Increased delta component in computerized sleep electroencephalographic analysis suggests abnormally deep sleep in primary monosymptomatic nocturnal enuresis

Analysis of sleep pattern in patients with nocturnal enuresis: A prospective, observational, pilot study

PURPOSE

This study aimed to analyze the sleep patterns of patients with nocturnal enuresis (NE) using a wearable brain-wave-sensing device.

MATERIALS AND METHODS

We prospectively analyzed 10 of the 14 patients who visited the hospital for NE between August 2023 and July 2024 and agreed to participate in the study. Four patients were excluded owing to pairing errors and loss to follow-up. Participants were instructed to maintain a frequency volume chart for 1 week and sleep while wearing MUSE-S™, a wearable brain-wave detection device. We monitored the arousal threshold state based on sleep patterns when NE occurred in all patients.

RESULTS

The median age of the patients was 8.7 years (interquartile range, 7.0-10.6), and 4 patients (40.0%) were male. In all participants, non-rapid eye movement (NREM) deep sleep was the dominant stage in the early part of sleep, whereas NREM light sleep was dominant in the middle part. The arousal threshold was high in the early part of sleep and decreased toward the end. A poor response to enuretic alarms was observed when NE occurred during the NREM deep-dominant period. In contrast, a good response was observed when NE occurred during the NREM light-dominant period.

CONCLUSIONS

Differences in sleep stages influence the arousal threshold more than individual characteristics. To effectively manage the NE, focusing on the timing of urination is important in the latter part of the sleep period.

Prevalence, Risk Factors, and Psychological Effects of Primary Nocturnal Enuresis in Chinese Young Adults

Purpose

This study aimed to investigate the prevalence, risk factors, and effects of primary nocturnal enuresis (PNE) on physical and mental health in young adults in mainland China.

Methods

An anonymous questionnaire was used to collect information including the sociodemographic characteristics, history of PNE, family history, daytime voiding symptoms, Pittsburgh Sleep Quality Index (PSQI) scores, Self-Esteem Scale (SES), and Self-Rating Depression Scale (SDS). A total of 22,500 university students from 23 provinces and 368 cities in mainland China were included.

Results

In total, 21,082 questionnaires were collected, and 20,345 of them qualified for statistical analysis. The PNE prevalence was 1.17%, and the distribution of monosymptomatic nocturnal enuresis (MNE) and nonmonosymptomatic nocturnal enuresis (NMNE) was 66.1% and 33.9%, respectively. In total, 28% of respondents with PNE reported bedwetting daily, 31.6% between 1 and 7 times weekly, and 40.4% between 1 and 4 times monthly; 80% of PNE cases had no history of treatment. The prevalence of PNE in patients with a family history, frequency, urgency, urinary incontinence, and recurrent urinary tract infections was significantly higher than in those without these conditions (P<0.001). PNE was significantly correlated with the PSQI total score (sleep quality) (P=0.011). The SES score was lower and the SDS was higher (P<0.001) in the PNE group than in those without PNE.

Conclusions

In mainland China, the PNE prevalence among young adults was found to be high, and PNE had significant effects on physical and mental health. Risk factors included a family history, daytime voiding symptoms, and lack of treatment.

Comorbidity between enuresis and attention deficit hyperactivity disorder: a case-control study

Background

Although there is a strong association between enuresis and psychopathology, little is known about the prevalence of specific psychiatric disorders. We investigate the prevalence of attention-deficit/hyperactivity disorder (ADHD) in children with enuresis and study the impact on child behavior, self-esteem, and different EEG findings. A total number of one hundred 6 to 12 years old children diagnosed as functional enuresis taken from specialized university setting for enuresis at Mansoura Pediatric Outpatient Clinic, in which they could be subdivided into 2 groups after assessment of attention deficit hyperactivity disorder (ADHD); according to DSM-IV criteria, we also compare them with a third ADHD group taken from Mansoura Psychiatric Outpatient Clinic n = 40 to match the co-morbid “enuresis with ADHD” group. All were subjected to a diagnostic interview conducted and completed with parents and developmental and family history as well, also they subjected to Conner’s parent rating scale-93(CPRS-93), Rosenberg self-esteem assessment scale, and EEG examination.

