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Ricci C, Ordnung M, Rothenbacher D, Genuneit J. Substituting Book Reading for Screen Time Benefits Preschoolers' Sleep Health: Results from the Ulm SPATZ Health Study. Nat Sci Sleep 2024; 16:315-324. [PMID: 38524767 PMCID: PMC10961022 DOI: 10.2147/nss.s448736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/19/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose Healthy sleep is essential for the physical, cognitive, and social development of children. Several studies have reported the increase in digital media use in preschool children and its association with impaired sleep. However, there is relatively little evidence on the effects of book reading as a potentially safe alternative. The objective of this study, therefore, was to investigate whether sleep in children could benefit from book reading, and whether the negative effects of media use on sleep can be mitigated by substituting book reading for screen time. Participants and Methods We used longitudinal data from three consecutive waves of the SPATZ Health study, including children at the ages of 4 (n=581), 5 (n=508), and 6 (n=426) years. All data were collected by self-administered questionnaires. Parent-reported child sleep was assessed by the Children's Sleep Habits Questionnaire. Results Across the three waves, screen-based media use increased and was associated with lower sleep quality. In contrast, the time spent with book reading decreased; however, book reading appeared to be beneficial for children's sleep. Substitution models revealed that the theoretical substitution of an equal amount of book reading for 50% of the time spent with screen-based media benefits several domains of preschoolers' sleep health, including parasomnias, sleep anxiety, daytime sleepiness, and sleep onset delay. Conclusion Besides implications for population-wide and individual prevention, book reading may also be incorporated as a useful intervention to improve sleep quality in children who are already affected by sleep problems. Given that book reading is perceived as a safe alternative, the presented evidence may suffice to support recommendations in this direction.
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Affiliation(s)
- Cristian Ricci
- Pediatric Epidemiology, Department of Pediatrics, Medical Faculty, Leipzig University, Leipzig, Germany
- Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, Potchefstroom, South Africa
| | - Madeleine Ordnung
- Pediatric Epidemiology, Department of Pediatrics, Medical Faculty, Leipzig University, Leipzig, Germany
| | | | - Jon Genuneit
- Pediatric Epidemiology, Department of Pediatrics, Medical Faculty, Leipzig University, Leipzig, Germany
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
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Paulus FW, Joas J, Friedmann A, Fuschlberger T, Möhler E, Mall V. Familial context influences media usage in 0- to 4-year old children. Front Public Health 2024; 11:1256287. [PMID: 38274543 PMCID: PMC10808691 DOI: 10.3389/fpubh.2023.1256287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/20/2023] [Indexed: 01/27/2024] Open
Abstract
Background The use of digital media (e.g., smartphones, tablets, etc.) and the Internet have become omnipresent for every age group and are part of children's and parents' everyday life. Focusing on young children, the availability of media devices, their use as well as associated problems (e.g., in social, emotional and motor development) have increased in recent years. Of particular interest for prevention of these problems in early childhood is the relationship between the familial context (parental digital media use, Problematic Internet Use, school graduation, presence of siblings) and the digital media use of infants and toddlers. The present study's goal was to describe media usage in 0-4-year-old children and to identify the potential relationship between familial context factors and child media usage. Methods The sample included N = 3,035 children aged 0 to 3;11 years (M = 17.37 months, SD = 13.68; 49.13% female). Recruitment took place within the framework of a restandardization study for a German developmental test. The parents of the participants answered a questionnaire on socio-demographics, on child media use, and on parental media use. Questions on parental media use included the full version of the Short Compulsive Internet Use Scale (S-CIUS). Results Significant increases in media usage times with child age were identified, but no significant gender differences. A multiple regression analysis revealed that increasing maternal total media usage time, a higher parental S-CIUS score, lower school leaving certificate of both mother and father, and increasing child's age led to higher child media usage time. Having siblings diminished young children's media usage in this study. Having more than one child and having children aged over a year was associated with a higher parental S-CIUS score. Conclusion Family factors such as maternal media use time, Problematic Internet Use and lower school graduation are significantly associated with young children's digital media use. Parents should be aware of their personal influence on their children's media use which might be due their role in terms of model learning.
