Association between primary nocturnal enuresis and habitual snoring in children

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.

Sleep-Disordered Breathing and Its Association with Nocturnal Enuresis at the Primary Schools in Saudi Arabia: A Cross-Sectional Study

The correlation between nocturnal enuresis (NE) and sleep-disordered breathing (SDB) was reported. We aim to determine whether there is an association between NE and SDB in children and to assess the prevalence of SDB and NE in primary school children aged 6-12 years in Saudi Arabia. A cross-sectional observational study was conducted among the caregivers of children aged 6-12 years in all Saudi Arabia regions. The data were gathered through a self-administered online questionnaire. It included demographic information, weight and height, and associated comorbidities, in addition to the weekly frequencies of snoring symptoms and of enuresis, as well as of unrefreshing sleep using Likert-type response scales. Counts and percentages, the mean ± standard deviation, chi-square test, independent samples t-test, and regression analysis were used in the statistical analysis using R v 3.6.3. The questionnaire was completed by 686 respondents. Most respondents did not report any comorbidities in their children (77.1%). Asthma and adenotonsillar hypertrophy were reported in 16.2% and 15.6% of children, respectively. Unrefreshing sleep, mouth breathing at night, snoring, chronic nasal obstruction, and difficulty breathing while asleep were reported once or twice per week in 38%, 34%, 28%, 18%, and 18% of children, respectively. The prevalence of NE was 22.3%, with about 36.6% of children having NE two or more times per week. Significantly, NE was reported in 26.6% of children who slept before 10 PM compared to 19% of children who slept after 10 PM; in 28.6% of children who snored or loudly snored (57.1%) three times or more per week; and in 51.2% and 27.5% of children with difficulty breathing while asleep and who breathed through their mouth at night for one or two nights per week, respectively. A multivariable regression analysis showed that male gender (OR = 1.52, p = 0.010), obesity (OR = 1.24, p = 0.028), early sleeping time (OR = 1.40, p = 0.048), loud snoring for three or more nights per week (OR = 1.54, p = 0.001), difficulty breathing for one or two nights per week (OR = 1.85, p = 0.010), and mouth breathing at night for one or two nights per week (OR = 1.55, p = 0.049) were associated with higher odds of NE. Our study revealed that 22.3% of primary school children reported suffering from NE. SDB is a common problem among children with NE. The exact mechanism that links SDB to the increase in the risk of NE is unknown. Male gender, obesity, early sleeping time, loud snoring, difficulty breathing, and mouth breathing at night are potential independent risk factors of NE in school-age children.

Adenotonsillectomy: the good, the bad and the unknown

PURPOSE OF REVIEW

Adenotonsillar hypertrophy is the most common pathogenetic contributor to obstructive sleep apnea syndrome (OSAS) in childhood, and adenotonsillectomy is the standard initial treatment. Here, we summarize the most recent evidence on the efficacy and complications of adenotonsillectomy and explore knowledge gaps in clinical management.

RECENT FINDINGS

Favorable adenotonsillectomy effects have been reported in children with very severe OSAS [apnea-hypopnea index (AHI) >20 episodes/h] and extremely severe OSAS (AHI >100 episodes/h), without postoperative mortality, need for endotracheal intubation, prolonged hospital stay or re-admission after hospital discharge. However, the risk of residual OSAS after adenotonsillectomy, which may reach 30-60%, has not been thoroughly established. Behavior, OSAS-related symptoms and quality of life improve postoperatively even in children with AHI 1-5 episodes/h. Natural history of enuresis resolution is accelerated postadenotonsillectomy and office-based systemic blood pressure is decreased in OSAS and hypertension. However, which children younger than 2 years should undergo adenotonsillectomy instead of adenoidectomy only to prevent recurrence of OSAS symptoms and revision surgery remains unclear. Adenotonsillectomy in children with Prader-Willi syndrome is frequently accompanied by postoperative residual OSAS while complications are not uncommon.

SUMMARY

In the last 2 years, several studies have provided evidence supporting the efficacy and safety of adenotonsillectomy as treatment intervention for otherwise healthy children with OSAS.

THE EFFECT OF ADENOTONSİLLECTOMY SURGERY İN PEDİATRİC ENUREZİS NOCTURNA PATİENTS

Objective: The aim of this study was to investigate the effect of tonsillectomy and adenoidectomy on EN in patients with tonsil hypertrophy and adenoid hypertrophy. Material and Method: Data of 94 patients was retrospectively valuated. The frequency of EN of the patients and whether they improved after the operation were investigated. Results: The mean age was 9.59 ± 2.04. EN patients was higher in the group with Adenoid Vegetation. EN was detected in 73 of the patients before surgery. There was a complete improvement in 63 patients and partial improvement in 10 patients after the operation. There was no statistically significant difference in EN improvement between the groups. Conclusion: In a multidisciplinary approach, the surgical procedures can be effective in the treatment of EN. Therefore the patients admitting with EN symptomsshould be questioned for complaints about upper airway obstruction and The correct surgical procedure for children with symptoms may constitute an important step in their treatment.

Assessment of nocturnal enuresis diagnostic criteria

INTRODUCTION

Nocturnal enuresis (NE) is a common disorder that affects both children and their families. The objective is to determine its prevalence in an extensive sample of children considering different diagnostic criteria.

