\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Polysomnography is an Important Method for Diagnosing Pediatric Sleep
Problems: Experience of One Children's Hospital}



\author[1]{Chien-Heng  Lin}%
\author[1]{Chieh-Ho  Chen}%
\author[1]{Syuan-Yu  Hong}%
\author[1]{I-Ching  Chou}%
\author[1]{Shinn-Jye  Liang}%
\author[1]{Liang-Wen Hang}%
\affil[1]{China Medical University}%


\vspace{-1em}



  
  \date{May 07, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
In this study, we collected and analyzed PSG data to investigate that
value of polysomnography (PSG) in diagnosing sleep problems in children.
The results of PSG studies of children (\textless{} 18 years old) with
sleep problems conducted from April 2015 to May 2017 at a children's
hospital in Taiwan were collected and analyzed retrospectively. Data for
310 patients (209 males and 101 females) who underwent PSG were
collected. The final diagnoses were as follows: obstructive sleep apnea
in 159 (51.3\%), snoring in 81 (26.4\%), limb movement sleep disorder in
25 (8.1\%), hypersomnias in 12 (3.9\%), central apnea in 8 (2.9\%),
enuresis in 7 (2.3\%), bruxism in 5 (1.6\%), sleep terrors in 5 (1.6\%),
narcolepsy in 3 (1.0\%), sleep seizures in 3 (1.0\%), sleep walking in 1
(0.3\%), and insomnia in 1 (0.3\%). PSG may help detect significant
sleep-related problems in children and is useful for making therapeutic
decisions regarding children. Obstructive sleep apnea syndrome (OSAS)
was the primarily sleep problem for most of the children (51.3\%);
however, only 7.4\% of them underwent surgery for OSAS, even though
those with OSAS underwent surgery without undergoing PSG. We therefore
suggest that children with sleep problems should undergo PSG.%
\end{abstract}%



\sloppy


\textbf{Polysomnography is an Important Method for Diagnosing Pediatric
Sleep Problems: Experience of One Children's Hospital}

Running head: Pediatric sleep problems and polysomnography

\emph{Chien-Heng Lin, MD\textsuperscript{1}, Chieh-Ho Chen,
MD\textsuperscript{1}, Syuan-Yu Hong, MD\textsuperscript{2}, I-Ching
Chou, MD\textsuperscript{2}, Shinn-Jye Liang, MD\textsuperscript{3},
Liang-Wen Hang, MD\textsuperscript{3*}}

\textsuperscript{1}Division of Pediatric Pulmonology, China Medical
University Children's Hospital, Taiwan

\textsuperscript{2}Divison of Pediatric Neurology, China Medical
University Children's Hospital, Taiwan

\textsuperscript{3}Sleep Medicine Center, Department of Pulmonary and
Critical Care Medicine, China Medical University Hospital, Taiwan

\textbf{*Corresponding Author:} Liang-Wen Hang, MD, Sleep Medicine
Center, Department of Pulmonary and Critical Care Medicine, China
Medical University Hospital

No. 2, Yuh-Der Road, Taichung 404, Taiwan.

Tel: +886-2-2194-5179

Fax: +886-2-2194-746

E-mail: sub179090@gmail.com

\textbf{Keywords:} polysomnography; obstructive sleep apnea; children;
sleep disorders; Taiwan

\textbf{Funding:} None.

\emph{}

\textbf{Abstract}

In this study, we collected and analyzed PSG data to investigate that
value of polysomnography (PSG) in diagnosing sleep problems in children.
The results of PSG studies of children (\textless{} 18 years old) with
sleep problems conducted from April 2015 to May 2017 at a children's
hospital in Taiwan were collected and analyzed retrospectively. Data for
310 patients (209 males and 101 females) who underwent PSG were
collected. The final diagnoses were as follows: obstructive sleep apnea
in 159 (51.3\%), snoring in 81 (26.4\%), limb movement sleep disorder in
25 (8.1\%), hypersomnias in 12 (3.9\%), central apnea in 8 (2.9\%),
enuresis in 7 (2.3\%), bruxism in 5 (1.6\%), sleep terrors in 5 (1.6\%),
narcolepsy in 3 (1.0\%), sleep seizures in 3 (1.0\%), sleep walking in 1
(0.3\%), and insomnia in 1 (0.3\%). PSG may help detect significant
sleep-related problems in children and is useful for making therapeutic
decisions regarding children. Obstructive sleep apnea syndrome (OSAS)
was the primarily sleep problem for most of the children (51.3\%);
however, only 7.4\% of them underwent surgery for OSAS, even though
those with OSAS underwent surgery without undergoing PSG. We therefore
suggest that children with sleep problems should undergo PSG.



