May 11, 2011
Here’s some heartbreaking news that was recently published in the Wall Street Journal and commented on at KevinMD: That 25% of all children in the United States is on regular prescription medications. According to the report, 45 million children are on asthma medications, 24 million on ADHD medications, another 10 million on antidepressants and 6.5 million on antipsychotics. You also have the antihypertensives, sleeping pills, diabetes medications, and high cholesterol medications. This list doesn’t include prescriptions used in acute situations or over-the-counter medications.
You might be asking by now, “What does all this have to do with sleep apnea?”
My answer is, everything. If you happen to follow my blog, I’ve shown studies linking obstructive sleep apnea to almost every chronic health condition out there. This is based on published, peer-reviewed studies. What I did was only to connect all the dots, so to speak, to conceive of my sleep-breathing paradigm: That all modern humans, due to jaw underdevelopment, have various degrees of sleep-breathing problems, where only the end result is called obstructive sleep apnea. This problem begins while you’re an infant, and is aggravated by dietary and behavioral factors such as bottle-feeding, thumb-sucking, and eating the Standard American Diet (SAD). It’s also possible that the back to sleep campaign (although it lowered the SIDS rate by 40%), by forcing infants to sleep on their backs, may inadvertently prevent quality deep sleep in infants. Babies need good amounts of deep sleep for memory consolidation and brain development.
We also know that multiple breathing pauses can cause your stomach juices to reflux into your throat, and then into your lungs (or nose). This can cause various degrees of inflammation. Neurologically, your lungs will tend to over-react to weather changes, such as cold air, or even temperature or humidity changes. Breathing problems can also cause poor quality sleep, leading to major alterations in your brain biochemistry.
Poor sleep can also aggravate or promote the onset of depression. Faulty neurotransmitters or even structural damage from poor sleep can also cause your brain signals to misfire, or activate disinhibition of certain behaviors.
It’s no wonder that in one way or another there are studies (or will be studies) that connect all the various medical conditions already mentioned to one another. So it’s not too far fetched to argue that a large proportion of these children on chronic long-term medications may also have some kind of a sleep-breathing problem.
What do you think about my arguments? A realistic, but scary possibility, or too far fetched?
May 10, 2011
There are numerous studies on the health benefits of breast feeding, and here’s another one that supports my sleep-breathing paradigm, that your overall state of health is directly proportional to how well formed your jaws are as you age (and subsequently your breathing passageways).
Researchers from Oxford University in the UK found that infants who were breast-fed for at least 4 months had a 33% less chance of having behavioral problems by age 5. They speculate that breast milk has higher amounts of healthy fatty acids, growth factors and hormones that contribute to healthier brain development.
The one thing that all these studies fail to address is that bottle-feeding can cause malocclusion and jaw narrowing. The smaller your jaws, the less room there is for your tongue, which can cause breathing problems when the infant is placed on his back. Add muscle relaxation from deep sleep, and you’re going to deprive infants of quality deep sleep which is vital for proper brain development. With the addition of back sleeping in infants to bottle-feeding, it’s likely that this combination is a major reason for the significant rise in pediatric developmental problems that are so rampant these days.
If you have obstructive sleep apnea, were you breast or bottle-fed as an infant?
May 6, 2011
Researchers are puzzled as to why there seems to be a significant rise on rates of asthma in children compared to previous years. A new study released from the CDC reported that nearly one in 10 children and one in 12 Americans have asthma. From 2001 to 2009, the overall rate of asthma increased 12.3%. In 2007, it cost $57 billion to care for asthma patients.
Despite lower rates of smoking and second-hand smoke, the prevalence of asthma increased in all demographic groups, including men, women, whites, blacks, and Hispanics. Possible reasons for this sudden increase include various allergens, traffic fumes, pesticides, certain plastics, diet and obesity.
Here’s one more possibility: Obstructive sleep apnea. We know that children are more overweight than ever, and along with this it’s expected that sleep apnea will increase as well. Multiple breathing pauses at night can literally suction up your stomach juices into your throat, which can then reach your nose or your lungs. This causes your nose and your lungs to become inflamed and overreactive to allergies, fumes, and even weather changes. Lack of deep sleep also causes your nervous system and your immune system to become hypersensitive, aggravating this vicious cycle.
