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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Summer 2012, Issue 4 Complimentary Copy

SLEEP AND AUTISM Helping Autistic Children Sleep Through the Night

ORAL APPLIANCES An Alternative to CPAP Therapy

UPPER AIRWAY RESISTANCE SYNDROME More Common Than You Think

SLEEP

MEDICATION www.sleepandwellness.net

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Does sleep fascinate you? The need for trained sleep professionals is in high demand across the country; More than 100 million Americans suffer from some form of sleep disorder, 18 million Americans suffer from sleep apnea. Sleep technologists have competitive wages and there are job opportunities found in hospitals, sleep disorder clinics, as well as in private labs. The American Sleep and Breathing Academy offers courses needed to become a Registered Polysomnography Technologist. The program is designed to prepare students to perform, monitor, and interpret sleep studies. Are you already a Sleep Professional? Join us every month for our Lunch Break Broadcast. The Lunch Break CEC is an hour long broadcast with 1 continuing education credit for all participants. Every month features a different topic with speakers that are experts in the field.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

The Sleep Institute of Utah and its team of Board Certified Sleep Specialists, Registered Sleep Technicians, and Respiratory Therapists are here to take care of all of your sleep disorders. We accept most insurance plans. Our services are range from Physician Consultations, In-Lab Sleep studies, In-Home Sleep Studies, to DME homecare. Free take-home oximetry pre-screening devices also available in our offices for easy pick up and go use. Giving you the most up to date information on new devices and concepts as the field develops and changes. With state of the art equipment and bedrooms designed to make you feel at home, the Sleep Institute of Utah offers a pleasant sleep experience for your sleep study. We have six convenient locations throughout the Wasatch front – call us today so you can start sleeping better tonight.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Summer Edition 2012--

FEATURES

Children and Autism - Jerry Kartzinel, M.D., F.A.A

12 Sleep and Medication - Simone de Lacy, B.S.C., RPSGT

40 Upper Airway Resistance Syndrome - Steven Y. Park, M.D.

46 Oral Appliances - Gary Lowder, D.D.S.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Table of Contents

DEPARTMENTS Sleep Positions - Sydney Risser, P.T.

Health and Wellness Basics of a gluten free/casein diet - Julie Mathews, C.N.C.

Gluten Free Recipes - courtesy of Delight Gluten-Free Magazine

24 Q&A About Night Terrors - Dr. Natasha Burgert

Children and Soda - Janet Peterson, DrPH

26 www.sleepandwellness.net

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

CONTRIBUTORS AMERICAN SLEEP & BREATHING ACADEMY EDUCATION BOARD Cindy Olsen, RPSGT Alex Jones, R.C.P Syed I. Nabi, M.D. Tala’at Al-Shuqairat, M.D. MANAGING EDITOR Alan Seko CONTRIBUTING WRITERS Gary Lowder, D.D.S. Steven Y. Park, M.D. Simone de Lacy, BSC RPSGT Kenneth Duckworth, M.D. Julie Mathews, C.N.C Janet Peterson, DrPH Sydney Risser, P.T. Natasha Burget, M.D. Jerry Kartzinel, M.D., F.A.A. Vanessa Maltin Weisbrod HEALTH AND WELLNESS EDITOR Ja-Ann Wolsey CREATIVE DIRECTOR XO Marketing SALES & MARKETING Angela Kyzer PRODUCTION DIRECTOR Carline Risser PUBLISHING

Sleep & Wellness Magazine is produced, published and distributed quarterly by The American Sleep and Breathing Academy, LLC, 8706 South 700 East Suite #207, Sandy, Utah 84070. The American Sleep and Breathing Academy, LLC also produces and publishes Principles of Polysomnography, Principles of Polysomnography practice examination manual, Principles of Polysomnography pocket guide, and other educational written materials key in the field of sleep. Entire contents copyright 2011 American Sleep and Breathing Academy, LLC all rights reserved. Reproduction in whole or in part is prohibited. PRODUCED IN THE UNITED STATES OF AMERICA.

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LETTER FROM THE EDITOR You are what you eat and drink. In this issue of Sleep & Wellness Magazine, we’ve dedicated two articles to the topic of diet and children, and some of the information presented may shock you. In her article, “Children and Soda,” Janet Peterson suggests, “With every single serving of soda your child consumes, his or her risk of being overweight or obese increases by 60 percent!” Peterson goes on to place the blame for soda consumption on parents. She notes that only 1.4 percent of all sodas consumed by children are done so in schools. She writes, “If you drink soda, then it is very likely that your children will as well. One of the first steps you can do to reduce your child’s soda consumption is to not purchase or drink soda in the home.” Julie Mathews, a certified nutritional consultant, takes on a completely different dietary issue in her article, “Basics of Implementing a Gluten-free and Casein-free Diet.” Mathews discusses how removing gluten and casein can improve the quality of life for children suffering from autism. Mathews notes, “Gluten is the protein in wheat, as well as other grains including rye, barley, spelt, kamut and commercial oats, and casein is the protein in dairy.” Mathews says the elimination of these ingredients “can help children feel and learn better by reducing inattentiveness and hyperactivity, improving speech and language, decreasing digestive disturbances and much more.” The fourth issue of Sleep & Wellness Magazine also includes articles on “Autism and Sleep,” “Medication and Sleep,” “Efficacy of Oral Appliances for Sleep Apnea” and “Sleep Positions.” Our regular Q&A section focuses on “Night Terrors” among children. Sleep & Wellness Magazine is brought to you by the American Sleep & Breathing Academy. We’re delighted to report that our relatively new publication now has an estimated circulation of 100,000 online and 75,000 print readers—and that number is growing every day. We look forward to bringing readers like you important information that can improve your quality of life. - American Sleep & Breathing Academy Education Board

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

NATIONAL SLEEP AWARENESS ROUNDTABLE

WELCOMES NEW MEMBER

The National Sleep Awareness Roundtable (NSART) is a national coalition of governmental, professional, voluntary, and other organizations whose mission is: 1) to raise awareness about; 2) to increase the understanding of; and 3) to reduce the public health and safety impact of sleep deprivation and sleep disorders by improving communication and collaboration among local, state and federal agencies; professional organizations; and the public. NSART is a program of the National Sleep Foundation (NSF), an independent, non-profit 501(c)(3) tax-exempt organization.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

You can now find Sleep & Wellnesss magazine online! Read your favorite articles and search past issues.

Education, Support and Advocacy

For nearly a quarter century, the American Sleep Apnea Association and its A.W.A.K.E. Network of support groups have provided education, support and advocacy to those diagnosed and living with Sleep Apnea. For additional information: www.sleepapnea.org n info@sleepapnea.org n 888.293.3650

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Jerry Kartzinel, M.D., F.A.A 12

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p and the SLEEP & WELLNESS MAGAZINE // SUMMER 2012

child

One

of the most common problems I deal with in my practice is the complaint that the child with autism does not sleep through the night. It is very gratifying for me to eliminate this problem from the list of concerns, not to mention the parents’ profuse appreciation for a full night’s rest!