\textbf{Introduction}

Sleep constitutes an opportunity for the body to conserve energy,
restore its normal processes, promote physical growth, and support
mental development. It also plays a vital and often underestimated role
in the growth and development of children. Sleep problems have been
reported to have high prevalence rates throughout childhood, affecting
25\% to 50\% of preschoolers and up to 40\% of
adolescents\textsuperscript{1-3}.

The taking of a detailed medical history is the first method that should
be applied to screen for and identify pediatric sleep problems, followed
by polysomnography (PSG), which is a powerful diagnostic sleep medicine
tool that can be used to continuously and simultaneously record multiple
different physiological parameters of a sleeping individual.

In this study, we retrospectively collected the data of children who
underwent PSG in our hospital due to sleep problems. The indications of
these PSG studies and the final diagnoses of these patients were then
analyzed and evaluated.



\textbf{Materials and Methods}

Ethical approval was provided by the ethical review board of China
Medical University Hospital (CMUH103-REC2-082). Patient consent was not
required for this research. The data for children (\textless{} 18 years
old) with sleep problems who came to the outpatient department (OPD) of
China Medical University Children's Hospital for help and underwent PSG
from April 2015 to May 2017 were collected and analyzed retrospectively.
However, data for those who underwent follow-up PSG studies after
adenotonsillectomy or for other reasons were excluded in this study.

The indications for PSG include snoring, sleep apnea, other
sleep-related breathing disorders,~excessive daytime sleepiness,~limb
movements while sleeping, bruxism, enuresis, sleep walking, insomnia,
difficulty falling sleeping, and others.

A level 1 PSG study is performed in our sleep laboratory with a sleep
technologist present, and 12 channels are recorded, including eight
channels of electroencephalography (EEG), 2 channels of
electrooculography (EOG), 1 channel of submentalis (chin)
electromyography (EMG), and 1 channel of
electrocardiogram~(ECG)/heart~rate, and 1 channel of pulse oximetry
(SpO\textsubscript{2}). A multiple sleep latency test (MSLT) was also
arranged for the day after any PSG study for those children who had a
history of more than 3 months of excessive daytime sleepiness.

Obstructive sleep apnea syndrome (OSAS) was diagnosed based on the PSG
data when obstructive events were noted and the apnea-hypopnea index
(AHI) was one or more per hour, with 1\textless{} AHI [?]5 taken to
indicate mild OSA, 5\textless{} AHI [?]10 taken to indicate moderate OSAS,
and an AHI \textgreater{}10/hr of total sleep time (TST) taken to
indicate severe OSAS.

The periodic limb movements (PLMs) during sleep were scored if there
were at least four movements of 0.5--5/sec' duration that occurred
between 5 and 90s apart. A PLM index of \textgreater{}5 per hour~of
sleep is generally considered to be rare in normal children, and
therefore this threshold was used to define the presence of periodic
limb movement disorder (PLMD).

Central sleep apnea (CSA) was defined as the absence of both inspiratory
effort and chest wall movement lasting longer than 20 seconds when
accompanied by a central apnea index greater than 1.

Furthermore, the presence of two or more sleep-onset rapid eye movement
(REM) periods (SOREMPs) and a mean sleep latency of \textless{}8 minutes
on the MSLT was regarded as being diagnostic of narcolepsy.



