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

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.

The Relationship between Nocturnal Enuresis and Obstructive Sleep Apnea in Children

BACKGROUND

The aim of this study is to determine the prevalence of nocturnal enuresis (NE) in children with obstructive sleep apnea (OSA), the effect of adenotonsillectomy (AT) and the width of the arches, and to compare them with control children without respiratory problems.

METHODS

Children from 2 to 12 years old were divided into three groups: children with OSA and NE (n = 51), children with OSA without NE (n = 79), and the control group (n = 168). NE was defined as at least one bedwetting incident per month. Arch widths were measured at the baseline and one year after. OSA was diagnosed by means of polysomnography, and the apnea-hypopnea index (AHI) was obtained. Parents completed the Pediatric Sleep Questionnaire (PSQ) to classify their children into those with and without NE.

RESULTS

NE was present in 39.2% of children with OSA compared to 28% in the control group (p = 0.04). After AT, 49% of the children with OSA and NE significantly improved. Both OSA groups had narrower arch widths than the control group (p = 0.012), with the NE group having the narrowest widths. NE is more prevalent in children with OSA and should be considered one of the first signs of breathing disorders. Adenotonsillectomy reduces NE in about half of the affected children. Both arch widths are narrower in children with OSA, particularly in those with NE.

Transition in enuresis patients: Identifying the gaps and opportunities for the future

BACKGROUND

Nocturnal enuresis is generally considered a children's condition, yet it may persist 1%-2% in adolescence and early adulthood. Refractory patients often demand follow-up by multidisciplinary teams, which is only restricted to some of the expert tertiary centers. However, there are no standardized transition programs/guidelines when follow-up must be passed from pediatric to adult healthcare providers.

AIM, MATERIALS & METHODS

To investigate this issue, we conducted a literature search on enuresis transition, which resulted in no articles. We, therefore, proceeded in a rescue search strategy: we explored papers on transition programs of conditions that may be related and/or complicated by enuresis, nocturia, or other urinary symptoms (chronic diseases, CKD, bladder dysfunction, kidney transplant, neurogenic bladder).

RESULTS

These programs emphasize the need for a multidisciplinary approach, a transition coordinator, and the importance of patient and parent participation, practices that could be adopted in enuresis. The lack of continuity in enuresis follow-up was highlighted when we investigated who was conducting research and publishing on enuresis and nocturia. Pediatric disciplines (50%) are mostly involved in children's studies, and urologists in the adult ones (37%).

DISCUSSION

We propose a stepwise approach for the transition of children with enuresis from pediatric to adult care, depending on the clinical subtype: from refractory patients who demand more complex, multidisciplinary care and would benefit from a transition coordinator up to children/young adults cured of enuresis but who persist in having or present lower urinary tract symptoms (LUTS)/nocturia later on. In any case, the transition process should be initiated early at the age of 12-14 years, with adequate information to the patient and parents regarding relapses or LUTS/nocturia occurrence and of the future treating general practitioner on the enuresis characteristics and comorbidities of the patient.

The Parasomnias

Parasomnias usually present in childhood and resolve spontaneously. The diagnosis of non-rapid eye movement-related parasomnias is mainly based on clinical descriptors and can be challenging. Rapid eye movement-related parasomnias may index an underlying psychiatric disorder. Even if benign, parasomnias can affect quality of life. Pediatricians and child psychiatrists should be familiarized with these sleep disorders and suggest adequate sleep hygiene, avoidance of sleep deprivation, and regular bedtimes even on weekends as the first step in management of these disorders. Clinicians should pursue the opportunity for tailoring treatments and consider referral to a sleep expert when indicated.

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.