PATIENTS AND METHODS

Cross-sectional descriptive study using a survey of parents of a selection of primary and secondary school Asturian children (6, 10 and 13 years). The questionnaire consisted of 80 or 55 questions (10 of which were answered by the children) for those who urinated or not in bed, respectively. NE was registered as primary or secondary, and the presence or not of enuresis as the only symptom. In addition, the prevalence was compared according to the different diagnostic criteria.

RESULTS

Of the 3548 questionnaires distributed, 56.6% were answered completed correctly. A total of 102 children urinated in bed (5.52%), which corresponds to a prevalence of 2.82% according to the DSM-IV-TR/5 and the (International Continence Society) ICC, 3.7% with the DSM-III and ICD-10. It was more frequent in boys than in girls (2.8:1), with a predominance of primary forms (81.2%), and non-monosymptomatic (68.66%). The spontaneous resolution in the older age group was higher in boys than in girls, with the different prevalences of previous ages being equal to 13 years.

CONCLUSIONS

The prevalence of NE in the studied region coincides with that observed in some other studies. There are differences according to the criteria used, which should draw attention to the need to unify the methodology of the studies and the criteria used in its diagnosis.

Assessing the need for adenotonsillectomy for sleep-disordered breathing in a community setting: A secondary outcome measures analysis of a randomized controlled study

OBJECTIVE

To assess whether children with sleep-disordered breathing (SDB) symptom severity above a certain level, measured by a validated questionnaire, improve after adenotonsillectomy (AT) compared to no intervention.

METHODS

Children with snoring and tonsillar hypertrophy (4 to 10-years old), who were candidates for AT, were randomly assigned to two evaluation sequences (baseline and 3-month follow-up): (a) evaluation immediately before AT and at 3 months postoperatively (AT group); or (b) evaluation at the initial visit and at the end of the usual 3-month waiting period for surgery (control group). Outcomes were (a) Pediatric Sleep Questionnaire sleep-related breathing disorder scale (PSQ-SRBD); (b) modified Epworth Sleepiness Scale (mESS); and (c) proportion of subjects achieving PSQ-SRBD <0.33 (low-risk for apnea-hypopnea index ≥5/h) if they had score ≥0.33 at baseline.

RESULTS

Sixty-eight children were assigned to the AT and 72 to the control group and two-thirds of them had PSQ-SRBD ≥0.33. The AT group experienced significantly larger improvement between follow-up and baseline than controls (between-group difference [95% CI] for PSQ-SRBD: -0.31 [-0.35 to -0.27]; and mESS: -2.76 [-3.63 to -1.90]; P < .001 for both). Children with baseline PSQ-SRBD ≥0.33 in the AT group had an eight-times higher probability of achieving PSQ-SRBD <0.33 at follow-up than controls with similar baseline score (risk ratio [95% CI]: 8.33 [3.92-17.54]; P < .001).

CONCLUSION

Among children with snoring, tonsillar hypertrophy, and clinical indications for AT, those with preoperative PSQ-SRBD score ≥0.33 show measurable clinical benefit postoperatively.

The relationship between urinary incontinence and obesity in childhood

AIM

To explore associations between weight and type/frequency of urinary incontinence (UI) in children presenting to a tertiary hospital incontinence clinic.

METHODS

We retrospectively reviewed medical records of children who first attended the incontinence clinic at The Children's Hospital at Westmead between January 2004 and December 2014. A random sample of 1000 children was selected from 2022 patient records, and data were collected on weight, height, age, gender, UI parameters, bowel habits and medical history. Associations between predictors (weight categories, gender, snoring, constipation, faecal incontinence) and outcomes (daytime urinary incontinence (DUI) and nocturnal enuresis (NE)) were examined using χ² tests and logistic regression analysis.

RESULTS

A total of 862 children were included in the study; 54% were male, and 28% were overweight/obese. No evidence of difference was found between the underweight/normal and overweight/obese weight children with NE (34 vs. 39%), DUI (7 vs. 9%) or combined NE and DUI (58 vs. 52.1%), P = 0.23. The frequency of NE (83 vs. 82%, P = 0.56) and DUI (52 vs. 58%, P = 0.20) was similar between the weight groups.

CONCLUSION

In a large cohort of children presenting to a tertiary incontinence clinic, weight was not associated with the type or frequency of UI.

Current perspectives on the correlation of nocturnal enuresis with obstructive sleep apnea in children

BACKGROUND

Obstructive sleep apnea (OSA) and nocturnal enuresis (NE) are common clinical problems in children. OSA and NE are thought to be interrelated, but the exact pathophysiological mechanisms are not yet clear. This review aims to explain the possible pathogenesis of NE in children with OSA.

DATE SOURCES

We have retrieved all relevant original articles from Database that have been published so far, including the prevalence studies of NE and OSA in children, sleep characteristic studies that use polysomnography (PSG) to focus on children with NE, and studies on the relationship between OSA and NE.

RESULTS

Clinical studies have revealed that the risk of NE in children with OSA was increased compared with that of their healthy peers. This increased risk may be associated with sleep disorders, bladder instability, detrusor overactivity, nocturnal polyuria, endocrine and metabolic disorders, and inflammation.

CONCLUSIONS

Cardiopulmonary and renal reflex-induced neuroendocrine disorder may play an important role in the mechanism of NE in children with OSA, but this remains to be confirmed by animal studies. Other causes such as oxidative stress and inflammatory responses need to be further researched.