\textbf{Results}

Data for a total of 325 patients with sleep problems who came to the OPD
for help from April 2015 to May 2017 and underwent PSG were collected in
our study. Among these patients, a total of 242 patients had problems of
snoring, sleep apnea, and other sleep-related breathing disorders. Forty
of the patients had involuntary limb movements during sleep.
Twenty-seven of the patients had symptoms suggestive of parasomnias such
as bruxism, enuresis, and sleep walking. Twenty-two patients had~a
history of excessive daytime sleepiness, and one had difficulty falling
asleep.

A total of 310 of the children (209 males and 101 females aged from 5-17
years old, with a mean age of 8.5 years and median age of 10 years) had
positive findings in the PSG and/or MSLT studies.

The final diagnoses in the 209 male patients were as follows: OSAS in
109 (52.2\%), primary snoring in 57 (27.3\%), PLMD in 19 (9.1\%),
idiopathic hypersomnia in 8 (3.8\%), central apnea in 6 (2.9\%),
enuresis in 6 (2.9\%), sleep terrors in 3 (1.4\%), narcolepsy in 3
(1.4\%), sleep seizures in 1 (0.5\%), 1 bruxism in 1 (0.5\%). There were
5 male children who were diagnosed with both OSAS and PLMD. In the 109
male children with OSAS, 80 had mild OSAS, 24 had moderate OSAS, and 5
had severe OSAS. Furthermore, 27 of them had asthma or allergic
rhinitis, 5 had obesity, 2 had Duchenne muscular dystrophy, 1 had
prematurity, and 1 had mucopolysaccharidosis (MPS) type 2. In the 19
male children with PLMD, 4 had underlying diseases: 2 had developmental
delays, 1 had Tourette syndrome, and 1 had hydrocephalus. In the 6 male
children with central apnea, 4 had congenital heart disease after
operation, 1 had ganglioglioma post operation, and the other did not
have any underlying diseases.

The final diagnoses in the 101 female patients were as follows: OSAS in
50 (49.5\%), primary snoring in 24 (23.8\%), limb movement sleep
disorder in 13 (12.9\%), idiopathic hypersomnia in 4 (4.0\%), bruxism in
4 (4.0\%), sleep terrors in 2 (2.0\%), sleep seizures in 2 (2.0\%),
enuresis in 1 (1.0\%), and sleep walking in 1 (1.0\%). There were 2
female children who had both OSAS and PLMD. In 101 female children with
OSAS, 66 had mild OSAS, 31 had moderate OSAS, and 4 had severe OSAS.
Furthermore, 10 of them had allergic rhinitis, 2 had diabetes mellitus,
1 had Down syndrome, and 1 had Prader-Willi syndrome. In the 13 female
children with PLMD, 4 had underlying diseases: 2 had a history of
febrile convulsion, 1 had a history of syncope history, and 1 had
cerebral palsy. In the 2 female children with central apnea, 1 of them
had congenital heart disease after operation, and the other did not have
any underlying diseases. All of the patients' final diagnoses are shown
in \textbf{Table 1} .

The methods used to manage the 270 of the 310 total patients with
positive findings (40 patients did not come back to the OPD for
follow-up visits) were as follows: operation with adenoidectomy and
tonsillectomy was suggested for 37 patients with moderate or severe
OSAS, and 23 patients (15 males and 8 females) (23/37=62\%, or 7.4\% of
all the children enrolled in this study) underwent the operation;
continuous positive airway pressure (CPAP) was used in 2 patients with
central apnea (0.6\%); medical treatment was used in 190 patients
(61.3\%); and the remaining patients were only placed under observation
(n=99, 31.9\%) (\textbf{Figure 1} ). For the 14 patients with moderate
or severe OSAS who did not undergo an operation, a repeated PSG study
6-12 months later was suggested, but only 3 of them returned for
follow-up visits, and their AHI results were decreased at those
follow-ups.



\textbf{Discussion}

As with adults, there are all sorts of reasons why children do not sleep
well. Some of those reasons are more serious than others. In our study,
the sleep problem of the majority of the children (51.3\%) was OSAS;
however, only 7.4\% of the total pediatric patients in the study
underwent surgery for OSAS, even though some of the children with OSAS
underwent surgery without undergoing preoperative PSG.