Results

There was high prevalence of ADHD in our study with about 40% in children with enuresis especially who met the DSM–IV criteria of inattention attending a specialized setting for enuresis at Mansoura Pediatric Outpatient Clinic which is a tertiary setting where the older the children of enuresis, the higher the prevalence of ADHD, also there is a relationship between abnormal epileptiform discharge in EEG finding and enuresis as same as ADHD which became greatly increased in the children who had both disorders who was the most affected group as regard behavioral problems and lowered self-esteem levels.

Conclusions

The strong association between ADHD and enuresis suggests that the presence of enuresis should motivate diagnostic assessment of ADHD especially the inattentive subtype. Abnormal EEG finding in the form of generalized slow and sharp waves may be useful as a predictor for the presence of ADHD in children with enuresis. Also, the co-morbidity increases the negative impact on child behavior and self-esteem.

Abnormal Thalamic Functional Connectivity During Light Non-Rapid Eye Movement Sleep in Children With Primary Nocturnal Enuresis

OBJECTIVE

To investigate abnormalities of thalamocortical and intrathalamic functional connectivity (FC) in children with primary nocturnal enuresis (PNE) during light non-rapid eye movement (NREM) sleep using a simultaneous electroencephalography (EEG)-functional magnetic resonance imaging (fMRI) method.

METHOD

Polysomnographic and EEG-fMRI data were obtained during sleep from 61 children with PNE (age 10.2 ± 1.7 years, 59% boys) and 61 age-matched controls (age 10.1 ± 1.4 years, 54% boys). All subjects first participated in one overnight video-polysomnographic study. Total sleep time, percentage of total sleep time in each sleep stage, arousal index, and awakening index were calculated. Simultaneous EEG-fMRI studies were then performed using a 3T MRI system with a 32-channel MRI-compatible EEG system. Visual scoring of EEG data permitted sleep staging. Thalamocortical and intrathalamic FCs in the waking state and at different stages of light sleep were calculated and compared.

RESULTS

Children with PNE had a higher percentage of total sleep time in light sleep and a higher arousal index compared with controls. Abnormal thalamocortical FCs were detected in the lateral prefrontal cortex, medial prefrontal cortex, and inferior parietal lobule during light NREM sleep. Abnormal intrathalamic FCs were also detected during light NREM sleep among the motor, occipital, prefrontal, and temporal subdivisions of the thalamus.

CONCLUSION

Abnormal prefrontal and parietal thalamocortical FCs, accompanied by abnormal intrathalamic FCs among the motor, occipital, prefrontal, and temporal subdivision of thalamus during light NREM sleep, may be related to abnormal sleep and enuresis in children with PNE.

Brazilian consensus in enuresis-recomendations for clinical practice

Introduction

Enuresis, defined as an intermittent urinary incontinence that occurs during sleep, is a frequent condition, occurring in about 10% of children at 7 years of age. However, it is frequently neglected by the family and by the primary care provider, leaving many of those children without treatment. Despite of many studies in Enuresis and recent advances in scientific and technological knowledge there is still considerable heterogeneity in evaluation methods and therapeutic approaches.

Materials and Methods

The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Enuresis and elaborated a draft of the document. On September 2018 the panel met to review, discuss and write a consensus document.

Results and Discussion

Enuresis is a multifactorial disease that can lead to a diversity of problems for the child and family. Children presenting with Enuresis require careful evaluation and treatment to avoid future psychological and behavioral problems. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.

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.

Nocturnal enuresis and poor sleep quality

BACKGROUND

Sleep disorders are strongly associated with childhood nocturnal enuresis (NE). In this study, we examined whether sleep disorders are present in children with NE, and whether NE is caused by sleeping disorders, or is simply comorbid.