Interruption of sleep is almost always a medical problem, but the solution to the problem may initially be very elusive. To start, we will discuss the two main kinds of sleep alteration: sleep disruption and sleep interruption. Except for the first few months of life, children should

sleep through the night. Children with autism, depending on the age when autistic symptoms emerge, most commonly do not sleep through the night. Here are examples of some different sleep disruption patterns: •

Never did initiate sleep well or maintain sleep

•

Not able to get to sleep until late (called initiating sleep), but once asleep, sleeps through the night

•

Goes to sleep easily, but wakes up three to four hours later and then may be up for the next 18 hours

•

Trouble going to sleep, and up every two to three hours, taking anywhere from 30 minutes to three to four hours to get back to sleep

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012 •

Difficult to get to sleep, stays asleep for 20 to 30 minutes, then up again

•

Children who go to sleep well, but always wake up with a bowel movement in the middle of the night

Some of the children I see did originally develop normal sleep patterns; then somewhere between 1 and 2 years of age these healthy patterns fall apart. The disruptions can happen abruptly or over time. Usually the parents adapt and develop some very unusual ways of coping with it just to get some sleep! Sleep interruptions are slightly different from sleep disruptions. They can manifest in a variety of ways with the child waking up: •

In a full panic

•

Giddy and laughing

•

Crying and sobbing

•

Full out screaming

•

With certain needs like the lights on, the TV on, requiring a parent to sleep near them

•

Bowel movement/urination

•

Just plain happy to be up (usually much to the parents’ dismay. Some parents have to actually drive the child around in the car to sleep! The best approach to managing a child with sleep cycle disruptions or interruptions requires the physician and parents to work closely together to help sort out the cause of these disruptions. Sleep and colic When a child less than 1 year of age has definite sleep cycle disruptions, the child is called a “colicky” kid. We have to seriously consider the type of foods the “colicky” child is receiving. Usually, these children do NOT tolerate dairy and soy formulas and need to be switched to elemental formulas such as Nutramigen, Alimentum or Neocate. If the formula is not the cause of the fussy baby, the physician should consider other gastrointestinal issues like reflux, constipation and maldigestion. Sleep and dairy I cannot tell you how many of my patients improve with just the removal of anything that contains dairy or dairy products. Make sure you check the labels of foods to ensure that they are completely dairy free. Many of the children I see are so intolerant of dairy that they wake up frequently due to stomach pain.

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Sleep and gluten Like dairy, gluten can cause sleep cycle disruptions. Now, I know this is very difficult to remove from a child’s diet, both at home, daycare, school, etc. But, this 100 percent removal is crucial to allow some children to sleep through the night. Some children can be very sensitive to gluten, which is part of most commonly used flours found in our diets. Please keep in mind, it is totally worth the trouble to remove gluten (remember, it must be 100 percent removal!) when it contributes to a full night’s rest for your child and for you. Sleep and bowel issues Constipation and diarrhea must be addressed and fixed to have any hope of our children sleeping through the night. Many times, constipation and diarrhea improve when gluten- and dairy-containing foods are removed from the diet. If not, they must be addressed. For more information on these topics, I would like to refer the reader to www.mendingautism.com. Inflammatory bowel disease, which is all too common in patients with autism, must too be addressed. As the name implies, “inflammation” always hurts, and a hurting child is just not going to sleep well. This condition can be diagnosed and managed by a pediatric gastroenterologist. Reflux is another bowel issue that affects the swallowing pipe called the esophagus. If acid from the stomach “backflows” up the esophagus, it will burn it, causing a condition called Reflux Esophagitis. This condition will definitely disrupt a child’s sleep. A pediatric gastroenterologist can diagnose this too, and the treatment is an antacid. Sleep and epilepsy Undiagnosed seizures can also disrupt sleep. In fact, there are seizures that are most prominent ONLY during sleep but you won’t see these as they are not associated with the out-of-control body movements typically associated with someone who has epilepsy. A pediatric neurologist can help us with the diagnosis and treatment, if necessary. Sleep and infections Chronic infections must be diagnosed and treated effectively. The doctor needs to check for chronic yeast infections, bacterial infections, viral infections and even parasitic infections. Interventions Studies have looked at patients on the autism spectrum and their decreased melatonin production1, and decreased rapid eye movement during sleep2, and decreased overall sleep2. I have found a lot of success in treating problems of not only going to sleep but staying asleep using

SLEEP & WELLNESS MAGAZINE // SUMMER 2012 only melatonin. Melatonin is critical to successfully initiate sleep. However, there may be a combination of supplements necessary to be used for maintenance of normal healthy sleep in some children. For children in my clinic who have issues of initiating sleep, we commonly start: •

•

Melatonin: ½ mg. to 3 mg. before bedtime, and maybe more if they wake between 1 and 2 a.m. Now, if the child can swallow capsules, there are slow release forms of melatonin that work nicely through the night. We can add 5 HTP if this is not enough to either initiate sleep, or maintain it through the night.

•

Calcium and magnesium supplements can be given with dinner

•

Vitamin D3 given with dinner, usually about 1000IU, but the dose can vary with age and blood levels of 25 OH vitamin D.

•

GABA 125 mg. with dinner, if something more needs to be tried.

•

Vitamin B6 50 mg. with Niacinaminde 500 mg.

•

Inositol 250 mg. to 1000 mg. at bedtime (helps with REM sleep).

5 Hydroxytryptophan (5HTP) 50 to 100 mg. I have found this especially useful when taken with Vitamin B6 and magnesium.

THE INTERRUPTION OF

SLEEP

IS ALMOST ALWAYS A MEDICAL PROBLEM, BUT THE SOLUTION TO THE PROBLEM MAY BE VERY ELUSIVE.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012 Herbs such as valerian and chamomile tea can be quite helpful, especially in those children who are really tough to get a full night sleep If these interventions are not successful, I can add in Benadryl and Ibuprofen at nighttime. This helps with possible allergic sources as well as pain and inflammation. Hyperbaric oxygen therapy treatments: Many children sleep amazingly well with this intervention. In fact, it seems to be one of the first changes seen during the therapy. If the above measures do not work, there are many prescription medications that can be used quite successfully, but that discussion is beyond the scope of this article.

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Finally, no matter where your child is on the spectrum, he or she will be able to function at a much higher level with a full night’s rest every night, and that is definitely worth striving for. 1. Melke J, Goubran GH, et al. Abnormal Melatonin Synthesis in Autism Spectrum Disorders. Mol Psychiatry. 2008 January; 13(1); 90-98. 2. Buckley AW, Rodriguez AJ, et al. Rapid Eye Movement Sleep Percentage in Children with Autism Compared with Children With Developmental Delay and Typical Development. Arch Pediatr Adolesc Med. 2010 Nov; 164(11); 1032-7.

