How Infections Can Raise Stroke Risk In Children

Here’s an article showing that children who suffer from stoke had some sort of infection in the days leading up the event. Researchers from UCSF found that 29% of children who suffered a stroke had an infection within 2 days of the stroke, whereas only 1% had infections in the control group.

It’s likely that if you already have narrowed breathing passageways, any additional inflammation and swelling will cause even more narrowing, leading to more severe episodes of snoring or apneas. We know that obstructive sleep apnea can significantly increase your risk of stroke. Furthermore, blood in patients with obstructive sleep apnea is found to be much thicker and more prone to clotting. 

I’m willing to bet that these children already had some sort of sleep-breathing problem, and the infection tipped them over the edge. Oftentimes, you’ll see large tonsils or adenoids, dental crowding, a high arched hard palate, nasal congestion, and an inability to sleep on their backs. Parents of these children are more likely to snore in this scenario.

Fortunately, this condition is rare (5/100,000), but the consequences can be devastating. This is why it’s important to pick up and address any underlying sleep-breathing issues before complications arise.

High Blood Pressure In Children Predicts Heart Disease In Parents

You may be thinking that I mixed up the words in the title. Yes, I did mean to say that children who have high blood pressure or high cholesterol have higher chances that their parents have diabetes or heart disease later on in life. Researchers found that 26 years after screening these children for health problems, 47% of parents of these same kids had suffered a heart attack, stroke, or underwent a procedure to unclog blocked arteries. Thirty-seven percent of parents developed diabetes.

Again, there’s not one mention of the likelihood that there’s any chance of obstructive sleep apnea. 

Can Reflux Medications Help Asthma Symptoms?

Here’s a classic example of a study with negative results which is not surprising. Researchers gave acid reducing medications (lansoprazole) to children with steroid dependent asthma. About 300 children were randomized to receive either the medication or a placebo. They found no significant differences between the two groups in terms of asthma symptoms. If you look at all the studies that link asthma to obstructive sleep apnea, and reflux to obstructive sleep apnea, it makes more sense that the two (asthma and reflux) are connected by obstructive sleep apnea. 

It’s been shown that apneas create conditions in the esophagus and throat which can cause your stomach juices to reach your throat. Furthermore, pepsin and bile have been found in lung and sinus washings. What this means is that your stomach juices are still coming up into your throat, especially if you have obstructive sleep apnea. However, what’s coming up is just less acidic juices, but still includes bile, digestive enzymes, and bacteria. We know that proton pump inhibitors and H2 blockers such as cimetidine don’t really do anything to prevent reflux into the throat. 

My hypothesis is supported by studies that show that pro-motility agents such as domperidone and clarithromycin can help lower asthma symptoms. There are also numerous studies showing that treating obstructive sleep apnea can help with symptoms of asthma and reflux. 

I’m Now Board Certified In Sleep!

I’m happy to tell all my readers that I just found out that I passed the sleep medicine board exam that I took last October. It was both challenging and rewarding, as I had just changed over to academia, and I was working full time. I’ve debated for years whether or not to take this exam, since obstructive sleep apnea is a very small fraction of the content of the test. However, by taking this test, I feel more well-rounded and more confident that I can better help people with obstructive sleep apnea and upper airway resistance syndrome. 

For those of you who didn’t know, until 2007, the board exam was administered by the American Board of Sleep Medicine. After 2007, it stopped giving the exam and a new board was created under the auspices of the American Board of Medical Specialties, an umbrella organization that covers most major medical specialties. Five specialties joined to co-sponsor this board: neurology & psychiatry, family practice, internal medicine, pediatrics and otolaryngology (ENT). Each member board administers the same sleep medicine exam test to their own candidates, but only after general certification is obtained. Beginning in 2007, this test was given every two years—2011 was the last year in which candidates could take the exam without doing a one year fellowship, as long as you demonstrated that you’ve seen a minimum number of sleep patients and interpreted a certain number of polysomnograms.

Sleep Apnea & Sudden Hearing Loss: Is There A Connection?

I’ve been saying all along that people with sudden sensorineural hearing loss have higher rates of sleep-breathing problems. Almost 100% of the time, whenever I see someone with sudden hearing loss that’s not explained by a brain tumor, the upper airway looks exactly like someone who has obstructive sleep apnea. These people typically can’t or prefer not to sleep on their backs. Many will also snore, and have parents that snore heavily.

A recent article published in the Archives of Otolaryngology – Head & Neck Surgery found that people with sudden sensorineural hearing loss were more likely to have obstructive sleep apnea. The authors combed  through insurance records and found that, after adjusting for various confounding factors, male patients with this type of hearing loss were 1.4 times more likely to have prior OSA than controls. This was statistically significant. The fact that women didn’t have this finding could be explained by the fact that the overall numbers of people with sudden sensorineural hearing loss is very small, and men have a much higher rate of obstructive sleep apnea than women. Just like all other medical journal articles, it concludes by saying this doesn’t prove that sleep apnea causes sudden sensorineural hearing loss, and that further studies are needed.