Is There an Association between Viral Infections and Risk for Pediatric Obstructive Sleep Apnea? A Systematic Review

(1) Background: Obstructive sleep apnea (OSA) affects approximately 1% to 5% of children. To date, the main pathophysiological factor is adenotonsillar tissue hypertrophy. As many respiratory viruses can persist in secondary lymphoepithelial organs after upper airway infection, the objective of this systematic review was to investigate the link between history of viral infections and the risk of pediatric OSA. (2) Methods: Corresponding references were searched electronically (PubMed [MEDLINE], Cochrane Library and Scopus) until 21 November 2022. Prospective or retrospective cohorts, evaluating the children suffering from OSA with history of viral infections and comparing them with children with no history of viral infections written in English, were included. Four independent reviewers selected studies, extracted data, and evaluated the risk of bias using ROBINS-I. (3) Results: Of 1027 potentially eligible articles, four studies (one retrospective, two prospective cohorts and one case-control) were included. (4) Conclusions: Exposure to lower airway infections may precede the diagnosis of pediatric OSA suggesting that respiratory viruses may play a mechanical role in the development of pediatric OSA. Further research is required to improve our understanding of the role of viral infections. Registration: PROSPERO CRD awaiting.

The role of the dentist in the diagnosis and management of pediatric obstructive sleep apnea

The objective of this article is to review the role of the dentist in the early diagnosis of pediatric obstructive sleep apnea (OSA) and to provide an in-depth review of the best evidence-based practices available to treat and/or to refer these patients for intervention.

Material and methods

A narrative review was performed using indexed data bases (PubMed, Medline, EMBASE, OVID, Scopus and Cochrane) up to year 2020, and approximately 1000 articles were reviewed. The articles included were those with the best information provided.

Results

Detailed review of the literature suggests that the role of the dentist has been redefined owing to their expertise in the orofacial region. Every patient consulting a dental practice is not merely a dental patient; he/she also requires a comprehensive medical review. The role of the dentist is pivotal in pediatric patients once diagnosed with OSA; as the patients grow, growth modification can be achieved, and future management will be easier. Initiating dental treatments during growth can benefit patients two-fold, saving them from malocclusion, and intervening in orofacial structural growth can help to avoid cumbersome treatments, such as CPAP and various surgeries. Proper diagnosis and management of systemic illnesses can prevent compromised quality of life, delays in treatment, morbidity and, in some cases, mortality.

Influence of rapid maxillary expansion on nocturnal enuresis in children

OBJECTIVES

To evaluate the influence of rapid maxillary expansion (RME) on nocturnal enuresis (NE) in children to discuss whether RME can be indicated as an alternative treatment for NE in those patients.

MATERIALS AND METHODS

An electronic search was performed in the following databases: PubMed/MEDLINE, Cochrane Library, Scopus, Science Direct, Google Scholar and LILACS. The literature review was blindly performed by two reviewers. References of each selected study were manually searched to identify articles that were not found by the electronic search. Kappa statistics were used to analyze interexaminer agreement after the selection of the articles. After reading the selected full-text articles, the studies that met the inclusion criteria were assessed qualitatively using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) and the Revised Cochrane risk-of-bias tool for randomized controlled trials-2 (RoB 2). The certainty level of evidence was assessed through the Grading of Recommendations, Assessment, Development and Evaluation tool. Kappa tests were used to analyze the interexaminer concordance level after the quality assessment of the studies.

RESULTS

A total of 488 articles were found; however, after applying the inclusion and exclusion criteria, only 8 studies were selected for the systematic review. A low certainty level of evidence suggested that RME seems to promote a variable reduction in frequency or a remission of NE in children in both the short (4, 6, and 8 months) and long term (13, 36, 48, and 120 months).

CONCLUSIONS

Based on currently available information, RME seems to promote an improvement in NE in children. However, the low quality of the existing evidence weakens the recommendation.

The Parasomnias

Parasomnias usually present in childhood and resolve spontaneously. The diagnosis of non-rapid eye movement-related parasomnias is mainly based on clinical descriptors and can be challenging. Rapid eye movement-related parasomnias may index an underlying psychiatric disorder. Even if benign, parasomnias can affect quality of life. Pediatricians and child psychiatrists should be familiarized with these sleep disorders and suggest adequate sleep hygiene, avoidance of sleep deprivation, and regular bedtimes even on weekends as the first step in management of these disorders. Clinicians should pursue the opportunity for tailoring treatments and consider referral to a sleep expert when indicated.