The etiologies of pediatric OSAS are multiple, and can be classified
into intrinsic upper airway narrowing or increased upper airway
collapsibility \textsuperscript{4}. Adenotonsillar hypertrophy is
currently the most common cause of intrinsic upper airway narrowing,
with other anatomical features resulting in upper airway narrowing
including craniofacial syndrome, achondroplasia, Down syndrome, Beckwith
Wiedemann syndrome, and MPS. In our study, three patients had underlying
diseases with intrinsic upper airway narrowing: one had Prader-Willi
syndrome, one had Down syndrome, and one had MPS. Adenotonsillectomy was
suggested for these three patients, but their families refused this
surgical intervention.

A decrease in muscle tone in the upper airway can cause increased upper
airway collapsibility, with potential cause of such decreases including
cerebral palsy, neuromuscular disorders, or inflammatory conditions such
as allergic rhinitis and asthma. In our study, 2 OSAS patients had the
underlying disease of Duchenne muscular dystrophy, and 24.5\% (37/159)
of the OSAS patients had allergic rhinitis or asthma.

Obesity appears to facilitate the emergency of OSAS; therefore, there is
a high prevalence of OSAS among obese children. However, there is a
higher proportion of children with OSAS who are obese. Thusm it appears
that both OSAS and obesity can coexist and potentiate the adverse
impacts of one another \textsuperscript{5}. The prevalence of OSAS is
increasing globally due to the growing occurrence of obesity in society.
In obese children, the fat deposits in the upper respiratory tract cause
breathing difficulties during sleep, thus causing
OSAS\textsuperscript{6,7}, with reports of the prevalence of OSAS in
obese children ranging from 13 to 59\% \textsuperscript{8}. In our
study, 3.1\% (5/159) of the children with OSAS were also obese, and all
of them were male patients. One of these 3 patients had severe OSAS and
underwent an adenotonsillectomy, while it was recommended that the other
2 patients achieve body weight reductions through an increase in their
dialy intense physical activities. A recent cross-sectional, prospective
multicenter study, the NANOS study, assessed the contribution of obesity
and adenotonsillar hypertrophy to pediatric OSAS and found that 46.6\%
of obese children in the community had OSAS \textsuperscript{9}.

Adenotonsillectomy is generally considered the first-line therapy in
children with moderate or severe OSAS. In our study, there were 65
children with moderate OSAS and 9 with severe OSAS, and it was suggested
that 26 of the moderate cases and all 9 of the severe cases undergo an
operation. Of those 37 patients, 62\% (23/37) underwent the operation.
Some of the patients did not receive the operation because they their
family members wanted to further observe their symptoms for a period of
time. For these fourteen patients who did not undergo the operation,
repeated PSG studies were performed for 3 of them who come back for
follow-up visits, and their AHI results were found to be decreased in
those follow-ups.

PSG prior to adenotonsillectomy is indicated for children with some
conditions that increase the risk of perioperative respiratory
complications. These conditions include obesity (especially if severe),
Down syndrome, craniofacial abnormalities, neuromuscular disorders,
sickle cell disease, or MPS \textsuperscript{10}. The purpose of the PSG
in these high-risk children is to improve diagnostic accuracy and define
the severity of OSAS to optimize perioperative planning. In our study,
the OSAS children for whom the operation was suggested did have at least
one of the aforementioned conditions, but some, including 3 with
obesity, 2 with Duchenne muscular dystrophy, 1 with Down syndrome, 1
with MPS, and 1 with Prader-Willi syndrome did not undergo the
operation.

Several authors have recommended that a clinical reevaluation be given
to all children several months after adenotonsillectomy to determine
whether snoring and the symptoms of OSAS have been resolved, especially
in those children with higher risk of persistent disease, such as those
with severe obesity or craniofacial syndromes. Furthermore, a
postoperative PSG should be considered even in the absence of snoring or
other symptoms in order to determine whether additional treatment is
necessary for residual OSAS\textsuperscript{4}. However, no studies to
date have evaluated the timing of postoperative PSG evaluations, and
this issue is not specifically addressed in the practice guidelines
regarding the management of pediatric OSA. In our study, we did not
collect postoperative PSG data, so further studies should be designed
for evaluating this issue.