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Affiliation(s)
- Frank W. Paulus
- Child and Adolescent Psychiatry, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Jens Joas
- Child and Adolescent Psychiatry, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Anna Friedmann
- Technical University of Munich, TUM School of Medicine and Health, Chair of Social Pediatrics, München, Germany
| | - Tamara Fuschlberger
- Technical University of Munich, TUM School of Medicine and Health, Chair of Social Pediatrics, München, Germany
| | - Eva Möhler
- Child and Adolescent Psychiatry, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Volker Mall
- Technical University of Munich, TUM School of Medicine and Health, Chair of Social Pediatrics, München, Germany
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Kahn M, Barnett N, Gradisar M. Let's Talk about Sleep Baby: Sexual Activity Postpartum and Its Links with Room Sharing, Parent Sleep, and Objectively Measured Infant Sleep and Parent Nighttime Crib Visits. JOURNAL OF SEX RESEARCH 2023; 60:1247-1258. [PMID: 35763039 DOI: 10.1080/00224499.2022.2092050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The postpartum period may pose a considerable challenge for both parent sleep and sexual activity. This study assessed the links between partnered sexual frequency and satisfaction postpartum and parent sleep, infant sleep, parent nighttime caregiving, and parent-infant room sharing. Participants were 897 parents of infants aged 1-18-months (M = 8.8 ± 4.3, 49% girls). Parents completed an online survey about their sexual frequency and satisfaction, sleep, relationship satisfaction, depression, and demographic characteristics. Infant sleep and parent nighttime crib visits were measured objectively using auto-videosomnography during 2-weeks, with 8,460 nights assessed. Results indicated that the frequency of partnered sexual activity was 3.8 ± 4.2 times per month. Frequency of sexual activity increased with infant age, yet increases beyond the first 6 months postpartum were non-significant. Adjusted GEE modeling revealed that more parent nighttime crib visits were significantly associated with lower sexual frequency, regardless of infant age. Other parent and infant sleep-related factors were not significantly linked with sexual frequency in adjusted models. Moreover, sexual satisfaction was not associated with parent nighttime caregiving, parent or infant sleep, or parent-infant sleeping arrangements in adjusted models, suggesting that it may not be susceptible to the effects of disrupted sleep in the postpartum period. These findings suggest that it is not infant or parent sleep disruption per se, but rather parent nighttime engagement with the infant that is associated with parent sexual activity frequency. Longitudinal investigations are warranted to examine the directional pathways of these links.
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Affiliation(s)
- Michal Kahn
- College of Education, Psychology and Social Work, Flinders University
| | | | - Michael Gradisar
- College of Education, Psychology and Social Work, Flinders University
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Tikotzky L, Ran-Peled D, Ben-Zion H. A preliminary study on the performance of the Nanit auto-videosomnography scoring system against observed video scoring and actigraphy to estimate sleep-wake states in infants. Sleep Health 2023; 9:611-617. [PMID: 37716834 DOI: 10.1016/j.sleh.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 06/25/2023] [Accepted: 07/22/2023] [Indexed: 09/18/2023]
Abstract
GOAL AND AIMS To examine the performance of the Nanit auto-videosomnography scoring system as a measure of sleep-wake states in infants compared to observed video scoring and actigraphy. FOCUS TECHNOLOGY Nanit's auto-videosomnography scoring system. REFERENCE Observed video scoring and actigraphy. SAMPLE Sixteen U.S. infants (age: 4-8 months). DESIGN Infants' sleep was assessed with the Nanit camera and actigraphy (micromotion logger sleep watch). Fifty nights were included in the analyses. Nanit's videos were processed via a computer vision algorithm and were scored by trained observers. Actigraphic data were scored with the validated Sadeh algorithm. CORE ANALYTICS Bland-Altman plots and epoch-by-epoch analyses (sensitivity, specificity, and total accuracy). ADDITIONAL ANALYTICS Specificity values for each night separately. CORE OUTCOMES Nanit estimates of sleep minute were not significantly different from observed sleep minute, but Nanit overestimated sleep minute relative to actigraphy by 17 minutes. Nanit overestimated wake minutes (wake after sleep onset by 5.3 minutes relative to observed scoring and underestimated wake after sleep onset by 19.1 minutes relative to actigraphy. The epoch-by-epoch analyses revealed that Nanit reached 97.8% sensitivity in classifying sleep and 60.4% specificity in classifying wake compared to observed scoring. The rates compared to actigraphy were 99.3% for sensitivity and 51.7% for specificity. IMPORTANT ADDITIONAL OUTCOMES Specificity values were lower for infants with lower wake after sleep onset. CORE CONCLUSION This preliminary study suggests that Nanit is highly accurate in detecting infant sleep compared to observed scoring and actigraphy. Specificity values are within the range of those reported previously for actigraphy devices that are commonly used in pediatric sleep research.