Relationship between enuresis and obstructive sleep apnea-hypopnea syndrome in children

OBJECTIVE

We explored the relationship between enuresis and obstructive sleep apnea-hypopnea syndrome (OSAHS) in children and influencing factors of enuresis with OSAHS.

METHODS

We recruited 196 children ≥5 years old from the otolaryngology outpatient department, who experienced snoring and underwent nasopharynx lateral radiography and in-laboratory polysomnography. We analyzed correlations between the apnea-hypopnea index (AHI) and lowest oxygen saturation (L-SaO2) with age, body mass index (BMI), tonsil size, and adenoidal-nasopharyngeal (A/N) ratio using the Pearson correlation test. Differences in severe OSAHS prevalence, age, AHI, L-SaO2, tonsil size, and A/N ratio between children with and without enuresis were assessed using the chi-square test and t-test. Risk factors of enuresis were analyzed using logistic regression. Follow-up was conducted to assess remission in children with enuresis after adenotonsillectomy.

RESULTS

BMI, tonsil size, and A/N ratio were correlated with AHI and L-SaO2. Severe OSAHS prevalence, AHI, tonsil size, and A/N ratio were higher and L-SaO2 were lower in children with enuresis. Logistic regression showed that BMI, AHI, tonsil size, and sleep apnea were risk factors for enuresis.

CONCLUSIONS

Our study findings showed that enuresis was associated with OSAHS in children. Adenotonsillectomy may improve the symptoms of enuresis.

Sleep Architecture in Valproate-Induced Nocturnal Enuresis in Primary School and Preschool Children

Nocturnal enuresis is one of the side effects of valproic acid treatment, and generally underdiagnosed by clinicians. Studies reported that a variable incidence of valproic acid-induced nocturnal enuresis is 2.2% to 24% with unclear explanations of the reasons behind valproic acid-induced nocturnal enuresis. A retrospective study was carried out on 260 children (aged 5-12 years) diagnosed with idiopathic epilepsy, treated with valproic acid to evaluate the nocturnal enuresis secondary to valproic acid, and to discuss the characteristics of their sleep architecture. Nocturnal enuresis was reported in 28 (10.7%) patients after a mean exposure time to valproate of 18.78±8.4 days. Nocturnal enuresis was significantly associated with younger age and serum level of valproate (P = .05). The polysomnographic study suggested that the underlying mechanism may be related to impaired sleep efficiency, frequent arousals, prolonged sleep latency, snoring, or increased sleep depth which may impair a child's ability to awaken to the sense of bladder fullness or contractions.Clinical trial registration: ClinicalTrials.gov identifiers: NCT04191863.

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.

Association between enuresis and obesity in children with primary monosymptomatic nocturnal enuresis

Objective

The purpose of this study was to determine whether the presence of obesity was related with symptoms of nocturnal enuresis (NE) and the efficacy of behavioral intervention in the treatment of NE.

Materials and Method

The patients diagnosed with primary monosymptomatic nocturnal enuresis (PMNE) were studied retrospectively. NE severity was classified as mild, moderate, and severe according to the frequency of enuresis. The children were divided into three groups, namely normal weight (5th-84th percentile), overweight (85th-94th percentile), and obesity (≥95th percentile), according to their Body Mass Index (BMI) percentage. The relationship between obesity level and enuresis severity was analyzed. After three months of behavioral therapy, the efficacy of treatment among normal, overweight, and obese groups were evaluated. Moreover, the predictive risk factors for treatment failure were investigated.

