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Nocturnal enuresis and rapid maxillary expansion: – long-term effect, prognostic variables, respiration during sleep and quality of life
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.ORCID iD: 0000-0001-5141-2935
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Description
Abstract [en]

Background:The orthodontic technique rapid maxillary expansion (RME) has been reported to have a potentially curative effect on nocturnal enuresis (NE). The mechanism behind this is unknown but could possibly be due to placebo and/or effects on respiration during sleep. 

Aim: This thesis aims to approach an answer to the following questions, with a randomized, placebo-controlled method: 1) Does rapid maxillary expansion have a curative effect on therapy-resistant NE? 2) Is the potential curative effect due to respiratory events that can be measured during sleep? 3) Do enuretic children have an impaired quality of life (QoL)?  

Subjects & Methods: In study I we evaluated the QoL in enuretic children while assessing the test re-test reliability of a Swedish version of an established QoL questionnaire. Study II and IV assess respiration during sleep in children with NE; in study II comparisons are made with healthy control children and in study IV we evaluate the respiratory effects of RME. Study III is a randomized placebo-controlled study investigating whether RME is a useful therapy for NE and if the treatment effect is due to placebo.

Results: Study I:The Swedish version of the questionnaire proved to be a reliable tool (Chronbach’s alpha 0.87) with excellent test-retest stability (ICC = 0.762). Enuresis affects the children’s QoL and interactions with peers.

Study II:The hypopnea index (HI) and the oxygen desaturation index were both significantly higher in the enuretic children compared to the healthy controls, (p=0.04 and p=0.05) but all values fell within the normal range.

Study III:RME resulted in a significant reduction in wet nights i.e. the mean number of wet nights out of 14 was 11.4 before and 9.2 after RME. (p=0.003) This was not observed in the placebo group (p=0.40).

Study IV:There was a significant reduction of sleep efficiency during RME. (p=0.001) The mean HI was also affected. (p=0.005)

Conclusions:

Children with nocturnal enuresis have an impaired self-esteem and their quality of life is affected in their relationship with friends.

There were no major differences in respiration during sleep between enuretic children and controls.

Rapid maxillary expansion reduces the number of wet nights in children with enuresis, but the effect is of limited clinical value.

The antienuretic effect does not seem to be due to a placebo effect of the appliance.

The majority of the children in our study sample did not have sleep disordered breathing as a co-morbidity to their nocturnal enuresis. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. , p. 66
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1582
Keywords [en]
Rapid maxillary expansion, nocturnal enuresis, sleep disordered breathing, respiration, polygraphic sleep recording, quality of life.
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-383405ISBN: 978-91-513-0692-6 (print)OAI: oai:DiVA.org:uu-383405DiVA, id: diva2:1315748
Public defence
2019-09-06, sal IV, Universitetshuset, Biskopsgatan 3, Uppsala, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2019-08-16 Created: 2019-05-14 Last updated: 2019-08-16
List of papers
1. Nocturnal enuresis impaired children's quality of life and friendships
Open this publication in new window or tab >>Nocturnal enuresis impaired children's quality of life and friendships
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2017 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 5, p. 806-811Article in journal (Refereed) Published
Abstract [en]

AimThere have not been any continence-specific measurement tools in Swedish that have allowed clinicians to investigate the quality of life (QoL) in children with bladder dysfunction. This study evaluated the QoL in Swedish children with nocturnal enuresis and tested the reliability of a Swedish translation of the Paediatric Incontinence Questionnaire (PinQ). MethodsThis prospective study comprised 46 children aged six to 18 years with nocturnal enuresis, who completed the PinQ after it was translated into Swedish. It was completed twice by 33 patients, and these responses were included in the test-retest evaluation. ResultsThe self-reported mean sum score for the whole group was 26.3 13.37 (range: 5-58), and the most affected domains were social relations with peers and self-esteem. The highest individual scores were four, three or two for 71.7%, 17.4% and 10.9% of the study population, respectively. Cronbach's alpha was 0.87 for the whole questionnaire, indicating good internal consistency. The test-retest stability was excellent, with an intra-class correlation coefficient of 0.76. ConclusionChildren with nocturnal enuresis had impaired self-esteem, and their impaired QoL affected their relationships with friends. The Swedish version of the PinQ proved to be a reliable tool that will be used in further studies.

Place, publisher, year, edition, pages
WILEY, 2017
Keywords
Nocturnal enuresis, Quality of life, Questionnaire, Self-esteem, Urinary incontinence
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-321783 (URN)10.1111/apa.13787 (DOI)000398859300021 ()28199734 (PubMedID)
Available from: 2017-05-11 Created: 2017-05-11 Last updated: 2019-05-14Bibliographically approved
2. Sleep disordered breathing in enuretic children and controls
Open this publication in new window or tab >>Sleep disordered breathing in enuretic children and controls
2017 (English)In: Journal of Pediatric Urology, ISSN 1477-5131, E-ISSN 1873-4898, Vol. 13, no 6, p. 620.e1-620.e6Article in journal (Refereed) Published
Abstract [en]

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

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

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

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

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

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

Place, publisher, year, edition, pages
ELSEVIER SCI LTD, 2017
Keywords
Nocturnal enuresis, Sleep disordered breathing, Respiratory polygraphy, Children
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-340287 (URN)10.1016/j.jpurol.2017.05.012 (DOI)000418045800024 ()
Available from: 2018-01-29 Created: 2018-01-29 Last updated: 2019-05-14Bibliographically approved
3. Rapid maxillary expansion in children with nocturnal enuresis: A randomized placebo-controlled trial
Open this publication in new window or tab >>Rapid maxillary expansion in children with nocturnal enuresis: A randomized placebo-controlled trial
Show others...
2019 (English)In: Angle orthodontist, ISSN 0003-3219, E-ISSN 1945-7103Article in journal (Other academic) Published
Keywords
Rapid maxillary expansion, nocturnal enuresis
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-383403 (URN)10.2319/031819-219.1. (DOI)
Available from: 2019-05-14 Created: 2019-05-14 Last updated: 2019-07-28
4. Respiratory changes during sleep in enuretic children treated with rapid maxillary expansion
Open this publication in new window or tab >>Respiratory changes during sleep in enuretic children treated with rapid maxillary expansion
(English)Manuscript (preprint) (Other academic)
Keywords
Rapid maxillary expansion, nocturnal enuresis, sleep disordered breathing
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-383401 (URN)
Available from: 2019-05-14 Created: 2019-05-14 Last updated: 2019-05-14

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