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Everyone Sleeps; But do we understand just how important our sleep is to our vitality? Visit our online library where you can watch videos, read articles, and learn more about sleep and sleep disorders. Search our directory for a sleep facility near you or shop for products that will

calm, relax, and improve your SLEEP.

Let’s discover sleep together visit

www.letsdiscoversleep.com

your online resource for everything SLEEP www.sleepandwellness.net

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Your Health ~ Your Choice

Follow me @ daywithjae.com

daywithjae

Health and Wellness

As Health Editor for Sleep and Wellness Magazine, Ja-Ann incorporates techniques and ideas for getting fit and eating healthy as a way to induce productive healthy sleep. In order to get the optimal rest and rejuvenation our bodies need; it’s imperative to practice healthy daytime behaviors. Many are living with hectic stressful days and then wondering why they are unable to relax and sleep at night. Being mindful of the interrelationship between good daytime habits and a goodnights sleep is a critical step towards longevity and achieving one’s personal best self. Join Ja-Ann in her pursuit of optimal health at daywithjae.com a healthy living resource blog Find helpful tips and support form experts on sleep, yoga, nutrition, and fitness to guide you in your personal health journey. With the right information and motivation a good nights sleep is just a healthy day away.

You can also find Ja-Ann on

SLEEP WELLNESS magazine

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

GLUTEN FREE

BASICS OF IMPLEMENTING Julie Mathews, C.N.C. A GFCF DIET Generation Rescue

Parents are becoming increasingly aware of the many

benefits children see when they implement the GFCF diet. Removal of gluten and casein--the gluten-free and casein-free (GFCF) diet--is a great way to begin nutritional intervention for autism. The diet is not difficult to do, and with some basic insights you can get you started right away. Gluten is the protein in wheat, as well as other grains including rye, barley, spelt, kamut and commercial oats, and casein is the protein in dairy. These proteins have been found to be problematic for many children on the spectrum. Eating foods containing them can affect their body’s physical and cognitive functions. Eliminating those foods (and ingredients containing these food proteins) from your child’s diet can help improve many symptoms of autism. It can help children feel and learn better by reducing inattentiveness and hyperactivity, improving speech and language, decreasing digestive disturbances, and much more. When going GFCF, you will need to look out for hidden sources--gluten or casein can be a hidden ingredient within processed food. With a few pointers it’s not difficult to ensure you are fully avoiding these substances.

Implementing GFCF

It is pretty easy to substitute your child’s favorite foods with gluten-free options--GF waffles, GF pancakes, GF muffins, GF pasta are all readily available in stores. GFCF hotdogs and chicken nuggets are also pretty close to the original gluten containing versions, and easy to substitute. Breads are more difficult to substitute, since gluten’s texture makes bread more difficult to duplicate with gluten-free flours. As you try different brands of GFCF bread, consider making some of your own. Gluten-free breads, with and without yeast, taste much better and have a fresher texture when made at home. Some aspects of going casein-free are also easy to change: butter substitutes such as ghee and coconut oil are delicious, healthy, and available in most health food stores. Coconut

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yogurt (by So Delicious) is dairy-free and soy-free. Caseinfree pudding and ice cream are also nearly indistinguishable from the dairy versions. Milk can be slowly diluted over time with dairy-free milk. Mac and cheese can be made fairly easily without any cheese substitute at all. Melted cheese such as on GF pizza is harder to mimic because of its gooey texture. Fortunately, Galaxy Foods makes a Vegan Rice cheese that is free of casein and caseinate, as well as soy-free, that can be used when you simply must have pizza.

Here are some initial steps for implementing GFCF: 1. Experiment. Before removing anything, introduce GFCF alternatives such as rice pasta, GF waffles, and other GFCF foods and snacks--this will support the elimination portion later. Try some prepared foods and mixes. Find options your child likes and that you can substitute later during implementation. 2. Explore GFCF resources (books, cookbooks, videos, autism websites) to become familiar with the diet and learn helpful ideas, what to expect, and what foods are allowed. Watch instructional videos--many available at YouTube. 3. Create a meal plan--a list of gluten-free and casein-free foods, meals and snacks your child will eat or that you would like to make on GFCF. 4. Shop for foods according to meal plan, as well as purchasing GFCF flours, milks and other cooking staples. 5. Then, begin eliminating one at a time: Start with the elimination of casein--for two weeks, then… • Remove gluten and continue both (gluten-free and casein-free) for three to six months. • After you plan and are ready to implement the diet, consider these additional factors: • Substitute the same foods your children like with gluten/ casein-free options. For example, if they eat waffles every morning, buy rice flour waffles. • Do not increase the amount of sugar in the diet. When going GFCF, it is common to start substituting anything

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Sources of GLUTEN to avoid

Sources of CASEIN to avoid

Gluten grains • Wheat • Rye • Barley • Spelt • Kamut • Triticale • Oats (commercial)--GF oats are available

Casein is found in all animal milk products (cow, goat, sheep milk, etc.) • Milk • Cheese • Yogurt and kefir • Butter • Cream, ice cream, and sour cream • Whey

Gluten containing ingredients and foods • Semolina • Malt • Hydrolyzed vegetable proteins * • Dextrin and maltodextrin * • Artificial flavors and coloring * • “Spices” * • Soy sauce (unless wheat-free) * • Potato chips/fries * • Sauces and gravies * • Bologna and hotdogs *

Casein containing ingredients and foods • Milk chocolate • Sherbet • Galactose • Casein, Caseinate • Lactose in seasoning • Lactalbumin, as natural flavor • Artificial butter flavor • Cool Whip • Lactic acid * • Canned tuna * • Seasoned potato chips * • Hotdogs and bologna (may contain) *

* May contain gluten, unless specified gluten-free

* May contain casein

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

•

gluten-free, including high sugar cookies. If you need to continue to use higher sugar foods (if they are already in the diet) during the transition, it is fine; however, you will want to take them out as soon as possible. Therefore, best to avoid them if you can. If the package does not say “gluten-free” and “caseinfree,” call the manufacturer to be sure. “Wheat-free” and “dairy-free,” do not necessarily mean GFCF. Even if there are no gluten or casein ingredients, you cannot assume GFCF--there may be trace ingredients that do not need to be listed. Also, remember to check that any gluten-free products are also casein-free. For younger kids, just make the changes when you can. Put gluten and dairy free options into your usual containers, i.e. put rice milk in the milk container. Make this transition--slowly diluting the dairy to non-dairy over a week or two. To aid digestion of wheat and dairy, try using a digestive enzyme with DPPIV. While it will not take the place of doing the diet, it can help children ease their way into the diet and help with cross-contamination until the diet is being implemented fully. When following a GFCF diet, it is common to oversubstitute corn and soy in place of gluten and casein. Corn and soy are also very common food sensitivities, and removing these foods as well can make a remarkable difference on the health, behavior and attention for children with autism. I suggest soy-free and corn-free, or only organic corn. Make sure your child’s nutritional needs are met. Diet choices should be as healthy as possible, and add a calcium supplement and/or a proper multivitamin/ mineral formula to make sure a child’s vitamin and mineral needs are met. Consider working with a nutrition professional to ensure all nutritional needs, including protein intake and calories, are met. My book, “Nourishing Hope for Autism,” will help guide your efforts. As you get the hang of the diet and your child is GFCF, begin to strategize on how you can introduce healthier foods such as vegetables and fresh vegetable juices, fermented foods, antioxidant-rich foods and other nutrient-dense choices. See Cooking To Heal for many tips, recipes and demonstrations.