Results

The rates of severe enuresis in patients with normal weight, overweight, and obesity were 63.9%, 77.5%, and 78.6%, respectively. Obese children depicted higher odds of having severe enuresis compared with normal-weight children (OR: 1.571; 95% confidence interval [CI]: 1.196-2.065; P=0.001). The odds of presenting with severe enuresis were 1.99 times higher in children who are obese or overweight compared to children with normal weight (OR: 1.994; 95% CI: 1.349-2.946; P=0.001). The complete response of the normal group was higher than those of the overweight and obese groups (26.8% vs. 14.0%, P=0.010; 26.8% vs. 0.0%, P=0.000). Overweight children showed higher complete response than obese ones (14.0% vs. 0.0%, P=0.009). Logistic regression analysis revealed that obesity level and enuresis frequency were significantly related to the treatment failure of behavioral intervention.

Conclusions

Obesity is associated with severe enuresis and low efficacy of behavioral therapy in children with nocturnal enuresis.

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.

Holistic Management of Obstructive Sleep Apnea: Translating Academic Research to Patient Care

A holistic approach is pertinent in managing obstructive sleep apnea (OSA). It goes beyond integrated multidisciplinary assessment and management in the hospital setting. Although clinicians should be aware of different treatment modalities and adjunctive measures, proactive management of OSA is as important. The future of OSA management lies in identifying patients at risk of developing OSA and developing strategy to prevent OSA from taking root. It involves active screening of patients with OSA and treating them and identifying patients with OSA with high risk of preventable serious morbidity and death and intervening early to prevent these from happening.

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.

Enuresis Management in the Primary Care Pediatrics Clinic

Enuresis is a frequent complaint not always volunteered by parents or patients. The pediatric clinician has to inquire about enuresis to break the secrecy surrounding this symptom that could be related to a more serious underlying renal, endocrine, or psychosocial disease. Determining the type of enuresis is crucial to offer optimal treatment. We present a review for the pediatric clinician to optimize their care of the child with monosymptomatic enuresis. [Pediatr Ann. 2018;47(10):e390-e395.].

An interprofessional approach to managing children with treatment-resistant enuresis: an educational review

Enuresis (intermittent urinary incontinence during sleep in a child aged ≥ 5 years) is commonly seen in paediatric practice. Despite the availability of effective interventions, treatment resistance is encountered in up to 50% of children. In this educational review we attempt to provide insight into the causes of treatment resistance, and offer practical suggestions for addressing this condition using an interprofessional approach. We explore the pathophysiology of and standard treatments for enuresis and discuss why standard treatments may fail. An interprofessional approach to treatment resistance is proposed which utilises the expertise of professionals from different disciplines to address the problems and barriers to treatment. The two interprofessional approaches include a multidisciplinary approach that involves the patient being sent to experts in different disciplines at different times to address their treatment resistance utilising the skills of the respective experts, and an interdisciplinary approach that involves a patient being managed by members of interdisciplinary team who integrate their separate discipline perspectives into a single treatment plan. Although an interdisciplinary approach is ideal, interdisciplinary teams may not be available in all circumstances. Understanding the roles of other disciplines and engaging clinicians from other disciplines when appropriate can still be helpful when treatment resistance is encountered.

Tips for managing treatment-resistant enuresis

Enuresis (bedwetting) is common in school-aged children and can impact health, psychosocial well-being and quality of life. Although effective treatment is available, treatment resistance is encountered in about 50%. This paper discusses the management of treatment-resistant enuresis from a multidisciplinary perspective. Causes of treatment resistance include lower urinary tract problems, constipation, incorrect alarm training techniques, sleep disorders including sleep apnoea and psychological comorbidities. Practical suggestions to address treatment resistance are offered utilising expertise from clinicians from different disciplines.

Increased Incidence of Obstructive Sleep Apnea in Hospitalized Children After Enterovirus Infection: A Nationwide Population-based Cohort Study

BACKGROUND

We report the first nationwide population-based cohort study using Taiwan's National Health Insurance Research Database on the association between enterovirus (EV) infection and the incidence of sleep disorders in a pediatric population.

