Sleep Problems in Children with Sickle Cell Disease

  • Umakanth KhatwaEmail author
  • Alia Bazzy-Asaad
  • Sanjeev V. Kothare
Part of the Respiratory Medicine book series (RM)


Sickle cell disease (SCD) is the most prevalent hemoglobinopathy in the USA. It has been reported that children with SCD have an increased risk for sleep problems including sleep-disordered breathing (SDB) compared to the general pediatric population. These children are also at an increased risk for adenotonsillar hypertrophy due to secondary hyperplasia of the lymphoid tissues following splenic infarction and extramedullary hematopoiesis. They are, therefore, more likely to develop upper airway obstruction. Both daytime and nocturnal hypoxemias are common in children with SCD; however, the accuracy of pulse oximetry in measuring oxyhemoglobin saturation has been questioned by several investigators. In this chapter, we attempt to review the prevalence of various sleep problems including SDB in children with SCD and discuss the link between SCD and hypoxemia, SDB, vaso-occlusive crises, stroke, and pulmonary hypertension. We review common sleep problems and their clinical presentation in children with SCD and outline their evaluation and treatment strategies.


Obstructive Sleep Apnea Sickle Cell Disease Pulse Oximetry Nocturnal Enuresis Cerebral Blood Flow Velocity 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Gladwin MT, Vichinsky E. Pulmonary complications of sickle cell disease. [Journal Article Review]. N Engl J Med. 2008;359(21):2254–65.PubMedCrossRefGoogle Scholar
  2. 2.
    Frenette PS, Atweh GF. Sickle cell disease: old discoveries, new concepts, and future promise. J Clin Invest. 2007;117(4):850–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Poillon WN, Kim BC, Rodgers GP, Noguchi CT, Schechter AN. Sparing effect of hemoglobin F and hemoglobin A2 on the polymerization of hemoglobin S at physiologic ligand saturations. Proc Natl Acad Sci USA. 1993;90(11):5039–43.PubMedCrossRefGoogle Scholar
  4. 4.
    Okoli K, Irani F, Horvath W. Pathophysiologic considerations for the interactions between obstructive sleep apnea and sickle hemoglobinopathies. Med Hypotheses. 2009;72(5):578–80.PubMedCrossRefGoogle Scholar
  5. 5.
    Sachdev V, Machado RF, Shizukuda Y, et al. Diastolic dysfunction is an independent risk factor for death in patients with sickle cell disease. J Am Coll Cardiol. 2007;49(4):472–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Fitzhugh CD, Lauder N, Jonassaint JC, et al. Cardiopulmonary complications leading to premature deaths in adult patients with sickle cell disease. Am J Hematol. 2010;85(1):36–40.PubMedGoogle Scholar
  7. 7.
    Quinn CT, Rogers ZR, McCavit TL, Buchanan GR. Improved survival of children and adolescents with sickle cell disease. Blood. 2010;115(17):3447–52. Epub 2010 Mar 1.PubMedCrossRefGoogle Scholar
  8. 8.
    McLaughlin Crabtree V, Beal Korhonen J, Montgomery-Downs HE, Faye Jones V, O’Brien LM, Gozal D. Cultural influences on the bedtime behaviors of young children. Sleep Med. 2005;6(4):319–24.PubMedCrossRefGoogle Scholar
  9. 9.
    Spilsbury JC, Storfer-Isser A, Drotar D, et al. Sleep behavior in an urban US sample of school-aged children. Arch Pediatr Adolesc Med. 2004;158(10):988–94.PubMedCrossRefGoogle Scholar
  10. 10.
    Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med. 1999;159(5 Pt 1):1527–32.PubMedGoogle Scholar
  11. 11.
    Rosen CL, Larkin EK, Kirchner HL, et al. Prevalence and risk factors for sleep-disordered breathing in 8- to 11-year-old children: association with race and prematurity. J Pediatr. 2003;142(4):383–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Spilsbury JC, Storfer-Isser A, Kirchner HL, et al. Neighborhood disadvantage as a risk factor for pediatric obstructive sleep apnea. J Pediatr. 2006;149(3):342–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Kaleyias J, Mostofi N, Grant M, et al. Severity of obstructive sleep apnea in children with sickle cell disease. J Pediatr Hematol Oncol. 2008;30(9):659–65.PubMedCrossRefGoogle Scholar
  14. 14.