Medical therapies such as anti-inflammatory agents or CPAP are used as
alternatives to adenotonsillectomy for children with OSAS, depending on
the severity and specific locations of airway obstruction in the
individual patient, and on associated comorbidities.

The second most common sleep problem among the children in our study was
primary snoring, and the management of pediatric primary snoring
consists of treating any upper airway obstructions or observation in
cases in which there is no upper airway obstruction.

The third most common sleep problem in our study was PLMD. Thirty-one
children (10\%) had PLMD proven by PSG, and 7 of those 31 also had OSAS.
In the large clinical case series reported by Gingras JL et al., PLMD
was found to be common, affecting 14\% of the 468 referred
children\textsuperscript{11}. It is relevant to note that there are no
Food and Drug Administration-approved treatments for PLMD in
children.~However, most children with PLMD have low iron storage;
therefore, iron therapy should be considered as the first line of
treatment in children with PLMD whose iron levels are low. In our study,
the iron level was checked in 9 children, and only one child with PLMD
had a low iron level and was thus treated with iron therapy. Therefore,
our management for PLMD consisted non-pharmacologic treatments, such as
education, massage, exercise, or observation only.

The fourth most common sleep problem in our study was idiopathic
hypersomnia, which is extremely rare in children. Hypersomnia is present
in 4\% to 6\% of the general population, with only 1\% of the population
having idiopathic hypersomnia and most of the people with that being
adolescents or adults \textsuperscript{12}. According to a report by Han
F et al.,~86\% (361/417) of the children presenting with a complaint of
primary hypersomnia to a sleep clinic in China met the criteria for
narcolepsy with cataplexy \textsuperscript{13}, while only 20\% (3/15)
of the children with excessive daytime sleepiness in our study had
narcolepsy.

The clinical characteristics and experiences of CSA are very limited in
children compared to the adult population, and it is thought to occur in
about 1-5\% of healthy~children \textsuperscript{14}. CSA has been noted
to occur more commonly in~children~with underlying~diseases,~and the
presence of CSA may influence the course of
those~diseases\textsuperscript{14}. In our study, there were 8 children
who had CSA; 6 of them had secondary CSA and 2 had idiopathic CSA.
Idiopathic CSA is really rare in children, and it cannot be reliably
identified or diagnosed on the basis of history or a specific set of
signs and symptoms \textsuperscript{14}. For the 2 children with a
PSG-based diagnosis of CSA in this study, we suggested a magnetic
resonance imaging (MRI) evaluation to assess for neuroanatomical
abnormalities, but neither of the children came back for a follow-up
visit.

A study by Felix O et al. reported that 18 of the 441 (4.1\%) patients
recorded during the study period had CSA, while 8 of the 310 (1.9\%)
patients in our study had central apnea \textsuperscript{15}. In the
study by Felix O et al, the underlying disorders were dominated by
neurosurgical disorders; however, congenital heart diseases dominated in
our study.

Many parasomnias in children can be recognized by history alone, but
some require nocturnal PSG for appropriate diagnosis and management. In
our study, there were 7 patients who had enuresis, 5 who had bruxism,
and 1 who had sleep walking according to the PSG results, with these 13
patients accounting for 4.2\% of all the patients who underwent PSG. We
believe however that there are still so many children with parasomnias
who do not go to pediatric OPDs for help.

There were several limitations in our study. The first was that our
study was only a 2-year retrospective study, and some children with
sleep problems, especially those suspected of having insomnias and
parasomnias, may go to psychiatric OPDs for help, not pediatric OPDs,
and thus may not undergo a PSG study. Second, long-term follow-up is
necessary for children with sleep problems in order to observe whether
their symptoms are relieved or their AHI results are decreased after
treatment, especially for those with OSAS after adenotonsillectomy.
Third, blood sample tests, such as tests of serum Fe or ferritin levels,
are not typically conducted for children with PLMD. Further studies
prospectively collecting PSG data from children with pediatric sleep
disorders will thus be required.