Symptoms of Obstructive Sleep Apnea, Nasal Obstruction, and Enuresis in Children With Nonsyndromic Cleft Lip and Palate: A Prevalence Study

OBJECTIVE

To estimate the prevalence of symptoms of obstructive sleep apnea (OSA), nasal obstruction, and enuresis in children with nonsyndromic unilateral cleft lip and palate.

DESIGN

Prospective cross-sectional study.

SETTING

Referral care center.

PARTICIPANTS

One hundred seventy-four children aged 6 to 12 years of both genders.

INTERVENTIONS

Symptoms of OSA and nasal obstruction were investigated by analysis of scores obtained by the Sleep Disturbance Scale for Children (SDSC) and Congestion Quantifier (CQ-5). Enuresis was considered as present when urinary loss was reported during sleep (at least 1 episode/month, last 3 months). To characterize the enuresis as mono- or polysymptomatic, symptoms of dysfunction of the lower urinary tract (DLUT) were investigated by the Dysfunctional Voiding Scoring System (DVSS). Statistical analysis was performed at a 5% level of significance.

RESULTS

Positive SDSC scores for OSA were observed in 60 (34%) children; positive CQ-5 scores for nasal obstruction in 45 (26%), positive DVSS scores for DLUT in 30 (17%), and enuresis was reported by 29 (17%), being categorized as primary in 66% and polysymptomatic in 72% of the children. Compared to the pediatric population, OSA, nasal obstruction, and enuresis prevalence ratios were up to 7 (95% confidence interval [CI] 5-9), 2 (95% CI 2-3), and 3 times (95% CI 2-5) higher, respectively. There was a positive/moderate correlation between symptoms of OSA and nasal obstruction ( P = .0001). No correlation was seen between symptoms of OSA and enuresis.

CONCLUSIONS

Children with nonsyndromic cleft lip and palate have high prevalence of nasal obstruction and enuresis and are at risk of OSA.

Sleep-disordered breathing in patients with sickle cell disease

Sickle cell disease is one of the most common hereditary hemoglobinopathies worldwide, and its vaso-occlusive and hemolytic crises cause considerable patient morbidity. A growing body of evidence has shown that sleep-disordered breathing, and in particular, obstructive sleep apnea, occurs at high frequency in the sickle cell population, and that there is significant overlap in the underlying pathophysiology of these two conditions. Through a variety of mechanisms including nocturnal hypoxemia and increased oxidative stress, production of pro-inflammatory cytokines, and endothelial dysfunction, sickle cell anemia and sleep-disordered breathing potentiate each other's clinical effects and end-organ complications. Here, we will review the shared pathophysiologic mechanisms of these conditions and discuss their clinical sequelae. We will also examine the results of studies that have been carried out with clinical intervention of nocturnal hypoxemia in patients with sickle cell disease in the attempts to overcome the complications of the disease. Finally, we will propose the areas of investigation that merit further investigations in future in patients with sickle cell disease and sleep-disordered breathing.

The role of upper airway obstruction and snoring in the etiology of monosymptomatic nocturnal enuresis in children

This study evaluated the necessity of examining the upper airway in children with nocturnal enuresis. 225 children (aged 5-16 years), who were referred from the urology outpatient clinic between May 2015 and May 2016 and who had completed toilet training, were included in this study. Participants were separated into monosymptomatic nocturnal enuresis (MNE) (group 1) and without MNE (group 2) groups. Tonsil hypertrophy, adenoid vegetation, septal deviation, turbinate hypertrophy, allergic rhinitis, upper airway obstruction, and snoring etiology were assessed. In total, 112 children with MNE (group 1) participated in addition to 113 children selected randomly without MNE (group 2). Adenoid score (p = 0.016), septal deviation (p = 0.017), and snoring (p = 0.007) were significantly different between the groups. No differences in tonsil score (p = 0.618), turbinate hypertrophy (p = 0.424), and allergic rhinitis (p = 0.544) were detected between the groups. Possible causes of upper airway obstruction and snoring which is a symptom of obstructive sleep-disordered breathing in the pediatric population, including adenoid hypertrophy and septal deviation, should be considered as possible etiological factors in children with MNE.

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.

Impact of a multidisciplinary evaluation in pediatric patients with nocturnal monosymptomatic enuresis

BACKGROUND

Enuresis (NE) is a clinical condition of multifactorial etiology that leads to difficulties in child/adolescent social interaction.

METHODS

This was a prospective study on the impact of multidisciplinary assessment of 6- to 17-year-old patients with monosymptomatic nocturnal enuresis (MNE), including a structured history, clinical/neurological examination, bladder and bowel diaries, sleep diary and questionnaires, psychological evaluation [Child Behavior Checklist (CBCL) and PedsQL 4.0 questionnaires], urinary sonography, blood and urine laboratory tests, polysonography (PSG), and balance evaluation.

RESULTS

A total of 140 enuretic participants were evaluated, of whom 27 were diagnosed with NE complicated by urinary disorder, four with hypercalciuria, three with nephropathy and one with attention-deficit hyperactivity disorder. Among the 87 participants who underwent PSG, six were diagnosed with severe apnea. Of the 82 MNE patients who underwent full assessment, 62 were male (75.6 %), and the mean age was 9.5 (±2.6) years. A family history of NE was diagnosed in 91.1 % of first- and second-degree relatives, constipation in 89.3 % and mild/moderate apnea in 40.7 %. Balance control alteration was identified by physical therapy evaluation of MNE patients. Participants' quality of life evaluation scores were significantly lower than those of their parents.

