Intriguing Sleep Apnea and Autism Connections

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.

20 Responses to “Intriguing Sleep Apnea and Autism Connections”

  1. Anna on November 5th, 2009 9:57 am

    There was/is so much compliance with the recommendation that infants sleep on their backs, which also means there was increased awareness of SIDS. That alone could be a contributing factor to the drop in incidence. Increases monitoring of sleeping infants as a result could also have played a role; in the same time frame baby monitors became far more sophisticated and widespread. I know parents who were freaked out if their child rolled off their backs while sleeping, as if stomach sleeping automatically resulted in SIDS. Now there are many products on the market designed to prevent infants from rolling over off their backs while sleeping. And lots of babies now end up needing skull braces to reform their heads because they flatten in the back so much. Beware the unintended consequences, eh? I’ll bet there are other contributing factors to the drop in SIDS incidence, but we need some good “think outside the box” research on it, which may or may not happen.

  2. Anna on November 5th, 2009 1:44 pm

    There was/is so much compliance with the recommendation that infants sleep on their backs, which also means there was increased awareness of SIDS. That alone could be a contributing factor to the drop in incidence. Increases monitoring of sleeping infants as a result could also have played a role; in the same time frame baby monitors became far more sophisticated and widespread. I know parents who were freaked out if their child rolled off their backs while sleeping, as if stomach sleeping automatically resulted in SIDS. Now there are many products on the market designed to prevent infants from rolling over off their backs while sleeping. And lots of babies now end up needing skull braces to reform their heads because they flatten in the back so much. Beware the unintended consequences, eh? I’ll bet there are other contributing factors to the drop in SIDS incidence, but we need some good “think outside the box” research on it, which may or may not happen.
    Oops…forgot to say great post! Looking forward to your next one.

  3. Sara on November 6th, 2009 11:57 am

    As a pediatric physical therapist, I find this to be very interesting. The “Back to Sleep” campaign has resulted in changes in how parents position their infants during waking hours as well. I have seen many an infant who does not tolerate prone/tummy lying as they have had little experience in this position. As a result of the intolerance, some of these infants become delayed in motor development, as they miss out on pushing up on their arms and developing core strength through the shoulder girdle. And as Anna mentioned, this positioning has resulted in increased skull deformity, and I have seen an increase in torticollis/wry neck as well.

    Amazing how an apparently simple change, such as sleep position, could have such far reaching impact!

    P.S. I am VERY happy to see UARS has been added to your tagline!

  4. Dr. Steven Y. Park on November 6th, 2009 12:23 pm

    Anna and Sara, thanks for your comments.

    There are many more positive and negative observations about the back to sleep campaign, including more parental vigilance (what Anna mentioned), underreporting by physicians and medical examiners, etc. There are definitely more cases of skull deformities and torticollis as a results with developmental delays as a result of this campaign. Even with more tummy time when awake, it’s probably not good enough. The main problem occurs when sleeping on infant’s back.

    I can’t yet commit to recommended going back to allowing infants to go back to tummy sleeping, but this is an important issue that needs to be reinvestigated. With my second son, he had a flat area in the back of the head and was recommended to see a neurosurgeon to make sure there wasn’t any cranial deformities. The neurosurgeon said it was from sleeping on his back. With my third son, Brennan, he had severe torticollis until he was able to turn himself to his side on his own.

    Perhaps there can be a compromise where only infants at high risk can be recommended to sleep supine, whereas other can sleep on whatever position the parents want.

    Sara, UARS is a HUGE problem and hopefully, people reading the material on this site can be much better educated. It’s poorly understood even by most sleep doctors.

  5. sbg on December 25th, 2009 1:01 am

    But is the rate of Autism increasing?

    A recent survey (England) supports that if you look at all ages and account for those having been diagnosed, still having the diagnosis or who now meet criteria that the rate is right around 1%. This study must be replicated, but it fits with other data showing that as the numbers of those diagnosed with ASD increases that there is a reduction in the diagnosis with other conditions. We really need to understand whether the rate is increasing or not before we more forward with a change in the care of children that might lead to an outcome that is far worse than Autism (i.e., death from SIDS).

  6. Ada on December 29th, 2009 11:38 am

    I have no connection to the medical community and make no pretense to any sweeping generalities, but thought to offer comment on some personal oberservations.

