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25% of Children In The United States With Sleep Apnea?

Here’s some heartbreaking news that was recently published in the Wall Street Journal and commented on at KevinMD: That 25% of all children in the United States is on regular prescription medications. According to the report, 45 million children are on asthma medications, 24 million on ADHD medications, another 10 million on antidepressants and 6.5 million on antipsychotics. You also have the antihypertensives, sleeping pills, diabetes medications, and high cholesterol medications. This list doesn’t include prescriptions used in acute situations or over-the-counter medications.

You might be asking by now, “What does all this have to do with sleep apnea?”

My answer is, everything. If you happen to follow my blog, I’ve shown studies linking obstructive sleep apnea to almost every chronic health condition out there. This is based on published, peer-reviewed studies. What I did was only to connect all the dots, so to speak, to conceive of my sleep-breathing paradigm: That all modern humans, due to jaw underdevelopment, have various degrees of sleep-breathing problems, where only the end result is called obstructive sleep apnea. This problem begins while you’re an infant, and is aggravated by dietary and behavioral factors such as bottle-feeding, thumb-sucking, and eating the Standard American Diet (SAD). It’s also possible that the back to sleep campaign (although it lowered the SIDS rate by 40%), by forcing infants to sleep on their backs, may inadvertently prevent quality deep sleep in infants. Babies need good amounts of deep sleep for memory consolidation and brain development.

We also know that multiple breathing pauses can cause your stomach juices to reflux into your throat, and then into your lungs (or nose). This can cause various degrees of inflammation. Neurologically, your lungs will tend to over-react to weather changes, such as cold air, or even temperature or humidity changes. Breathing problems can also cause poor quality sleep, leading to major alterations in your brain biochemistry.

Poor sleep can also aggravate or promote the onset of depression. Faulty neurotransmitters or even structural damage from poor sleep can also cause your brain signals to misfire, or activate disinhibition of certain behaviors.

It’s no wonder that in one way or another there are studies (or will be studies) that connect all the various medical conditions already mentioned to one another. So it’s not too far fetched to argue that a large proportion of these children on chronic long-term medications may also have some kind of a sleep-breathing problem.

What do you think about my arguments? A realistic, but scary possibility, or too far fetched?

SIDS & Sleep Apnea, Revisited

Here’s the response I wrote on KevinMD to blog on the dangers of sleep positioners and SIDS. The author of that blog probably won’t like what I have to say. You’ll see that what I suggest may have huge implications with our children’s health.

SIDS, Back Sleeping, and Sleep Apnea?

I was doing some research on the internet about sleep position and SIDS (sudden infant death syndrome) and came across a blog post that says exactly what I was going to say, but in much more detail, and with a critical analysis of the statistics used when the American Academy of Pediatrics recommended that all infants be kept on their backs while sleeping. This campaign has lowered the rate of SIDS by about 50%, but about 3000 infants still die from SIDS every year.

Reading this story is heart-wrenching. It’s a long post, but I strongly recommend that you read through it. I frequently see parents in my practice that are literally in tears when they are berated by their pediatricians to keep their infants on their backs, despite the fact that their child can’t sleep in this position.

Sleep and pediatric researchers have shown that one possible mechanism as to why back sleeping helps to prevent SIDS is that it keeps babies in a lighter stage of sleep. This makes them much more easily aroused. If there is some kind of dangerous breathing stoppage, they’re more likely to wake up and start breathing again. What he also points out is that deep sleep is diminished by 8-9% in infants that sleep on their backs for the first 6 months. He calculated that back sleeping infants lose about 4 hours of sleep per day and 120 hours of sleep in the first month. We know that quality sleep is so important to an infant’s brain development and motor skills.

So it’s not surprising that there’s been an increase in rates of motor skill, cognitive and other developmental delays. Other studies have shown increased rates of sleep apnea, flat-head (my second son had this), and acid reflux. There’s even one blog that points to the back to sleep campaign as a major cause of the autism spike that began in the mid 1990s. I’ve also suspected that the decreasing rates of tonsillectomies in the 1980s and 1990s may adversely affect cognitive development (ADHD).

Numerous studies have shown that there are a number of other significant risk factors that increase the risk for SIDS, including bed-sharing, cold weather months, smoking, and soft bedding, whereas pacifier use and breast-feeding are protective. African Americans and Native Americans had significantly higher rates.

One major anatomic reason for SIDS is the fact the the infant’s voice box is very high in the throat, behind the tongue, with the epiglottis overlapping the soft palate. Gradually, over the course of 2-4 months, the voice box begins to descend. At a certain point, the collapsibility of the tongue into the newly created oropharynx may reach a critical point when various factors come into play (sleep stage, sleep position, cigarette smoke, etc). This timeframe is also when the rate of SIDS peaks.

In particular, the author points out that most SIDS studies use an odds ratio calculation that can easily overestimate the true risk, and is often confused with relative risk. Because these studies are retrospective studies with relatively small numbers of subjects along with a number of different variables, odds ratio is used over relative risk. The explanation of the difference between odds ratio and relative risk is a bit lengthy so I recommend you read the article, which is very clear. He hammers on the concept that correlation does not equate with causation. To date there’s no good explanation for SIDS, which still happens in about 1/1000 babies, of which 1/3 die while on their backs.

One interesting statistic that he pointed out is the fact the the risk of dying from SIDS if you have no other risk factors is only 10% (including no tummy sleeping) of the original risk. He poses this interesting question: Is it worth sleep depriving all infants of 25% of sleep in the first few months to protect less than 0.1% of babies?

I’m not recommending that everyone go against mainstream medicine’s recommendations. However, we need to re-evaluate the rationale for this recommendation and consider all the possible unintended consequences.

What are your thoughts on this subject?

 

 

 

The Tummy Time Controversy

As you may know by now, sleep position is a very important issue for me and I write about it quite often. When I recently came across this article in Slate magazine, I just had to comment. The gist of the article is that since the start of the back to sleep campaign in 1992, the rate of SIDS (sudden infant death syndrome) has been cut 50%. But there seems to be a downside: Parents are being overly cautious and not allowing enough tummy time when their children are awake. As a result, it’s been suggested that motor skill development such as lifting the head or rolling over, has been significantly delayed.

The arguments in this article are plausible, but a more immediate issue that’s completely being ignored is the fact then when babies are forced to sleep on their backs, by definition, you’re preventing them from staying in deep sleep. The thinking is that supine sleep allows infants to wake up easier if they ever obstruct. There are tomes of data that show that lack of deep sleep can have significant detrimental effects on your memory consolidation, affect, executive functioning, and motor skills. Imagine what can happen if you force this on an infant’s developing brain. It’s no wonder there’s been an epidemic of pediatric developmental, behavioral, and medical problems in the past few decades. It’s even been suggested that the incidence of  autism spiked just after the back to sleep campaign was implemented.

Honestly, I don’t know what the right answer is. I’m not saying that we should place all our infants on their stomachs. However, this is an important issue that needs to be discussed, even if it means that the medical profession has to admit this was not the best thing to do.

What’s your opinion on this issue? How well was your baby able to sleep on his or her back?

Part II Of My Discussion on Infant’s Back Sleeping & Pacifiers

I came across a disturbing reference to pacifiers and how it was shown to prevent sudden infant death syndrome (SIDS). In Part I of this post, I described the reason why back sleeping, while lowering SIDS by 40%, could actually impair proper brain development. Both back sleeping and pacifiers are thought to work by keeping the baby in a lighter stage of sleep. Here’s why I think this is a bad idea:

When babies are first born, 50% of sleep is REM sleep and essentially no deep sleep (slow wave sleep). But around 2-3 months slow wave sleep begins to develop. Furthermore, this is the time in which your baby’s voice box slowly begins to drop lower in the throat, creating a space between the soft palate and the voice box that the tongue can fall back into and obstruct your breathing. Due to gravity, the tongue can fall back more easily, especially in deeper stages of sleep, when your muscles are more relaxed.

Promoting pacifiers to put infants to sleep is also a bad idea, since any kind of artificial nipple can aggravate dental crowding and malocclusion. Having something to suckle on all the time while sleeping can definitely keep infants in a lighter stage of sleep.

There are countless studies that show that deep sleep deprivation can have profound and detrimental effects the infant’s memory consolidation and brain development. It’s no wonder there’s been so many issues these days with younger children and behavioral, cognitive, and developmental delays, not to mention an increased incidence of allergies, asthma, and various other hypersensitivity reactions. I predict that as a society, we’re going to have pay for it in one way or another.

What’s your opinion on this issue? Should we keep things the same, and accept the consequences of a 40% lower SIDS rate? Or should we seriously look into this issue and make changes to the back sleeping recommendation, perhaps do it only for high-risk infants, or come up with better monitoring technology to prevent SIDS? I suspect that even if a definitive study came out proving my point, the medical institution will be reluctant to make any changes to their stance on this issue.

Autism, Vaccines, & Sleep Apnea: My Multi-Hit Theory

I remember during M&M (morbidity and mortality) rounds as a resident, our chairman felt strongly that an error never occurs in isolation. He insisted that a bad outcome happens from a series of mistakes, oversights and lack of communication. Even in engineering or aviation, whenever something goes wrong, there’s usually a series of events that led to the final adverse outcome. The same analogy also applies with cancer.

Although vaccines were essentially exonerated by recent large-scale studies (showing that the rate of autism was no different before and after Thimerisol was removed), there are still many proponents of the vaccine theory. I think that there’s some merit to this possible connection, but not for the reasons that you may think. Let me explain.

You may remember in one of my previous posts, I described reading about a theory that proposes that since the Back to Sleep campaign for infants in the early 90s, the incidence of autism went up significantly afterwards. This campaign led to a 40% reduction in sudden infant death syndrome (SIDS). However, one of the consequences of keeping infants on their backs is to keep them in a lighter state of sleep. This can prevent proper memory consolidation and brain development.

Although it sounds like a feasible explanation, it’s going to be difficult to prove. Medically and politically, doctors are not going to retract this recommendation, even if it is found to be plausible. However, if you add to this the fact that modern jaws are smaller due to a more bottle-feeding and poor nutrition, sleeping on your back can definitely lessen your deep sleep efficiency.

In another recent post, I alluded to allergy shots aggravating obstructive sleep apnea, by increasing nasal congestion. Anything that causes inflammation in the nose or throat, including allergies, colds, migraines, reflux or weather changes, can aggravate more frequent pauses in your breathing, especially when in deep sleep.

The human voice box is unique in that it’s located below the tongue. This migration downwards begins at birth and continues until your 60 or 70s. Around 4 to 6 months, a space is created between your soft palate and your voice box, called the oropharynx. Only humans have a true oropharynx. Descent of the larynx is needed for complex speech and language. But this also predisposes humans to breathing problems, especially when on our backs. This is when the tongue and voice box falls back the most, due to gravity. When you add muscle relaxation during deep sleep, you’re more likely to stop breathing and wake up.

Not breathing at night while sleeping, from a brief second to 30 seconds or more, can be detrimental to your brain. The end extreme of this spectrum is called obstructive sleep apnea, but even multiple short episodes of breathing pauses due to upper airway obstruction can lead to various pathways that can lead to significant neurological impairment.

If you put all these mechanisms together, then it creates a situation where you can suffer serious brain damage. In most cases, you won’t be able to see any anatomic changes using traditional imaging studies, such as with a CT scan or an MRI. These are sub-radiologic changes that occur within the brain tissues itself.

Vaccines and flu shots, just like anything else that creates a mild infection, can cause swelling and inflammation in your nose and throat. If your anatomy is already predisposed, and you add additional variables such as back sleeping and bottle-feeding, then even an allergy attack could in theory cause changes in your brain that can mimic autism. Given that the total number of child immunizations has increased tremendously only adds to my argument. Not too surprisingly, there are also known reports of children who develop autism after a simple cold or flu infection.

Ultimately, it may not be the specific type of vaccine or flu shot, or even the specific materials that they’re made with, but rather the general inflammation causing properties of these immunizations that may be the trigger that tips children over the edge to progress into any of the autism spectrum disorders. I may be going out on a limb here, but in the big scheme of things, autism may even be a childhood manifestation of the same process that causes Alzheimer’s.

What’s your opinion on my thought experiment? Will you agree with me that autism has multifactorial causes and not just one trigger?

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.

Why Are Teens So Sleepy In The Morning?

A number of my friends and acquaintances have commented to me that their teenaged children have a lot of trouble waking up in the morning. The usual explanation is that teens' sleep cycles are shifted, going to bed later and waking up later. Some experts in sleep medicine have even recommended that schools start much later in the morning to accommodate for this phenomenon in teenagers. 

 

Besides shifted sleep cycles, here's another interesting perspective on why teens are so sleepy in the morning:

 

I've described in previous blogs and in my book, Sleep, Interrupted, the concept of laryngeal descent. Your voice box (larynx) had to drop down below the tongue to allow for complex speech and language. Comparative anatomists and evolutionary biologists have stated that speech and language development was ultimately detrimental to humans. This is why only humans have various breathing and swallowing problems that other animals, for the most part, don't suffer from. 

 

In humans, the voice box continues to descend throughout life, but there are two major stages of laryngeal descent that are important. The first one occurs around 4-6 months, when the voice box drops down from behind the tongue (at vertebral levels C3-C4) to a position below the tongue. This process also create a space called the oropharynx between the soft palate and voice box, where the tongue can fall back more easily. Before this happens, human infants can suckle and breathe at the same time, but during this transition they have to relearn how to swallow and breathe. Interestingly, this is also the time when the rate of SIDS (sudden infant death syndrome) is at its' highest.

 

The second stage occurs during adolescence. The voice box begins to drop even further, reaching its' final relative position in the late teens (vertebral level C7). In fact, the voice box continues to drop another 1/2 vertebral height well into your 80s (see figure 2.1 in this link). In boys, this happens to a greater degree than in girls, leading to a deeper voice in men. As the voice box drops lower and lower, the more your tongue is susceptible to collapse while sleeping supine (on your backs), and when in deep sleep, since your muscles are most relaxed during this time. If you add to this additional dental crowding and jaw narrowing, you'll see that it can explain many of the health problems that all modern humans suffer from.

 

This leads to less efficient sleep, leading the teen to be attracted to stimulating activities that compensate for this fact. No wonder many teens are so incredibly productive, engaging in sports, clubs, academics, and social activities. Because of this mental, emotional and physical overload, they can't shut down their minds at night, leading to delayed sleep times. But then they are forced to wake up long before they achieve the necessary hours of restorative sleep.

 

Add to this all the distractions of modern society, including cell phones, texting, chats, light bulbs, computers and TV. Also notice how bright the LED lights are in all the bedroom electronic devices. One modern LED is now 10 times brighter than a traditional night light. 

 

Do your teenaged children have trouble getting up in the morning? What kind of activities are they engaged in during the day? What's their nighttime routine before going to bed? Please enter your response to this blog in the comments box below.

Intriguing Sleep Apnea and Autism Connections

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.

Sudden Infant Death Syndrome & Obstructive Sleep Apnea

I recently stumbled upon a handful of studies about sudden infant death syndrome (SIDS) in a book on sleep apnea by Dr. Allan Pack. SIDS is a tragic condition where an infant dies suddenly in the first year of life or no apparent reason. Apparent life threatening events (ALTEs, or near-miss SIDS) are episodes then a child stops breathing, but comes back to life. Not too surprisingly, Dr. Christian Guilleminault (who published the original paper on upper airway resistance syndrome, and the link between sleep apnea and cluster headaches and sleep walking) and colleagues reported that in 3/5 families of children with SIDS or near-miss SIDS, parents and grandparents had elevated AHIs and excessive sleepiness. All seven children in this study with near-miss SIDS were found to have obstructive sleep apnea at 12 months. 

In a follow-up study, Guilleminault followed 25 children with near-miss SIDS (by 4.5 months) in a group of 700 that required sleep studies for over one year. All 25 were found to have obstructive sleep apnea by age 5. Deray, et al found that loud snoring frequency in fathers of SIDS or near-miss SIDS children was over 2 times that of control. It was stated clearly that this is a subgroup of all children with SIDS, but my gut feeling is that it’s much bigger than they think it is.

I alluded to another study in a past post where breast-feeding was found to lower SIDS rates. I’ve presented evidence that bottle-feeding may increase the chances of developing obstructive sleep apnea. It’s interesting to note that the peak incidence of SIDS occurs around 4-6 months. This is also the time that the infant’s voice box descends and separates away from the soft palate. This transitional period can be a dangerous time for infants, as they go from obligate nasal breathers (when they can suckle and breathe in parallel) to nasal and mouth breathers. 

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