CONCLUSION

Enuresis is a multifactorial disorder that requires a structured diagnostic approach.

Effects of adenotonsillar hypertrophy corrective surgery on nocturnal enuresis of children

BACKGROUND

Nocturnal enuresis is considered a common urological complaint especially among children. Respiratory obstructive diseases have been one of the possible etiologies of such a condition. The most common type of upper respiratory obstructive diseases in childhood is adenotonsillar hypertrophy. In this study, it was tried to estimate the prevalence of nocturnal enuresis in adenotonsillar hypertrophy as an upper obstructive airway disease and cure rate after corrective operation.

MATERIALS AND METHODS

In this longitudinal study, 184 children with adenotonsillar hypertrophy as case group and 200 healthy children as control group were randomly compared for nocturnal enuresis incidence and risk factors. Then they were followed after 6 months to estimate the cure rate after corrective operation.

RESULTS

In case group, nocturnal enuresis was more common than control group (26% vs. 17%, P = 0.1). Factors which had a role in enuresis in case group were family history (P = 0.03) and male sex (P = 0.05). Three months after surgery, 48% of children totally cured from enuresis (P = 0.001) and 71% cured both partially or totally (P = 0.03). The response rate after moderate obstruction relieving was 100% while that in severe cases was 60% (P = 0.2).

CONCLUSIONS

Nocturnal enuresis due to upper obstructive airway disease occurs more in male and in the presence of family history. The cure rate after 6 months of operation was more prominent in moderate obstruction which suggests enuresis in severe airway obstruction may need a longer time to subside. Cure rate of primary enuresis due to obstructive airway disease after 6 months of relieving was 48% in children over 5 years old.

Impact of adenotonsillectomy on nocturnal enuresis in children with sleep-disordered breathing: A prospective study

OBJECTIVES/HYPOTHESIS

To investigate the relationship between sleep-disordered breathing (SDB) and nocturnal enuresis (NE) in children and to prospectively evaluate the effectiveness of adenotonsillectomy on resolving enuresis in indicated SDB patients with NE.

METHODS

We prospectively collected data from 183 children (121 males, mean age 8.17 ± 2.84 years) who underwent adenotonsillectomy to treat SDB between July 2011 and July 2013, and analyzed the prevalence of NE. Before and 3 months after surgery, all parents were requested to answer a self-reported SDB scale questionnaire (22 questions, 0-22 points) and a NE questionnaire (episodes of enuresis per month). Paired t test, Student t test, and Chi-square test were used to analyze the data.

RESULTS

Overall prevalence of NE was 9.3% (17 patients) preoperatively and 1.5% postoperatively (four patients). After adenotonsillectomy, prevalence of NE and the mean SDB scale were significantly decreased (both P values < 0.001). After adenotonsillectomy, 13 of the 17 NE patients (76.5%) showed complete resolution. There was significantly higher prevalence of NE in patients with obstructive sleep apnea (OSA) than those without OSA (13.1%, 14 of 107 vs. 3.9%, 3 of 76; P = 0.036).

CONCLUSION

There is strong association between NE and SDB, and adenotonsillectomy can markedly improve enuresis in the majority of children with NE and SDB.

LEVELS OF EVIDENCE

4. Laryngoscope, 126:1241-1245, 2016.

Association between Asthma and Primary Nocturnal Enuresis in Children

PURPOSE

Enuresis, sleep respiratory disorders and asthma compromise the quality of sleep in children and may occur in association with each other. An association between sleep respiratory disorders and enuresis has already been demonstrated. According to united airways disease abnormalities of the upper and lower airways may coexist. A child who wheezes has a greater chance of snoring and having obstructive sleep apnea. Since asthma and sleep respiratory disorders may be associated, and sleep respiratory disorders are associated with enuresis, we determined the possibility of an association between asthma and enuresis.

MATERIALS AND METHODS

Between August 20 and March 2015 parents/guardians of children 6 to 14 years old from 16 elementary schools in our area were randomly chosen for study. Children with nonmonosymptomatic enuresis and urological or neurological disease were excluded. The Tucson and ISAAC (International Study of Asthma and Allergies in Childhood) questionnaires were used to assess sleep respiratory disorders and asthma, respectively.

RESULTS

A total of 523 children (283 males and 240 females) with a mean ± SD age of 9.42 ± 2.46 years were included in analysis. The overall prevalence of enuresis was 15.87% (95% CI 12.98-19.26). Asthmatic children with wheezing in the last 12 months were 2.33 times more likely to have had enuresis at some point in life (OR 2.33, 95% CI 1.37-3.95, p = 0.0017). If enuresis was present, the chance increased to 2.78 (95% CI 1.38-5.61, p = 0.0041). Enuretic children were 5.34 times more prone to have apnea reported by parents (95% CI 2.19-13.03, p = 0.0002).

CONCLUSIONS

These findings demonstrate that asthma as well as sleep respiratory disorders is associated with primary nocturnal enuresis.