    Hargrave DR, Wade A, Evans JP, Hewes DK, Kirkham FJ. Nocturnal oxygen saturation and painful sickle cell crises in children. Blood. 2003;101(3):846–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Umlauf MG, Chasens ER. Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis. Sleep Med Rev. 2003;7(5):403–11.PubMedCrossRefGoogle Scholar
  16. 16.
    Jacob E, Miaskowski C, Savedra M, Beyer JE, Treadwell M, Styles L. Changes in sleep, food intake, and activity levels during acute painful episodes in children with sickle cell disease. J Pediatr Nurs. 2006;21(1):23–34.PubMedCrossRefGoogle Scholar
  17. 17.
    Lauren L, Daniel C, Grant M, Kothare S, Dampier C. Sleep patterns in pediatric sickle cell disease. Pediatr Blood Cancer. 2010;55:501–7.CrossRefGoogle Scholar
  18. 18.
    Hunt CE. Neurocognitive outcomes in sleep-­disordered breathing. J Pediatr. 2004;145(4):430–2.PubMedCrossRefGoogle Scholar
  19. 19.
    Gozal D. Obstructive sleep apnea in children: implications for the developing central nervous system. Semin Pediatr Neurol. 2008;15(2):100–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Bhattacharjee R, Gozal D. Cardiovascular disease and sleep disordered breathing: are children vulnerable? Sleep. 2009;32(10):1251–2.PubMedGoogle Scholar
  21. 21.
    Moldofsky H. Rheumatic manifestations of sleep disorders. Curr Opin Rheumatol. 2010;22(1):59–63Google Scholar
  22. 22.
    Onen SH, Onen F, Courpron P, Dubray C. How pain and analgesics disturb sleep. Clin J Pain. 2005;21(5):422–31.PubMedCrossRefGoogle Scholar
  23. 23.
    Robertson PL, Aldrich MS, Hanash SM, Goldstein GW. Stroke associated with obstructive sleep apnea in a child with sickle cell anemia. Ann Neurol. 1988;23(6):614–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Sidman JD, Fry TL. Exacerbation of sickle cell disease by obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 1988;114(8):916–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Maddern BR, Reed HT, Ohene-Frempong K, Beckerman RC. Obstructive sleep apnea syndrome in sickle cell disease. Ann Otol Rhinol Laryngol. 1989;98(3):174–8.PubMedGoogle Scholar
  26. 26.
    Brooks LJ, Koziol SM, Chiarucci KM, Berman BW. Does sleep-disordered breathing contribute to the clinical severity of sickle cell anemia? J Pediatr Hematol Oncol. 1996;18(2):135–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Derkay CS, Bray G, Milmoe GJ, Grundfast KM. Adenotonsillectomy in children with sickle cell disease. South Med J. 1991;84(2):205–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Noguchi CT, Torchia DA, Schechter AN. Polymerization of hemoglobin in sickle trait erythrocytes and lysates. J Biol Chem. 1981;256(9):4168–71.PubMedGoogle Scholar
  29. 29.
    Gislason T, Benediktsdottir B. Snoring, apneic episodes, and nocturnal hypoxemia among children 6 months to 6 years old. An epidemiologic study of lower limit of prevalence. Chest. 1995;107(4):963–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Marcus CL. Sleep-disordered breathing in children. Am J Respir Crit Care Med. 2001;164(1):16–30.PubMedGoogle Scholar
  31. 31.
    Samuels MP, Stebbens VA, Davies SC, Picton-Jones E, Southall DP. Sleep related upper airway obstruction and hypoxaemia in sickle cell disease. Arch Dis Child. 1992;67(7):925–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Salles C, Ramos RT, Daltro C, Barral A, Marinho JM, Matos MA. Prevalence of obstructive sleep apnea in children and adolescents with sickle cell anemia. J Bras Pneumol. 2009;35(11):1075–83.PubMedCrossRefGoogle Scholar
  33. 33.
