cases, 28.7%), and (3) multiple episodes every day (26 cases, 25.8%). Baseline parameters were obtained from frequency volume charts for 2 days, first morning urine osmolality, and a questionnaire for the presence of frequency, urgency, and daytime incontinence.

Results

The severity of enuresis increased with younger age (p=0.037) and reduced functional bladder capacity (p=0.007) and daytime symptoms of frequency and daytime incontinence (p=0.012, p=0.036). No statistical difference in urine osmolality or urgency was found among the three groups. Both reduced functional bladder capacity and low urine osmolality increased according to the severity of enuresis (p=0.012).

Conclusions

In children with nocturnal enuresis, severity was increased by younger age, reduced functional bladder capacity, and the presence of daytime voiding symptoms of frequency and daytime incontinence. The incidence of small functional bladder capacity was increased in children with everyday wetting, and the incidences of both small functional bladder capacity and low urine osmolality were increased in children with everyday multiple wetting.

Urinary incontinence in children

BACKGROUND

Urinary incontinence (bedwetting, enuresis) is the commonest urinary symptom in children and adolescents and can lead to major distress for the affected children and their parents. Physiological and non-physiological types of urinary incontinence are sometimes hard to tell apart in this age group.

METHODS

This article is based on selected literature retrieved by a PubMed search and on an interdisciplinary expert consensus.

RESULTS AND CONCLUSION

Nocturnal enuresis has a variety of causes. The main causative factors in monosymptomatic enuresis nocturna (MEN) are an impaired ability to wake up when the bladder is full, due to impaired or absent perception of fullness during sleep, and an imbalance between bladder capacity and nocturnal urine production. On the other hand, non-monosymptomatic enuresis nocturna (non-MEN) is usually traceable to bladder dysfunction, which is also the main cause of diurnal incontinence. A basic battery of non-invasive diagnostic tests usually suffices to determine which type of incontinence is present. Further and more specific testing is indicated if an organic cause is suspected or if the treatment fails. The mainstay of treatment is urotherapy (all non-surgical and non-pharmacological therapeutic modalities). Some patients, however, will need supportive medication in addition. Urinary incontinence has different causes in children and adults and must therefore be diagnosed and treated differently as well. All physicians who treat the affected children (not just pediatricians and family doctors, but also pediatric nephrologists, urologists, pediatric surgeons, and child psychiatrists) must be aware of the specific features of urinary incontinence in childhood.

Aggressive behavior, bullying, snoring, and sleepiness in schoolchildren

BACKGROUND

To assess whether urban schoolchildren with aggressive behavior are more likely than peers to have symptoms suggestive of sleep-disordered breathing.

METHODS

Cross-sectional survey of sleep and behavior in schoolchildren. Validated screening assessments for conduct problems (Connor's rating scale), bullying behavior, and sleep-disordered breathing (pediatric sleep questionnaire) were completed by parents. Teachers completed Connor's teacher rating scale.

RESULTS

Among 341 subjects (51% female), 110 (32%) were rated by a parent or teacher as having a conduct problem (T-score ⩾65) and 78 (23%) had symptoms suggestive of sleep-disordered breathing. Children with conduct problems, bullying, or discipline referrals, in comparison to non-aggressive peers, more often had symptoms suggestive of sleep-disordered breathing (each p<0.05). Children with vs. without conduct problems were more likely to snore habitually (p<0.5). However, a sleepiness subscale alone, and not a snoring subscale, predicted conduct problems after accounting for age, gender, a measure of socioeconomic status, and stimulant use.

CONCLUSIONS

Urban schoolchildren with aggressive behaviors may have symptoms of sleep-disordered breathing with disproportionate frequency. Sleepiness may impair emotional regulation necessary to control aggression.

Facial patterns and primary nocturnal enuresis in children

PURPOSE

Aims of our study are evaluating: (1) the prevalence of dolicofacial pattern among enuretic and control-group children, (2) the prevalence of an abnormal head posture in bedwetters, and (3) the correlation with sleep-related breathing disorders (SRBD) identified by polysomnography (PSG) recording. Nocturnal enuresis is a multifactorial disease, but has been related also to obstructive sleep-disordered breathing in both adults and children. Anatomical factors recognized to predispose to SRBD include adenotonsillar hypertrophy, neuromuscular disorders, craniofacial abnormalities associated with macroglossia, retrognathia or maxillary hypoplasia, and obesity.

METHODS

Two hundred seventy enuretic children aged 7-12 years (mean 9.62 ± 2.31) were compared with a control-matched group of 274 children. To screen nocturnal sleep habits, all subjects' mothers filled out the Sleep Disturbance Scale for Children. Among these scales, only SBD scale was taken into account. Sleep breathing disorders (SBD) scale is composed of three items: sleep breathing difficulties, sleep apnea, and snoring. Cephalic index was calculated for each patient in order to identify facial patterns. An overnight PSG was performed in 28 (15 males, 13 females), randomly chosen, enuretic children and in 38 healthy volunteer controls (18 males, 20 females) matched for age (8.73 ± 0.79 vs. 9.12 ± 1.23; p = 0.147) and sex distribution (chi-square = 0.062; p = 0.803).

RESULTS

Bedwetters show different sleep habits, higher prevalence of dolicofacial pattern, and abnormal head posture more than controls.

CONCLUSIONS

Our preliminary study support further investigation of usage of the cephalic index as a predictor of SRBD.