Hemoglobinopathies and sleep--The road less traveled

Sickle cell disease and thalassemia are common hereditary blood disorders associated with increased systemic inflammation, tissue hypoxia, endothelial dysfunction and end-organ damage, the latter accounting for the substantial morbidity and abbreviated lifespan associated with these conditions. Sleep perturbations in general, and sleep-disordered breathing in particular are also highly prevalent conditions and the mechanisms underlying their widespread end-organ morbidities markedly and intriguingly overlap with the very same pathways implicated in the hemoglobinopathies. However, little attention has been given to date to the potential contributing role of sleep disorders to sickle cell disease manifestations. Here, we comprehensively review the pathophysiological mechanisms and clinical manifestations linking disturbed sleep and hemoglobinopathies, with special emphasis on sickle cell disease. In addition to a broad summary of the available evidence, we identify many of the research gaps that require attention and future investigation, and provide the scientific contextual setting that should enable opportunities to investigate the intertwined pathophysiological mechanisms and clinical outcomes of sleep disorders and hemoglobinopathies.

Nocturnal enuresis is associated with moderate-to-severe obstructive sleep apnea in children with snoring

BACKGROUND

Conflicting data suggest that prevalence of monosymptomatic primary nocturnal enuresis (NE) increases with increasing severity of obstructive sleep apnea (OSA) in childhood and especially in girls. We hypothesized that NE is associated with increased risk of moderate-to-severe OSA (obstructive apnea-hypopnea index (AHI) >5 episodes/hour) among children with snoring.

METHODS

Data of children (≥5 y old) with snoring who were referred for polysomnography over 12 y were reviewed.

RESULTS

Data of 525 children with mean age (±SD) 7.5 (± 2.2) y and median obstructive AHI (10th-90th percentiles) 1.9 (0.4-7.3) episodes/hour were analyzed. Three hundred and fifty-five children (67.6%) had NE and 87 (16.6%) had moderate-to-severe OSA. There was no interaction between NE and gender regarding the association with moderate-to-severe OSA (P > 0.05). NE was associated significantly with presence of moderate-to-severe OSA after adjustment for tonsillar hypertrophy, obesity, gender, and age (adjusted odds ratio = 1.92 (1.08-3.43); P = 0.03). Presence of NE had high sensitivity (78.2%) and low positive predictive value (19.2%) for detecting moderate-to-severe OSA and low specificity (34.5%) and high negative predictive value (88.8%) for ruling it out.

CONCLUSION

Children with snoring and without NE referred for polysomnography are less likely to have moderate-to-severe OSA compared to those with NE.

Five years of experience in nocturnal enuresis and urinary incontinence in children: where we are and where we are going

BACKGROUND

Nocturnal enuresis (NE) is a very common pediatric disorder. The aim of this study was to evaluate the characteristics of patients with NE or urinary incontinence (UI) during a period of 5 years to increase the knowledge on these conditions and optimize their diagnosis and treatment.

METHODS

We enrolled 278 children with NE or UI referred to the pediatric nephrology ambulatory, 'A. Gemelli' University Hospital of Rome, from December 2006 to December 2011.

RESULTS

We observed that heredity, parasomnias, left-handedness, polythelia and constipation are correlated to NE and UI.

CONCLUSIONS

We wanted to clarify the definition of NE and UI and describe our experience on the main characteristics of these conditions by referring to the latest knowledge reported in the literature.

Obstructive sleep apnea in children: a critical update

Obstructive sleep apnea (OSA) in children is a highly prevalent disorder caused by a conglomeration of complex pathophysiological processes, leading to recurrent upper airway dysfunction during sleep. The clinical relevance of OSA resides in its association with significant morbidities that affect the cardiovascular, neurocognitive, and metabolic systems. The American Academy of Pediatrics recently reiterated its recommendations that children with symptoms and signs suggestive of OSA should be investigated with polysomnography (PSG), and treated accordingly. However, treatment decisions should not only be guided by PSG results, but should also integrate the magnitude of symptoms and the presence or absence of risk factors and signs of OSA morbidity. The first-line therapy in children with adenotonsillar hypertrophy is adenotonsillectomy, although there is increasing evidence that medical therapy, in the form of intranasal steroids or montelukast, may be considered in mild OSA. In this review, we delineate the major concepts regarding the pathophysiology of OSA, its morbidity, diagnosis, and treatment.

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.

Diagnosis and management of childhood obstructive sleep apnea syndrome

OBJECTIVE

This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS).

METHODS

The literature from 1999 through 2011 was evaluated.

RESULTS AND CONCLUSIONS

A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.

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.

Nocturnal enuresis in children: prevalence, correlates, and relationship with obstructive sleep apnea

OBJECTIVES

To examine the prevalence and correlates of nocturnal enuresis (NE) in primary school children, and to compare the prevalence of NE in children with and those without obstructive sleep apnea (OSA).

STUDY DESIGN

Parents of children aged 6-11 years completed a questionnaire eliciting information on sleep-related symptoms, demography, and family and past medical history. Children screened due to high risk for OSA, along with a randomly chosen low-risk group, underwent overnight polysomnography (PSG).

RESULTS

A total of 6147 children (3032 girls) were studied. The overall prevalence of NE (≥1 wet night/month) was 4.6% (6.7% of boys and 2.5% of girls). Boys had a significantly greater prevalence across all age groups. In 597 children (215 girls) who underwent PSG, the prevalence of NE was not greater in children with OSA, but was increased with increasing severity of OSA in girls only. Boys with NE had longer deep sleep duration. Sex and sleep-related symptoms were associated with NE.

CONCLUSIONS

This community-based study demonstrated a sex-associated prevalence of NE in relation to increasing OSA severity.