    I have been a major care giver to my two newest grandchildren, now 3 1/2 and 21 months. Both were made to sleep on their backs (foam buffers in their cribs so they couldn’t roll to their sides or stomachs), and they are both alert, highly intelligent and very social and sociable. But in early infancy each exhibited what I deemed to be dissatisfaction with back sleeping. In their playpens they would thrash and fuss when laid on their backs to nap — despite a setup similar to their cribs, bumpers, etc. I started putting them on their stomachs so they would fall asleep more easily (I watched them LIKE A HAWK!), then turning them to their backs when they were well asleep.

    It was particularly distressing for me when the elder child was an infant. She had digestive problems and projectile vomiting despite being breast fed. I was always afraid of the possibility of her choking, and lying on her tummy seemed to ease the gas and pain that she felt. The “proof” is that she slept quietly and for longer periods on her tummy than when she slept on her back.

    Thank you for permitting me to offer these comments. I always appreciate your insightful comments when I see them on NYT blogs and articles.

  7. Wry Nose Syndrome | AXI on January 15th, 2010 6:18 am

    [...] Intriguing Sleep Apnea And Autism Connections | Doctor Steven Y Due to this recommendation, the rate of SIDS (sudden infant death syndrome) dropped about… [...]

  8. Worth more research on February 19th, 2010 10:16 am

    My daughter, now 8 months old, never seemed comfortable sleeping on her back. She woke constantly, often multiple times in a single hour, and never seemed rested or content. When she started rolling over around 3 months of age, I began putting her down on her side to sleep (using a special device that held her in position so she couldn't roll onto her stomach). She slept slightly better, but not great. Let me point out, that she also lagged developmentally on several levels, including height and weight. Finally, at 5 months of age, she began rolling onto her stomach to sleep, despite the positioning device. I removed the device and let nature have its way.
    Now, sleeping on her stomach, she sleeps from 7:30 p.m. to 7:30 a.m every night, often with no night-time awakening at all. She seems far more rested and happy than ever before and has caught up on all developmental levels, and in fact surpassed other babies in her age range for some developmental markers. For my daughter, back sleeping simply was not comfortable. She had NO other risk factors for SIDS, other than her age, yet our pediatrician steadfastly recommended placing her on her back to sleep, and threatened to notify child services authorities when I told him I was now putting her to sleep on her stomach.
    Accepting the medical community's directive to put all babies to sleep on their backs is simply knee-jerk stupidity, especially in cases where the infants have no other risk factors for SIDS besides there age. At the very least, the medical community needs to take a serious look at the possible link between the "Back to Sleep" campaign and the coincident increase in the number of Autism cases.

  9. Steven R. Edelman on April 19th, 2011 1:48 pm

    My full-time job is as the psychologist at one of the 18 agencies serving children under 3 years old here in North Carolina. We are a part of the Division of Public Health. I almost always ask about sleep when I receive a referral for an autism diagnosis. There is another, rare, autism-like d/o that is sleep related. Acquired Epileptiform Aphasia (aka, Landau-Kleffner Syndrome) has core symptoms of a loss of speech skills, social deficits, etc. However, these children have nocturnal seizures (NOT myoclonus).

    I also have a small part-time private practice. Everyone of my ADHD and autism referrals gets an inquiry about sleep. Did you hear about the treatment of premies having apnea using vanilla extract (inhaled) rather than caffeine? That was cited in an issue of “Pediatrics” (April 1997 if memory serves).

  10. Judith on May 11th, 2011 11:45 am

    Children now get at least an hour less sleep in every 24 hours than they did 30 years ago. Could this be a cause of Autism?

    There was a study that stated that if a child does not get enough sleep in the first 3 years of life, the child will have more risk of having ADHD when he was 6, even if he got enough sleep from ages 3 to 6. If lack of sufficient sleep can effect the risk of getting ADHD, couldn’t it also effect the risk of having autism?

  11. Steven Park on May 11th, 2011 12:04 pm

    Judith,

    Absolutely! Whether it’s lack of quality or quantity of sleep, it can negatively affect a child’s brain development.

  12. Judith on May 17th, 2011 7:26 am

    NEW RESEARCH CONFIRMS TOXIC GAS THEORY FOR COT DEATH (SIDS)

    7 October 2008
    MEDIA RELEASE FOR PUBLICATION
    NEW RESEARCH CONFIRMS TOXIC GAS THEORY FOR COT DEATH (SIDS)

    New US research confirms the toxic gas theory for the cause of cot death, stated New Zealand cot death prevention expert Dr Jim Sprott OBE today.

    Research published in the October 2008 issue of Archives of Pediatric & Adolescent Medicine (1) found that having a fan on during sleep was associated with a 72% decreased risk of cot death among babies, as compared with sleeping without a fan in operation. The reduction in risk was greatest for babies sleeping in warm rooms (temperature above 21 degrees Celsius); and fan use also decreased cot death risk among babies who slept on their stomachs or sides.