    Kennelly PJ, Rodwell V. Chapter 6. Proteins: myoglobin and hemoglobin. In: Murray R, Rodwell V, Bender D, Botham K, Weil PA, Kennelly PJ, editors. Harper’s illustrated biochemistry. 28th ed. Lange: McGraw-Hill; 2009.Google Scholar
  34. 34.
    Pianosi P, Charge TD, Esseltine DW, Coates AL. Pulse oximetry in sickle cell disease. Arch Dis Child. 1993;68(6):735–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Ortiz FO, Aldrich TK, Nagel RL, Benjamin LJ. Accuracy of pulse oximetry in sickle cell disease. Am J Respir Crit Care Med. 1999;159(2):447–51.PubMedGoogle Scholar
  36. 36.
    Fabry ME, Desrosiers L, Suzuka SM. Direct intracellular measurement of deoxygenated hemoglobin S solubility. Blood. 2001;98(3):883–4.PubMedCrossRefGoogle Scholar
  37. 37.
    Wall MA, Platt OS, Strieder DJ. Lung function in children with sickle cell anemia. Am Rev Respir Dis. 1979;120(1):210–4.PubMedGoogle Scholar
  38. 38.
    Rackoff WR, Kunkel N, Silber JH, Asakura T, Ohene-Frempong K. Pulse oximetry and factors associated with hemoglobin oxygen desaturation in children with sickle cell disease. Blood. 1993;81(12):3422–7.PubMedGoogle Scholar
  39. 39.
    Homi J, Levee L, Higgs D, Thomas P, Serjeant G. Pulse oximetry in a cohort study of sickle cell disease. Clin Lab Haematol. 1997;19(1):17–22.PubMedCrossRefGoogle Scholar
  40. 40.
    Blaisdell CJ, Goodman S, Clark K, Casella JF, Loughlin GM. Pulse oximetry is a poor predictor of hypoxemia in stable children with sickle cell disease. Arch Pediatr Adolesc Med. 2000;154(9):900–3.PubMedGoogle Scholar
  41. 41.
    Quinn CT, Ahmad N. Clinical correlates of steady-state oxyhaemoglobin desaturation in children who have sickle cell disease. Br J Haematol. 2005;131(1):129–34.PubMedCrossRefGoogle Scholar
  42. 42.
    Kirkham FJ, Hewes DK, Prengler M, Wade A, Lane R, Evans JP. Nocturnal hypoxaemia and central-nervous-system events in sickle-cell disease. Lancet. 2001;357(9269):1656–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Castele RJ, Strohl KP, Chester CS, Brittenham GM, Harris JW. Oxygen saturation with sleep in patients with sickle cell disease. Arch Intern Med. 1986;146(4):722–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Pashankar FD, Carbonella J, Bazzy-Asaad A, Friedman A. Longitudinal follow up of elevated pulmonary artery pressures in children with sickle cell disease. Br J Haematol. 2009;144(5):736–41.PubMedCrossRefGoogle Scholar
  45. 45.
    Johnson MC, Kirkham FJ, Redline S, Rosen CL, Yan Y, Roberts I, et al. Left ventricular hypertrophy and diastolic dysfunction in children with sickle cell disease are related to asleep and waking oxygen desaturation. [Journal Article]. Blood. 2010;116(1):16–21.PubMedCrossRefGoogle Scholar
  46. 46.
    Caboot JB, Allen JL. Pulmonary complications of sickle cell disease in children. Curr Opin Pediatr. 2008;20(3):279–87.PubMedCrossRefGoogle Scholar
  47. 47.
    Koumbourlis AC, Zar HJ, Hurlet-Jensen A, Goldberg MR. Prevalence and reversibility of lower airway obstruction in children with sickle cell disease. J Pediatr. 2001;138(2):188–92.PubMedCrossRefGoogle Scholar
  48. 48.
