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Sleep Apnea, Prematurity & Craniofacial Conditions

I was listening to a sleep medicine continuing educational audio course and the speaker happened to mention that being born premature increases your risk of sleep apnea by 3 times normal. Coincidentally, an article in the New York Times reported on the March of Dimes’ efforts of cut down on rising rates of electively delivering babies before 39 weeks. They report that as many as 36% of elective deliveries are now occurring before 39 weeks. In a recent poll of women who recently gave birth, the majority chose 34 to 36 weeks as the earliest point in pregnancy to deliver. 

The safest gestational age is 39 to 40 weeks, and with each week that babies are delivered earlier, the higher the risk of complications such as respiratory distress, jaundice, infections, low blood sugar, or extra days spent in the hospital.

For example, infants born at 36 to 38 weeks had 2.5 times higher rates of complications compared with infants born at 39 to 40 weeks. The death rate at 37 weeks is 2-3 times that at 40 weeks. Infants’ brains at 35 weeks are only 2/3 the weight of those born at 39 to 40 weeks.

Another under-appreciated process that’s rarely mentioned is that infants’ faces and jaws are not fully formed when born premature. At the other extreme of this spectrum are babies born with Downs syndrome (DS) or cerebral palsy (CP). We know that these two conditions, as well as various other craniofacial conditions have much higher rates of obstructive sleep apnea.

In a study published in the European Journal of Orthopedics, researchers showed that the presence of DS or CP, bottle-feeding, and non-nutritive sucking habits (thumb sucking), and recent respiratory infections significantly increases the chances of various levels of malocclusion (open bite deformities and crossbites).

This goes to show that any degree of jaw underdevelopment, as well as early feeding habits can significantly increase your chances of developing obstructive sleep apnea later on in life. 

 

 

More Breastfeeding Could Save $13 Billion

It's common knowledge that breastfeeding is better for your baby compared with formula, and this new study estimated a figure on dollars saved if 90% of new moms breastfed exclusively for 6 months: $13 Billion. The results are not too surprising. One criticism that was mentioned was the fact that there are costs involved in breastfeeding, including unpaid time off work and lost productivity. This is an important issue that our society has to grapple with: What's more important—job productivity and wages that pay for food, or having a healthier baby?

What they found was that 3/4 start out breastfeeding initially, but at 3 months, less than 1/3 are breastfeeding. The excess annual cost associated with poor levels of breastfeeding compared to the ideal 90% compliance rate was: $9.1 Billion (991 estimated preventible deaths due to SIDS, necrotizing enterocolitis, and lower respiratory tract infections). The remaining amounts were due to otitis media, atopic dermatitis and childhood obesity.

What I discovered after reading the full article was interesting—to define breastfeeding, they asked survey respondents if they have “ever breastfed or fed breast milk.” Exclusivity was defined as the following:  "…not having fed anything other than breast milk, including water, in- fant food, juice, formula, cow’s milk, or sugar water." What's clear is that either natural feeding from the mother's breast, or pumped milk from the mother is defined as breast feeding. 

There are many dentists and lactation experts that would argue that there's a big difference between the two. Dr. Brian Palmer has argued convincingly that feeding from the mother's breast protects against developing obstructive sleep apnea. In other words, bottle-feeding can aggravate malocclusion and dental crowding. If you notice the various related illnesses in the study, they are all potential complications of untreated obstructive sleep apnea. Something to think about.

What's your take on this issue? Please enter your comments in the text area below.

Do You Really Grow Out Of Your Tonsils? The Possible Link Between Sleep Apnea and Autism

In the 1950s to 1970s, it used to be a rite of passage for young children to get their tonsils taken out. These days, we're a lot more conservative with tonsillectomy, and frequently, parents are told that their child will grow out of their tonsils. While this is true in some cases, there's a consequence to the watching and waiting option. 

 

Your tonsils are lymphoid tissue that's part of Waldeyer's ring, which is a ring of lymphoid tissue made of the palatine tonsils (your typical tonsils), the adenoids (in the back of the nose), and the lingual tonsils (at the base of the tongue in the midline). In some children with overdeveloped lymphoid tissues, you'll see a communication between all four of these glands, forming a complete circle. These tissues are normally involved in educating your immune system, since everything you breathe or swallow has to go through this ring. As a result, it's expected that the tonsils (and adenoids) will be enlarged during the ages of 3-5. 