The authors’ explanation is that plaque buildup in blood vessels that reach the inner ears can clog up and create blockages. I’ve written in the past that people with OSA have much thicker blood, which can also clot more easily. Untreated obstructive sleep apnea causes massive inflammation in blood vessels and the brain, which can lead to a variety of medical ailments.

If you’ve ever suffered from sudden sensorineural hearing loss, can you sleep on your back at all? 

Hypothyroidism in Pregnancy Goes Largely Undiagnosed

Researchers combed through 117,892 Quest Diagnsotics records and found that about 15% of women tested positive for gestational diabetes. Based on this finding, they estimate that as many as 483,000 women with gestational diabetes may go undiagnosed every year. Asian women had the highest rates of being tested and being positive for this condition, and older women and overweight women were much more likely to be tested during pregnancy. 

Hypothyroidism during pregnancy can lead to lower IQ scores in children after birth. 

I’ve written extensively before that pregnancy increases your chances of sleep-breathing problems, especially in light of significant weight gain that occurs. Gaining weight is a major risk factor for obstructive sleep apnea, which has been shown to significantly increase your risk or diabetes and hypertension. Any form of physiologic stress can has been shown to lower your thyroid levels as well. You don’t have to have obstructive sleep apnea to have significant breathing problems at night.

Having low thyroid levels can also promote weight gain. Poor sleep quality also promotes weight gain. Weight gain narrows your throat, causing more breathing problems. It’s a vicious cycle. Regardless of which comes first (sleep apnea or hypothyroidism), it’s a two-way street.

If you consider that our population as a whole is now heavier, and women are having babies at much later ages, then hypothyroidism is one of many conditions related to sleep-breathing problems and pregnancy that is expected to increase in numbers.

Shortage Of ADHD Medications Creates An Uproar

A recent New York Times article reports on the shortage of medications for people with ADHD, or attention deficit hyperactivity disorder. There’s a lot of speculation about why this is happening. One explanation that was put forth was that the FDA (Food and Drug Administration) is limiting the available supply, due to the high rates of possible abuse of these stimulant medications. My response was a little off-topic, but I just had to comment. Here’s a reprint of what I wrote:

“There’s no doubt that ADHD medications can be lifesaving for millions of Americans, but there’s another dimension to this issue that’s being ignored by the mainstream media and the general public, despite growing evidence in published studies. 

It’s a general consensus in sleep medicine that sleep deprived adults get drowsy, whereas children become fidgety and hyperactive. Not only are todays’ children sleep deprived (homework, TV, etc.), many are not able to breathe properly at night, due to narrowed airways.

In a study published in Pediatrics in 2006, 28% of children scheduled for tonsillectomy were found to have undiagnosed ADHD, compared to 7% in controls. After tonsillectomy, 50% of the ADHD group were cured. Another study showed that children with ADHD are more likely to snore, and that about 25% of children with ADHD could be treated effectively by treating their sleep apnea.

Notice all the typical findings in a child with sleep-breathing problems that are also found with ADHD: inability to sleep supine, snoring, nasal congestion, mouth breathing, snoring parents, unrefreshing sleep, frequent urination, inability to focus or concentrate, history of needing braces, and bottle-feeding. You don’t have to be obese or snore to have sleep apnea.

It’s clear that in some children with ADHD, stimulants like Ritalin or Adderall work because they’re sleepy. My feeling is that all children with ADHD should be screened for obstructive sleep apnea.“

Let me make it clear that I’m NOT saying that all children with ADHD have obstructive sleep apnea. But even if it’s only 25% (a very conservative number), the implications are huge. If you look at the CDC’s website on ADHD statistics, it’s frightening. 

• 9.5% or 5.4 million children 4-17 years of age have ever been diagnosed with ADHD, as of 2007
• Rates of ADHD diagnosis increased an average of 3% per year from 1997 to 2006 [Read article ] and an average of 5.5% per year from 2003 to 2007
• Prevalence of parent-reported ADHD diagnosis varied substantially by state, from a low of 5.6% in Nevada to a high of 15.6% in North Carolina
• As of 2007, 2.7 million youth ages 4-17 years (66.3% of those with a current diagnosis) were receiving medication treatment for the disorder
• Rates of medication treatment for ADHD varied by age and sex; children aged 11-17 years of age were more likely than those 4-10 years of age to take medication, and boys are 2.8 times more likely to take medication than girls.

Remember that these are 2007 statistics. Ten percent of the pediatric population has ADHD, and 6-7% are on medications! As a population, we’re much heavier than we were 5 years ago, which means that these figures are probably an underestimation. The children that we’re medicating now are mostly likely the ones that we’re going to have to give even more medications to later in life after they develop the medical complications of untreated obstructive sleep apnea (diabetes, depression, anxiety, hypertension, high cholesterol, obesity, heart disease, heart attack and stroke). In my mind, all these conditions are connected. They are all one and the same disease, but with different manifestations.