METHODS

We examined 14 children with monosymptomatic NE and 15 age-matched controls. Sleep disorders were assessed for ≥5 days using contactless biomotion sensors to detect breathing and body movements during at-home sleep. To assess sleep quality, we compared median sleep efficiency and the number of shallow sleep episodes between the groups. We also investigated the change in sleep quality after successful NE treatment in five children.

RESULTS

Median sleep efficiency was significantly lower in the NE group (87.3%) than in the control group (93.4%; P < 0.001). The number of shallow sleep episodes per night was significantly higher in the NE group (5.11) than in the control group (1.50; P < 0.001). Neither sleep efficiency nor the number of shallow sleep episodes improved in the five children whose NE was successfully stopped after bedwetting-alarm therapy (P = 0.50 and 0.22, respectively).

CONCLUSIONS

Sleep disorders are present in children with NE. Although there are insufficient data to conclude that sleep disorders are not the cause of NE, we suggest that they are comorbid because sleep disorders persisted even after NE was halted.

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.

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.

Urodynamic function during sleep-like brain states in urethane anesthetized rats

The aim was to investigate urodynamic parameters and functional excitability of the periaqueductal gray matter (PAG) during changes in sleep-like brain states in urethane anesthetized rats. Simultaneous recordings of detrusor pressure, external urethral sphincter (EUS) electromyogram (EMG), cortical electroencephalogram (EEG), and single-unit activity in the PAG were made during repeated voiding induced by continuous infusion of saline into the bladder. The EEG cycled between synchronized, high-amplitude slow wave activity (SWA) and desynchronized low-amplitude fast activity similar to slow wave and 'activated' sleep-like brain states. During (SWA, 0.5-1.5 Hz synchronized oscillation of the EEG waveform) voiding became more irregular than in the 'activated' brain state (2-5 Hz low-amplitude desynchronized EEG waveform) and detrusor void pressure threshold, void volume threshold and the duration of bursting activity in the external urethral sphincter EMG were raised. The spontaneous firing rate of 23/52 neurons recorded within the caudal PAG and adjacent tegmentum was linked to the EEG state, with the majority of responsive cells (92%) firing more slowly during SWA. Almost a quarter of the cells recorded (12/52) showed phasic changes in firing rate that were linked to the occurrence of voids. Inhibition (n=6), excitation (n=4) or excitation/inhibition (n=2) was seen. The spontaneous firing rate of 83% of the micturition-responsive cells was sensitive to changes in EEG state. In nine of the 12 responsive cells (75%) the responses were reduced during SWA. We propose that during different sleep-like brain states changes in urodynamic properties occur which may be linked to changing excitability of the micturition circuitry in the periaqueductal gray.

Nocturnal enuresis: A topic review and institution experience

The objective is to provide a review of nocturnal enuresis (NE), including its epidemiology, etiology, pathophysiology, evaluation, and current management. We also set to provide further insight on the treatment of this condition from the experience derived from patients cared for at our tertiary-care institution. NE affects approximately 15% of all children at 5-year-old, affecting boys more frequently than girls. At our large university tertiary pediatric urology center, NE and incontinence, in general, is one the most common chief complaints prompting urologic care. In this review, we examine the condition in detail, highlighting specific goals of the initial evaluation and treatment. We contrast the commonly implemented treatment recommendations, available from the literature with strategies we have found valuable from our extensive experience in treating patients with this disorder. Using current urologic reference textbooks, book chapters, Medline, journal articles and reviews describing the many aspects of NE were reviewed in order to describe NE and the current practices at our institution. Although, this is not a systematic literature review, it includes relevant available research, institutional experience and urological expert opinion and current practices at a tertiary state health facility. The treatment of NE remains a challenge for many pediatricians and pediatric urologists. This likely stems from the multiple possible etiologies of the disorder. We have established a treatment algorithm at our institution, which we have found successful in the majority of our patients. This consists of starting patients on urotherapy, then offering both the enuresis alarm device and medication therapy as first line treatments, and finally adding anticholingerics for combination therapy. Our hope is with further research the treatment of NE will continue to improve.