    Sylvester KP, Patey RA, Milligan P, et al. Pulmonary function abnormalities in children with sickle cell disease. Thorax. 2004;59(1):67–70.PubMedGoogle Scholar
  49. 49.
    Koumbourlis AC, Lee DJ, Lee A. Longitudinal changes in lung function and somatic growth in children with sickle cell disease. Pediatr Pulmonol. 2007;42(6):483–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Strunk RC, Brown MS, Boyd JH, Bates P, Field JJ, DeBaun MR. Methacholine challenge in children with sickle cell disease: a case series. Pediatr Pulmonol. 2008;43(9):924–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Boyd JH, DeBaun MR, Morgan WJ, Mao J, Strunk RC. Lower airway obstruction is associated with increased morbidity in children with sickle cell disease. [Journal Article Research Support N I H Extramural]. Pediatr Pulmonol. 2009;44(3):290–6.PubMedCrossRefGoogle Scholar
  52. 52.
    Field JJ, DeBaun MR, Yan Y, Strunk RC. Growth of lung function in children with sickle cell anemia. [Journal Article]. Pediatr Pulmonol. 2008;43(11):1061–6.PubMedCrossRefGoogle Scholar
  53. 53.
    MacLean JE, Atenafu E, Kirby-Allen M, et al. Longitudinal decline in lung volume in a population of children with sickle cell disease. Am J Respir Crit Care Med. 2008;178(10):1055–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Sylvester KP, Patey RA, Kassim Z, et al. Lung gas transfer in children with sickle cell anaemia. Respir Physiol Neurobiol. 2007;158(1):70–4.PubMedCrossRefGoogle Scholar
  55. 55.
    Needleman JP, Franco ME, Varlotta L, et al. Mechanisms of nocturnal oxyhemoglobin desaturation in children and adolescents with sickle cell disease. Pediatr Pulmonol. 1999;28(6):418–22.PubMedCrossRefGoogle Scholar
  56. 56.
    Craft JA, Alessandrini E, Kenney LB, et al. Comparison of oxygenation measurements in pediatric patients during sickle cell crises. J Pediatr. 1994;124(1):93–5.PubMedCrossRefGoogle Scholar
  57. 57.
    Needleman JP, Setty BN, Varlotta L, Dampier C, Allen JL. Measurement of hemoglobin saturation by oxygen in children and adolescents with sickle cell disease. Pediatr Pulmonol. 1999;28(6):423–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Spivey JF, Uong EC, Strunk R, Boslaugh SE, DeBaun MR. Low daytime pulse oximetry reading is associated with nocturnal desaturation and obstructive sleep apnea in children with sickle cell anemia. Pediatr Blood Cancer. 2008;50(2):359–62.PubMedCrossRefGoogle Scholar
  59. 59.
    Levin AV. Eye emergencies: acute management in the pediatric ambulatory care setting. Pediatr Emerg Care. 1991;7(6):367–77.PubMedCrossRefGoogle Scholar
  60. 60.
    Comber JT, Lopez BL. Evaluation of pulse oximetry in sickle cell anemia patients presenting to the emergency department in acute vasoocclusive crisis. Am J Emerg Med. 1996;14(1):16–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Fitzgerald RK, Johnson A. Pulse oximetry in sickle cell anemia. Crit Care Med. 2001;29(9):1803–6.PubMedCrossRefGoogle Scholar
  62. 62.
    Abdu A, Gomez-Marquez J, Aldrich TK. The oxygen affinity of sickle hemoglobin. Respir Physiol Neurobiol. 2008;161(1):92–4.PubMedCrossRefGoogle Scholar
  63. 63.
    Rodkey FL, Hill TA, Pitts LL, Robertson RF. Spectrophotometric measurement of carboxyhemoglobin and methemoglobin in blood. Clin Chem. 1979;25(8):1388–93.PubMedGoogle Scholar
  64. 64.