METHODS

Two matched groups of children under 18 years of age were included in the analyses for nonapneic sleep disorder and obstructive sleep apnea (OSA). Among them, 316 subjects were diagnosed with OSA during the surveillance period, including 182 in the EV infection group and 134 in the non-EV infection group.

RESULTS

Hospitalization because of EV infection was associated with OSA after adjusting for age, sex, urbanization atopic disease and perinatal complications (adjusted hazard ratio: 1.62, 95% confidence interval: 1.18-2.21; P = 0.003). An additional factor significantly associated with sleep apnea was allergic rhinitis (hazard ratio: 4.82, 95% confidence interval: 3.45-6.72).

CONCLUSIONS

Children with severe EV infection (ie, requiring hospitalization) carry a significantly higher risk of developing OSA, particularly in those with allergic rhinitis. As pediatric obstructive sleep apnea is a treatable sleep disorder, we emphasize regular follow-up and early detection in children with EV infection.

Pediatric sleep-disordered breathing: an update on diagnostic testing

PURPOSE OF REVIEW

Recent advances in diagnostic testing for obstructive sleep apnea in children have refined the standard tests while identifying several new tools that hold promise to radically change how we diagnose sleep apnea.

RECENT FINDINGS

Studies have demonstrated that the polysomnogram may be modified to permit home assessment of sleep disturbed breathing in children to ensure more widespread access to the test. Alternately, questionnaires, nocturnal oximetry, and diagnostic urinary biomarkers have shown great promise as both sensitive and specific tools to diagnose sleep apnea in children as well as track the severity of the disease.

SUMMARY

The gold standard polysomnogram has been refined to permit its application in a modified form at home and for brief examinations in children. This standard has been challenged on several fronts, including questionnaires, nocturnal oximetry, drug-induced sleep endoscopy, and noninvasive urinary biomarkers that may ultimately supplant polysomnography as the gold standard to diagnose obstructive sleep apnea syndrome in children.

Association of pediatric obstructive sleep apnea with poor academic performance: A school-based study from India

BACKGROUND

Pediatric obstructive sleep apnea (OSA) is a highly prevalent but often neglected disorder. There is paucity of reports on the prevalence of pediatric OSA from India. This study was done to estimate the prevalence of OSA in school children aged 5-10 years and its association with academic performance.

METHODOLOGY

This school-based cross-sectional epidemiological study was conducted from July 2015 to November 2015. A questionnaire seeking information on sociodemographic variables, school performance, sleeping pattern, and a validated 22-item pediatrics sleep-related breathing disorder (SRBD) scale was distributed to 1820 pupils in three primary schools. The prevalence of OSA (defined as SRBD score >33%) was reported as proportion and its 95% confidence interval (CI).

RESULTS

We received 1520 questionnaires out of 1820 distributed and of which 1346 were complete and were analyzed. The prevalence of OSA among children in our study was 9.6% (95% CI: 8.1%-11.7%). On multivariate analysis, working mother (adjusted odds ratio [OR]: 1.8; 95% CI: 1.2-2.7), sleep bruxism (adjusted OR: 1.7; 95% CI: 1.1-2.6), and sleep talking (adjusted OR: 3.0; 95% CI: 1.9-4.7) were found to be independently associated with OSA. Students with positive SRBD were more prone to nocturnal enuresis (NE) (OR 3.48; 95% CI 2.27-5.26) and poor academic performance in all subjects.

CONCLUSION

OSA is highly prevalent (9.6%) in Indian children. OSA is associated with NE and poor academic performance in all subjects. This study found association of maternal occupation and OSA which needs to be confirmed in larger studies.

CPAP Treats Enuresis in Adults With Obstructive Sleep Apnea

ABSTRACT

Enuresis, or "bedwetting," in children is associated with obstructive sleep apnea (OSA), and often resolves with treatment of OSA. However, it is poorly understood whether a similar relationship exists in adults. We describe a case series of 5 adult patients in whom OSA was diagnosed by laboratory polysomnography, who presented with enuresis that resolved after treatment with continuous positive airway pressure (CPAP). All cases occurred in the setting of obesity, in addition to other known risk factors for urinary incontinence and enuresis. OSA was diagnosed as severe in all but one case, which was mild. One patient noted recurrence of enuresis that coincided with malfunction of his CPAP machine. There is growing evidence that CPAP therapy may alleviate OSA and enuresis in adults with both conditions. Clinicians should routinely ask about enuresis in patients suspected of having OSA. A systematic study of the association between enuresis and OSA in adults is warranted.