Peripheral blood leukocyte gene expression patterns and metabolic parameters in habitually snoring and non-snoring children with normal polysomnographic findings

BACKGROUND

Children who snore but do not have gas exchange abnormalities or alterations of sleep architecture have primary snoring (PS). Since increasing evidence suggest that PS may be associated with morbidity, we hypothesized that assessing genome-wide gene expression in peripheral blood leukocytes (PBL) will identify a distinct signature in PS children.

METHODS

Children (aged 4-9 years) with and without habitual snoring and a normal PSG were designated as either PS or controls. Whole genome expression profiles of PBL and metabolic parameters in 30 children with PS and 30 age-, gender-, ethnicity-, and BMI-matched controls were compared. Pathway-focused gene network analysis of the PBL transcriptome was performed. Metabolic parameters were measured in an independent follow-up cohort of 98 children (64 PS and 34 controls) to evaluate the computationally derived findings.

RESULTS

PS was not associated with a distinct transcriptional signature in PBL. Exploratory functional network analysis of enriched gene sets identified a number of putative pathways-including those mapping to insulin signaling, adipocyte differentiation, and obesity-with significant alterations in glucose metabolism and insulin sensitivity emerging in the follow-up cohort of children with PS, but no differences in lipid profiles.

CONCLUSIONS

PS children do not exhibit global perturbations in their PBL transcriptional response, suggesting that current normative PSG criteria are overall valid. However, subtle differences in functionally coherent pathways involved in glycemic homeostasis were detected and confirmed in a larger independent pediatric cohort indicating that PS may carry increased risk for end-organ morbidity in susceptible children.

Correlation of urinary excretion of sodium with severity of sleep-disordered breathing in children: a preliminary study

BACKGROUND

Nocturnal urinary sodium excretion is related to blood pressure (BP) levels. Elevated BP and increased nocturnal natriuresis have been demonstrated in adults with sleep apnea. Although evidence indicates increased BP in children with obstructive sleep-disordered breathing (SDB), it is unknown whether these children have also enhanced urinary sodium excretion.

OBJECTIVE

To evaluate the effects of SDB and morning BP on urinary sodium excretion.

METHODS

Consecutive children with snoring (n = 95) underwent polysomnography and morning BP measurement. Fractional excretion of sodium (FE(Na)) was the primary outcome measure and was calculated using sodium and creatinine concentrations in early morning serum and urine specimens.

RESULTS

Subjects with moderate-to-severe SDB had similar log-transformed FE(Na) to that of children with mild SDB and higher than children with primary snoring: -0.13 ± 0.53 versus -0.28 ± 0.41 versus -0.61 ± 0.65 (P = 0.657 and P = 0.003). Obstructive apnea-hypopnea index was significantly related to FE(Na) after adjustment for age, gender and body mass index z-score (P = 0.002). Children with moderate-to-severe SDB had similar systolic BP z-scores to those of subjects with mild SDB and higher than participants with primary snoring: 0.7 ± 1.2 versus 0.1 ± 1.0 versus -0.02 ± 1.0 (P = 0.074 and P = 0.046). In addition, participants with diastolic BP z-scores in the upper quartile of measured values had higher FE(Na) than subjects with z-scores in the lower quartiles: -0.08 ± 0.39 versus -0.41 ± 0.57 (P = 0.007).

CONCLUSIONS

Morning natriuresis is related to severity of SDB in children and this association may be mediated in part by elevated BP.

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.

Impairments in attention in occasionally snoring children: an event-related potential study

OBJECTIVE

To determine whether minimal snoring is benign in children.

PROCEDURE

22 rarely snoring children (mean age = 6.9 years, 11 females) and age- and sex-matched controls participated in an auditory oddball task wearing 128-electrode nets. Parents completed the Conners Parent Rating Scales-Revised Long (CPRS-R:L).

RESULTS

Snorers scored significantly higher on four CPRS-R:L subscales. Stepwise regression indicated that two ERP variables from a region of the ERP that peaked at 844 msec post-stimulus onset predicted CPRS-R:L Attention Deficit Hyperactivity Disorder (ADHD) Index scores.

CONCLUSIONS

Occasional snorers, according to parental report, do exhibit ADHD-like behaviors. Basic sensory processing is longer than in controls, suggesting that delayed frontal activation requires more effort in snorers.

Associations of tonsillar hypertrophy and snoring with history of wheezing in childhood

BACKGROUND

Reports in adults and children have correlated history of wheezing or asthma with the presence of obstructive sleep-disordered breathing but the mechanism of this epidemiologic association is unknown. The goal of the present study was to examine whether tonsillar hypertophy can explain this association.

METHODS

Children were recruited from the Emergency Department and the Pediatric Pulmonology Clinic. History of wheezing requiring treatment (explanatory variable) and snoring > or = 1 night/week (outcome) were recorded and presence of tonsillar hypertrophy (outcome) was assessed.

RESULTS

Four hundred forty-two children were recruited (mean age: 7.6 + or - 3.6 years) and 210 of them had history of wheezing. History of wheezing was significantly associated with the presence of tonsillar hypertrophy and snoring even after adjustment for age, gender, obesity, and passive smoking [odds ratio (95% confidence interval): 2.23 (1.37-3.63); P = 0.001 and 1.73 (1.12-2.67); P = 0.013, respectively]. When only children with tonsillar hypertrophy were considered (n = 92), history of wheezing was significantly related to the presence of snoring, whereas in subjects without tonsillar hypertrophy (n = 350) wheezing did not affect snoring [odds ratio: 2.76 (1.10-6.93); P = 0.031 and 1.49 (0.92-2.43); P = 0.107, respectively].