Cross-contamination

Preventing cross-contamination can get so “nit-picky” and

overwhelming that it causes some parents to not implement a special diet at all--this needn’t be. To keep things simple, initially just be concerned with the major crosscontamination offenders such as: bulk foods, commercial fryers that fry breaded foods, the toaster and wooden cutting boards or wooden utensils that can get gluten and casein lodged in the porous wood. Everything else that is non-porous can be washed well.

Foods your child can eat on a GFCF diet GFCF (soy-free and corn-free) oils • Ghee (made from butter but casein-free) • Coconut oil • Olive oil • Sesame oil • Lard or other animal fat Casein-free (and soy-free) milk substitutes • Rice milk • Nut milks • Coconut milk • Potato milk Gluten-free grains and flours • Rice • Quinoa • Amaranth • Buckwheat • Millet • Sorghum flour • Tapioca flour • Potato starch and flour • Nut and seed flours • Bean flours • Corn (organic only)

Cooking staples •

•

Vinegar. Rice vinegar, apple cider vinegar, red and white wine vinegars and balsamic vinegar are glutenfree. Distilled vinegars are also gluten-free because of the manufacturing process. Be careful at restaurants; cheap brands of vinegar that use colors or flavors may contain gluten. Ketchup and mustard are made with vinegar so you’ll want to check with the brand to ensure they’re glutenfree. French’s mustard is gluten-free. Dijon mustard is also gluten-free. Heinz and Westbrae ketchups are gluten-free. Always check with the company to confirm they don’t use any gluten-containing ingredients.

The foods and substances that children eat d happens in their brain--and parents’ food choi 22

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012 •

•

Vanilla extract may or may not be gluten-free depending on the alcohol used. Frontier and McCormick’s are gluten-free and most gluten-free vanilla says so right on the label. Herbs and spices. Good quality herbs and spice brands such as Frontier, Penzy, even McCormick are gluten-free for the most part. For these brands, herbs and spices that are single spices such as “basil,” “cinnamon,” or “onion powder,” are gluten-free. However, spice blends, even for these higher end brands, are typically not gluten-free, such as apple pie spice, Mexican seasoning and chili powder (such is a blend of chilis). GFCF baking powderRumford brand is GFCF and aluminum-free.

Meal ideas

Breakfast. Always try to serve some protein such as eggs or sausage at breakfast. Try two or three of these ideas together such as: scrambled eggs with bacon and a piece of fruit-unless breakfast already contains fat, carbohydrate and protein such as French toast or a smoothie. • Eggs, scrambled eggs, an omelet, any style without milk • Breakfast sausage. Store bought or simply a homemade meat patty (with no nitrates/ites) • Bacon • GFCF waffle or pancake • GFCF toast with nut butter or ghee and/or coconut oil (butter substitute) • GFCF cereal or other GFCF breakfast • French toast (GF bread) • Fruit • Fruit smoothie--Non-dairy milk, frozen fruit such as blueberries, bananas, peaches, and pear, honey, protein powder (if not in conjunction with other protein), nondairy yogurt Lunch/dinner. Include a protein, vegetable, some fat, and a starch (the starch is not necessary and is eliminated on certain diets). Have hot leftover dinner for lunch by using a Thermos. Protein • Meatballs--Ground beef, buffalo, lamb or any meat • Burger--Ground chicken, beef, turkey, or other meat • GFCF, nitrate/ite-free hotdog and sausage • Homemade GF chicken nuggets • Any roasted chicken or meat

directly impact what ices can have a direct

Vegetables • Steamed or boiled vegetables with ghee or coconut oil melted on top • Stir-fry vegetables • Salad or carrot sticks • Raw sauerkraut Fruit • Fresh fruit • Cooked into a sauce like apple sauce or pear sauce • Starch • GF pasta • Sweet potato or potato fries • Rice or quinoa • GF crackers, bread or rice cakes Additional lunch and dinner ideas • GF sandwich with sliced lunch meat • GF sandwich with sunflower seed butter and jelly (a peanut/nut-free PB&J) • Stews and soups--Pureed or broth soup • Casseroles Snacks • Chicken nuggets or chicken pancakes • Celery or apple with nut butter • Vegetables with hummus • Potato chips or other chips (ideally with guacamole or other healthy dip) • Carrot chips • Vegetable latkes with apple sauce on top • Smoothie (or frozen into popsicles) • Vegetable juice (fresh made) • GF French toast strips with coconut oil and a bit of salt (not sweet if possible) • Fruit or apple/pear sauce Foods and nutrients can impact the symptoms of autism. Autism is a whole-body disorder, the gut-brain connection is an important area for parents to understand. The foods and substances that children eat directly impact what happens in their brain--and parents’ food choices can have a direct effect. These GFCF basics can help you get started with this important dietary approach. With a little practice and familiarity, GFCF can easily become a regular part of your family’s health and healing program. ********************************************************** Julie Mathews, a leading autism nutrition specialist, helps parents successfully apply healing autism diets to support their children. As a Certified Nutrition Consultant and Defeat Autism Now! (DAN!) Practitioner, she educates parents and professionals on diet and nutrition for autism and is the creator of “Nourishing Hope for Autism: Nutrition Intervention for Healing Our Children” (Book) and “Cooking to Heal: Autism Nutrition and Cooking Class” (DVD). Visit www.NourishingHope.com to study autism diets and view video presentations.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

DELIGHTFUL... AND GLUTEN FREE

Stir Fried Shrimp and Vegetables with Thai Red Curry Sauce

BLACK BEAN HUMMUS Gluten-Free ~ NutFree ~ Dairy-Free ~ Rice-Free ~ EggFree ~ Corn-Free ~ Soy-Free Yield: 8 servings - 3 tablespoons olive oil - ½ medium onion diced (about ½ cup) - 1 jalapeno pepper seeded and diced (about 3 teaspoons) - 2 minced garlic cloves (1 tablespoon) - 1 can (15-ounce) black beans drained and rinsed - 1 teaspoon cumin - 1 teaspoon lime juice - 1 teaspoon black pepper - Handful fresh cilantro (about 1 tablespoon)

for five minutes (onion will be translucent). 2. Add minced garlic and sauté another 2 minutes. 3. Transfer sautéed onion, jalapeno, and garlic into food processor. Add beans, cumin, lime juice, black pepper, cilantro, and 2½ tablespoons of olive oil. 4. Blend thoroughly, scraping down the sides of your food processor to ensure a smooth consistency. Serve with tortilla chips or raw vegetables. Can also be used as a sandwich spread.