Respiration during sleep in children with therapy-resistant enuresis

AIM

Although there is a known association between enuresis and snoring or sleep apnoeas, respiration during sleep has not been thoroughly studied in enuretic children. This study was performed with the aim of filling this gap in our knowledge.

METHODS

Thirty-four children with therapy-resistant enuresis, but no history of heavy snoring or sleep apnoeas, underwent sleep registrations, including standard electroencephalography (EEG) and electrooculography (EOG) as well as registration of oxygen saturation, respiratory effort and nasal air flow. To assess nasal airway patency, rhinomanometry and acoustic rhinometry were performed before and after nasal decongestion.

RESULTS

The children were found to have a higher than expected apnoea hypopnoea index (AHI), due to a high frequency of hypopnoeas. They were also noted to have a tendency for respiratory arousals. Standard polysomnographic variables were normal.

CONCLUSION

We provide baseline data of nocturnal respiration in enuretic children. The children were found to have subclinical signs of disordered respiration. This may be one of the explanations for their high arousal thresholds.

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.

Effects of desmopressin on the sleep of children suffering from enuresis

AIM

To evaluate the effect of 1-desamino-8-D-Arginine Vasopressin (DDAVP) on sleep architecture and arousal reactions in children with primary monosymptomatic nocturnal enuresis (PME).

METHODS

A prospective, placebo-controlled, randomized, double-blind, cross-over study was performed on children suffering from bed-wetting. Placebo and DDAVP were given for 7 days each after which an unattended home polysomnography (PSG) was recorded. After lifting the blinding, the PSGs were compared.

RESULTS

A total of 20 children with PME, aged 6-15 years, were enrolled in the study. The number of wet nights decreased significantly with DDAVP treatment. Delta power, distribution of sleep stages, number of arousals, arousal index and the effect of arousals on sleep stages did not differ significantly. Bed-wetting occurred within each sleep stage and did not follow any particular pattern. In most cases, it was preceded by an arousal reaction, but no awakening occurred.

CONCLUSION

DDAVP has no effect on the sleep architecture of children with PME when analysed by classical PSG, which is determined by collecting the electric activity of cortical neurons. Taking recent research findings into account, this supports the thesis that the disturbances causing PME occur at brain stem level and do not reach consciousness.

Risk factors and consequences of excessive autonomic activation during sleep in children

PURPOSE

The aim of this study was to assess risk factors for excessive autonomic activation during sleep (EAAS) and its association with sleep problems, impaired behavior, and poor academic performance in primary school children.

METHODS

Data from a community-based study on 997 primary school children were used. Based on nocturnal home pulse oximetry, autonomic activation during sleep was defined as a pulse rate increase by more than 20%. Children with ≥35.9 autonomic activations per hour (i.e., ≥ the 95(th) centile) were classified as suffering from EAAS and compared with controls. Sleep problems, impaired behavior, and academic performance were assessed by parental questionnaires and analysis of school reports.

RESULTS

According to the above-mentioned definition, EAAS was diagnosed in 52 children (67% male). Risk factors for EAAS were male gender (odds ratio [95% confidence interval]: 2.06 [1.14-3.72]) and presence of symptoms of sleep-disordered breathing (3.48 [1.29-9.43]). Children with EAAS had a higher prevalence of hyperactive behavior (39.2% vs. 26.0%; p = 0.05) and enuresis (5.8% vs. 0.8%; p = 0.017) but not of poor academic performance. The association with hyperactive behavior was confirmed in a subsample (n = 119) using the Strengths and Difficulties Questionnaire. Mean (SD) score of the hyperactive-inattentive scale was 4.5 (2.8) for EAAS and 3.4 (2.7) for non-EAAS (p = 0.04).

CONCLUSION

EAAS may be a marker of sleep disruption in children and may predict the occurrence of enuresis and hyperactive behavior.

Enuretic sleep: deep, disturbed or just wet?