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Affiliation(s)
- Liat Tikotzky
- Department of Psychology, Ben-Gurion University of the Negev, Beersheba, Israel.
| | - Dar Ran-Peled
- Department of Psychology, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Hamutal Ben-Zion
- Department of Psychology, Ben-Gurion University of the Negev, Beersheba, Israel
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Kahn M, Barnett N, Gradisar M. Implementation of Behavioral Interventions for Infant Sleep Problems in Real-World Settings. J Pediatr 2023; 255:137-146.e2. [PMID: 36375604 DOI: 10.1016/j.jpeds.2022.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare the real-world frequency, timing, duration, difficulty, and helpfulness of 3 infant Behavioral Sleep Intervention (BSI) approaches: Unmodified Extinction, Modified Extinction, and Parental Presence and to examine the effectiveness and safety of these approaches by comparing infant sleep, parent sleep, daytime sleepiness, depression, and parent-infant bonding between parents who had and had not implemented these interventions. STUDY DESIGN Participants were 2090 parents (75% mothers, 79% White/Caucasian) of US infants (49% girls) aged 3-18 months (M = 9.1, SD = 4.1). Parents completed online questionnaires regarding their infant's sleep, their own sleep, daytime sleepiness, depression levels, and parent-infant bonding. Infant sleep was assessed via objective-albeit exploratory-autovideosomnography data obtained from the 14 days prior to survey completion. RESULTS Sixty-four percent of parents reported implementing BSIs. The average age at intervention was 5.3 months (SD = 2.6). Unmodified and Modified Extinction were rated as significantly more difficult to implement compared with Parental Presence but also as more helpful, shorter, and quicker to show improvements. Infant nighttime sleep was longer and more consolidated in the Unmodified and Modified Extinction groups compared with the Parental Presence and non-BSI groups. No differences were found between BSI groups in parent sleep, sleepiness, depression, or parent-infant bonding. CONCLUSIONS Implementation of BSIs outside clinical settings is pervasive and occurs earlier than generally recommended. Unmodified and Modified Extinction were associated with longer and more consolidated infant sleep. Despite concerns regarding the potential harm of BSIs, implementation of these approaches was not linked with negative outcomes, providing additional evidence for their safety and effectiveness.
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Affiliation(s)
- Michal Kahn
- College of Education, Psychology and Social Work, Flinders University, Adelaide, South Australia, Australia.
| | | | - Michael Gradisar
- Wink Sleep Pty Ltd, Adelaide, South Australia, Australia; Sleep Cycle AB, Gothenburg, Sweden
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Insomnia in Infancy, Childhood, and Adolescence. Sleep Med Clin 2023; 18:135-145. [PMID: 37120157 DOI: 10.1016/j.jsmc.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Insomnia is the most prevalent sleep disorder in youth, tends to persist over time, and is associated with a myriad of adverse outcomes. This paper synthesizes the current evidence regarding the phenomenology, prevalence, assessment, consequences, cause, and treatment of pediatric insomnia, highlighting areas that warrant further research and addressing the unique characteristics of this disorder in infants, children, and adolescents.
