If Your Child Has ADHD, You Must See This Video

May 5, 2014

If you’re at your wit’s end with a young child who has major behavioral problems, you’re not alone. Before you consider placing him on medications, here’s something that you should know: Your child’s attention deficit hyperactivity disorder (ADHD) may actually be a problem breathing while sleeping.  Here’s a powerful video of a young boy whose parents struggled for years before finding the right team of doctors to help their son.


Connor’s mom is organizing a cycling fundraiser to help donate $10,000 to Lurie Children’s Hospital of Chicago’s Sleep Medicine Department. 

Do you have similar struggles with your child? Please feel free to comment below.

5 Things You Can Do When Your Doctor Doesn’t Listen

April 22, 2014

One of my friends was worried about his health. He was getting sick all the time, and felt exhausted no matter how long he slept. His wife told him he was snoring and stopped breathing once in a while at night. He told his doctor that he suspected that he may have obstructive sleep apnea. His doctor told him that he’s too thin and doesn’t fit the typical profile.

This went on for many years. Finally, he came to see me, and sure enough, he had moderate to severe obstructive sleep apnea. He started using CPAP and felt like a new person. Needless to say, he went to a different doctor after this.

Patients will often tell me various symptoms that may initially seem unlikely, or even whacky. But one thing I learned over the last 15 years in practice is that usually, the patient is right. You as the patient will know your own body much better than your doctor.

What I found was that there was usually another more important issue that stood underneath the main symptom or complaint. If you feel like your doctor isn’t listening to you or understanding you, here are 5 thing you can do or say:    

   1. Try to rephrase your concern or symptom. Sometimes reframing your statement can not only get your doctor to listen, but it’s a gentle way of reminding him or her that you have something important to say.    

   2. Be direct and state that you feel like he is not listening. Different people will have different comfort levels with this, but in general, honesty is the best policy.    

   3. Explain in much more detail why this issue is so important to you. My friend’s father had similar health issues when younger and died early of a heart attack.    

   4. Be understanding and bring it up again the next time. Maybe she’s having a bad day, or he’s running late. Don’t take it personally.    

   5. Move on to another doctor. If this pattern continues despite multiple attempts to relay your concerns, then it’s time to find another doctor.

Have you ever been in this situation? If so, what did you do or say?

Sleep Apnea May Have Caused Metro North Train Crash

April 15, 2014

It’s now official: The train engineer from last year’s deadly train derailment was found to have severe obstructive sleep apnea, where he stopped breathing 65 times per hour. To date, there’s no conclusive proof that the crash was a direct result of his untreated sleep apnea, since he was also taking a sedating antihistamine and had changed shift hours two weeks prior. However, federal transportation officials are convinced that driver fatigue may have played a role in crash that killed four and injured 70 people. 

In an article about this incident, a transportation union official was quoted as saying the crash was a “tragic accident,” and that “there isn’t enough awareness of sleep apnea within the transportation industry.” This is an interesting comment, in light of the fact that recently, the National Transportation Safety Board (NTSB), Federal Motor Carrier Safety Administration (FMCSA), American Trucking Association (ATA), Federal Aviation Administration (FAA), and even Congress have worked tirelessly to bring more awareness about sleep apnea to the public. 

Congress just passed a law (H.R. 3095) requiring investigation, data collection and gathering expert opinion into screening requirements for sleep apnea in various transportation industries. The FAA recently announced that they will be more vigilant about screening for OSA, especially in severely overweight pilots. In this press release, the FAA noted that there are almost 5000 pilots with OSA on treatment that have been issued special issuance certificates. Interestingly, the NTSB database reports 34 accidents, 32 of which were fatal, involving people who had sleep apnea and 294 incidents involving another type of sleep disorder. 

Around 170,000 individuals are injured in trucking accidents each year. About 5,000 semi-trucks per year are involved in fatal traffic accidents in the United States. In a study conducted by the University of Pennsylvania and sponsored by the FMCSA and the American Trucking Association, almost one-third (28%) of commercial truck drivers were found to have OSA.

Given that the incidence of obstructive sleep apnea is so high in these industries, perhaps there should be universal screening. What do you think? Is it invading privacy to force mandatory sleep apnea testing, or does public safety take priority over individual rights?


Peripheral Neuropathy and Obstructive Sleep Apnea

March 16, 2014

I just saw a patient 5 weeks after major tongue and soft palate surgery for obstructive sleep apnea, and as expected more often than not, his sleep quality was significantly improved. He did not suffer from brain fog anymore, and was able to think clearly again, something he was not able to do for more than 30 years. He was very happy with the results. As he was leaving the exam room, he wanted to show me something. He took off his shoes, and then his socks, and asked me what I thought.

I was a bit confused by his request, but then I remembered that he showed me his feet many months prior to his procedures. Compared to his right foot at that time, his left foot was more dusky, red and scaly, and not too healthy looking. He had peripheral neuropathy with pain, burring and numbness, for which he was being treated by another doctor. On the post-operative visit, his left foot looked much healthier. He also noted proudly that although he still had some numbness, his burning and pain were completely gone.

Peripheral neuropathy is a common condition seen usually in diabetics, but can also occur in non-diabetics. I wasn’t surprised by his result, but it was a bit unexpected. It not something that’s routinely described as a potential benefit of treating obstructive sleep apnea. We know that sleep apnea causes a stress response that clamps down on blood vessels of the distant extremities. 

I did a quick literature search of the connection between obstructive sleep apnea and peripheral neuropathy and found a handful of studies. One report found that patients with obstructive sleep apnea without any symptoms in the feet had objective measures of diminished nerve function, which improved significantly after CPAP therapy. Another paper described resolution of peripheral neuropathy pain (but not numbness) in a non-diabetic after CPAP. 

Knowing that obstructive sleep apnea and diabetes frequently go hand in hand, and that diabetes and peripheral neuropathy also go together, there’s a good possibility that the first and the last can also be linked as well. The real question that needs to be asked is, how many people with peripheral neuropathy have obstructive sleep apnea, and if treated adequately, how many can be helped or even cured? Another question that follows is, should all diabetics be routinely screened for obstructive sleep apnea? Knowing that obese diabetics can have up to an 80% chance of having obstructive sleep apnea, perhaps the answer should be yes.

If you’ve been diagnosed with obstructive sleep apnea, did your foot pain or numbness get any better after using CPAP, dental appliances or surgery?


Inflammation, PTSD and Sleep Apnea

March 5, 2014

Post traumatic stress disorder, or PTSD, is a commonly seen condition, especially in victims of sexual abuse, or in military personnel after deployment. For the most part, it’s categorized as a mental health disorder that’s treated with medications and/or psychotherapy. Personal or family history of anxiety or depression is though to increase your risk of developing PTSD.
In this new study, the presence of inflammation was found to predict later development of PTSD. In particular, each 10 fold level of C-reactive protein (CRP) was associated with a 51% increased likelihood of showing at least one PTSD symptoms after deployment to Iraq or Afghanistan.
When I came across this study, the first thing that came to mind was the numerous previous studies showing that having obstructive sleep apnea (OSA) is strongly associated with elevated levels of CRP, and that treating OSA with CPAP can lower CRP levels. 
In addition to higher levels of CRP, OSA is also associated with elevated levels of IL-1, IL-6, and TNF-alpha. CRP is a general marker of inflammation and can even be elevated after surgery.
A good analogy is to say that having a fever increase the chances that you have a cold. Your temperature can also go up if you have pneumonia. There’s nothing special about having an elevated temperature, since it’s a general marker of inflammation. In a similar way both obstructive sleep apnea and PTSD are both associated with elevated levels of CRP. 
But what if obstructive sleep apnea increases your chances of developing PTSD? Not too coincidentally, there’s a study showing that veterans with PTSD have up to 50% rate of OSA. Treating OSA can oftentimes improve PTSD symptoms. I’ve had numerous veterans report that their PTSD was completely gone after starting CPAP.
Something to always think about when you’re dealing with PTSD.

If You Sleep Less Than 6 Hours, You Must Read This…

February 26, 2014

I haven’t talked a great deal about sleep deprivation, so when I came across this article on Medscape, I thought the overview of the various epidemiologic findings related to sleeping less than 6 hours was worth reviewing:

“Sleep deprivation has a profound impact on multiple disease states. For example, if you sleep less than 6 hours, epidemiologic studies show the following:

• Stroke is increased by a factor of 4 times.

• Obesity is increased by an increase in ghrelin, which is a hunger hormone.

• Diabetes is increased because sleep deprivation increases insulin resistance.

• Memory loss is accelerated. Epidemiologic studies show that there is not only permanent cognitive loss but also evidence of early brain deterioration.

• Osteoporosis is increased, at least in an animal model, with changes in bone mineral density. Even changes in bone marrow are evident within 3 months of a study in a rat model.

• Cardiac disease is increased. There is a 48% increase in early cardiac death, as well as increased cardiac-related mortality.

• A 4-fold overall increase in mortality.

As it relates to gastrointestinal disease, there is an increased risk for colon cancer, and at least 1 epidemiologic study shows an association between sleep deprivation (or lack of sleep) and an increase in the likelihood of precancerous (adenomatous) polyps.”

The author also summarized the results of this finding that sleep deprived mice had higher rates of tumor growth.

More and more studies are linking sleep deprivation and obstructive sleep apnea with numerous medical conditions, including cancer.

If you sleep less than 6 hours, something else to sleep on…

The Missing Link in Insomnia and Sleep Disordered Breathing: Interview With Dr. Krakow

February 12, 2014

Insomnia is treated by sleep specialists as a completely different condition from obstructive sleep apnea. Similar to how sleep problem is now considered a “co-morbid” condition to depression and various other medical conditions, insomnia is now beginning to be considered a “co-morbid” condition alongside obstructive sleep apnea.  I’ve interviewed Dr. Barry Krakow in the past on upper airway resistance syndrome and complex insomnia (click here for the interviews; search for Krakow). Here’s a must-read interview that was just published in Sleep Review Magazine. The magazine interviews Dr. Krakow on complex insomnia and how everyone with severe insomnia should also be considered for a possible sleep-breathing disorder.

The Link Between Asthma, Reflux, and Mood Disorders

January 6, 2014

About one in 12 people in the US (about 25 million, or 8% of the population) had asthma in 2009. More than 1/2 of all adults and children with asthma had an attack in 2008. 185 children and 3,262 adults died from an asthma attack in 2007. These numbers are likely to be higher in 2014 (source: CDC).

Asthma is thought to be a chronic inflammatory disorder of the lungs. Symptoms include chronic cough, wheezing, chest tightness and shortness of breath. 

A recent study out of Taiwan reported that teenagers with asthma had a significantly higher chance of developing depression or bipolar disease 10 years later. After adjusting for other conditions such as allergic rhinitis, atopic dermatitis, and other confounders, patients with asthma were 1.81 times more likely to develop major depression, 1.74 times more likely to develop any depressive disorder, and 2.27 times more likely to develop bipolar disorder than patients without asthma. This was the first prospective study linking asthma with mood disorders.

Not too coincidentally, another study came out that showed that pepsin, a stomach enzyme, was found in 71% of  bronchial washings in children with chronic lung diseases. In contrast, healthy children had no cases of pepsin in bronchial washings. 

Obstructive sleep apnea is found in up to 10% of chidden and about 25% of adults. During an apnea, tremendous vacuum forces are created in the chest cavity, leading to a suctioning effect of normal stomach juices into the throat. These juices can then go into the lungs or the nose and ears. Stomach juices not only contain acid, but also bile, digestive enzymes, and bacteria. Even microscopic amounts of these materials can wreak havoc inside your lungs or nose.

Here’s a review of the link between asthma and obstructive sleep apnea. Not too surprisingly, the peak time for the highest levels of restricted breathing in asthmatics is during 3 to 5 AM. This is also the same time that REM sleep peaks, when apneas are most common. There are countless studies showing strong associations between obstructive sleep apnea and mood disorders. 

This is another great example of  how everything comes together when you start to connect the dots.


Longer Breastfeeding Tied to Better Development

January 2, 2014

There’s no doubt about the benefits of breastfeeding, but most of the benefits that are written about in medical journals is related to the nutritional and immunologic benefits of human breast milk. Here’s one more of many articles touting the developmental benefits of breastfeeding over bottle-feeding. Most of the studies compare breast milk (including pumped milk) to formula, but this study specifically states that children who where specifically breast-fed had significantly higher scores in cognitive development, receptive communication, expressive communication, and fine motor development. Children who were breastfed for more than 6 months had the highest scores compared with children that were never breastfed.

There’s a general consensus within the dental community that bottle-feeding can potentially promote dental crowding. The physical act of swallowing is very different when sucking from an artificial nipple vs. suckling from a mother’s breast. Dr. Brian Palmer has an excellent explanation on his website. 

In the original study, nowhere is where any mention of the biomechanics differences with breast-feeding versus sucking from an artificial nipple from a bottle. Poor swallowing mechanics leads to improper tongue motion, which can cause malocclusion (dental crowding), which in turn can increase your chance of narrowed airways and sleep-related breathing disorders (such as obstructive sleep apnea). This is also why using a pacifier or even thumb sucking has similar, detrimental effects. 

What are your experiences with breast or bottle feeding and dental crowding issues in your children?

A Small Taste of My Own Medicine

December 30, 2013

It’s been a while since my last post. With all the holiday season activities it’s been quite busy. But the main reason I haven’t written is that I just underwent minor surgery. Not just any surgery, but something that I do on a routine basis—a lingual frenulectomy. In other words, I just had my tongue tie cut and released. 

The medical term for tongue tie is ankyloglossia. Many people have a band of tissue that tethers the bottom of the tongue to the floor of the mouth in the midline. This prevents proper tongue movement and normal resting posture in the mouth. My condition was mild to moderate in degree and I had no significant effects that I knew of, but since my son was scheduled to undergo this procedure, I decided to have it done as well, just to show him my support. 

The procedure was performed by an oral surgeon DDS and MD, in his office. After a topical anesthetic was applied, Novocaine (an anesthetic) was injected. Getting the numbing medication was the most uncomfortable part. Afterwards, he used a CO2 laser to make the cut and remove the thin band of tissue.

Is was a bit rough for the first few days, but by day 5 to 6, I was able to eat normal foods. It’s been about one week since the surgery, and I’m slowly beginning to feel better and better. My speech is still a bit affected, but I can talk relatively normally. I’m now feeling things in my mouth that I could never feel before.

Newborn infants came to me in years past with severe tongue tie, which prevented them from latching on to their mother’s breast. After a simple cut in the office, infants are usually able to latch on and start feeding immediately. It’s a wonderful feeling to see this. Since the tongue is your most important orthodontic appliance, it’ important to have good tongue mobility. Having underdeveloped jaws can lead to dental crowding and sleep-related breathing disorders such as obstructive sleep apnea.

Not all cases of tongue tie should to cut, but if there’s any significant tethering, it’s something to bring up with your doctor. Oftentimes, the younger you are, the easier the recovery. This  ended up being the case for my son—he’s healing much faster. Having undergone even this minor procedure is a great reminder for me what my own patients must experience, especially with much more aggressive procedures. Sometimes, a doctor needs a taste of his or her own medicine once in a while.

For a great resource on tongue tie, take a look at this article on Dr. Brian Palmer’s website.

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