Yield: 4 servings

NUTRITION: Calories per serving: 234, Total fat: 5.58g, Carbohydrate, by difference: 35.18g, Total dietary fiber: 8.46g, Protein: 11.79g, Total sugars: 1.77g, Sodium: 3mg

1. Heat 2 teaspoons olive oil in sauté pan on low/medium heat. Add diced onion and jalapeno and sauté

Special Thank you to“Vanessa Maltin-Weisbrod for these recipes. Vanessa is the Executive Editor of Delight Gluten-Free Magazine, an international publication geared towards people with food allergies, celiac disease and other medical conditions relating to food. 24

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STIR FRIED SHRIMP AND VEGETABLES

- 1 pound large peeled, deveined and washed shrimp - 1 cup snow peas - ½ can precooked baby corn - 1 cup carrots, sliced - 1 cup onions, diced - 1 cup mushrooms, quartered - 14 ounce can light coconut milk - 2 tablespoons Thai red curry paste - ½ teaspoon Kosher salt - ¼ teaspoon freshly cracked black pepper - 2 teaspoons canola oil - 2 teaspoons freshly squeezed lime juice - 2 cups cooked jasmine rice (optional) Heat a medium-sized skillet to medium heat. Put 2 tablespoons of coconut cream (thick part of coconut milk at the top of the can) in the pan and add the red curry paste. Stir and cook for 2 minutes. Add the rest of the coconut milk and bring to a boil, and then reduce to a simmer and cover. Heat a separate sauté pan to medium-high and add oil. Once oil is hot, add onions and cook for 3 to 5 minutes. As onions begin to soften, add carrots and cook for 2 minutes. Add snowpeas, mushrooms, and baby corn. Cook for an additional 2 minutes. Season the shrimp with kosher salt and freshly cracked black pepper. Add the shrimp to the pan and cook about 1 minute on each side until pink. Remove lid from coconut curry mixture; add freshly squeezed lime juice. Stir to combine. Pour thickened coconut curry mixture over shrimp and vegetables; stir well. Serve over steamed jasmine rice.

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Recipes courtesy of Delight Gluten-Free Magazine. Search these recipes and others at:

delightglutenfree.com ASPARAGUS RISOTTO Asparagus Risotto Yield: 4 servings Gluten-Free, Egg-Free, Soy-Free, NutFree, Corn-Free - 1 bunch asparagus - 1 quart vegetable stock - 3 tablespoons butter - 2 shallots, minced - 1½ cup Arborio rice - 1 cup white wine - Zest of 1 lemon - ½ cup parmesan cheese - 2 tablespoons lemon juice

STUFFED PORTOBELLO MUSHROOMS Stuffed Portobello Mushrooms Yield: 4 servings

1. Rinse asparagus and snap off the woody ends. Chop the stalks into 1-inch pieces. 2. Fill a wide pan with 1 inch of water and heat to boiling. 3. Add the asparagus and cook 1 to 2 minutes (depending on thickness), until just tender. Drain and set aside. 4. Warm the stock in a pot, and keep it covered on low heat. 5. Melt the butter in a large pot, and add shallots. Cook 2 to 3 minutes until the shallots start to soften. 6. Add the rice, and stir until the grains of rice are coated in the butter. 7. Add the wine, and stir constantly, until absorbed. 8. Add a ladleful of broth, and continue stirring until the broth is absorbed. Continue this, until all the broth is added, about 25 minutes. 9. Add lemon zest and asparagus and stir. Remove from heat and stir in Parmesan cheese. Add the lemon juice and stir until combined.

- 8 large portobello mushroom caps - 3 tablespoons butter - 1 large Vidalia onion, sliced thinly - ¼ teaspoon sugar - ¼ cup olive oil - ¼ cup dry red wine (Chianti will work well) - 1 eggplant, small dice - 6 ounces goat cheese, crumbled - ½ cup oil-packed sun-dried tomatoes, finely chopped - 2 garlic cloves, minced - 2 tablespoons fresh basil, chopped - 1½ cups Parmesan cheese

NUTRITION per serving: Calories: 193, Total fat: 10.84 g. Cholesterol: 30 mg. Carbohydrates: 7.70 g. Dietary fiber: 1.06 g. Protein: 5.38 g. Total sugars: 3.60 g. Sodium: 1125mg

Preheat oven to 375 degrees F. Lightly coat a baking sheet with olive oil. Place

cleaned mushroom caps rounded side up and bake for 10 minutes to drain excess liquid. Remove from oven and set aside, leaving oven on. Meanwhile, in a medium nonstick pan, melt 3 tablespoons of butter over medium heat. Add the sliced onion and sugar and slowly cook for 10 minutes, until golden brown. Turn heat to mediumhigh and cook for an additional 10 minutes. Remove from pan and reserve. In a large skillet, heat ¼ cup of olive oil over medium heat. Add eggplant, sundried tomatoes, and garlic. Cook until eggplant is soft, about 8 to 10 minutes.

Stir in red wine and cook for about 2 to 3 minutes, until alcohol evaporates. Remove skillet from heat and fold in the goat cheese, 1 tablespoon of basil, and reserved caramelized onions. Flip over portobello mushrooms to rounded side down. Fill each mushroom with a heaping scoop of the eggplant mixture. Sprinkle each of the mushroom caps with Parmesan cheese and bake for 20 minutes. Remove the stuffed mushrooms from oven, sprinkle with the remaining tablespoon of basil, and serve warm.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Janet Peterson, DrPH

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children and

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Soda consumption has increased dramatically since the 1960s, mirroring the increased rates of obesity. It is estimated that 95 percent of Americans drink soda at some point during the year and more than 50 percent drink one or more sodas every day. Boys are more likely to drink soda at a younger age with over 70 percent of them consuming one or more sodas per day. These statistics are for soda alone! If you take in to account all sugary drinks (sweetened juices, lemonades and ice teas) the amount of added sugar consumed daily greatly increases. Added sugar intake during childhood increases the risk of health issues later in life.

That is a lot of extra sugar, not to mention calories in one’s diet, particularly for a child. The current recommendation for sugar consumption per day for children is 10 teaspoons (50 grams) for girls and 15 teaspoons (75 grams) for boys and no more. Most children meet or exceed the recommended sugar intake simply through what they eat in their regular diet. The additional sugar intake from beverages such as soda or other sweetened drinks can be detrimental to your child’s health.

