Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Obstructive Sleep Apnea in School-Aged Children Presented with Nocturnal Enuresis

  • 100 Accesses



We aimed to detect obstructive sleep apnea (OSA) among school-age children presented with nocturnal enuresis (NE) and to identify the possible risk factors for OSA in them.


Sixty-six children aged > 5–16 years presented with NE were enrolled in the study. Children with urinary tract anatomical abnormalities or infection, intellectual disabilities, genetic syndromes, psychological issues, and diabetes mellitus were excluded. They were clinically examined, scored using sleep clinical record score (SCR), and subjected for full-night polysomnogram (PSG). Children with obstructive apnea/hypopnea index (AHI) ≥ 2 episodes/hour (h) were considered as OSA.


Fifty-four children (81.8% of the recruited children) aged 8.3 ± 2.8 years agreed to undergo PSG as 68.5% had OSA with median obstructive AHI of 6.1 (3.7–13.2) episodes/h, median oxygen saturation of 97% and nadir of 88%. Thirty-three percent were obese with significantly higher AHI [7.0 (3.7–12.4) vs. 2.4 (1.3–6.1) episodes/h; p = 0.023]. SCR score correlated significantly with AHI (r2 = 0.462, p = 0.001) with 91% sensitivity in detecting OSA ≥ 5 episodes/h. Nasal obstruction, adenoid/adult facial phenotype, and arched palate were associated with OSA (p < 0.05).


NE is commonly associated with OSA especially in obese children. Nasal obstruction, abnormal facial phenotype, and high-arched palate were common risk factors.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3



Attention deficit hyperactivity disorder


Apnea / hypopnea index




Area under the curve


Bronchial asthma


Body mass index


Ear, nose and throat examination


Interquartile range


Nocturnal enuresis


Oxygen desaturation index


Obstructive sleep apnea


Body mass index percentile


Polysomnography study


Receiver operator characteristic curve

SaO2 :

Arterial oxygen saturation


Sleep breathing disorders


Sleep clinical record


Standard deviation


  1. 1.

    Marcus CL, Brooks LJ, Draper KA et al (2012) Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 130(3):576–584

  2. 2.

    Halbower AC, Degaonkar M, Barker PB et al (2006) Childhood obstructive sleep apnea associates with neuropsychological deficits and neuronal brain injury. PLoS Med 3(8):e301

  3. 3.

    Goodwin JL, Kaemingk KL, Mulvaney SA, Morgan WJ, Quan SF (2005) Clinical screening of school children for polysomnography to detect sleep-disordered breathing–the Tucson Children's Assessment of Sleep Apnea study (TuCASA). J Clin Sleep Med 1(3):247–254

  4. 4.

    Desta M, Hagglof B, Kebede D, Alem A (2007) Socio-demographic and psychopathologic correlates of enuresis in urban Ethiopian children. Acta Paediatr 96(4):556–560

  5. 5.

    Shreeram S, He JP, Kalaydjian A, Brothers S, Merikangas KR (2009) Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among US children: results from a nationally representative study. J Am Acad Child Adolesc Psychiatry 48(1):35–41

  6. 6.

    Alexopoulos EI, Malakasioti G, Varlami V, Miligkos M, Gourgoulianis K, Kaditis AG (2014) Nocturnal enuresis is associated with moderate-to-severe obstructive sleep apnea in children with snoring. Pediatr Res 76(6):555–559

  7. 7.

    Basha S, Bialowas C, Ende K, Szeremeta W (2005) Effectiveness of adenotonsillectomy in the resolution of nocturnal enuresis secondary to obstructive sleep apnea. Laryngoscope 115(6):1101–1103

  8. 8.

    Kaditis AG, Alonso Alvarez ML, Boudewyns A et al (2016) Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J 47(1):69–94

  9. 9.

    Villa MP, Paolino MC, Castaldo R et al (2013) Sleep clinical record: an aid to rapid and accurate diagnosis of paediatric sleep disordered breathing. Eur Respir J 41(6):1355–1361

  10. 10.

    Brouilette R, Hanson D, David R, Klemka L, Szatkowski A, Fernbach S, Hunt C (1984) A diagnostic approach to suspected obstructive sleep apnea in children. J Pediatr 105(1):10–14

  11. 11.

    Marzocchi GM, Cornoldi C (2000) Una scala di facile uso per la rilevazione dei comportamenti problematici dei bambini con Deficit di Attenzione e Iperattivita. [A scale to identify behavioural problems in ADHD children.]. Psicologia Clinica dello Sviluppo 43–64.

  12. 12.

    Hassan AM, Al-Haidar F, Al-Alim F, Al-Hag O (2009) A screening tool for attention deficit hyperactivity disorder in children in Saudi Arabia. Ann Saudi Med 29(4):294–298

  13. 13.

