Flathead Syndrome Associated with Lower Developmental Scores in Preschoolers

December 31, 2012

Deformational plagiocephaly (PD), or flathead syndrome, is a common condition, especially since our country began to place our infants on their backs during sleep, to prevent sudden infant death syndrome (SIDS). Even my middle son had it and was referred to a neurosurgeon for evaluation. In this Pediatrics study, researchers found that preschoolers with PD compared to those without PD had significantly lower scores in cognition, language, and parent-reported adaptive behavior, while the smallest difference was seen in motor development. The authors note that having PD doesn’t imply that it causes developmental problems, but that it may serve as a maker for developmental risk.

Here’s my take on this important issue: Keeping infants on their backs has been shown to increase the risk of developing PD. While the “back to sleep” campaign in 1993 did lower the rate of SIDS by about 50%, it may also have had a detrimental effect on deep sleep quality for all of our infants. Supine sleep has been shown to promote less efficient sleep, compared to side or tummy side down sleep. Given that infants and toddlers spend a large amount of time sleeping, and since we know that good quality deep sleep is essential for proper brain and cognitive development, it’s not too far fetched to says that having PD means that you’re not getting good, quality sleep. Dentists have also proposed that any asymmetry in the back of the head can cause detrimental changes in the front of the head and face, with possible bite changes and malocclusion.

For those of you with children, did they sleep better on their sides, front, or back? If they were back sleepers, did they have any PD?

Sleep-Breathing Problems Tied To Special Education Needs

September 5, 2012

Here’s another study showing how important good breathing during sleep is when it comes to a child’s development. Researchers studied 11,000 children in England and found that those that sleep-disorderd breathing problems or other sleep problems in the first 5 years of life had significantly more special education needs at age 8. This article points out another study that I mentioned in the past, finding that infants who snore are more likely to have problems such as hyperactivity, depression and inattention.

The authors talk about lowered oxygen levels leading to potential brain damage, but even short breathing pauses that don’t lead to hypoxia can still lead to arousals that takes you out of deep sleep.

If your child has ADHD, developmental disorders or special education needs, did he or she have poor sleep as an infant or toddler?

Esophageal Pressure in Children Correlates with Disruptive Behavior

August 8, 2012

It’s common knowledge that esophageal pressure readings are the gold standard when determining more subtle levels of breathing obstruction, such as what’s found in upper airway resistance syndrome. Here’s an interesting study from the University of Michigan which showed that in children, esophageal pressure readings correlated with a disruptive behavior disorder (Diagnostic and Statistical Manual of Mental Disorders, 4thEdition: attention-deficit/hyperactivity disorder, conduct disorder, or oppositional defiant disorder), and more sleepiness after adenotonsillectomy. However, it did not correlate with the pediatric apnea-hypopnea index, or the respiratory disturbance index. Neither esophageal pressure or the AHI predicted ADHD, cognitive performance, or improvement after surgery.

With such a high prevalence of obstructive sleep apnea in children with ADHD, the addition of esophageal pressure readings may be useful in children when there’s suspicion of an underlying sleep-breathing disorder.

Mood Disorders in Teens and Sleep Apnea

July 6, 2012

A number of recent studies have reported on teens and behavior problems. This Harvard study showed 2/3 of teens engaged in violent behavior that included property damage. They also showed that one in 12 teens met the official criteria for Intermittent Explosive Disorder (IED). Another study showed that teens with obstructive sleep apnea had shorter attention spans and aggressive behavior. I’m betting that there’s a significant overlap between theses two groups. What do you think?

Moans In The Night

June 17, 2012

An interesting article in a recent sleep medicine journal describes a rare condition where women moan intensely while sleeping. Contrary to what you may have been thinking, these women were not moaning due to either pain or erotic dreams. These seven women sought treatment at Stanford’s sleep clinic due to a condition which has been coined catathrenia. They were all embarrassed by their condition, as well as having family members who were alarmed by the strange noises. Catathrenia has been classified in the parasomnia category, which are disturbances that occur during sleep-wake transitions, in contrast to sleep-breathing problems such as obstructive sleep apnea. This condition is typically seen in younger, premenopausal women, who are relatively thin.

When these women underwent an overnight sleep study, none were found to have obstructive sleep apnea. However, they all had in common the typical feature of multiple breathing pauses with arousals, leading to inefficient sleep. All these women also had in common smaller jaw sizes and a history of dental extractions for crowding or orthodontic problems. Many also complained of chronic fatigue symptoms as well.

This article caught my attention because of the nature of the cure for this condition. All the women were essentially cured with treatment that’s normally given for people with obstructive sleep apnea. Yet, they didn’t have obstructive sleep apnea. What they really had was upper airway resistance syndrome (UARS). As I’ve described at length in other articles, UARS is a variation/precursor to obstructive sleep apnea, where people have narrowed upper airway anatomy that causes brief obstructions and breathing pauses that are not severe enough to be called obstructive sleep apnea.

