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.

Written by Steven Park · Filed Under Blog
Tagged: ,autism, SIDS, sleep apnea

8 Responses to “Intriguing Sleep Apnea and Autism Connections”

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.
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.
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!
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.
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).
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.
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… [...]
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.