Enuretic children sleep "deeply" in the sense that they are difficult to arouse from sleep, but not in the sense that their sleep is necessarily polysomnographically different from other children. The enuretic children's arousal difficulties may be due to a disturbance at the brainstem level and/or to frequent arousal stimuli from the bladder. It may be hypothesised that the sleep disturbance of enuretic children may lead not only to the wetting of the sheets but to disturbances of daytime psychological functioning as well.

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.

Parasomnias and sleep disordered breathing in Caucasian and Hispanic children - the Tucson children's assessment of sleep apnea study

BACKGROUND

Recent studies in children have demonstrated that frequent occurrence of parasomnias is related to increased sleep disruption, mental disorders, physical harm, sleep disordered breathing, and parental duress. Although there have been several cross-sectional and clinical studies of parasomnias in children, there have been no large, population-based studies using full polysomnography to examine the association between parasomnias and sleep disordered breathing. The Tucson Children's Assessment of Sleep Apnea study is a community-based cohort study designed to investigate the prevalence and correlates of objectively measured sleep disordered breathing (SDB) in pre-adolescent children six to 11 years of age. This paper characterizes the relationships between parasomnias and SDB with its associated symptoms in these children.

METHODS

Parents completed questionnaires pertaining to their child's sleep habits. Children had various physiological measurements completed and then were connected to the Compumedics PS-2 sleep recording system for full, unattended polysomnography in the home. A total of 480 unattended home polysomnograms were completed on a sample that was 50% female, 42.3% Hispanic, and 52.9% between the ages of six and eight years.

RESULTS

Children with a Respiratory Disturbance Index of one or greater were more likely to have sleep walking (7.0% versus 2.5%, p < 0.02), sleep talking (18.3% versus 9.0%, p < 0.006), and enuresis (11.3% versus 6.3%, p < 0.08) than children with an Respiratory Disturbance Index of less than one. A higher prevalence of other sleep disturbances as well as learning problems was observed in children with parasomnia. Those with parasomnias associated with arousal were observed to have increased number of stage shifts. Small alterations in sleep architecture were found in those with enuresis.

CONCLUSIONS

In this population-based cohort study, pre-adolescent school-aged children with SDB experienced more parasomnias than those without SDB. Parasomnias were associated with a higher prevalence of other sleep disturbances and learning problems. Clinical evaluation of children with parasomnias should include consideration of SDB.

Sleep problems in children with common medical disorders

Sleep problems are common in many pediatric medical disorders and complicate management and patient outcomes. A wide range of conditions, including asthma, cystic fibrosis, sickle cell disease, gastroesophageal reflux, neuromuscular diseases, scoliosis, craniofacial abnormalities, obesity, and chromosomal disorders, have various sleep disturbances, including sleep-disordered breathing, ventilatory dysfunction, sleep-onset and sleep maintenance problems, and circadian rhythm disturbances. Given the adverse neurocognitive and physiologic outcomes associated with a deranged night's sleep, it is important for pediatricians to be able to anticipate, recognize, and appropriately manage these problems. This article reviews the known sleep-related problems of a few relatively common pediatric disorders.

Nocturnal enuresis

PURPOSE OF REVIEW

The purpose of this review is to highlight and comment upon important areas of enuresis research.

RECENT FINDINGS

Current areas of pathophysiological focus are nocturnal urine production, in which alternative mechanisms other than deficient vasopressin secretion has been implicated in some patients. Bladder reservoir function has gained renewed interest, and has proved to be one of the best predictors of treatment response to desmopressin. Various aspects of central nervous system function, including arousability and pontine reflexes, are in focus, and molecular genetics has provided firm evidence of a link between enuresis and different chromosomal markers. The therapeutic focus is directed towards a differential approach based upon the underlying mechanism and towards combination therapies such as alarm devices and desmopressin as well as anticholinergic agents and desmopressin. Furthermore, new exciting treatment concepts such as laser acupuncture have shown promising results in initial studies.

SUMMARY

Despite recent advances in our understanding of nocturnal enuresis, we are still far from understanding in detail this socially discomfiting and scientifically intriguing condition, and many controversies remain. However, the substantiation that enuresis is a heterogeneous condition that requires a differential approach has provided the basis for further progress.