To receive a diagnosis of obstructive sleep apnea, you have to stop breathing completely or partially for 10 seconds or more, at least 5 times every hour while you sleep. But if you stop breathing 15 times every hour, but wake up after 2-3 seconds each, then your apnea score is 0 and you’re told you don’t have obstructive sleep apnea. These UARS patients are constantly tired and suffer from various other chronic conditions such as recurrent sinus pain or infections, low blood pressure, cold hands or feet, various gastrointestinal symptoms, anxiety/depression, and almost invariably, prefer not to sleep on their backs.

The lead author of this article (Dr. Guilleminault at Standford University) was the first to describe UARS as well. In his original UARS paper, he treated these constantly tired people with CPAP, or continuous positive airway pressure. This is a device that delivers gentle air pressure through the nose, thereby keeping their breathing passageways open. For the most part, they all did well, but in the long term, they could not continue sleeping with masks and hoses attached to their faces. Most UARS patients, due to heightened sensitivities, are unable to tolerate this device.

In this current study describing catathrenia, many of the patients tried CPAP as well, which worked, but they all refused to use it continuously. Most of the patients subsequently underwent various surgical procedures of the throat, and were reported as being “cured.”

It’s amazing how often I find studies that link common and uncommon medical conditions to sleep-breathing disorders. Knowing that sleep-breathing disorders (obstructive sleep apnea or upper airway resistance syndrome) may be linked to depression, anxiety, cold hands, migraines, irritable bowel syndrome, chronic fatigue syndrome, polycystic ovarian syndrome, obesity, ADHD, TMJ, diabetes, high blood pressure, high cholesterol, heart disease, heart attack and stroke, could a breathing problem during sleep be the common link? I’ve even seen articles linking obstructive sleep apnea to epilepsy, cluster headaches, and even cancer. In my book, Sleep, Interrupted, I propose that the this may be a possibility. It may be a bit of a stretch to say a definite yes, but I’m confident that in 10 to 15 years, the answer to the above question will be more clear. This just goes to show that what we generally take for granted my have an alternate explanation.

Developmental Issues That Stem From Pediatric Sleep Apnea

March 26, 2012

A guest blog by Nader Ahmadni of Sleepdisorders.com.

Pediatric sleep apnea is a sleep disorder characterized by obstructed or narrowed respiration while a child sleeps. The condition affects an estimated 25 percent of children in the US and typically occurs between ages 2 and 8, though it is quite under diagnosed. Pauses in breathing during sleep in patients with pediatric sleep apnea are typically much shorter and lighter than those in adults with sleep apnea. While an adult may snore loudly and make choking noises, a child may simply stop breathing momentarily and then wake up. Both conditions can lead to sleep deprivation and a wealth of other health issues if left untreated.

Children with pediatric sleep apnea often suffer from symptoms such as restlessness and bed wetting. Parents may notice that their kids tend to snore or breathe irregularly, through their mouths. During the day, children may seem tired and inattentive as a result of poor sleep the night before. Daytime symptoms of pediatric sleep apnea can also include hyperactivity and mood swings.

The majority of pediatric sleep apnea patients have enlarged tonsils and adenoids, which physically block the child’s upper airway. Usually, a minor surgical procedure to have the tonsils and/or adenoids removed will cure the condition. However, there are other conditions that may cause sleep apnea in young children, such as physical deformities or muscle weakness. Obese children and children with thicker necks are much more prone to pediatric sleep apnea.

Finding immediate treatment for pediatric sleep apnea is perhaps even more important than for older patients. Pediatric sleep apnea that starts at such an early stage can stunt growth and lead to a number of developmental issues. Over time, if a child is not getting enough quality sleep, he or she does not acquire sufficient amounts of oxygen to aid in normal brain and body development. The child is more likely to be diagnosed later in life with health conditions like attention-deficit hyperactivity disorder (ADHD) and childhood obesity.  Patients who grow up with untreated, chronic sleep apnea are also more likely to having learning disabilities, behavioral problems and metabolic problems.

In addition to making sure your child maintains proper diet and exercise, it is crucial that parents that notice symptoms of pediatric sleep apnea in their kids go to visit a primary care physician or a sleep center for further information. A sleep doctor can perform an overnight test called a polysomnography, which allows specialists to observe behavior, breathing and vital functions while the child sleeps in a sleep lab room. Data collected overnight will lead to proper diagnosis of the child’s sleep disorder so that the child can move forward with treatment either with a CPAP machine, oral appliances or surgery. As children aren’t able to identify the problem on their own, it’s crucial for parents to pay close attention to their children’s sleep habits and daytime behavior. In the event of an irregularity in breathing, be sure to visit a sleep doctor as soon as possible.

Sleepdisorders.com is designed to link sleep disorder sufferers to local sleep doctors and sleep centers. In addition to our directory of sleep doctors, you can find informational articles related to your unique sleep disorder.