Sleep: The Missing Link in Weight Loss

Tara Parker-Pope, New York Times health columnist, wrote a great article in last week’s Times Magazine called, “The Fat Trap.” She details a poignant account of her personal struggles with obesity, and the various scientific studies that support the notion that there are a number of genetic, biochemical and environmental factors that prevent certain people from losing weight. 

But one thing that was clearly missing in her article was the importance of getting a good night’s sleep. There are a number of reasons why most modern Americans are not getting enough sleep.

A National Sleep Foundation poll in 2005 showed that Americans averaged 6.9 hours of sleep per night, which is about one hour less per night compared with 50 years ago. Furthermore, our sleep duration has dropped another 20 minutes since 2001. Invasion of technology has been blamed as one major factor, as cellphones, computers, and various media options are rampant in today’s society. The bad economy is also thought to create more insomnia and diminished total sleep times.

Not only has our sleep duration dropped, but the quality of our sleep is dropping even further. Obesity is a major risk factor for having obstructive sleep apnea. As obesity has reached epidemic proportions in the United States, it’s likely that rates of obstructive sleep apnea has increased as well. Untreated obstructive sleep apnea, by causing multiple breathing interruptions, prevents continuous, quality deep sleep. It also significantly increases your future risk of developing heart disease, heart attack, stroke and motor vehicle accidents.

A healthy diet, portion control, and regular exercise are cornerstones of most diets or weight loss programs. But without good quality sleep, your chances of losing a significant amount of weight and keeping is off is relatively low. One major reason for this is that poor sleep promotes weight gain. It’s been shown that hormonally and metabolically, one tends to either gain weight, or has difficulty losing weight, no matter how much you diet or exercise.

One great example was reported by Glamour Magazine in 2009: Seven women of varying weights were told to sleep at least 7.5 hours every night. After 10 weeks, 6 of the 7 women lost anywhere from 6 to 15 pounds, without any changes in their eating or exercise habits. The one woman that didn’t lose any weight did lose 2.5 inches off her waist, bust and hips.

This just goes to show that unless you can optimize sleep, losing weight through dieting and/or exercise won’t work as well, or last.

If you’re currently dieting, have you incorporated an optimal sleep program into your weight loss regimen?

Can a Robot Help Cure Sleep Apnea?

Every few years, another new technical innovation is touted as the latest in sleep apnea treatment. One such example is robotic surgery for obstructive sleep apnea. The press plays it up like what they do for lasers and various other high-tech surgical gadgets. What they don’t tell you is that a tool is only as good as the surgeon that’s performing the procedure. I’ve used this example before: Tiger Woods can beat your pants off using $60 Wilson starter gold clubs, even if you’re using top-of-the-line, $3000 custom made golf clubs.

The laser is another such tool that people are still fascinated by—it’s just another cutting amongst a handful of useful options. They key is to know when to use it, and how to use it safely. You should be able to perform the procedure even if the laser or the robot is not available. For sleep apnea surgery, these new tools should not determine whether or not you’re going to perform the procedure at all. 

Being a gadget freak myself, I’m usually one of the first to try anything new that comes along. But one thing I’ve learned over the years is that you shouldn’t depend on these devices to to your surgery for you. It’s inevitable that even in the OR, there will be technical problems or software issues that prevent having the device available. Looking back, I had to spend a lot of time trouble-shooting these devices, and there’s definitely a learning curve with any new technology. One such example is 3-D image guided navigation. I use it only for my most difficult or complex sinus cases. But if you’re using it routinely, what happens when the computer crashes? It’s like having to fly a plane using visual cues and your experience if you lose instrument navigation.

I’m not saying robotic surgery doesn’t work. It can work, but only if you’re choosing the right patients to operate on and you use sound judgement and technique, whether or not you’re using robotic assistance.  

33% of All Cops May Have Sleep Apnea

I’ve always wondered about police officers—just like the rest of the population, many are generally overweight.  A new study published in the Journal of the American Medical Association revealed that about 40% of police officers screened positive for at least one major sleep disorder. Sleep apnea was the most commonly found condition, at 34%. Insomnia and shift word disorder were the two other conditions seen. About 80% were overweight or obese. And 26% reported falling asleep while driving at least once or twice per month.

These findings are not too surprising, since police officers frequently work odd hours that include night shift and weekends. Their poor eating habits can contribute as well. We also know that poor sleep can promote weight gain. The irony is that police officers probably need to be outdoors, walking or driving around, since an indoor desk job will not be stimulating enough. The question is which comes first: poor sleep habits and lifestyles that lead to weight gain and sleep apnea, or anatomic predisposition to sleep apnea that leads to choosing these type of occupations that promote weight gain, which leads to sleep apnea? I’m sure that if you studied fire fighters, you’ll find similar results, and that you’ll agree with me that this is a potentially major public health issue.

Based on these findings, do you think mandatory screening for obstructive sleep apnea should be required on a periodic basis for all police officers?

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