    “These findings are very strong confirmation of the toxic gas theory for cot death”, stated Dr Sprott. “An operating fan dissipates gases generated in the baby’s sleeping environment. In particular, the highly toxic gas phosphine (generated from phosphorus, which is very common in bedding) is likely to remain around a baby in the cot owing to the density of this gas, so it is no surprise that research has found that fan use greatly reduces cot death risk.

    “The finding that fan use reduces the risk even more in warmer rooms is also consistent with the toxic gas theory for cot death”, stated Dr Sprott. “If a baby’s bedding is capable of toxic gas generation, overheating in the cot greatly increases the likelihood of fungal generation of the gases in question.”

    “Crucially, the fact that fan use greatly reduces cot death risk among babies sleeping face-down or on their sides demonstrates that the partial protective effect of face-up sleeping against cot death is not related to any medical condition or physical defect in the baby. So once again we have further demonstration that cot death does not have a medical or physiological cause.

    “Face-up sleeping reduces cot death risk because the toxic gases which cause cot death are all more dense than air. They diffuse away from a baby’s face, and therefore a baby sleeping face-up is less likely to ingest them.”

    The researchers’ suggestion that fan use may reduce cot death risk by preventing a baby from re-breathing exhaled carbon dioxide is already disproved, stated Dr Sprott. “Longstanding epidemiology demonstrates that cot death is not caused by babies re-breathing exhaled air in the cot.”

    Dr Sprott called on the New Zealand Ministry of Health to immediately endorse mattress-wrapping for cot death prevention.

    Since 1995 a mattress-wrapping protocol for cot death prevention has been publicised nationwide in New Zealand. On the basis of three studies into the incidence of mattress-wrapping (2), it is calculated that at least 170,000 New Zealand babies have slept on “wrapped mattresses”. There has been no reported cot death among those babies.

    Since the commencement of mattress-wrapping the New Zealand cot death rate has fallen by 68%; and the cot death rate of the population group most likely to wrap babies’ mattresses (European/Paheka) has fallen by around 85%. (3)

    Notes:
    1. Coleman-Phox, K, et al, “Use of a fan during sleep and the risk of sudden infant death syndrome”, Arch Pediatr Adolesc Med 2008; 162: 963-968.
    2. NZ Med J 2000; 113: 8-10; NZ Med J 2000; 113: 326-327; Eur J Pediatrics 2008; 167(2): 251-252 (Short Report).
    3. Source of statistics: New Zealand Ministry of Health.

    Found this online: Do you know if this is accurate; may be the solution to our autism/back to sleep issue. also questioning if new zealand’s rate of autism matches the u.s.

    Media release issued by:
    T J Sprott OBE MSc PhD FNZIC
    Consulting chemist & forensic scientist
    10 Combes Road
    Remuera
    Auckland 1050
    NEW ZEALAND
    Phone/fax: +64-9-5231150
    e-mail: sprott@iconz.co.nz
    Content copyright 2009-2011. Averysagenotion. All rights reserved.
    Web Hosting Companies

  13. marie middleton on June 1st, 2011 11:36 am

    My grandbabies were made to sleep on their backs. I was concerned about unintended consequences, and took note of the recent rise in autism diagnoses.
    It seems obvious that a baby who is on his back whenever in bed, then is placed is some reclining seat (also on his back) when out of bed, and in the car seat, and in the stroller – how can that not affect his development, visual, mental and physical? A baby on his tummy pushes up on his arms, encouraging cardio-vascular, lung, and upper body development. With the new added practice of swaddling, the baby can not exercise arms and legs. Then, when they can’t turn or crawl, the doctor sends them to a therapist because they are developmentally delayed. Surprise, surprise!

    I sincerely hope that pediatricians will start to consider all of this, rather than blindly following the p/c practice of scaring new mothers into thinking that, if they let their baby sleep on their tummy, it could result in SIDS. The recent reduction in the rate of such deaths is attributable to many other things than sleeping position, and a generation of babies has been adversely affected by this practice.
    I understand that there is no credible research indicating that back-sleeping babies are less vulnerable to SIDS, or that tummy-sleeping babies are more vulnerable. So why has this continued?

  14. Mack D Jones, MD on April 9th, 2012 11:28 pm

    The important question being overlooked in this discussion of prone vs supine positioning during sleep is, “Does this infant have sleep apnea?” If the answer is yes, then treatment is indicated regardless of the infants sleeping position.