CONCLUSIONS

Children with history of wheezing have more frequently tonsillar hypertrophy than those without wheezing. Tonsillar hypertrophy may mediate at least in part the reported association between asthma and obstructive sleep-disordered breathing in childhood.

Tonsillar size in 2- to 14-year-old children with and without snoring

BACKGROUND

Few investigations have assessed tonsillar size in children of variable age, sleep-disordered breathing (SDB) status and degree of adiposity. This study evaluated the size of tonsils in young and older, lean and obese children, without or with snoring.

METHODS

Children attending the Emergency Department or Pulmonology Clinic were recruited and tonsillar size was scored 1-4. Snoring >or=1 night/week was considered diagnostic of SDB and body mass index z-score >or=1.645 was defined as obesity. Age was analyzed as dichotomous variable (<or=7 years old vs. >7 years old).

RESULTS

362 children (2-14 years old) were recruited; 78 (21.5%) were obese and 108 (29.8%) had SDB. SDB-but not age or obesity-was significantly related to tonsillar size (P = 0.001). There was not enough evidence to support the presence of interactions between SDB and age or obesity regarding the size of tonsils (P = 0.157 and P = 0.978, respectively). Young subjects without SDB had larger tonsils than older subjects without SDB (1.9 +/- 0.7 vs. 1.7 +/- 0.8; P = 0.017), whereas age did not affect tonsillar size in children with SDB (P = 0.78).

CONCLUSIONS

Young and older children with SDB have similar tonsillar size. In contrast, older subjects without snoring have smaller tonsils than young subjects without snoring. Tonsillar enlargement in children with SDB probably occurs in early childhood without change in older age.

The epidemiology and factors associated with nocturnal enuresis among boarding and daytime school children in southeast of Turkey: a cross sectional study

Background

Nocturnal enuresis is an important problem among young children living in Turkey. The purpose of this study was to determine the possible differences in the prevalence of enuresis between children in boarding school and daytime school and the association of enuresis with sociodemographic factors.

Methods

This was a cross-sectional survey. A total of 562 self-administered questionnaires were distrubuted to parents from two different types of schools. One of them was a day-time school and the other was a boarding school. To describe enuresis the ICD-10 definition of at least one wet night per month for three consecutive months was used. Chi-square test and a logistic regression model was used to identify significant predictive factors for enuresis.

Results

The overall prevalence of nocturnal enuresis was 14.9%. The prevalence of nocturnal enuresis declined with age. Of the 6 year old children 33.3% still wetted their beds, while the ratio was 2.6% for 15 years-olds. There was no significant difference in prevalence of nocturnal enuresis between boys and girls (14.3% versus 16. 8%). Enuresis was reported as 18.5% among children attending day time school and among those 11.5% attending boarding school (p < 0.05). Prevalence of enuresis was increased in children living in villages, with low income and with positive family history (p < 0.05). After multivariate analysis, history of urinary tract infection (OR = 2.02), age (OR = 1.28), low monthly income (OR = 2.86) and family history of enuresis (OR = 3.64) were factors associated with enuresis. 46.4% of parents and 57.1% of enuretic children were significantly concerned about the impact of enuresis.

Conclusion

Enuresis was more frequent among children attending daytime school when compared to boarding school. Our findings suggest that nocturnal enuresis is a common problem among school children, especially with low income, smaller age, family history of enuresis and history of urinary tract infection. Enuresis is a pediatric public health problem and efforts at all levels should be made such as preventive, etiological and curative.

The effect of weight loss on sleep-disordered breathing in obese teenagers

The objective of this study was to assess the effect of weight loss on sleep-disordered breathing (SDB) in obese teenagers attending a residential treatment center. We also assessed whether the presence of SDB at the start of the weight management therapy was correlated with the amount of weight loss achieved. Obese teenagers were recruited and underwent anthropometry and sleep screening. Subjects with SDB (apnea hypopnea index (AHI)>or=2) received a follow-up screening after weight loss therapy. Sixty-one obese subjects were included (age=14.8+/-2.3; BMI z score=2.7+/-0.4). Thirty-one subjects were diagnosed with SDB with 38% continuing to have residual SDB after a median weight loss of 24.0 kg. Subjects with SDB had a higher median relative decrease in BMI z score compared to subjects without SDB which was 30.5, 33.6, and 50.4% in the group with AHI of the baseline screening study<2, 2<or=AHI<5, and AHI>or=5, respectively (P=0.02). AHI of the baseline screening study correlated significantly with the relative decrease in BMI z score (partial r=0.37; P=0.003), controlling for gender, age, initial BMI z score, and time between both studies. In conclusion, weight loss was successful in treating SDB in obese teenagers. In addition, there was a positive association between the severity of SDB at the start of the treatment and the amount of weight loss achieved. These findings are in favor of considering weight loss as a first-line treatment for SDB in obese children and adolescents.

The multiple challenges of obstructive sleep apnea in children: diagnosis

PURPOSE OF REVIEW

To review some of the inherent problems in defining the diagnosis of pediatric obstructive sleep apnea (OSA) and propose a novel approach to clinical evaluation and referral of habitually snoring children.