Notice how it’s not just asthma rates that are going up. Many of the other childhood related conditions are going up as well: obesity, ADHD, autism, allergies, etc. These are all part of the same continuum that unfortunately, are treated as independent conditions. With multiple breathing pauses at night, any of these conditions can occur or aggravate an already existing condition.
If you have asthma, how many of you can’t sleep on your back? (I’ll tell you why I ask this question a bit later.)
April 6, 2011
I was doing some research on the internet about sleep position and SIDS (sudden infant death syndrome) and came across a blog post that says exactly what I was going to say, but in much more detail, and with a critical analysis of the statistics used when the American Academy of Pediatrics recommended that all infants be kept on their backs while sleeping. This campaign has lowered the rate of SIDS by about 50%, but about 3000 infants still die from SIDS every year.
Reading this story is heart-wrenching. It’s a long post, but I strongly recommend that you read through it. I frequently see parents in my practice that are literally in tears when they are berated by their pediatricians to keep their infants on their backs, despite the fact that their child can’t sleep in this position.
Sleep and pediatric researchers have shown that one possible mechanism as to why back sleeping helps to prevent SIDS is that it keeps babies in a lighter stage of sleep. This makes them much more easily aroused. If there is some kind of dangerous breathing stoppage, they’re more likely to wake up and start breathing again. What he also points out is that deep sleep is diminished by 8-9% in infants that sleep on their backs for the first 6 months. He calculated that back sleeping infants lose about 4 hours of sleep per day and 120 hours of sleep in the first month. We know that quality sleep is so important to an infant’s brain development and motor skills.
So it’s not surprising that there’s been an increase in rates of motor skill, cognitive and other developmental delays. Other studies have shown increased rates of sleep apnea, flat-head (my second son had this), and acid reflux. There’s even one blog that points to the back to sleep campaign as a major cause of the autism spike that began in the mid 1990s. I’ve also suspected that the decreasing rates of tonsillectomies in the 1980s and 1990s may adversely affect cognitive development (ADHD).
Numerous studies have shown that there are a number of other significant risk factors that increase the risk for SIDS, including bed-sharing, cold weather months, smoking, and soft bedding, whereas pacifier use and breast-feeding are protective. African Americans and Native Americans had significantly higher rates.
One major anatomic reason for SIDS is the fact the the infant’s voice box is very high in the throat, behind the tongue, with the epiglottis overlapping the soft palate. Gradually, over the course of 2-4 months, the voice box begins to descend. At a certain point, the collapsibility of the tongue into the newly created oropharynx may reach a critical point when various factors come into play (sleep stage, sleep position, cigarette smoke, etc). This timeframe is also when the rate of SIDS peaks.
In particular, the author points out that most SIDS studies use an odds ratio calculation that can easily overestimate the true risk, and is often confused with relative risk. Because these studies are retrospective studies with relatively small numbers of subjects along with a number of different variables, odds ratio is used over relative risk. The explanation of the difference between odds ratio and relative risk is a bit lengthy so I recommend you read the article, which is very clear. He hammers on the concept that correlation does not equate with causation. To date there’s no good explanation for SIDS, which still happens in about 1/1000 babies, of which 1/3 die while on their backs.
One interesting statistic that he pointed out is the fact the the risk of dying from SIDS if you have no other risk factors is only 10% (including no tummy sleeping) of the original risk. He poses this interesting question: Is it worth sleep depriving all infants of 25% of sleep in the first few months to protect less than 0.1% of babies?
I’m not recommending that everyone go against mainstream medicine’s recommendations. However, we need to re-evaluate the rationale for this recommendation and consider all the possible unintended consequences.
What are your thoughts on this subject?