Non-REM Sleep Instability in Children With Primary Monosymptomatic Sleep Enuresis

STUDY OBJECTIVES

Sleep enuresis is one of the most common sleep disturbances in childhood. Parental perception of deeper sleep in children with sleep enuresis is not confirmed by objective studies. However, evidence of disturbed sleep has been demonstrated by questionnaire, actigraphy, and polysomnographic studies, but no neurophysiological correlation with low arousability has been found. The goal of this study was to analyze the sleep microstructure of children with sleep enuresis using cyclic alternating pattern (CAP) analysis.

METHODS

Forty-nine children were recruited, 27 with enuresis (19 males and 8 females, mean age 9.78 years, 2.52 standard deviation) and 22 normal control patients (11 males and 11 females, mean age 10.7 years, 3.43 standard deviation); all subjects underwent clinical evaluation followed by a full-night polysomnographic recording. Psychiatric, neurological, respiratory, and renal diseases were excluded.

RESULTS

No differences in sex, age, and apnea-hypopnea index were noted in the patients with enuresis and the control patients. Sleep stage architecture in children with sleep enuresis showed a decrease in percentage of stage N3 sleep. CAP analysis showed an increase in CAP rate in stage N3 sleep and in phase A1 index during stage N3 sleep in the sleep enuresis group, but also a significant reduction of A2% and A3% and of phases A2 and A3 indexes, supporting the concept of decreased arousability in patients with sleep enuresis. The decrease of phase A2 and A3 indexes in our patients might reflect the impaired arousal threshold of children with sleep enuresis. Sleep fragmentation might result in a compensatory increase of slow wave activity (indicated by the increase of CAP rate in stage N3 sleep) and may explain the higher arousal threshold (indicated by a decrease of phase A2 and A3 indexes) linked to an increased sleep pressure.

CONCLUSIONS

The findings of this study indicate the presence of a significant disruption of sleep microstructure (CAP) in children with sleep enuresis, supporting the hypothesis of a higher arousal threshold.

When and why to treat the child who snores?

Obstructive sleep-disordered breathing (SDB) can result in cardiovascular and neurocognitive morbidity as well as adversely affect behavior, growth, quality of life, and nocturnal continence. This article summarizes the latest evidence regarding the morbidity related to obstructive SDB, commenting on the impact of severity of obstruction, that is, the difference in effects seen of moderate to severe obstructive sleep apnea syndrome (OSAS) compared to those of mild OSAS or primary snoring. The impact of therapy is discussed, focusing on which children are likely to benefit from treatment interventions; namely those with moderate or severe OSAS irrespective of the presence of morbidity, children with mild OSAS with associated morbidity or predictors of SDB persistence such as obesity, and children with complex conditions accompanied by upper airway obstruction like craniosynostosis and Prader-Willi syndrome. The co-existing conditions which may improve when treatment for obstructive SDB is offered are reviewed, while the clinical parameters associated with spontaneous improvement or resolution of obstructive SDB are discussed. The intention being to enable clinicians to make informed decisions on who should be treated, when and why. Pediatr Pulmonol. 2017;52:399-412. © 2016 Wiley Periodicals, Inc.

How do we recognize the child with OSAS?

