Sleep Architecture Disruption and Cognitive Performance in East Mediterranean School-Aged Children with Primary Nocturnal Enuresis: A Multicenter Neurophysiological Study
Tiago Moreira¹, Inês Carvalho², Marta Lopes³, Ricardo Almeida⁴, Sofia Nunes⁵
Keywords:
nocturnal enuresis, pediatric sleep, REM sleep, cognition, East MediterraneanAbstract
Primary nocturnal enuresis (PNE) affects 12–18% of children aged 5–12 in the East Mediterranean, yet the neurocognitive implications associated with sleep disturbances in this population remain understudied. This multicenter cross-sectional study enrolled 738 children with PNE and 402 age- and sex-matched healthy controls across pediatric clinics in Saudi Arabia, Jordan, and Tunisia between 2022 and 2024. The objective was to assess differences in sleep architecture and cognitive function between groups.
All participants underwent overnight polysomnography and standardized neuropsychological assessments, including working memory (WISC-V), attention span (CPT-3), and processing speed tasks. Children with PNE demonstrated significantly lower sleep efficiency (81.2% vs. 91.7%, p < 0.001), higher arousal index (15.4 vs. 6.8 events/hour), and a 26% reduction in REM sleep duration compared to controls.
Neurocognitive scores revealed that the PNE group scored lower in working memory index (mean: 84.7 ± 9.6 vs. 94.3 ± 10.2, p < 0.001) and sustained attention tasks (omission error rate: 17.1% vs. 9.6%, p < 0.001). Multivariate regression showed that reduced REM sleep duration and increased arousals were the strongest predictors of cognitive underperformance (adjusted R² = 0.41, p < 0.001).
Moreover, 61.3% of PNE children with disrupted REM patterns reported school difficulties compared to 28.7% without REM disruption (p < 0.001). These findings suggest that PNE may be a neurophysiological condition with broader cognitive impact, rather than an isolated urological disorder.
This is the first comprehensive sleep and cognition study in East Mediterranean children with PNE. Early screening and targeted behavioral therapy for sleep stabilization may improve both continence and learning outcomes in affected children.