November 25, 2010
I came across a disturbing reference to pacifiers and how it was shown to prevent sudden infant death syndrome (SIDS). In Part I of this post, I described the reason why back sleeping, while lowering SIDS by 40%, could actually impair proper brain development. Both back sleeping and pacifiers are thought to work by keeping the baby in a lighter stage of sleep. Here’s why I think this is a bad idea:
When babies are first born, 50% of sleep is REM sleep and essentially no deep sleep (slow wave sleep). But around 2-3 months slow wave sleep begins to develop. Furthermore, this is the time in which your baby’s voice box slowly begins to drop lower in the throat, creating a space between the soft palate and the voice box that the tongue can fall back into and obstruct your breathing. Due to gravity, the tongue can fall back more easily, especially in deeper stages of sleep, when your muscles are more relaxed.
Promoting pacifiers to put infants to sleep is also a bad idea, since any kind of artificial nipple can aggravate dental crowding and malocclusion. Having something to suckle on all the time while sleeping can definitely keep infants in a lighter stage of sleep.
There are countless studies that show that deep sleep deprivation can have profound and detrimental effects the infant’s memory consolidation and brain development. It’s no wonder there’s been so many issues these days with younger children and behavioral, cognitive, and developmental delays, not to mention an increased incidence of allergies, asthma, and various other hypersensitivity reactions. I predict that as a society, we’re going to have pay for it in one way or another.
What’s your opinion on this issue? Should we keep things the same, and accept the consequences of a 40% lower SIDS rate? Or should we seriously look into this issue and make changes to the back sleeping recommendation, perhaps do it only for high-risk infants, or come up with better monitoring technology to prevent SIDS? I suspect that even if a definitive study came out proving my point, the medical institution will be reluctant to make any changes to their stance on this issue.
November 17, 2010
I remember during M&M (morbidity and mortality) rounds as a resident, our chairman felt strongly that an error never occurs in isolation. He insisted that a bad outcome happens from a series of mistakes, oversights and lack of communication. Even in engineering or aviation, whenever something goes wrong, there’s usually a series of events that led to the final adverse outcome. The same analogy also applies with cancer.
Although vaccines were essentially exonerated by recent large-scale studies (showing that the rate of autism was no different before and after Thimerisol was removed), there are still many proponents of the vaccine theory. I think that there’s some merit to this possible connection, but not for the reasons that you may think. Let me explain.
You may remember in one of my previous posts, I described reading about a theory that proposes that since the Back to Sleep campaign for infants in the early 90s, the incidence of autism went up significantly afterwards. This campaign led to a 40% reduction in sudden infant death syndrome (SIDS). However, one of the consequences of keeping infants on their backs is to keep them in a lighter state of sleep. This can prevent proper memory consolidation and brain development.
Although it sounds like a feasible explanation, it’s going to be difficult to prove. Medically and politically, doctors are not going to retract this recommendation, even if it is found to be plausible. However, if you add to this the fact that modern jaws are smaller due to a more bottle-feeding and poor nutrition, sleeping on your back can definitely lessen your deep sleep efficiency.
In another recent post, I alluded to allergy shots aggravating obstructive sleep apnea, by increasing nasal congestion. Anything that causes inflammation in the nose or throat, including allergies, colds, migraines, reflux or weather changes, can aggravate more frequent pauses in your breathing, especially when in deep sleep.
The human voice box is unique in that it’s located below the tongue. This migration downwards begins at birth and continues until your 60 or 70s. Around 4 to 6 months, a space is created between your soft palate and your voice box, called the oropharynx. Only humans have a true oropharynx. Descent of the larynx is needed for complex speech and language. But this also predisposes humans to breathing problems, especially when on our backs. This is when the tongue and voice box falls back the most, due to gravity. When you add muscle relaxation during deep sleep, you’re more likely to stop breathing and wake up.
Not breathing at night while sleeping, from a brief second to 30 seconds or more, can be detrimental to your brain. The end extreme of this spectrum is called obstructive sleep apnea, but even multiple short episodes of breathing pauses due to upper airway obstruction can lead to various pathways that can lead to significant neurological impairment.
If you put all these mechanisms together, then it creates a situation where you can suffer serious brain damage. In most cases, you won’t be able to see any anatomic changes using traditional imaging studies, such as with a CT scan or an MRI. These are sub-radiologic changes that occur within the brain tissues itself.
Vaccines and flu shots, just like anything else that creates a mild infection, can cause swelling and inflammation in your nose and throat. If your anatomy is already predisposed, and you add additional variables such as back sleeping and bottle-feeding, then even an allergy attack could in theory cause changes in your brain that can mimic autism. Given that the total number of child immunizations has increased tremendously only adds to my argument. Not too surprisingly, there are also known reports of children who develop autism after a simple cold or flu infection.
Ultimately, it may not be the specific type of vaccine or flu shot, or even the specific materials that they’re made with, but rather the general inflammation causing properties of these immunizations that may be the trigger that tips children over the edge to progress into any of the autism spectrum disorders. I may be going out on a limb here, but in the big scheme of things, autism may even be a childhood manifestation of the same process that causes Alzheimer’s.
What’s your opinion on my thought experiment? Will you agree with me that autism has multifactorial causes and not just one trigger?
October 8, 2010
I was talking with a mother about her young child, who just happened to be a natural stomach sleeper. The mother was very emotional as she described what she had to do a few months after her daughter was first born, to keep her from rolling onto her stomach. Her doctors chastised her for allowing her child to sleep on her stomach, despite the fact that she slept much more deeply and soundly in this position. There were even implied threats of calling children’s services.
What she ended up doing was to stay up all night, watching her sleep, just to make sure that she didn’t roll over or stop breathing. Often, she would end up crying due to her chronic sleep deprivation and seeing that her daughter wasn’t able to sleep comfortably at all on her back.
I wrote in the past about a proposed theory that the back to sleep campaign in the early 1990s, although it did lower the rate of sudden infant death syndrome (by about 50%), it may have aggravated the sudden rise in the rate of autism. The rationale is that by keeping infants on their backs, it keeps them in a lighter stage of sleep, so that they’re more likely to wake up if there’s any form of partial or total obstruction. If this is true, then you’re also preventing proper memory consolidation and brain development.
I’m not proposing that we all go against the back sleeping recommendation for infants. However, I just wanted to bring up a potentially important issue that deserves much more discussion and further study.
What do you think about this issue? Is it plausible, or just a ridiculous theory? I’d like to hear your opinions.
January 18, 2010
In the 1950s to 1970s, it used to be a rite of passage for young children to get their tonsils taken out. These days, we're a lot more conservative with tonsillectomy, and frequently, parents are told that their child will grow out of their tonsils. While this is true in some cases, there's a consequence to the watching and waiting option.
Your tonsils are lymphoid tissue that's part of Waldeyer's ring, which is a ring of lymphoid tissue made of the palatine tonsils (your typical tonsils), the adenoids (in the back of the nose), and the lingual tonsils (at the base of the tongue in the midline). In some children with overdeveloped lymphoid tissues, you'll see a communication between all four of these glands, forming a complete circle. These tissues are normally involved in educating your immune system, since everything you breathe or swallow has to go through this ring. As a result, it's expected that the tonsils (and adenoids) will be enlarged during the ages of 3-5.
However, with the shrinking size of modern human jaws, now there's less room for the normal-sized tonsils, which takes up relatively more space. This aggravates more frequent obstructions and arousals, leading to more inflammation from refluxed stomach contents and more swelling of the tonsils. The chronic negative pressure created from this process can prevent proper jaw enlargement, similar to what can occur with bottle-feeding. In many children, their snoring and sleep problems will prompt the parents to see an ENT for tonsillectomy. For children with mild to moderately enlarged tonsils that are not causing any symptoms, or those that are symptomatic but are told that they'll outgrow it, there can be permanent long-term consequences.
In children with huge tonsils, one of the reasons why they look so big is that the space that the tonsils sit in is too narrow. Taking out the tonsils can make a dramatic difference is most children, but there are some children that won't respond to tonsillectomy or only partially. One recent meta-analysis showed that adenotonsillectomy was helpful in about 2/3 of all children. But the remaining 1/3 still had residual symptoms or signs of obstructive sleep apnea. These are the children that have smaller jaws than the children who responded to the procedure.
In a recent Stanford University study, children who were scheduled for tonsillectomy were divided into two groups. One group underwent standard tonsillectomy, and the other under went rapid maxillary palatal expansion. The results were equivalent for both groups. When children in both groups were crossed over and given the other procedure, the overall results were additive. This just goes to show that one reason why you can have large tonsils that that your jaw is too small. Of course, everyone is on a continuum, and as usual in modern medicine, you're treated only if you are at the extreme end of the continuum.
This is pure speculation, but I wonder if the significant increase in the rate of ADHD in the 1980s and 1990s could be related to the dramatic decline in the rate of tonsillectomies. Furthermore, since the peak incidence of autism is around ages 3-4, it's interesting that this is also the time that the tonsils become enlarged in most children. If you have enlarged tonsils to begin with, any simple cold or infection (even vaccines!) can cause swelling which starts a vicious cycle, leading to a sudden increase in breathing problems and poor sleep. Sleep apnea by definition causes systemic inflammation and an increased susceptibility to form microscopic clots in the brain.
This is also the time (around age 4) when the voice box reaches its' final position below then tongue as it descends from its' original position behind the tongue. A space is created behind the tongue and between the soft palate and the epiglottis called the oropharynx, which exist only in humans, and allows for complex speech.
One last interesting phenomenon to point out is that in the early 1990s, parents were recommended to place infants on their backs, to prevent SIDs. We know that back sleeping lowers your time spent in deep sleep and leads to more frequent arousals.
All these factors taken together may be what's developed into the "perfect storm," leading to the dramatic rise in ADHD and autism in our current times. Obviously, there are many other dominant theories for ADHD and autism, but from a sleep-breathing standpoint, what I propose is something that definitely needs to be proven in clinical studies.
What do you think about all this? Please enter your responses in the comments box below.
November 5, 2009
I stumbled across this blog post, where I discovered an interesting discussion on the possible link between the sudden rise of newly diagnosed autism cases and the onset of the "back to sleep" campaign in 1992. This is when the American Academy of Pediatrics recommended that all infants up to one year old be placed on their backs while sleeping. Due to this recommendation, the rate of SIDS (sudden infant death syndrome) dropped about 40% (from 1992 to 1999). During this same time period, the rate of infants placed on their backs increased from about 10% to almost 70%. Coincidentally, the rate of autism rose sharply as well.
The person proposing this association (Thomas McCabe) has made it clear that infants, by being placed on their backs, have less efficient sleep due to more frequent obstructions and arousals. He sites numerous studies and papers showing that stomach sleeping results in much lower arousals, shorter length of breathing pauses, and lower rates of body movements and sighs. Another study showed that infants sleeping on their stomachs slept 8.3% more than back sleepers.
He cites various other papers that report developmental and neurocognitive delays in back sleepers in the first 6 months compared with stomach sleepers. Furthermore, McCabe states that back sleeping interference with deep sleep (slow wave sleep – SWS) as well as REM sleep. Both are important for memory consolidation and cognitive function. What he’s suggesting is the possibly that all at-risk infants undergo some sort of screening EEGs and place those infants highest at-risk on CPAP.
It’s a little technical, but take a look at his posts, as well as his e-book. His ideas may sound radical, but worth considering, in light of the fact that now in certain parts of NJ, about 1% of all boys have autism or some variation.
It’s important to point out that SIDS peaks at around 2-4 months. Not too surprisingly, this is also the same timeframe when the baby’s voice box descends and separates aways from the soft palate, allowing the tongue to move further back into the throat. This is when they go from obligate nose breathers to oral and nose breathers. During this transitional state, the baby has to relearn how to swallow and breathe.
Based on what I’m discovering every day about our health and sleep-breathing problems, I would’t be surprised if this hypothesis turned out to be true. Of course, more definitive research must be done to prove this hypothesis. Unfortunately, the orthodox medical profession doesn’t like to admit it was wrong, so it won’t even consider asking if there’s any merit to this possible link.
Our infants have been sleeping on their stomachs for almost all of known history. Although it’s hard to argue with the SIDS data and the significant lowering of infant deaths, but there’s something unnatural about changing our natural sleep positions all of a sudden 17 years ago.
Even my youngest son Brennan naturally rolled over onto his stomach while sleeping as soon as he was able to.
Should the medical community at least take another look at this issue? Please reply with your comments below.