Sleeping nightmare: How snoring meant my child was naughty and only surgery could help

Notes from Dr. Norman Blumenstock

My advice to parents is if you have a child who snores and whose behaviour is out-of-control, have a sleep test.

Katrina Creer with her son Mitchel, 4, battled sleep aponea for years.

WE used to think it was a blessing our youngest child was a terrible snorer. Exhausted after a morning of meltdowns it was never a problem putting him down for his nap. And his snoring was so loud I didn’t even have to walk down the corridor to check on him.

But when he was awake, things were different. While most two-year-olds have tantrums our toddler’s were in the extreme. While other children amused themselves at the local playgroup, my son was trying to escape out the door.

SIGNS OF SLEEP APONEA

• Snoring in children with sleep aponea normally starts around two years

• It can also occur in seven to nine year olds, usually as a result of allergy or obesity

• Children tend to sleep with their neck and head stretched back

• They are fussy eaters preferring soft foods like cheese and yoghurts over hard to swallow foods

• They are often restless and sweaty sleepers

• They can be cranky during the start and end of the day, but will often appear hyperactive

• Take a video of your child sleeping and see your GP

• Other signs are blocked nose, dry lips and dark rings around eyes. They can also have a cross bite

Whenever possible, I needed someone to help me put him in his car seat as he would lie down on the floor kicking and waving his arms. This went on for two years.

Not surprisingly, there were very few offers to babysit. Friends and family didn’t always see the same loving and cuddly little boy we knew, which always reassured us there was probably nothing seriously wrong.

But by his third birthday, Mitchell barely slept through the night and his behaviour was wearing thin. Dinnertime was a struggle but by chance, one day I noticed a huge set of tonsils.

I sounded desperate but luckily our GP agreed and sent us to an Ear, Nose and Throat specialist.

While we had sought medical help before for his behaviour, we were told he would most likely outgrow it. In our sleep-deprived fog, we don’t remember anyone asking us “does your son snore?”

The specialist immediately suspected sleep aponea.

The condition causes a loss of airflow during rest often due to enlarged tonsils or adenoids.

It can also make young children naughty, despite being very tired they appear hyped-up. According to doctors, it mimics the symptoms ADHD.

The only way to make a definite diagnosis was a sleep study. The cost was covered by our private health insurance. Mitchell was wired up and eventually dosed off during our overnight stay in hospital.

Katrina Creer with her son Mitchel, 4, now enjoy a more soothing night’s sleep.

As I lay in the same room, I could hear him noisily sucking in the air. Occasionally it would go quiet and then restart. He never fully woke and if we were at home, we would have thought it was a good night.

The test showed Mitchell had a moderate sleep aponea waking on average 26 times every hour with his oxygen levels dipping to 80 per cent. It is likely he had never been in a deep enough sleep to ever dream.

I felt relief when told the results. Over the years I’d been given plenty of parenting advice, but deep down I always felt like he just couldn’t help it.

Three months after surgery and a much calmer little boy had emerged. And now, almost a year after surgery, he has become an absolute joy.

My advice to parents is if you have a child who snores and whose behaviour is out-of-control, have their sleep checked.

For further information contact the Woolcock Institute on (02) 9114 0000 or www. woolcock.org.au

Bronx Train Tragedy Continues to Resonate

Tragedy often sparks change, and last year’s Bronx train derailment may ultimately lead to more and better sleep disorder screening for New York transit employees. In addition, new procedures will make it harder for sleep deprived employees to allow trains to get back into service.

According to Gannett’s news, Metro-North in the Bronx plans to ask the Metropolitan Transportation Authority in December to approve hiring a company to provide sleep apnea screening in a pilot program. The train conductor presiding over last year’s derailment (which killed four and injured dozens) had “severe sleep apnea.”