Health and soda consumption

Perhaps the most urgent concern for our children is the contribution of soda to the overweight and obesity epidemic. With every single A 12 ounce Soda lacks good serving of soda your child can of soda can contain: consumes, his or her risk of being nutrition 10 teaspoons of sugar = overweight or obese increases by Food and drink are 50 grams = 60 percent! Most people drink soda 200 empty calories classified as nutrient in addition to eating all the calories dense--lots of good they require in a day. Any excess quality nutrients and not calories consumed--more than you are a lot of calories--and energy burning during the day--from any source (protein, dense--very little nutritious value fat or carbohydrate, i.e. sugar) will be stored as fat. with lots of calories, in other words Most experts argue that drinking excess calories “empty calories.” Soda and other high from soda in combination with a sedentary lifestyle sugar drinks are classified as energy is a major contributor to becoming obese. dense, loaded with empty calories. The average 12-ounce soda has more than Obesity is not the only soda-related health concern: 10 teaspoons of sugar (50 grams) which soda consumption has been linked to type 2 is equivalent to 200 empty calories.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

PANCREATIC CANCER

TOOTH DECAY/ GINGIVITIS

METOBOLIC SYNDROME

OVERWEIGHT/ OBIESITY

LEARNING DISORDERS

HEART DISEASE

WEEK OR BRITTLE BONES

SLEEP DISORDERS

INABILITY TO CONCENTRATE

HEARTBURN/ STOMACH ACHE

STROKE

diabetes, tooth decay, weak bones, digestive issues, inability to concentrate, pancreatic cancer, sleep disorders and learning problems. “One of the issues I’ve seen with drinking soda is that children may be replacing a glass of milk (or dairy products) with the soda,” says Kelly Pritchett, Ph.D., assistant professor and registered dietitian at Central Washington University. Low dairy consumption is associated with reduced calcium intakes, resulting in weak bones and teeth.

The importance of role modeling

A majority of soda consumption occurs in the home--not when the kids are at school or out and about. In fact, only 1.4 percent of all sodas consumed by children are done so in schools. So where are kids getting all this soda from? Mostly, their parents are providing the sugar-laden drinks. Parental role modeling has a large influence on the dietary

TYPE 2 DIABETES

(and other lifestyle) choices children make. If you drink soda, then it is very likely that your children will as well. One of the first steps you can do to reduce your child’s soda consumption is to not purchase or drink soda in the home. This will provide health benefits for the whole family.

If I can’t drink soda, what can I drink?

Is there anything that children can drink that is considered healthy? The answer is a resounding yes! Pure and simple the answer is water: Noncarbonated, unflavored, tap water is the best option. Sure, the occasional glass of fruit juice is OK, as long as the calories are accounted for, but most of your daily fluid intake should come from water. Not happy with that answer? Some other alternatives to soda that are low in calorie and noncarbonated include unsweetened or diluted fruit juices, flavored waters and unsweetened (decaffeinated) iced tea.

Alternatives to soda that are low in calorie and noncarbonated include unsweetened or diluted fruit juices, flavored waters and unsweetened (decaffeinated) iced tea. 28

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

What does HOPE look like?

Mary Tyler Moore International Chairman

Hope looks like Christine, Jillian, Tres, Jackson and Thomas Mary Tyler Moore and her young friends have type 1 diabetes (T1D). Their hope lies in the worldwide research that JDRF is funding and the clinical trials that are underway. They want to be a part of their own cure. To learn more visit www.jdrf.org.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

SLEEP Sydney Risser, P.T.

positions

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

DID YOU KNOW...

THAT NEARLY ONE THIRD OF OUR LIVES ARE SPENT IN BED? With so many hours reclined, what’s the best position to keep us comfortable, ensure a restful night and minimize some of those morning aches and pains? To understand the best support for your body, you need to first understand the spine. If you look at the spine from the side you’ll see four graceful primary curves: the cervical (neck) curve, the thoracic (rib cage) curve, the lumbar (low back) and the sacral (pelvis) curves. When the spine is in its proper alignment and viewed from the side, the ears should align directly over the shoulders, the hips and finally over the ankles. This alignment of our curves is called neutral spine. Whether you view the neutral spine position from the back, front or side, you’ll see a nice straight line. The same concept applies to our sleep position. No matter what position we sleep in--whether on our back or side--the goal is the same: to align in neutral spine. The neutral spine alignment always falls in the same straight line--ears to shoulders and hips to heels, no matter if on our side or back. Now that you understand the goal of neutral spine positioning, let’s start with the most basic support-the mattress. The question many seem perplexed by is, “How firm should my mattress be?” Too soft of a mattress allows your spine to sag out of neutral causing our spine to look like a crooked line. However, the old mattress adage, “firmer is better” is no

longer true. Too firm a mattress won’t accommodate our body shapes, again throwing us out of neutral and causing pressure points.

You want to choose a mattress that will contour to your body. One that is soft enough to give or compress to our wider bony areas such as hips and shoulders but firm enough to fill in support to our narrower areas like the waist and neck. In other words, a mattress that will support you in neutral spine. If you were to lie on your side on a properly supporting mattress, your spine would look like a straight line. If you have low back pain, you may want to consider putting a pillow between your legs. Make sure the pillow supports both your knee and your foot. This will stabilize your legs and pelvis, eliminating any rotation of the low back out of neutral. The pillow should be big enough so that your knee and foot are level with that sharp-feeling front hip bone. Add a pillow to support your top arm and you should be cozy and comfortable. A long body pillow can support both the arm and the leg.

The next question is typically about the pillow. Like the mattress, the concept is the same--to support the spine in neutral. When lying on your side, if the pillow is just right, your nose should be horizontal. If your pillow

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012 is too high, your nose will slope downward toward the floor; too low and the nose will point upward toward the ceiling. When lying on your back, the curve of the pillow should again just fill the curve of your neck. If too big, your nose will slope down toward your chest. Too high, and your nose will point up toward the ceiling. You want the ear to align with the shoulder so, you guessed it, the spine is in neutral. Tired of hearing it yet?

If you have a pre-shaped cervical pillow, the thing to remember is that there are two different sized curves on each end of a cervical pillow. The small curve is to support your neck when lying on your back. The large curve supports your neck in side-lying. So, if you change positions in the middle of the night, say from your back to your side, you need to rotate your pillow as well. Keep in mind that cervical pillows need to fit your build. A large man will not have the same pillow as a petite

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woman. The pillow needs to fit your size, so that when lying on your side, the large curve fits into the space between the mattress, your shoulders and your neck and holds your spine to--you guessed it--neutral. If you have certain physical conditions, such as severe arthritis or a disc herniation, you may want to meet with your physical therapist to adapt the position to meet your individual needs. And know that even if the position is perfect, if it’s not the position you are accustomed to sleeping in, your body and brain won’t like it. It won’t say “sleep time” to you and it may not feel natural even if it’s good. When this happens you have to retrain the brain! Try resting in the correct position for at least five minutes and then don’t worry about it. Eventually, in about three weeks, your brain will stop rebelling and recognize it as the position that signals sleep time and you’ll wake in the morning with a few less aches and pains.

