January 15, 2013
Deformational (or positional) plagiocephaly (DP) is a commonly seen condition, especially since pediatricians began to recommend placing our infants on their backs to sleep. Here’s a study showing that children with DP have lower developmental scores at age 3 compared to those that didn’t have DP. The largest differences were seen in cognition, language, and parent-reported adaptive behavior.
This study doesn’t say anything about sleep positions, but I’m wondering if the children without PD were more likely to sleep on their sides. We know that back sleep, while it can lower your chances of developing sudden infant death syndrome, can potentially lower deep sleep quality, leading to less than optimal brain development.
Dentists are also saying that having an asymmetric or flattened skull in the back can translate to asymmetry of the facial skeletons in the front, leading to TMJ problems and crooked teeth.
How many of you have children that had PD?
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?
March 19, 2012
I was shocked and saddened to find out that my friend and colleague, Dr. Brian Palmer, recently passed away. Dr. Palmer was responsible for opening my eyes to the importance of breastfeeding and good dental hygiene when it comes to your risk of developing obstructive sleep apnea. His decades of research and teaching has educated thousands of health care professionals. I had him as a guest on my Expert Interview program twice, the last time being December, 2011. Prophetically, I do remember him telling me that his 2 hour presentation was his gift to society. You can listen to his talk on the Evolution of Malocclusion and Sleep Apnea here. His website is a valuable resource for the lay public and professionals alike.
Rest in peace, Brian.
March 7, 2012
The American Academy of Pediatrics just published a policy statement reiterating their recommendation that infants should be breastfed exclusively for 6 months. They also made this recommendation in their 2005 paper, but this time they actually quantify the health benefits.
The authors wrote that others have suggested that more than 900 infant deaths per year in the United States could be prevented if 90% of mothers breastfeed exclusively for six months. They also cited evidence that breastfeeding improves neurodevelopmental outcomes and enhances development of host defenses in infants born preterm. Other benefits include the following:
- 72% reduction in hospitalization for respiratory infections
- 64% reduction in the incidence of gastrointestinal infections
- 58% to 77% reduction in the incidence of necrotizing enterocolitis
- 36% to 45% reduction in the risk of sudden infant death syndrome
- 27% to 42% reduction in the incidence of asthma, atopic dermatitis, and eczema
- 52% reduction in the risk of celiac disease
- 31% reduction in the risk of inflammatory bowel disease
- 15% to 30% reduction in the incidence of obesity in adolescences and adulthood
- 15% to 20% reduction in the risk of childhood leukemia and lymphoma.
I’ve also proposed arguments made by dentists that bottle-feeding increases your risk of dental crowding and malocclusion. The smaller your jaws, the less airway you’ll have to breathe through properly during the day and especially at night. Notice that sleep-related breathing problems can directly or indirectly influence most, if not all the bullets listed above.
It’s also important to note that the physical act of breastfeeding itself is what protects against dental crowding and an increased risk of developing obstructive sleep apnea later in life. Obviously, exclusive breastfeeding without pumping is not practical or realistic in our society. However, you have to think about these implications.
Do you think Pediatricians are going a good job promoting breastfeeding?
May 11, 2011
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?
May 4, 2011
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.
April 6, 2011
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?
December 3, 2010
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?
November 25, 2010
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.
November 17, 2010
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?