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Diler F, Başkale H. The influence of sleep patterns and screen time on the sleep needs of infants and toddlers: A cross-sectional study. J Pediatr Nurs 2022; 67:e201-e207. [PMID: 35914990 DOI: 10.1016/j.pedn.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/10/2022] [Accepted: 07/15/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of this study was to examine the effects of screen time and sleep patterns on the sleep needs of infants and toddlers. DESIGN AND METHODS A descriptive cross-sectional data were collected from 304 parents of children aged 6 to 36 months old. The screen use of children and parents was assessed with seven questions and A Brief Infant Sleep Questionnaire (BISQ) was used to assess infant sleep. RESULTS The results of this study indicate that children's adherence to the recommended sleep standards is poor. The most important criteria that caused poor sleeping were the number of awakenings at night, the duration of sleeplessness at night and the minimum total sleep time of <9 h. The most frequently used screen type in all of the age groups and parents was TV, followed by smartphones. As the age of the children increased, the rate of all screen-type use also increased. Factors predicting sleep needs included bedtime, the PED usage of children, parents' watching TV and care of the children by the babysitter. CONCLUSIONS Sleep needs are associated with the sleep patterns and screen usage of the children and parents. PRACTICE IMPLICATIONS Given that screen usage behaviors are tracked from infancy to early childhood, these findings highlight the need for prevention and intervention efforts, as well as for education and policy measures, to limit screen use and exposure from an early age.
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Affiliation(s)
- Fatma Diler
- Fatma Diler, Milas State Hospital, Milas/Muğla, Türkiye
| | - Hatice Başkale
- Hatice Başkale, Pamukkale University Faculty of Health Sciences, Denizli, Türkiye.
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Landsem IP, Cheetham NB. Infant sleep as a topic in healthcare guidance of parents, prenatally and the first 6 months after birth: a scoping review. BMC Health Serv Res 2022; 22:1135. [PMID: 36076290 PMCID: PMC9454198 DOI: 10.1186/s12913-022-08484-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 08/23/2022] [Indexed: 11/26/2022] Open
Abstract
Background This scoping review focuses on infant sleep-related factors and themes that are relevant when health practitioners provide preventive health services to expectant and new parents. Methods A systematic literature search in CINAHL, PubMed, and PsycINFO, published in 2010 or later, identified 1661 records. The search was further narrowed to focus on sleep in healthy term-born infants until the second half of the first year of life. A blinded review by both authors covered 136 papers, of which 43 papers were reviewed in the full text. Finally, 38 articles were included in the data extraction. Results The analysis process showed that the selected studies formed three main information categories: 11 studies thematised safe infant sleep issues, 10 studies described design and findings from sleep-related intervention studies, and 17 studies focused on different parent-child interactive aspects that may influence the quality and duration of infant sleep in the first six months of life. The main finding is that knowledge about early infant sleep is very complex, and includes both child, parent, and environmental factors. Several studies have shown that the concepts and factors related to safe infant sleep also influence the development of healthy infant sleep patterns. Thus, these aspects are interwoven with each other and should be addressed together in communication with parents. Conclusions Health practitioners with different professional backgrounds need to search for an agreement on when and how different aspects of sleep-related knowledge should be communicated to new and expectant parents to enable the design of national follow-up programs. Parents want coherent and personalized services regarding infant sleep issues that may allow them to choose sleeping arrangements, routines, and behaviors that fit in with their sociocultural attitudes and traditions. Many different sources and formats may be used to empower parents regarding infant sleep issues. Studies have described the use of group or individual meetings, videos, and written materials. The key issue is the importance of consistent and seamless knowledge-based services.