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Dr. Natasha Burgert

is a general pediatrician who has worked in a private practice in Kansas City, Mo. for almost six years. She specializes in early childhood development and early patient education. She shares her expertise with her patients one on one, through her blog, www.kckidsdoc.com, through Facebook (Pediatric Associates Kansas City), twitter (apedsassoc) and with her practice group in Kansas City.

By: ASBA Educational Committee 34

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Q: What are night terrors? A: Night terrors are really, really scary. A lot of patients and parents come in really wondering what is happening to their child at night when they are having these odd behaviors. Kids who are experiencing night terrors are usually younger, anywhere from as young as toddlerhood to early elementary typically. Parents describe their kids waking up screaming and thrashing and unable to awaken and very panicked and unable to wake for a brief period of time. Although the child doesn’t remember those events in the morning, the parent certainly does.

Q: What causes night terrors? A: Night terrors are really a disorder of sleep.

Q&A

They’re a problem with how the person is trying to be aroused or un-aroused from sleep. So it is kind of considered a parasomnia or a sleep problem. Night terrors occur when there is a disruption in the early parts of the sleep period in a specific type of sleep called non-REM sleep. During non-REM sleep their body tries to arouse them but they are not fully awake.

Q: How long after the child goes to sleep does he or she experience night terrors? A: Usually this happens in the early part of the night sleep period. Usually the first third or so of the night. Probably within the first hour and a half to two hours after falling asleep.

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Q&A

NIGHT TERRORS occur when there is a disruption in the earl

in a specific type of sleep called non-REM s

Q: How long do they typically last? A: I think it is pretty varied. Most of the ones I hear about are usually between five and 10 minutes. I’ve had a few patients tell me they can go as long as 30 minutes. Usually events last somewhere in between those two numbers. It’s not a fairly quick event, meaning a minute or less, but usually enough that the parents are pretty alarmed because it doesn’t seem like things are changing or they are unable to wake them for what seems like a fairly long period of time.

Q: How can you safely awaken your child from a night terror? A: I tell parents that although it is difficult, the best way to wake them, if you even can, is by using very calm words and very calm voices. As parents, our natural reaction when our kids are thrashing and sweaty, going crazy and bolting upright in bed is to run to them, put our arms around them, and yell their name, shake them and try to wake them up. If you do this, the child usually wakes up in a panic, frightened by the yelling and the grabbing. Instead, you need to transition the child into a wakened state in a calm manner. This is best done by using firm restraints, tight hugs and a soft voice.

Q: Why doesn’t a child acknowledge the parent during a night terror? A: They’re not aware that this is going on. Their nervous system is not in a fully awake state. They are literally

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of out of control. They are yelling and moving without cognition.

Q: What are some symptoms associated with night terrors? A: In their waking life, we know that kids that are a little more anxious or more stressed are more prone to night terrors. But that is very difficult to determine if that is the situation in a toddler for instance. For the vast majority of kids, there are no symptoms that you are going to see during the day.

Q: Is there a specific age range that is typically affected by night terrors? A: Most people think of it as the preschool age, like toddler to preschool. I have had a few kids into late grade school that still experienced them. If a kid is going to have them in a later part of life, typically they are going to be starting in the toddler to preschool time period, somewhere between 2 to 6. The actual peak is somewhere around 3 to 4.

Q: What is the significance if night terrors occur during adulthood? A: It can be seen in adults but that is kind of outside the range of my expertise. Typically it is a continuation of what has happened in their childhood, so that is usually part of their sleep rhythm or sleep dysrhythmia, but as far as true experiences that is kind of outside my scope.

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

ly parts of the sleep period sleep

How is a diagnosis of night terrors made? A: I really think that for the vast majority of kids the diagnosis of the night terrors can be made on history alone. As far as associated factors with that, I always ask parents about levels of stress at home, level of anxiety, talking about how they may or may not have good sleep habits, good regular sleep habits and a good regular bedtime routine, which can all kind of contribute to the frequency of them. Most kids are going to grow out of them on their own, in due time without any intervention at all. The events themselves are not harmful; they’re not anything that needs to be prevented. Although, clearly, they cause a lot of family disruption they are not harmful for the child. Usually we let them play out on their own. Usually by grade school they are gone, if they have started in the toddler or preschool time period.

Q: What is the difference between a night terror and a nightmare? A: Nightmares can happen over a range of ages. It’s really specific to that toddler or preschool ages. With nightmares, kids, when they wake up, remember what they just dreamed. They remember the event into the next part of the day. They are easily wakened from the bad dream that they are experiencing. Most kids who have nightmares just whimper, cry or moan. They aren’t

waking up thrashing and screaming and being inconsolable at that the time. Night terrors are also associated with the nervous system kind of going crazy. So, a child’s heart rate is going to be really high. They are going to be sweaty; they can be staring off into space, and not really making eye contact. The night terror experience is a lot more physical than the nightmare is.

Q: Are there treatment options for night terrors? A: It’s hopeful to decrease the frequency they happen. Kids, in general, like to have very predictable events in their lives, and sleep is certainly under that umbrella. So, by trying to avoid being over tired, to have a routine schedule seven days a week, to have a good bedtime routine that is relaxing--that is going to have your kid be engaged in the activity of sleep will certainly be helpful. A couple of pitfalls that I found parents getting into, especially when they are traveling, is using medication that they typically don’t use. For example, cold or cough medicines, or antihistamines, and then all of a sudden, they are having these horrible night terrors. Sometimes with drug exposure you

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Q&A have unexpected consequences of sleep disruption. So, just making sure we are avoiding those kinds of stuff can help decrease the frequency for some kids that have more of a predictable night terror. For example Monday, the first day back to school after the weekend, is a more exhausting day and is more predictable for sleep disruption. If the child is having night terrors, you can wake him or her up 15 to 30 minutes before you think he or she is going to have the night terror. This kind of knocks them out of that sleep cycle and tries to prevent the night terror from happening. I have had some parents use this very successfully, if it is predictable. You don’t always have that luxury. If it is predictable, it is a good trick.

Q: Can medications induce, or be a trigger of night terrors? A: Yeah they can. Especially antihistamines like Benadryl. Parents commonly can use them to help their kids go to sleep at times, which we certainly don’t recommend, but that does happen. Antihistamine type medications can induce night terrors. For older adults, illicit drugs, alcohol and sleeping pills will increase sleep disruption. For little kids, a trigger could be as simple as a fever, to cause those sleep disruption. Kids do all sorts of goofy things when they have a fever, and night terrors can be among these.

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Q: On average what percentage of children is affected by night terror? A: I think that the literature quotes around 15 percent. Practically I don’t hear about them that often. I would probably say less than 5 percent in my practice. Nightmares are more common than night terrors.

Q: Are night terrors genetic? A: Absolutely, they definitely run in families. It is not very specific as far as direct genetic transmission or anything like that.