RECENT FINDINGS

OSA has emerged in the last 30 years as a highly prevalent condition in children. However, the diagnostic uncertainties associated with the clinical presentation and physical examination, and changes in the clinical phenotype over time dictated by the escalation of obesity in children, along with the objective difficulties in accessing appropriately equipped sleep laboratories, have led to substantial underrecognition and to implementation of empirically driven treatment interventions for which scientific validity and efficacy remain undefined.

SUMMARY

Current tools for the diagnosis of OSA in children are labor-intensive, and onerous, and remain unvalidated. Novel diagnostic approaches linking objective physiological, biological, or both, measures to defined outcomes of pediatric OSA need to be developed and validated to enable wider and earlier recognition of this condition.

The snoring child

Snoring is a common manifestation of obstructive sleep apnea and represents one end of the spectrum of sleep-related breathing disorders. Children with primary snoring initially may develop OSAS later, so inquiring about symptoms of OSAS should be part of each visit. Obstructive sleep apnea can result in serious cardiovascular and metabolic consequences and neurocognitive deficits. Adenotonsillar hypertrophy remains the most common cause of OSA although the rising prevalence of obesity is of increasing importance. Polysomnography remains the gold standard in the diagnoses of OSAS and in assessing the risks associated with surgery. Most children with OSAS can be treated with adenotonsillectomy in the ambulatory surgery center. However, there are children at risk for severe OSAS and for postoperative complications, who will need PICU care. In addition to adenotonsillectomy, OSAS can be treated successfully in referral centers with other surgical approaches and by the use of positive airway pressure. Children with obesity-related OSAS often require CPAP or BPAP for control of OSAS.

Increased morning brain natriuretic peptide levels in children with nocturnal enuresis and sleep-disordered breathing: a community-based study

INTRODUCTION

Habitual snoring and obstructive sleep apnea have been associated with bed-wetting in children, and effective obstructive sleep apnea treatment may improve enuresis.

OBJECTIVES

The purpose of this work was to assess whether habitual snoring is associated with increased incidence of enuresis and whether severity of obstructive sleep apnea correlates with enuretic frequency and to evaluate brain natriuretic peptide levels.

METHODS

Parental surveys of 5- to 7-year-old children were reviewed for habitual snoring and enuresis. Enuresis was also assessed in a cohort of 378 children with habitual snoring undergoing overnight polysomnographic evaluation, and brain natriuretic peptide plasma levels were determined in 20 children with obstructive sleep apnea, 20 with habitual snoring without obstructive sleep apnea, and 20 nonsnoring children, matched for enuresis.

RESULTS

There were 17,646 surveys completed (50.6% boys; 18.3% black). A total of 1976 (11.2%) of these children were habitual snoring (53% boys; 25.2% black). A total of 531 habitual snoring children also had enuresis (26.9%), with a predominant representation of boys (472 boys [87.5%]). Among the 15670 nonsnoring children, enuresis was reported in 1821 children (11.6%), of whom 88.8% were boys. However, enuresis among 378 children with habitual snoring did not correlate with the magnitude of sleep respiratory disturbances. Indeed, enuresis was reported in 33 of 149 children with obstructive sleep apnea (obstructive apnea hypopnea index: >2 per hour of total sleep time; 53% boys) as compared with 36 habitual snoring children with enuresis (62% boys) and obstructive apnea hypopnea index <2 per hour of total sleep time. Brain natriuretic peptide levels were elevated among children with enuresis and were marginally increased among children with obstructive sleep apnea.

CONCLUSIONS

Habitual snoring is associated with increased prevalence of enuresis, and brain natriuretic peptide levels are increased in enuretic children with further increases with obstructive sleep apnea. However, the prevalence of enuresis is not modified by severity of sleep disturbance. Even mild increases in sleep pressure because of habitual snoring may raise the arousal threshold and promote enuresis, particularly among prone children, that is, those with elevated brain natriuretic peptide levels.

Prevalence of adenoid hypertrophy and nocturnal enuresis in primary school children in Istanbul, Turkey

OBJECTIVE

The purpose of this study is to investigate the prevalence of an existing relationship between adenoid hypertrophy and nocturnal enuresis in primary school children.

METHODS

The study was performed in four primary schools that were chosen randomly in Kartal, Istanbul. The children's parents were asked to fill out a questionnaire that included questions concerning the associated symptoms of adenoid hypertrophy and nocturnal enuresis. The interrelations between adenoid hypertrophy and nocturnal enuresis items were examined by X2 tests.

RESULTS

The study population consisted of 1132 (625 girls, 621 boys) primary school children between 5 and 14 years of age (mean 9.59+/-2.60 years). The children were divided into three groups with 5-7 years old children in Group I (n=232), 8-10 years old children in Group II (n=506) and 11-14 years old children in Group III (n=394). Of the 1132 distributed questionnaires, 1090 (87.4%) were filled in adequately and were accepted for evaluation. Prevalence of adenoid hypertrophy in school children was found to be 58 in Group I (27%), 94 in Group II (19.5%) and 78 in Group III (19.9%). Prevalence of nocturnal enuresis in school children was found to be 35 in Group I (15.1%), 51 in Group II (10.1%) and 18 in Group III (4.6%). No statistically significant association was present between adenoid hypertrophy and nocturnal enuresis in either Group I, II or III school children.

CONCLUSION

In contrast to previous studies, our prevalence study did not find an association between adenoid hypertrophy and nocturnal enuresis. Thus, this prevalence study provides otolaryngologists new and interesting information.