Can Snoring As A Baby Predict Behavior Problems?

March 5, 2012

Here’s a new study which reinforces what I’ve been saying about sleep-breathing problems and children: That it’s a major undiagnosed cause of developmental and behavior problems in childhood. Researchers from Albert Einstein College of medicine followed over 11,000 children over a 6 year period. Parents were asked about snoring in sleep surveys from 6 months on, and at 7 years, they filled out a behavioral assessment. Not too surprisingly, children who snored as early as 6 months of age had a 50% increased risk of developing behavior problems by age 7 compared to controls. 

We know that children who are sleep deprived become paradoxically hyperactive. In contrast, adults get sleepy (there are always exceptions to this observation). This study supports another study which I mentioned in the past showing that in children with ADHD who undergo tonsillectomy, about 50% can be cured for their ADHD condition. It’s no wonder that stimulants like Ritalin can help to calm a hyperactive child. 

It’s important to note that I’m not saying all cases of ADHD are due to sleep-breathing disorders. However, it’s been estimated that a significant number of children (25 to 50%) with an ADHD diagnosis could have a treatable sleep-breathing problem. With these numbers in mind, wouldn’t it make sense to routinely screen for obstructive sleep apnea or a sleep-breathing problem before being given an ADHD diagnosis?


How Many Hours Should Your Child Sleep Every Night?

February 16, 2012

How many hours should your child be sleeping? A new study found that opinions vary significantly amongst sleep experts, but the bottom line is that we’ve been saying for over 100 years that children need to sleep more. Unfortunately, the media has put a spin on this research, concluding that you should “never trust sleep experts.”

While it is true that we’ve been saying children need more sleep for years, critics are saying that there’s no evidence that children actually need more sleep. I beg to differ. It’s been reported that teens in one competitive high school sleeps an average 5-6 hours per night. We know from hundreds of studies that eve 1-2 hours of chronic sleep deprivation leads to significant declines in cognitive and behavioral measures. Adults need about 7-8 hours per night. Teens need about 8 to 9 hours per night, school-aged children, 10-11, and 3-6 year olds, anywhere from 10-12.

I know from personal experience that some of my 9 year old son’s classmates get 6-7 hours per night. I even blogged about seeing parents bring their preschool children with them to see a movie that ended at midnight. Granted everyone has different sleep needs, but if you’re saying a child can function normally on 3-5 hours of regular sleep deprivation every night, you’re fooling yourself. If your child is functioning normally, it’s more likely that he or she is being medicated with stimulants.

What’s more important than the number of hours you sleep is the quality of your sleep. Even if your child is able to sleep 10 hours per night, if she stops breathing even 1-5 times per hour, then by definition, it’s going to cause problems, whether it manifests in physical, emotional, or behavioral ways. What’s worse is if you don’t sleep efficiently, and you sleep less than you should, it’s a double whammy. We know that chronic sleep deprivation can also increase cravings for fatty, sugary foods, and promote weight gain. Sleep length has been directly linked to weight in children. No wonder there’s also an obesity epidemic in children these days.

How long do your children sleep? How much longer should they be sleeping?

Shortage Of ADHD Medications Creates An Uproar

January 4, 2012

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 Adobe PDF file] 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.


Look into several drug rehab centers and choose the one that fits you best!

Missing Teeth = Poor Health?

October 19, 2011

Ever since I began seeing patients in my new position at Montefiore medical center, I’ve been surprised by how many patients have missing teeth. In fact, many have no teeth at all, and often have to wear dentures, especially if they’re in the elderly years. Not too surprisingly, these same patients also have a number of chronic medical conditions, such as hypertension, diabetes, high cholesterol, heart disease, as well as numerous medications for these respective conditions. Many are obese.

Being in a major tertiary-care referral-based hospital, it’s expected that patients will have complex medical issues. But this observation only supports what dentists have been saying for years—that poor dental health equals poor general health. Not only do I see multiple missing teeth, there’s also significant jaw narrowing and crowding of the soft tissues of the mouth. Having smaller airways due to missing teeth and smaller jaws can aggravate significant medical problems, such as hypertension, diabetes, high cholesterol, and heart disease.

We’re seeing an epidemic of jaw underdevelopment these days, with dental crowding and numerous orthodontic and airway issues that arise as a result. The rise in premature babies, modern feeding habits, nutritional factors, and various toxins in our environment can prevent proper facial growth and development. It’s no wonder that we’re seeing increasing rates of ADHD, autism, and various other developmental delays. These are the same kids that will go on the develop high blood pressure, diabetes, obesity, high cholesterol, and heart disease later in adulthood.

You could argue that having bad teeth is a consequence of the particular population that we serve, but knowing what we know about the importance of proper jaw development and dental health, it’s likely that poor dental issues also predisposes people to chronic medical problems.


What do you think about my observations? 

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