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Affiliation(s)
- Inger Pauline Landsem
- The Arctic University of Norway, The Health Research Faculty, Institute of Health and Caring Science, Hansine Hansens veg 18, 9019, Tromsø, Norway. .,Child and Adolescent Department, University Hospital of North Norway, Sykehusvegen 38, 9019, Tromsø, Norway.
| | - Nina Bøhle Cheetham
- The Arctic University of Norway, The Health Research Faculty, Institute of Health and Caring Science, Hansine Hansens veg 18, 9019, Tromsø, Norway
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Effects of Screen Viewing Time on Sleep Duration and Bedtime in Children Aged 1 and 3 Years: Japan Environment and Children's Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073914. [PMID: 35409594 PMCID: PMC8997461 DOI: 10.3390/ijerph19073914] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 02/04/2023]
Abstract
This study aimed to clarify the effects of television/digital versatile disc (TV/DVD) viewing time and portable electronic device (PED) usage time on sleep duration and bedtime and the difference between the effects of TV/DVD and PED on sleep. The effect of TV/DVD viewing time or PED usage time on sleep duration and bedtime was analyzed using a multiple logistic regression analysis adjusted for covariates. A total of 74,525 participants were included in the analysis, using data from Japan Environment and Children’s Study. TV/DVD viewing was not associated with short sleep duration, but PED usage was associated with short sleep duration. In addition, the risk of short sleep duration increased as PED usage time increased. We also investigated the effects of sleep habits at age 1 year on sleep at age 3 years. This study showed that late bedtime at age 1 year posed a significant risk of late bedtime at age 3 years. In summary, particular caution should be paid to PED use from a child’s health perspective, and sleep habits should be focused on bedtime from the age of 1 year.
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Quante M, Redline S. Touchscreen devices-impact on 24-hour sleep in "cyber" babies. Sleep 2021; 44:6158961. [PMID: 33709151 DOI: 10.1093/sleep/zsab023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mirja Quante
- Department of Neonatology, University of Tuebingen, Tuebingen, Germany
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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11
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Durham K, Wethmar D, Brandstetter S, Seelbach-Göbel B, Apfelbacher C, Melter M, Kabesch M, Kerzel S. Digital Media Exposure and Predictors for Screen Time in 12-Month-Old Children: A Cross-Sectional Analysis of Data From a German Birth Cohort. Front Psychiatry 2021; 12:737178. [PMID: 34912248 PMCID: PMC8668323 DOI: 10.3389/fpsyt.2021.737178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Early exposure to digital media may affect the physical and cognitive development in young children. The American Academy of Pediatrics and national guidelines recommend no digital media use at all under the age of 18 months. The aim of our study was to determine the actual exposure to digital media in 12-month-old infants and to reveal potential risk factors for screen time. Methods: In this prospective cross-sectional survey, data was collected from the KUNO Kids birth cohort study using parent-report questionnaires regarding the media exposure of the study child. We determined age at first contact with different digital media, mean screen time on an average weekday, and the influence of major demographic and socioeconomic factors. Results: Data for screen time analysis was available for 630 children. In summary, 45% of children had already been exposed to digital media by their first birthday. The most frequent first digital media exposure was the TV (33.0%) followed by smartphones (16.9%), both most commonly exposed to around the age of 8 months. On a regular weekday, 20% of the children spent 0.5-1 h in front of a TV and 9% were exposed to a smartphone for the same time frame, compared to 31% of joint parent-child media use. Predictors for screen time were having one sibling, less living space per person, and excessive TV use in the household, the latter of which doubled the chance of the child being exposed to digital media. Conclusion: A proportion of 10% of 1-year-old children were already regularly exposed to digital media. The TV remains the most predominant device but new media, particularly smartphones, might be catching up. Our study provides further support that family TV time is a major predictor of infant screen time. Pediatric recommendations should be re-evaluated in the light of the actual exposure to digital media already in infancy and parents should be proactively counseled regarding possible effects on child development.
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Affiliation(s)
- Kira Durham
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - David Wethmar
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Susanne Brandstetter
- University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany.,WECARE Research and Development Campus Regensburg, Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Birgit Seelbach-Göbel
- University Department of Obstetrics and Gynecology, Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Christian Apfelbacher
- WECARE Research and Development Campus Regensburg, Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany.,Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Michael Melter
- Department of Pediatrics, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Michael Kabesch
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Sebastian Kerzel
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO), Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
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