\textbf{Conclusion}

The sleep problem of the majority of the children (51.3\%) in this study
was OSAS; however, only 7.4\% of the total pediatric patients in the
study underwent surgery for OSAS, even though some of the children with
OSAS underwent surgery without undergoing PSG. We thus suggest that
children with sleep problems should all undergo PSG studies, as PSG
could help to detect significant sleep-related problems, and the
application of PSG results is useful for making therapeutic decisions
regarding children.

\textbf{Acknowledgements:} N/A

\textbf{Funding:} None

\textbf{Conflict of Interest:} The authors have stated that they had no
interests which might be perceived as posing a conflict or bias.

\textbf{Experimental and Publication Ethics:} Ethical approval was
provided by the ethical review board of China Medical University
Hospital (CMUH103-REC2-082).

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Bhargava S. Diagnosis and management of common sleep problems in
  children. Pediatr Rev 2011;32(3):91-99.
\item
  Owens JA, Spirito A, McGuinn M, Nobile C. Sleep habits and sleep
  disturbance in elementary school-aged children. J Dev Behav Pediatr
  2000;21(1):27-36.
\item
  Pagel JF, Forister N, Kwiatkowki C. Adolescent sleep disturbance and
  school performance: the confounding variable of socioeconomics. J Clin
  Sleep Med 2007;3(1):19-23.
\item
  Dehlink E, Tan HL. Update on paeditric obstructive sleep apnoea. J
  Thorac Dis 2016;8(2):224-235.
\item
  Narang I,~Mathew JL. Childhood obesity~and~obstructive sleep apnea. J
  Nutr Metab 2012;2012:134202. doi: 10.1155/2012/134202.
\item
  Lim DC, Pack AI. Obstructive sleep apnea: Update and future.~Annu Rev
  Med 2016;68:99--112.
\item
  Glicksman A, Hadjiyannakis S, Barrowman N, Walker S, Hoey L, Katz SL.
  Body fat distribution ratios and obstructive sleep apnea severity in
  youth with obesity.~J Clin Sleep Med 2017;13(4):545--550.
\item
  Katz ES, D'Ambrosio CM. Pediatric obstructive sleep apnea syndrome.
  Clin Chest Med 2010;31:221.
\item
  Alonso-\selectlanguage{ngerman}Álvarez ML,~Cordero-Guevara JA,~Terán-Santos J, et al.
  Obstructive sleep apnea in obese community-dwelling children: The
  NANOS study. Sleep 2014;37(5):943-949.
\item
  Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW,
  Kuhar S, Mitchell RB, Seidman MD, Sheldon SH, et al. Clinical practice
  guideline: Polysomnography for sleep-disordered breathing prior to
  tonsillectomy in children. Otolaryngol Head Neck Surg
  2011;145:S1.Hypersomnia
\item
  Gingras JL, Gaultney JF, Picchietti DL. Pediatric periodic limb
  movement disorder: sleep symptom and polysomnographic correlates
  compared to obstructive sleep apnea. J Clin Sleep Med
  2011;7(6):603-9A. doi: 10.5664/jcsm.1460.
\item
  Daunvilliers Y, Buguet A. Hypersomnia. Dialogues Clin Neurosci
  2005;7(4):347--356.
\item
  Han F, Lin L, Li J, Aran A, Dong SX, An P, Zhao L, Li M, Li QY, Yan H,
  et al. Presentations of primary hypersomnia in Chinese children. Sleep
  2011;34(5):627-632.
\item
  McLaren AT, Bin-Hasan S, Narang I. Diagnosis, management and
  pathophysiology of central sleep apnea in children. Paediatr Respir
  Rev 2018;30:49-57. doi: 10.1016/j.prrv.2018.07.005.
\end{enumerate}

Felix O, Amaddeo A, Arroyo JO, Zerah M, Puget S, Cormier-Daire V, Baujat
G, Pinto G, Fernandez-Bolanos M, Fauroux B. Central sleep apnea in
children: experience at a single center. Sleep Med 2016;25:24-28. doi:
10.1016/j.sleep.2016.07.016.



\textbf{Figure legend}

Figure 1 Management of 310 patients\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