Ken Valenti writes that the Federal Railroad Administration is writing rules to address sleep disorders and reduce fatigue in train engineers and other employees. “Our goal is to reduce the likelihood of accidents, injuries, and fatalities caused by fatigue,” FRA spokesman Michael England said in an email. He did not know when the rules would be completed or implemented.

Among the additional proposed changes was a system to protect workers put in place after track foreman Robert Luden was killed by a train on a track that had been taken out of service. The new system reportedly blocks a rail traffic controller from allowing trains back on an out-of-service track without entering a computer code given only to a supervisor at the work site.

Source: Gannett Company Inc

Sleep Duration Affects Risk for Ulcerative Colitis

Notes from Dr. Norman Blumenstock

Another important reason to get the right amount of quantity and quality of sleep

Published on October 22, 2014

If you are not getting the recommended 7 to 8 hours of sleep each night, you may be at increased risk of developing ulcerative colitis. This is according to a new study1 in Clinical Gastroenterology and Hepatology, the official clinical practice journal of the American Gastroenterological Association.

“Both short and long durations of sleep have important health implications and are associated with increased overall mortality, cardiovascular disease and cancer,” says lead study author Ashwin N. Ananthakrishnan, MD, MPH, Massachusetts General Hospital, in a release. “Our findings indicate that ulcerative colitis may potentially be added to this list. We found that less than 6 hours of sleep per day and more than 9 hours of sleep per day are each associated with an increased risk of ulcerative colitis.”

Researchers conducted a prospective study of women who were enrolled in the Nurses’ Health Study (NHS) I since 1976 and NHS II since 1989 and followed through detailed biennial questionnaires with greater than 90%  follow-up. The large size of the cohorts, prospective design, and prolonged duration of follow-up provide a unique opportunity to examine the association between sleep duration and incident disease with sufficient power to adjust for potential confounders.

The results demonstrated that there is a “U-shaped” relationship between sleep duration and risk of ulcerative colitis, with both short and long duration of sleep being associated with an increased risk of disease. These observed associations were independent of other known environmental risk factors.

In a previous study, 2 also published in Clinical Gastroenterology and Hepatology last year, Ananthakrishnan and colleagues had reported that poor sleep quality, even while in remission, resulted in a twofold increase in risk of Crohn’s disease flares at 6 months. “All these data together support a growing recognition of the impact of sleep disruption on the immune system, and the need for providers to frequently inquire about sleep duration and quality as an important parameter of health in patients with inflammatory bowel diseases,” Ananthakrishnan says.

The authors acknowledge several study limitations. First, the study population consisted predominantly of white female nurses and is thus not representative of the gender and ethnic distribution in the general population. Sleep duration was also self-reported. However, the size of the study and quality of data substantiate these findings.

Future studies are warranted to better understand mechanisms by which sleep may influence intestinal inflammation.

REFERENCES

1 Ananthakrishnan AN. Sleep duration affects risk for ulcerative colitis: a prospective cohort study. Clinical Gastroenterology and Hepatology. 2014:12(11):1879-1886.

2 Ananthakrishnan AN. Sleep disturbance and risk of active disease in patients with Crohn’s disease and ulcerative colitis. Clinical Gastroenterology and Hepatology. 2013:11(8):965-971.

NTSB: Engineer’s Sleepiness Caused Deadly Bronx Metro-North Train Derailment

October 28, 2014 5:35 PM

NEW YORK (CBSNewYork/AP) — Another stinging report was issued on the Metro-North Railroad Tuesday, concluding this time that a sleep-deprived engineer nodded off at the controls of a Metro-North train just before taking a 30 mph curve at 82 mph, causing a derailment that killed four people and injured more than 70 in the Bronx.

As CBS 2’s Don Champion reported, the National Transportation Safety Board report also announced the findings into the investigation of four other Metro-North accidents that occurred in New York and Connecticut in 2013 and 2014, and concluded that the railroad blew off safety concerns as a matter of habit.

EXTRA: Click Here For The Full NTSB Report

U.S. Sens. Charles Schumer (D-N.Y.) and Richard Blumenthal (D-Conn.) were furious about the findings.

“The MTA has blood on its hands,” Blumenthal said.

“The NTSB report represents a horror-house of negligence resulting in injury, mayhem and death,” added Schumer.

And as if the reaction from lawmakers did not sting enough, the findings alone by the NTSB also paint a nasty picture of the culture inside that nation’s second largest commuter rail line.

“Two accidents on one railroad in a short period of time may be a coincidence,” Hart said. “Five accidents in one railroad in less than a year begged the question — how important was safety at Metro-North?”

The NTSB concluded that safety was not important at the Metro-North. In fact, the report found the railroad often failed to keep up with regular track maintenance — opting to put it off.

The lack of detailed, visual track inspections were pinpointed in two of the accidents investigated.

“Maintenance and other ongoing efforts to address known safety issues should not have to wait for accidents in order to be implemented, but instead should be preventive measures and be completed before an accident occurs,” said Acting NTSB Chairman Christopher Hart.

The NTSB also found that the railroad was seven years’ behind schedule in replacing some track parts.

And as for the Bronx derailment near the Spuyten Duyvil station on the Hudson Line, the NTSB said engineer William Rockefeller’s sleepiness was due to a combination of an undiagnosed disorder — sleep apnea — and a drastic shift in his work schedule, the NTSB said in the report.

“We determined that the cause of this tragic accident was the engineer’s non-compliance with the 30 mph speed restriction because he had fallen asleep due to undiagnosed, severe obstructive sleep apnea,” Hart said.

The agency said the railroad lacked a policy to screen engineers for sleep disorders, which also contributed to the Dec. 1, 2013 crash. It also said a system that would have automatically applied the brakes would have prevented the crash.The NTSB also took issue with the lack of a federal rule requiring railroads screen engineers for sleep disorders. Metro-North plans to start screening in December.

For its part, in the past year, Metro-North said it has already invested millions of dollars into new safety programs and infrastructure.

“This would be almost a comedy of errors if it weren’t so tragic,” Schumer said. “It’s clear these mistakes were avoidable.”

The NTSB had reported Rockefeller’s sleep apnea in April, saying tests revealed it interrupted his sleep dozens of times each night.

Investigators said Rockefeller told them he had felt strangely “dazed” right before the crash. But until Tuesday it had refrained from declaring his sleepiness as the cause of the crash.

It said that less than two weeks before the crash, Rockefeller had switched from a work day that began in late afternoon to one that began early in the morning. The board said that probably compounded his sleep problem.

It also noted that the technology known as positive train control was not in use at the time of the crash. Positive train control can automatically bring a train to a stop if it’s exceeding a speed limit. Metro-North has said it is working to install the technology.

On the other accidents, the NTSB found:

- A May 17, 2013, derailment and collision in Bridgeport, Connecticut was caused by broken joint bars, which are used to join rails of different sizes. At least 65 people were injured. The board said Metro-North had deferred scheduled track maintenance and lacked “a comprehensive track maintenance program.”

- A track foreman who was fatally struck by a train in West Haven, Connecticut on May 28, 2013 was probably due to a mistake by a student rail traffic controller. The controller misunderstood some instructions and canceled the signals protecting the section of track the man was on, the NTSB said.

- In a similar accident in Manhattan on March 10, 2014, a Metro-North worker was killed by a train while trying to re-energize tracks that had been out of service for maintenance. The NTSB blamed the accident of briefings that poorly communicated which part of the track would be safe.

- The derailment of a freight train on Metro-North tracks in the Bronx on July 18, 2013, which caused no injuries, was caused by deteriorated concrete ties and other problems compounded by deferred maintenance, the NTSB said.

“Seeing this pattern of safety issues in a single railroad is troubling,” Hart said. “The NTSB has made numerous recommendations to the railroad and the regulator that could have prevented or mitigated these accidents. But recommendations can only make a difference if the recipients of our recommendations act on them.”

On Tuesday, the railroad’s newly-hired president admitted Metro-North lost focus by putting on-time performance above everything else.

“It’s been a continuous process to get this railroad back up where it belongs and keep the safety on it,” said Metro-North President Joe Giulietti.

Giulietti said the report will be taken very seriously.

“We truly take to heart all the issues that have been stated,”Giulietti said. As an example, he said the railroad already has begun a test project on engineer sleep apnea that will be expanded.

In March, the Federal Railroad Administration issued a stinging report on Metro-North, saying the railroad let safety concerns slip while pushing to keep trains on time. Railroad executives pledged to make safety their top priority.

Since the incidents, the MTA has also hired David Mayer as the chief safety officer. His job is to work with Metro-North to keep a close eye on equipment and crews and make sure these crashes don’t keep happening.

The NTSB said it will also issue safety recommendations designed to “improve railroad safety on Metro-North and other railroads.”

Riders welcome changes.

“You have to have faith that the system work and that they’re going to fix those things,” said rider Gerald Watford.

The NTSB in the report also put blame in its report on the Federal Railroad Administration, for essentially failing to regulate Metro-North.

Snoring, heart disease and sudden death

Notes from Dr. Norman Blumenstock

Despite CPAP good efficacy, it fails approximately 50% of the time due to lack of compliance.

Philippine Daily Inquirer 4:08 AM | Saturday, October 25th, 2014

So now we know better. Snoring, as a symptom of obstructive sleep apnea (OSA), is definitely not a benign disorder which carries no serious implications. It is linked with the development of difficult-to-treat high blood pressure, heart enlargement, heart failure, diabetes, accidents due to daytime sleepiness, memory lapses, irregular heartbeat and even sudden cardiac death (SCD).

Mayo Clinic researchers in the United States studied the sleep characteristics of close to 11,000 adults in an overnight sleep laboratory, and found that OSA can cause low nighttime oxygen saturation in the blood, and this may be a triggering risk factor for SCD, due to a fatal irregularity of the heart beat called ventricular fibrillation.

Some of these unfortunate patients may die suddenly in their sleep. Many cases of what we attribute to bangungot may actually be related to OSA.

In the Mayo Clinic study, OSA was one of two  factors that contributed to the highest risk of SCD. OSA has been implicated in SCD, and the study is the first large study to rigorously test the hypothesis and offer some hard evidence to support it.

Frequently overlooked

Physicians should always watch out for OSA in their heart patients and treat it promptly when present. This is a frequently overlooked problem in clinical practice.

Various treatment options are used in patients with OSA. Lifestyle measures like weight reduction in overweight individuals,  and avoiding alcohol and smoking can help and might be sufficient to treat mild cases of OSA. Medications that relax the central nervous system like sedatives and muscle relaxants should also be avoided.

A change in sleeping position can also do the trick. Many people may snore less when sleeping at a 30-degree elevation or higher of the upper body, as if sleeping on a recliner. This prevents the collapse of the airway, in the usual supine sleeping position. Sleeping on one’s side instead of sleeping on the back may also help.

For moderate to severe cases of OSA, a CPAP (continuous positive airway pressure) device can be a life-changer. An OSA patient puts on a well-fitted nasal or facial mask which is connected to the CPAP device and this helps keep the airway open when asleep.

The CPAP device is the most commonly used device for OSA, but other, newer modalities may also be used. These include the VPAP (variable positive airway pressure), also known as bilevel or BiPAP device. It monitors the patient’s breathing, and provides two different pressures, a higher one during inhalation and a lower pressure during exhalation. The VPAP or BiPAP is more expensive, and is sometimes used in patients who have other coexisting respiratory problems.

One can also read about appliances, splints or mouth guards that are being advertised in the Internet and in various health publications. All of them are designed to hold the lower jaw slightly down and forward relative to the natural, relaxed position. This position holds the tongue farther away from the back of the airway, and may be enough to help relieve apnea and improve one’s breathing during sleep. However, none of them has been shown to be more effective than the CPAP or BiPAP devices.

Premarket approval
A few months back, the United States Food and Drug Administration granted premarket approval for an upper airway stimulation system that senses respiration, and delivers mild electrical stimulation to the hypoglossal nerve in order to increase muscle tone at the back of the tongue so it will not collapse and obstruct the airway. It is powered by an implantable pulse generator, similar to a heart pacemaker device implanted in patients with heart blocks and very slow heart rates. Although the device is promising and has been shown to be effective, I think it’s a lot simpler, more convenient and economical to just use a CPAP device.

In more severe cases wherein an anatomical problem in the airway is identified, surgery may be considered to modify airway anatomy. This is still controversial and should only be considered as a final resort.

Other surgical procedures to relieve airway obstruction like straightening of the nasal septum, tonsillectomy and/or adenoidectomy, removal or reduction of parts of the soft palate, and tracheostomy (incising a hole in the anterior part of the neck to the windpipe)  may have to be done in more extreme cases.

Obstructive sleep apnea is more common than previously thought. It can become serious if undetected and untreated. It can be a stealthy killer; it comes figuratively and literally like a thief in the night. Make sure you’re not one of its victims.

Sleep Apnea Increases Risk of Atrial Fibrillation After Bypass Surgery

MedicalResearch.com Interview with:
Adrian Baranchuk MD FACC FRCPC
Associate Professor of Medicine
Director, EP Training Program Queen’s University
Kingston, Ontario, Canada



Medical Research: What are the main findings of the study?

Dr. Baranchuk: In this study, we investigated whether obstructive sleep apnea increases the risk of atrial fibrillation after coronary artery bypass surgery. We found the risk to increase by approximately two-fold for patients with obstructive sleep apnea, suggesting that this disease is a strong predictor of atrial fibrillation after coronary artery bypass surgery.

We also found that the risk increases in patients with more severe obstructive sleep apnea.

This is an important association to explore since atrial fibrillation after coronary artery bypass surgery increases patient mortality, the risk of stroke, hospital stay, healthcare costs, and has substantial burden on patients and their families. It is also a common complication of the surgery, occurring in up to half of the patients. Knowing which factors increase its risk gives us a better understanding of how to manage it and mitigate its negative consequences.

Medical Research: What was most surprising about the results?

Dr. Baranchuk: Factors like age, obesity, and many others can influence the risk of atrial fibrillation after coronary artery bypass surgery. Some studies we investigated in our systematic review controlled for these factors, and obstructive sleep apnea became a stronger risk factor when these study results were pooled.

This suggests that obstructive sleep apnea independently predicts which patients are more likely to have atrial fibrillation after coronary artery bypass surgery.

Medical Research: What should clinicians and patients take away from your report?

Dr. Baranchuk: Healthcare specialists of multiple disciplines, including cardiologists, anesthesiologists, and cardiac surgeons should equip themselves with the necessary knowledge and tools to both recognize and optimally manage obstructive sleep apnea. This can include screening patients for obstructive sleep apnea using questionnaires, as well as following up to date guidelines and using the best available evidence to manage it.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Baranchuk: We were not able to identify any studies that investigated the effectiveness of obstructive sleep apnea management strategies on reducing the risk and negative consequences of atrial fibrillation following coronary artery bypass surgery. This is an appealing research topic to explore, since it can inform whether managing obstructive sleep apnea, such as using continuous positive airway pressure, has a positive impact for outcomes in this patient population.

Citation:

Obstructive Sleep Apnea as a Predictor of Post Coronary Artery Bypass Graft Atrial Fibrillation: A Systematic Review and Meta-analysis
Qaddoura, Amro et al.