 

However, with the shrinking size of modern human jaws, now there's less room for the normal-sized tonsils, which takes up relatively more space. This aggravates more frequent obstructions and arousals, leading to more inflammation from refluxed stomach contents and more swelling of the tonsils. The chronic negative pressure created from this process can prevent proper jaw enlargement, similar to what can occur with bottle-feeding. In many children, their snoring and sleep problems will prompt the parents to see an ENT for tonsillectomy. For children with mild to moderately enlarged tonsils that are not causing any symptoms, or those that are symptomatic but are told that they'll outgrow it, there can be permanent long-term consequences.

 

In children with huge tonsils, one of the reasons why they look so big is that the space that the tonsils sit in is too narrow. Taking out the tonsils can make a dramatic difference is most children, but there are some children that won't respond to tonsillectomy or only partially. One recent meta-analysis showed that adenotonsillectomy was helpful in about 2/3 of all children. But the remaining 1/3 still had residual symptoms or signs of obstructive sleep apnea. These are the children that have smaller jaws than the children who responded to the procedure.

 

In a recent Stanford University study, children who were scheduled for tonsillectomy were divided into two groups. One group underwent standard tonsillectomy, and the other under went rapid maxillary palatal expansion. The results were equivalent for both groups. When children in both groups were crossed over and given the other procedure, the overall results were additive. This just goes to show that one reason why you can have large tonsils that that your jaw is too small. Of course, everyone is on a continuum, and as usual in modern medicine, you're treated only if you are at the extreme end of the continuum. 

 

This is pure speculation, but I wonder if the significant increase in the rate of ADHD in the 1980s and 1990s could be related to the dramatic decline in the rate of tonsillectomies. Furthermore, since the peak incidence of autism is around ages 3-4, it's interesting that this is also the time that the tonsils become enlarged in most children. If you have enlarged tonsils to begin with, any simple cold or infection (even vaccines!) can cause swelling which starts a vicious cycle, leading to a sudden increase in breathing problems and poor sleep. Sleep apnea by definition causes systemic inflammation and an increased susceptibility to form microscopic clots in the brain. 

 

This is also the time (around age 4) when the voice box reaches its' final position below then tongue as it descends from its' original position behind the tongue. A space is created behind the tongue and between the soft palate and the epiglottis called the oropharynx, which exist only in humans, and allows for complex speech.

 

One last interesting phenomenon to point out is that in the early 1990s, parents were recommended to place infants on their backs, to prevent SIDs. We know that back sleeping lowers your time spent in deep sleep and leads to more frequent arousals. 

 

All these factors taken together may be what's developed into the "perfect storm," leading to the dramatic rise in ADHD and autism in our current times. Obviously, there are many other dominant theories for ADHD and autism, but from a sleep-breathing standpoint, what I propose is something that definitely needs to be proven in clinical studies. 

 

What do you think about all this? Please enter your responses in the comments box below.

Breast Feeding Protects Against Crib Death / SIDS

Breastfeeding was found to cut SIDS (sudden infant death syndrome) rates in half. A recent paper published in Pediatrics confirmed previous suspicions about the benefits of breastfeeding on the incidence of SIDS. 

 

This study supports my sleep-breathing paradigm, which is also supported by Dr. Brian Palmer’s assertion that bottle-feeding promotes dental crowding and development of obstructive sleep apnea. The jaw narrowing that results persists into childhood and adulthood, leading to smaller breathing passageways. It’s interesting to note that the peak incidence of SIDS is around 4-6 months. Coincidentally, this is also the time of transition where infants go from obligate nose breathers to mouth and nose breathers. 

 

During this transition, the voice box slowly drops to a position under the tongue, which creates a space behind the tongue that only humans have (the oropharynx). This new anatomy is necessary for complex speech and language ability. During this time, the infant has to adjust to different breathing, swallowing and speaking abilities and you can imagine that problems can occur during this time. 

 

Comparative anatomists and evolutionary biologists have said that speech and language development was ultimately detrimental to humans. If you have a common channel that has to serve breathing, swallowing and communication, then overdevelopment of one can detrimentally affect the other two. This is why only humans have so many problems breathing and swallowing. 

 

As I mention in my book, Sleep, Interrupted, our transition in the past few centuries to more processed foods and highly refined sugars, along with bottle feeding, aggravated this problem by causing even more dental crowding and upper airway narrowing.

 

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