Obstructive sleep-disordered breathing includes a spectrum of clinical entities with variable severity ranging from primary snoring to obstructive sleep apnea syndrome (OSAS). The clinical suspicion for OSAS is most often raised by parental report of specific symptoms and/or abnormalities identified by the physical examination which predispose to upper airway obstruction (e.g., adenotonsillar hypertrophy, obesity, craniofacial abnormalities, neuromuscular disorders). Symptoms and signs of OSAS are classified into those directly related to the intermittent pharyngeal airway obstruction (e.g., parental report of snoring, apneic events) and into morbidity resulting from the upper airway obstruction (e.g., increased daytime sleepiness, hyperactivity, poor school performance, inadequate somatic growth rate or enuresis). History of premature birth and a family history of OSAS as well as obesity and African American ethnicity are associated with increased risk of sleep-disordered breathing in childhood. Polysomnography is the gold standard method for the diagnosis of OSAS but may not be always feasible, especially in low-income countries or non-tertiary hospitals. Nocturnal oximetry and/or sleep questionnaires may be used to identify the child at high risk of OSAS when polysomnography is not an option. Endoscopy and MRI of the upper airway may help to identify the level(s) of upper airway obstruction and to evaluate the dynamic mechanics of the upper airway, especially in children with combined abnormalities. Pediatr Pulmonol. 2017;52:260-271. © 2016 Wiley Periodicals, Inc.

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.

Enuresis Nocturna in children with asthma: prevalence and associated risk factors

Background

Enuresis Nocturna (EN) is a common disorders in childhood. Although many different underlying pathophysiological mechanisms have been proposed to explain EN, its etiology is multifactorial. Some reports demonstrate that there is an association between EN and allergic diseases.

To study (1) the prevalence of EN in children with asthma, (2) to determine the possible risk factors for EN in asthmatic children.

Methods

Five hundreds and six children aged 6–14 years-old diagnosed with asthma and 380 age-matched non-asthmatic controls were enrolled into this cross-sectional case–control study. We studied an allergy panel that included skin prick tests with (8 inhalant allergens), total IgE, and blood eosinophil count for both groups. Semi-structured interviews were conducted with the parents of children presenting EN. Factors associated with EN in children with asthma were analyzed using a logistic regression model.

Results

The prevalence of EN was significantly higher in children with asthma as compared to the controls: 132 (26 %), 43 (11.5 %) respectively (p = 0.001). Emergency visits frequency, and family history of enuresis were higher in the asthmatic children with EN than in asthmatic children without EN. According to the logistic regression analysis, positive pollen sensitization (p = 0.027, OR = 1.94), allergic rhinitis (p = 0.032, OR = 2.36), and high eosinophil count (p = 0.004, OR = 1.40) were independent risk factors for EN in children with asthma.

Conclusion

This study showed that the prevalence of EN in children with asthma was higher than in same age controls. Sensitization to pollens, allergic rhinitis and high blood eosinophil count associate to the EN in children with asthma.

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.

Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management

This document summarises the conclusions of a European Respiratory Society Task Force on the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and refers to children aged 2-18 years. Prospective cohort studies describing the natural history of SDB or randomised, double-blind, placebo-controlled trials regarding its management are scarce. Selected evidence (362 articles) can be consolidated into seven management steps. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are present (step 1). Central nervous or cardiovascular system morbidity, growth failure or enuresis and predictors of SDB persistence in the long-term are recognised (steps 2 and 3), and SDB severity is determined objectively preferably using polysomnography (step 4). Children with an apnoea-hypopnoea index (AHI) >5 episodes·h(-1), those with an AHI of 1-5 episodes·h(-1) and the presence of morbidity or factors predicting SDB persistence, and children with complex conditions (e.g. Down syndrome and Prader-Willi syndrome) all appear to benefit from treatment (step 5). Treatment interventions are usually implemented in a stepwise fashion addressing all abnormalities that predispose to SDB (step 6) with re-evaluation after each intervention to detect residual disease and to determine the need for additional treatment (step 7).

Pediatric Pulmonology year in review 2014: Part 1

Our discipline and our journal cover an extremely broad range of research and scholarly topics related to children's respiratory disorders. To better meet the needs of our readership for updated perspectives on the rapidly expanding knowledge in our field, we here summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages.