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Newborn Screening vs. Sleep Apnea Screening

I recently came across an article that touted the importance of newborn screenings, such as for PKU,  hypothyroidism, galactosemia, and sickle cell disease. The rationale for these tests is that if detected, simple treatments can prevent serious health problems, or even death. Just out of curiosity, I looked up the incidence of these four conditions and found the following: PKU (1/50,000 births or .002%),  hypothyroidism (1/4,000 or .025%), galactosemia (1/60,000 or .002%), and sickle cell disease (1/1,000 or .1%).

While it’s important to pick up these rare, but treatable conditions.  But with the incidence of obstructive sleep apnea estimated at 24% for men and 9% for women, I wonder why it’s not screened for routinely. We know that untreated, sleep apnea can cause or aggravate high blood pressure, diabetes, heart disease, heart attack, stroke, and even early death. Your chances of getting into a car accident increases 4 to 7 times normal. With a number of simple screening tests as well as relatively reliable home sleep studies, this condition should be screened for on every routine physical exam. Doctors have to throw out everything that they learn about sleep apnea in medical school and training—that sleep apnea patients are typically overweight, snore, and have big necks. We now know that even young, thin women that don’t snore can have significant sleep apnea.

During your last visit for your annual physical exam, did your doctor ask your about sleep or about sleep apnea?

Part II Of My Discussion on Infant’s Back Sleeping & Pacifiers

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.

Why Do Toddlers Sleep Better In Strollers Or Car Seats?

I’m so proud of my wife—she’s beginning to think like me when it comes to my sleep-breathing paradigm. She just told me that a fellow mommy had just mentioned that her toddler son has major sleep problems at night, but when in his stroller or car seat, he sleeps fine. That brought up memories of taking our first son Jonas out for a drive, just to get him to sleep. Even now with my third son Brennan, he refuses to take naps in his crib, but falls asleep fine in his stroller. I experimented once by reclining his stroller back completely horizontal, and he woke up very quickly. This has huge implications which I’ll get to at the end of this post.

Her brilliant idea was that with strollers and car seats, you’re propped up partially, and not fully horizontal, as with a crib. For may children, they don’t like to sleep on their backs. Even if they’re able to sleep on their backs, they can’t stay asleep, and will wake up rather easily. When your back, the tongue and voice box falls back partially due to gravity, but if your jaws are more narrow than normal (most modern humans), then the tongue takes up relatively too much space and will obstruct your breathing much easier, especially when on your back (due to gravity) and when in deep sleep (due to muscle relaxation).

Infants are born with the epiglottis (the top of the voice box) overlapping the soft palate. After birth, it slowly descends, and creates a gap between these two structures called the orophayrnx. Only humans have a true oropharynx. The problem is that the tongue can fall back more easily into this space, potentially occluding your airway. This is also why only humans have choking and swallowing problems. The benefit to having all the floppy and pliable soft tissues is that it allowed for complex speech and communication.

Imagine if you are a natural side or stomach sleeper and you were forced to sleep on your back. How would you feel? Would you consider this a form of torture?

Think about what we’re doing to our infants by forcing them to sleep on their backs. The experts’ explanation for why it cuts down on the rate of SIDS (only 40%) is that it keeps babies in a lighter stage of sleep!!! Knowing what we know about quality deep sleep and brain development, it’s not surprising that there’s an epidemic of neuro-cognitive-behavrioral problems in our society. I read in one sleep blog that the rate of autism began to rise significantly just after the back to sleep campaign was started in 1993. I’m not saying that we should ignore pediatricians’ recommendations of infant sleep position, but doctors should at least acknowledge that there may be a real problem here.

Stay tuned for Part II of my post on infant sleep position and SIDS.

How do you feel about this issue? I’d like to hear your opinions in the comments box below.

Breast Implants, Autoimmune Disease, & Sleep Position

I wrote about breast implants and sleep problems a few weeks before, but I wanted to address an additional aspect of breast implants that deserves even more attention. In past years, there was a push to move towards saline-based over silicone-based implants, since there were reports autoimmune diseases with silicone implants. Studies performed at that time were inconclusive, but for the most part, most surgeons now recommend saline implants, although patients still seem to prefer silicone.

If you’re a stomach sleeper, and you elect to undergo breast implants, there’s a good chance that you’ll have to sleep on your back after your procedure. If you have smaller jaws than normal (almost everyone these days), then your sleep efficiency will go downhill the longer you stay on your back. Poor sleep quality not only increases your adrenaline levels and stress hormones, it also will over-activate your immune system. Once this happens, your immune system won’t be able to differentiate your own body’s tissues vs. foreign bodies or invaders. As a result, various areas of your body can be damaged, including your joints, kidneys, skin, your bowels, and even your brain.

This may be a big leap, but could it be possible that poor sleep quality due to poor breathing makes you sleep on your side or stomach to begin with, but when made even worse by forcing you to sleep on your back, is it enough to cause your body’s immune system to go onto overdrive and attack it’s own tissues?

What do you think about my theory? Please enter opinions in the comments box below.

Can Sleep Apnea Cause Nerve Deafness?

More than a handful of times, whenever someone comes to me with sudden hearing loss on one ear, there’s usually a precipitating event, such as an infection, stressful event, or trauma. Here’s a sequence of events where an underlying sleep-breathing problem clearly caused hearing loss.

A middle aged man with known severe hearing loss in both ears came to see me with sudden worsened hearing loss in his left ear 4 weeks ago. He normally uses hearing aids, but now he can’t understands people as well, even with his hearing aid. It turns out that exactly 4 weeks ago, while lifting something from his driveway, he pulled his back, with resulting severe back pain. He went to see his doctor, who prescribed a strong narcotic, which didn’t help that much. He’s usually a stomach sleeper, but due to his back pain, he had to sleep on his back. The night after he took his pain medication, he woke up and noticed his hearing loss on his left ear. His recent hearing test showed significantly diminished hearing in his left ear.

When I examined him, he had the classic anatomy of someone who has obstructive sleep apnea: small jaws, high arched hard palate, and very narrow posterior airway space (space behind the tongue), especially when on his back. All throughout his life, he naturally preferred to sleep on his stomach, but when suddenly forced to sleep on his back, wasn’t able to sleep efficiently (due to gravity’s effect on his tongue). But when he took his pain medication, his muscles relaxed even further, and he probably stopped breathing much more often. This caused a major and sudden stress response which probably caused either major inflammation or a mini-stroke in his inner ear blood vessels. Studies have shown that the area in the brainstem that controls the ear, as well as blood vessels that supply the inner ear are much more susceptible to damage. In particular, the area that’s responsible for the high frequencies is more prone to injury.

His exam only reinforced my observation that people who suffer from sudden nerve deafness all have very similar upper airway breathing passageways.

The traditional thing to do in this situation is to give oral steroids, but since it’s been about 4 weeks, the evidence for improving his condition is poor. Instead, I ordered a formal sleep study.

Who Taught Me Most About Sleep Apnea?

Whenever I get asked by patients who are my best teachers, my answer usually surprises them. I tell them my best teachers are my patients. Over the years, I’ve learned more from listening to patients than from anything I’ll ever learn in medical journals or textbooks.

Here’s one great example: One of the most common problems that I see in my practice is when patients complain of a lump in the throat or difficulty swallowing. In most cases, after seeing inflammation in the voice box, I diagnose silent reflux. I usually go one step further and treat the actual cause of the reflux (obstructed breathing), rather than just cover it up with medications. Oftentimes, however, the voice box looks completely normal, but they still have the symptoms. Usually, I’ll blame it on microscopic amounts of stomach juices that you can’t see.

Just this week I saw a young woman who complained of a lump sensation and a tightness in her throat, with difficulty swallowing. She had classic laryngopharyngeal reflux disease. I recommended the usual conservative measures, such as not eating late, avoiding alcohol close to bedtime, proper nasal breathing, and sleep position..

However, in passing, she commented that whenever she swims, the lump sensation goes away temporarily. I didn’t even think about the significance of this statement until a few hours later when I was seeing another patient with similar complaints. Of course! Not only is swimming a good form of exercise, it’s also a type of rhythmic, controlled breathing exercises. By taking regular, deep breaths, she’s doing the same thing that you’d normally do in yoga as you perform the relaxing breath.

Deep breathing has a calming effect on your involuntary nervous system, especially activities that promote prolonged exhalation. This also includes singing, whistling, humming, wind instruments, and even talking. The longer time you spend breathing out, the longer time you stimulate the parasympathetic nervous system. Since the vagus nerve is your main parasympathetic nerve that innervates the voice box as well as your digestive system, this makes absolute sense. Maybe this is why good conversation with friends or family during a slow-paced meal helps you to digest better.

One possible explanation for a lump in your throat is excessive tension and stress in your cricipharyngeal muscle, which is a sphincter-type muscle that closes off the top of your esophagus just behind your voice box. If you’re not sleeping well, then your body will have more physiologic stress, causing tension and spasms in various parts of your body, including the cricopharyngeus muscle. Plus, if there’s direct irritation by stomach juices in the immediate area, then it’s even more likely to go into spasm. (If this tension happens to occur in your muscles of mastication, then you’re likely to have TMJ.)

As a result of the above patient’s passing comment, I reaffirmed that complementary ways of stress reduction and relaxation are just as important as any medical recommendation that I recommend for better sleep. I experience numerous other similar “eureka” moments almost every day, mainly by listening for my patients’ pearls of wisdom.

What’s your opinion on this subject?

More Doctors Should Ask About Sleep

A good primary care doctor will ask  good questions about your medical problems, but quality of life issues, especially involving chronic medical conditions, is not asked about. This conclusion was found in a recent article published in the Mayo Clinic Proceedings. Jane Brody of the  New York Times wrote an excellent article summarizing the findings. However, I was disappointed that she didn’t mention anything about the importance of asking about sleep. I can argue that lack of quality sleep (or quantity) can aggravate, if not cause almost every medical condition that she mentions in her article (diabetes, arthritis, ADHD, IBS, cancer, urinary problems, sexual dysfunction, anxiety, depression).

In medicine, it’s commonly assumed that chronic disease can cause poor sleep. But there are numerous studies that show that poor sleep can cause or aggravate each of the medical conditions mentioned above. Furthermore, since such a high proportion of the population has undiagnosed obstructive sleep apnea (24% of men and 9% of women, and over 50% as seniors), it’s a travesty that doctors almost never ask about sleep, and even if they do ask, most end up prescribing a sleeping pill.

Does your doctor ask about how well you sleep? If so, how is it addressed?

Autism, Vaccines, & Sleep Apnea: My Multi-Hit Theory

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?

Can Allergy Shots Cause Obstructive Sleep Apnea?

During a routine visit, a patient of mine commented that he noticed an interesting phenomenon whenever he checks his wife’s CPAP compliance data. Normally, her RDI hovers around 3-4, and she’s fine, but whenever it goes up to 7-8 or above, she’s more cranky, tired and irritable. In particular, these spikes correlate with the days immediately after she undergoes allergy shots.

Immunotherapy, or allergy shots, is meant to cause a reaction by your immune system, and in the process, produces inflammation. If this inflammation and swelling occurs in her nose, then it’s conceivable that additionally nasal resistance can increased your CPAP pressure needs.

Inflammation or swelling caused by colds, allergies or infections of the nose can aggravate OSA by increasing vacuum pressures downstream, allowing the tongue to fall back more easily. This is one simple reason why you don’t sleep well when you have allergies or a cold.

Do you have similar experiences? Do you not sleep well after undergoing allergy shots?

Expert Interview: Dr. Barry Krakow on Complex Insomnia, UARS, & PTSD

For this Expert Interview, I’m honored to have Dr. Barry Krakow as my guest. Dr. Krakow is a world-renown sleep researcher, and author of numerous books, including Sound Sleep, Sound Mind, and Insomnia Cures. We’re going to have a fascinating discussion about:

- complex insomnia (insomnia and sleep apnea)

- upper airway resistance syndrome

- post-traumatic stress disorder

Next Page »

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