Canadian Journal of Cardiology

Received: September 23, 2014; Received in revised form: October 10, 2014; Accepted: October 13, 2014; Published Online: October 14, 2014

DOI: http://dx.doi.org/10.1016/j.cjca.2014.10.014

Your Brain May Get Smaller if You Don't Sleep Enough

Notes from Dr. Norman Blumenstock

EmpowerHER reports that a portion of the brain may shrink when individuals do not get an adequate amount of sleep.

The cerebral cortex is the site of complex functions of the brain, and controls how we think and interact with the world. According to the study, lack of sleep may shrink part of the frontal cortex, which deals with problem-solving, self-control, planning and logic. Lack of sleep also accelerates the rate of brain loss in regions that process sound, language and spatial orientation.

Monkey Business Images/PhotoSpin

Getting a good night’s sleep has all sorts of health benefits, while a bad night’s sleep can lead to health issues, from aging skin to weight gain. But these effects seem less drastic in light of a study published last month in the journal Neurology. It showed that poor quality sleep is actually linked with wasting away of the brain, especially in those over 60 years old.

Researchers from University of Oxford and University of Oslo sampled 147 adults. The subjects ranged from 20-84 years old and encompassed a variety of physical activity levels, body mass index (BMI) and blood pressure levels.

Each subject completed a questionnaire that measured sleep quality. The questionnaire assessed three main things: sleep latency (how long it takes to fall asleep), sleep duration (how many hours of sleep per night) and sleep efficiency (the percentage of time spent actually sleeping).

Two MRI scans were done for each subject, an average of 3.5 years apart, to see how different sleep habits affected the brain. After comparing brain volumes from the two scans, the researchers found that physical activity, BMI and blood pressure were not related to brain volume.

However, poor sleep quality was related to reduced brain volume, specifically in the cerebral cortex.

The cerebral cortex is the site of complex functions of the brain, and controls how we think and interact with the world. According to the study, lack of sleep may shrink part of the frontal cortex, which deals with problem-solving, self-control, planning and logic. Lack of sleep also accelerates the rate of brain loss in regions that process sound, language and spatial orientation.

The correlation between lack of sleep and reduced brain size was strongest for subjects over 60 years old, a period in life that is often characterized by poorer sleep. Generally, people older than 60 sleep less, take longer to fall asleep and wake up more often in the middle of the night, according to a New York Times article.

The researchers of the Neurology study emphasized that they didn’t know for sure whether poor sleep causes brain shrinkage or whether it's the other way around. Perhaps brains naturally decay somewhat as we age, which leads to worse quality of sleep, the study said.

Other people have suggested that poorer quality of sleep in older people doesn’t come from their age, but rather their illnesses or medications. “The more disorders older adults have, the worse they sleep,” Sonia Ancoli-Israel, a sleep researcher at the University of California, San Diego, told New York Times.

It turns out that sleeping well is just as important for the over-60 crowd as for 20 year olds, although what defines sleeping well could be different for the two age groups.

Regardless, there seems to be a consensus that getting a good night’s sleep is important, no matter the age. And for those over 60 years old, good sleep may be essential to slowing down brain loss.

Sources:

The Elderly Always Sleep Worse, and Other Myths of Aging. New York Times.com. Retrieved October 5, 2014.
http://www.nytimes.com/2007/10/23/health/23age.html?_r=0

Human Brain: Facts, Anatomy & Mapping Project. LiveScience.com. Retrieved October 5, 2014.
http://www.livescience.com/29365-human-brain.html

Lack of sleep may shrink your brain. CNN.com. Retrieved October 3, 2014.
http://www.cnn.com/2014/09/04/health/no-sleep-brain-size/index.html?hpt=...

Poor sleep quality is associated with increased cortical atrophy in community-dwelling adults. Neurology. Retrieved September 28, 2014.
http://www.neurology.org/content/early/2014/09/03/WNL.0000000000000774

Reviewed October 8, 2014
by Michele Blacksberg RN