    Berry RB, Budhiraja R, Gottlieb DJ et al (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events; Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 8(5):597–619

  14. 14.

    El-Mitwalli A, Bediwy AS, Zaher AA, Belal T, Saleh AB (2014) Sleep apnea in children with refractory monosymptomatic nocturnal enuresis. Nat Sci Sleep 6:37–42

  15. 15.

    Su MS, Li AM, So HK, Au CT, Ho C, Wing YK (2011) Nocturnal enuresis in children: prevalence, correlates, and relationship with obstructive sleep apnea. J Pediatr 159(2):238–421

  16. 16.

    Jeyakumar A, Rahman SI, Armbrecht ES, Mitchell R (2012) The association between sleep-disordered breathing and enuresis in children. Laryngoscope 122(8):1873–1877

  17. 17.

    Kaditis AG, Alexopoulos EI, Hatzi F, Kostadima E, Kiaffas M, Zakynthinos E, Gourgoulianis K (2006) Overnight change in brain natriuretic peptide levels in children with sleep-disordered breathing. Chest 130(5):1377–1384

  18. 18.

    Sans Capdevila O, Crabtree VM, Kheirandish-Gozal L, Gozal D (2008) Increased morning brain natriuretic peptide levels in children with nocturnal enuresis and sleep-disordered breathing: a community-based study. Pediatrics 121(5):e1208–e1214

  19. 19.

    Dhondt K, Raes A, Hoebeke P, Van Laecke E, Van Herzeele C, Vande Walle J (2009) Abnormal sleep architecture and refractory nocturnal enuresis. J Urol 182(4 Suppl):1961–1965

  20. 20.

    Neveus T (2003) The role of sleep and arousal in nocturnal enuresis. Acta Paediatr 92(10):1118–1123

  21. 21.

    Villa MP, Shafiek H, Evangelisti M, Rabasco J, Cecili M, Montesano M, Barreto M (2016) Sleep clinical record: what differences in school and preschool children? ERJ Open Res 2(1):00049

  22. 22.

    Barone JG, Hanson C, DaJusta DG, Gioia K, England SJ, Schneider D (2009) Nocturnal enuresis and overweight are associated with obstructive sleep apnea. Pediatrics 124(1):e53–e59

  23. 23.

    Weintraub Y, Singer S, Alexander D et al (2013) Enuresis–an unattended comorbidity of childhood obesity. Int J Obes (Lond) 37(1):75–78

  24. 24.

    Verhulst SL, Schrauwen N, Haentjens D et al (2007) Sleep-disordered breathing in overweight and obese children and adolescents: prevalence, characteristics and the role of fat distribution. Arch Dis Child 92(3):205–208

  25. 25.

    Guven A, Giramonti K, Kogan BA (2007) The effect of obesity on treatment efficacy in children with nocturnal enuresis and voiding dysfunction. J Urol 178(4 Pt 1):1458–1462

  26. 26.

    Miller AJ, Vargervik K, Chierici G (1984) Experimentally induced neuromuscular changes during and after nasal airway obstruction. Am J Orthod 85(5):385–392

  27. 27.

    Park S, Lee JM, Sim CS et al (2016) Impact of adenotonsillectomy on nocturnal enuresis in children with sleep-disordered breathing: A prospective study. Laryngoscope 126(5):1241–1245

  28. 28.

    Waleed FE, Samia AF, Samar MF (2011) Impact of sleep-disordered breathing and its treatment on children with primary nocturnal enuresis. Swiss Med Wkly 141:w13216

  29. 29.

    Villa MP, Brasili L, Ferretti A et al (2015) Oropharyngeal exercises to reduce symptoms of OSA after adenotonsillectomy. Sleep Breath 19(1):281–289

  30. 30.

    Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo S, Lin CH (2013) Critical role of myofascial reeducation in pediatric sleep-disordered breathing. Sleep Med 14(6):518–525

  31. 31.

    Chervin RD, Weatherly RA, Garetz SL et al (2007) Pediatric sleep questionnaire: prediction of sleep apnea and outcomes. Arch Otolaryngol Head Neck Surg 133(3):216–222

Download references

Author information

Correspondence to Hanaa Shafiek.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 64 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Shafiek, H., Evangelisti, M., Abd-elwahab, N.H. et al. Obstructive Sleep Apnea in School-Aged Children Presented with Nocturnal Enuresis. Lung 198, 187–194 (2020). https://doi.org/10.1007/s00408-019-00304-6

Download citation


  • Sleep clinical record
  • Obesity
  • Obstructive apnea/hypopnea index
  • Facial phenotype