    Apneas occur in all positions. Some have most apneas supine, others more when prone, others mixed. Infants should be monitored with a respiratory monitor for sleep apnea from the day of birth through at least the first two years of life. If apneas appear, they must to be prevented with PAP.

    Prevention of repeated bouts of hypoxemia from sleep apnea will prevent SIDS, ADD/ADHD, autism, depression, bipolar disorder, schizophrenia, dyslexia, and other behavioral and learning disorders.

  15. jan on April 27th, 2012 7:32 pm

    I agree,The pediatrician told my son to wake there Healthy baby every 3-4 hours
    around the clock to feed, this went on for months,always on his back sleeping, or in carriers, swing, upright position, on shoulder,He is delayed in most of the developmental milestones, he now shows all the signs of autism
    Could it be? Blood to the brain, less pressure on the scull, it all makes sense
    an infant lifting there head, I strongly agree with all said,
    I surely hope all the pediatricians are reconsidering there recommendations for sleeping infants, at least inform parents that there is research out there .

  16. Carolyn Pierce on May 9th, 2012 3:07 am

    I am not a medical professional; I’m a mother of two and cared for many more babies over an 18-year family daycare provider career.

    I found this website while searching to see if there have been any studies checking for a correlation between the rise in autism and the Back to Sleep campaign — and I can’t believe there apparently haven’t been any!

    My “Eureka” moment came after reading an article (Washington Post, Health section, 5/8/12) about how SIDS has been greatly reduced in the past couple of decades since Back to Sleep was introduced in 1992 — and realizing that’s precisely when autism rates have increased so drastically. The article glossed over possible developmental delays due to back sleeping (but only in motor skills) and didn’t mention autism at all, but SOMETHING new, different and widespread has to be responsible for the autism epidemic in the U.S., and I think Back to Sleep is highly suspect! And hasn’t autism increased even more sharply since 2000, when the article says the guidelines were changed from side- or back sleeping to ONLY back?

    I was originally thinking more along the lines that the body/head position itself may be harmful to developing brains. Newborns sleep most of the time, and that’s a LOT of time flat on their backs for tiny babies! That position has always seemed unnatural to me, and certainly was never the norm until the 1990′s and 2000′s. After reading more here, I realize that the fact that the baby is prevented from ever getting good, deep, prolonged sleep, is also a very negative result that could prevent the brain from developing properly.

    WHY hasn’t this been studied? I would hate to think that the government and the American Academy of Pediatrics just don’t want to admit they may have caused major harm by one of their recommendations — but . . . . . . . .

  17. Margaret Weston on June 18th, 2012 6:46 am

    My 4 year-old granddaughter snores. She was recently diagnosed with autism. We worry about the effect that snoring is having on her brain. Do you think there is any connection between snoring and autism?

  18. Steven Park on June 18th, 2012 1:46 pm

    Snoring is a symptom of obstructive sleep apnea.

  19. Laura Jordan on September 7th, 2012 9:11 am

    Thank you so much for your article. My oldest son was treated for enlarged tonsils due to his spitting up and then throwing up within an hour everytime he fell asleep. He was a back sleeper from infancy on due to the SIDS information that was posted. He is not on the autism spectrum.
    Two years after my first child was born, my second came into this world. He was a back sleeper too. He spoke sentences at 1 year of age, but then quickly lost his language. He was placed on the autism spectrum at age 2. Right before his 3rd year of life we had him tested for sleep apnea, due to my oldest son’s problems. Cole, my second child, did not display any symptoms of sleep apnea. He did not snore or spit up. He seemed to sleep well. Fortunately, he was diagnosed with sleep apnea and the main concern was his very enlarged tonsils. They were removed. Soon after the surgery he began to learn at a significant rate. His language started to develop and some of the symptoms of ASD began to subside.
    Cole is now in fifth grade. He went from going to special education classes, to having an aid, to now being on his own in class and making A’s and B’s. Most individuals do not know that Cole is on the Autism Spectrum. The only lasting effect of ASD is that he still has auditory sensitivity and his short term memory is a little slower than others. He has learned to pull himself out of loud situations.
    I truly believe that if we had not had is enlarged tonsils removed we would be dealing with a much differnt boy.
    I hope the medical community starts doing research on the connection.

  20. jill on September 11th, 2013 10:26 pm

    I have always felt putting a baby on its back was unnatural. When our grandson was diagnosed with ASD I too wondered if back sleeping was perhaps a contributor. I have also spoke with someone in the medical field who wondered if the increase in ultrasounds has contributed to the increase in the incidence of autism. I hope these two factors will be further studied.

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