    Coulange M, Barthelemy A, Hug F, Thierry AL, De Haro L. Reliability of new pulse CO-oximeter in victims of carbon monoxide poisoning. Undersea Hyperb Med. 2008;35(2):107–11.PubMedGoogle Scholar
  65. 65.
    Kara CO, Ergin H, Kocak G, Kilic I, Yurdakul M. Prevalence of tonsillar hypertrophy and associated oropharyngeal symptoms in primary school children in Denizli, Turkey. Int J Pediatr Otorhinolaryngol. 2002;66(2):175–9.PubMedCrossRefGoogle Scholar
  66. 66.
    Abreu RR, Rocha RL, Lamounier JA, Guerra AF. Etiology, clinical manifestations and concurrent findings in mouth-breathing children. J Pediatr (Rio J). 2008;84(6):529–35.CrossRefGoogle Scholar
  67. 67.
    Ziliotto KN, dos Santos MF, Monteiro VG, et al. Auditory processing assessment in children with obstructive sleep apnea syndrome. Braz J Otorhinolaryngol. 2006;72(3):321–7.PubMedGoogle Scholar
  68. 68.
    Budhiraja R, Parthasarathy S, Quan SF. Endothelial dysfunction in obstructive sleep apnea. J Clin Sleep Med. 2007;3(4):409–15.PubMedGoogle Scholar
  69. 69.
    Salles C, Ramos RT, Daltro C, Nascimento VM, Matos MA. Association between adenotonsillar hypertrophy, tonsillitis and painful crises in sickle cell disease. J Pediatr (Rio J). 2009;85(3):249–53.Google Scholar
  70. 70.
    Ijaduola GT, Akinyanju OO. Chronic tonsillitis, tonsillectomy and sickle cell crises. J Laryngol Otol. 1987;101(5):467–70.PubMedCrossRefGoogle Scholar
  71. 71.
    Verduzco LA, Nathan DG. Sickle cell disease and stroke. Blood. 2009;114(25):5117–25.PubMedCrossRefGoogle Scholar
  72. 72.
    Scott RM, Smith ER. Moyamoya disease and moyamoya syndrome. N Engl J Med. 2009;360(12):1226–37.PubMedCrossRefGoogle Scholar
  73. 73.
    Ohene-Frempong K, Weiner SJ, Sleeper LA, et al. Cerebrovascular accidents in sickle cell disease: rates and risk factors. Blood. 1998;91(1):288–94.PubMedGoogle Scholar
  74. 74.
    Dowling MM, Quinn CT, Rogers ZR, Buchanan GR. Acute silent cerebral infarction in children with sickle cell anemia. Pediatr Blood Cancer. 2010;54(3):461–4.PubMedCrossRefGoogle Scholar
  75. 75.
    Adams RJ, McKie VC, Hsu L, et al. Prevention of a first stroke by transfusions in children with sickle cell anemia and abnormal results on transcranial Doppler ultrasonography. N Engl J Med. 1998;339(1):5–11.PubMedCrossRefGoogle Scholar
  76. 76.
    Adams RJ, Brambilla D. Discontinuing prophylactic transfusions used to prevent stroke in sickle cell disease. N Engl J Med. 2005;353(26):2769–78.PubMedCrossRefGoogle Scholar
  77. 77.
    Ware RE, Zimmerman SA, Schultz WH. Hydroxyurea as an alternative to blood transfusions for the prevention of recurrent stroke in children with sickle cell disease. Blood. 1999;94(9):3022–6.PubMedGoogle Scholar
  78. 78.
    Hill CM, Hogan AM, Onugha N, et al. Increased cerebral blood flow velocity in children with mild sleep-disordered breathing: a possible association with abnormal neuropsychological function. Pediatrics. 2006;118(4):e1100–8.PubMedCrossRefGoogle Scholar
  79. 79.
    Jacob E, Sockrider MM, Dinu M, Acosta M, Mueller BU. Respiratory symptoms and acute painful episodes in sickle cell disease. J Pediatr Oncol Nurs. 2010;27(1):33–9.PubMedCrossRefGoogle Scholar
  80. 80.
    Nur E, Kim YS, Truijen J, et al. Cerebrovascular reserve capacity is impaired in patients with sickle cell disease. Blood. 2009;114(16):3473–8.PubMedCrossRefGoogle Scholar
  81. 81.
    Dowling MM, Lee N, Quinn CT, et al. Prevalence of intracardiac shunting in children with sickle cell disease and stroke. J Pediatr. 2010;156(4):645–50.PubMedCrossRefGoogle Scholar
  82. 82.
    Kato GJ. Novel small molecule therapeutics for sickle cell disease: nitric oxide, carbon monoxide, nitrite, and apolipoprotein A-I. Hematology Am Soc Hematol Educ Program. 2008;1:186–92Google Scholar
  83. 83.
    Suell MN, Bezold LI, Okcu MF, Mahoney Jr DH, Shardonofsky F, Mueller BU. Increased pulmonary artery pressures among adolescents with sickle cell disease. J Pediatr Hematol Oncol. 2005;27(12):654–8.PubMedCrossRefGoogle Scholar
  84. 84.
    Ambrusko SJ, Gunawardena S, Sakara A, et al. Elevation of tricuspid regurgitant jet velocity, a marker for pulmonary hypertension in children with sickle cell disease. Pediatr Blood Cancer. 2006;47(7):907–13.PubMedCrossRefGoogle Scholar
  85. 85.
    Pashankar FD, Carbonella J, Bazzy-Asaad A, Friedman A. Prevalence and risk factors of elevated pulmonary artery pressures in children with sickle cell disease. Pediatrics. 2008;121(4):777–82.PubMedCrossRefGoogle Scholar
  86. 86.
    Hunt CE, Brouillette RT. Abnormalities of breathing control and airway maintenance in infants and children as a cause of cor pulmonale. Pediatr Cardiol. 1982;3(3):249–56.PubMedCrossRefGoogle Scholar
  87. 87.
    Gozal D, O’Brien LM. Snoring and obstructive sleep apnoea in children: why should we treat? Paediatr Respir Rev. 2004;5(Suppl A):S371–6.PubMedCrossRefGoogle Scholar
  88. 88.
    Sajkov D, McEvoy RD. Obstructive sleep apnea and pulmonary hypertension. Prog Cardiovasc Dis. 2009;51(5):363–70.PubMedCrossRefGoogle Scholar
  89. 89.
    American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med. 1996;153(2):866–78.Google Scholar
  90. 90.
    Kheirandish L, Goldbart AD, Gozal D. Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing after tonsillectomy and adenoidectomy in children. Pediatrics. 2006;117(1):e61–6.PubMedCrossRefGoogle Scholar
  91. 91.
    Abad VC, Guilleminault C. Treatment options for obstructive sleep apnea. Curr Treat Options Neurol. 2009;11(5):358–67.PubMedCrossRefGoogle Scholar
  92. 92.
    Marshall MJ, Bucks RS, Hogan AM, et al. Auto-adjusting positive airway pressure in children with sickle cell anemia: results of a phase I randomized controlled trial. Haematologica. 2009;94(7):1006–10.PubMedCrossRefGoogle Scholar
  93. 93.
    Souza LC, Viegas CA. Quality of sleep and pulmonary function in clinically stable adolescents with sickle cell anemia. J Bras Pneumol. 2007;33(3):275–81.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Umakanth Khatwa
    • 1
    Email author
  • Alia Bazzy-Asaad
    • 2
  • Sanjeev V. Kothare
    • 3
    • 4
  1. 1.Division of Respiratory Diseases, Department of MedicineChildren’s Hospital Boston, Harvard Medical SchoolBostonUSA
  2. 2.Department of PediatricsYale University School of MedicineNew HavenUSA
  3. 3.Division of Epilepsy and Clinical Neurophysiology, Department of NeurologyChildren’s Hospital Boston, Harvard Medical SchoolBostonUSA
  4. 4.Center for Pediatric Sleep Disorders, Department of NeurologyChildren’s Hospital Boston, Harvard Medical SchoolBostonUSA

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