Q: How frequent do they occur in a child that suffers from night terrors? A: That’s a good question. The older they are the less frequent they happen. For example a toddler may have a night terror one time a week, an older kid, a school age kid, it may be one time a month. If you are having events that are very frequent, incredibly predictable, happening every night, certainly without fail, then that is something that needs to be addressed with a medical professional. Because typically night terrors are something that is more intermittent.

If a child is going to have

NIGHT TERRORS typically they are going to be starting in the toddler to preschool time period, peaking somewhere between 3 to 4. 38

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Simone de Lacy B.S.C., RPSGT, President, European Society of Sleep Technologists 40

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

hey say there is nothing better than a good night’s sleep for healing the body and resting the mind. But what happens if you can’t sleep or need a little help getting there or indeed to combat more serious health complaints? That’s when we turn to the doctor or pharmacist for help and this often comes in the guise of medication. According to data released in 2004 by the Department of Health and Human Services (HHS), at least half of all Americans take at least one prescription drug, with one in six taking three or more medications. But what are these medications doing to our sleep? First, let’s look at some of the medications we take that are actually intended to help us get to sleep.

Sleeping tablets:

According to the National Sleep Foundation (NSF) 25 percent of Americans take some type of medication every year to help them sleep. There are many different drugs that are designed to help induce or maintain sleep such as hypnotics, antihistamines and melatonin. Hypnotics such as benzodiazepines (e.g. Diazepam, Flurazepam, Triazolam) and the ”Z-drugs” (e.g. Zopiclone, Zolpidem, Zalaplon) work by increasing the activity of GABA--a neurotransmitter (chemical messenger) released by nerve cells in the brain. The effect of this is to cause drowsiness and thus induce

and maintain sleep. The main difference among the various hypnotic medications is their half-life, that is, how long the drug is active in the body. In contrast, some antihistamine-containing sleeping aids (e.g. Nytol, Sominex) cause drowsiness by reducing the amount of histamine, an excitatory neurotransmitter, in the brain. These can usually be obtained over the counter (OTC). Melatonin, however, is a hormone which is naturally secreted by the pineal gland in the brain in response to light and darkness cycles. Drugs which mimic its action (agonists) and synthetic versions of this hormone can be prescribed or indeed bought OTC and are often taken to help combat problems due to disruption to the timing of sleep such as shift working and jet lag. Ideally, a sleeping tablet should induce sleep, but have no possible problems. Unfortunately, there is no perfect sleeping tablet. Some of the problems, side effects, when taking sleeping tablets include: headache, poor concentration, palpitations, depression, nausea, diarrhea, constipation and abdominal pain to name but a few. The sleep that they induce is not ”normal” sleep and the relative proportion of light, deep and dreaming sleep may be significantly altered. The effects of commonly prescribed sleeping medications, such as flurazepam (Dalmane) and

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

“Sleep

antihistamines such as diphenhydramine (Benadryl) can persist beyond the normal period of sleep causing daytime sleepiness and impaired concentration. Because of their numerous side effects and the propensity for tolerance

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and dependence, sleeping pills should only be prescribed for short-term usage, usually no more than three weeks. Withdrawal after long-term usage can result in a marked increase in REM sleep and nightmares.

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Medications for other conditions and their effects

on sleep: Antidepressants: According to the World Health Organisation, depression is the second most common cause of disability related to illness and more than 11 million people take antidepressants. Tricyclic antidepressants (TCAs) such as Triazolam (Halcion) can increase the likelihood of parasomnias (unwanted movements and behaviours in sleep) such as sleepwalking, bed-wetting, tooth-grinding and confusional awakenings. Many antidepressants have a sedative effect while others are more stimulatory and are therefore prescribed to be taken at a certain time of the day for best effect. Stimulating antidepressants such as fluoxetine (Prozac) should be taken in the morning so as not to disrupt sleep. Prozac belongs to a group of anti-depressants called Selective Serotonin Re-uptake Inhibitors (SSRIs) and these drugs may have a propensity to cause or exacerbate restlessness in the legs and disruptive limb movements during sleep. They may also supress dreaming sleep.

“

Anti-Parkinsonian drugs: In contrast to the SSRIs some anti-Parkinson drugs such as Sinemet and Pramipexole may be used to treat restless legs and periodic limb movements in sleep but may similarly affect dreaming and possibly induce nightmares.

Cardiac and hypertensive drugs: Suppression of REM sleep is frequently seen with longterm antihypertensive beta-blockers like pindolol and propranolol (Inderal) and the use of the latter can also predispose a patient to experiencing nightmares. Some calcium channel blockers such as amplodipine may cause insomnia and diuretics such as Furosemide will increase urine production and therefore increase the number of trips to the bathroom during the night. Pain medications: For severe or intractable pain some patients are prescribed opiate analgesics such as fentanyl and morhpine. These drugs act directly on the central nervous system and can

p is the golden chain that ties IT’S ESTIMATED that 50,000 healthpeople and our- bodies together. worldwide are affected with narcolepsy. ”

”

--Thomas Dekker

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

“Fatigue is the safest- sleeping draught.” -Virginia Woolf

cause euphoria and deep relaxation but in high doses can induce deep coma and depression of the respiratory system causing severe breathing difficulties. Less powerful opioids such as codeine may be useful in treating restless legs and periodic limb movements in sleep where other drugs have failed. “Sleep is a symptom of caffeine deprivation.” ~Author Unknown

Alcohol, nicotine and caffeine: Alcohol is a sedative and a muscle relaxant. It will cause drowsiness and shorten sleep latency and initially induce deep sleep, making it the friend of many insomniacs. However, it is a false friend because when its effects wear off there may be rebound insomnia characterised by intrusive thoughts, hampering the ability to return to sleep once the diuretic effect of a full bladder and thirst has taken its toll. Its muscle relaxation properties will exacerbate snoring and sleep apnea. Caffeine and nicotine by contrast are stimulants. Caffeine temporarily increases alertness by increasing adrenaline production and interfering with sleep-inducing chemicals and according to the National Sleep Foundation, is the most popular drug in the world. As well as the obvious caffeine culprits--coffee, tea and chocolate--it can also be found in some cold and pain medications. Excessive caffeine may cause insomnia and multiple trips to the bathroom during the night. Caffeine withdrawal may also cause sleep disturbance and headaches. Nicotine has similar withdrawal effects to caffeine but it also has other sleep disturbance effects. It will exacerbate snoring and research has shown that it increases light sleep and decreases deep sleep. In summary, the best sleep you can get is natural sleep. All drugs that can cross the blood brain barrier have the ability to alter sleep predominantly by affecting the relative inhibitory or excitatory neurotransmission in the

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brain. While many medications may be detrimental to sleep quality and quantity, others may have a therapeutic effect. It is important to understand that poor sleep may have as much to do with the medication you are taking as to the actual medical condition it is being taken for. If you are experiencing problems with poor sleep you should see your doctor. It may be that an alternative medication could be prescribed or further investigation into the route cause or your sleep disturbance is needed. Simone de Lacy BSc RPSGT, President, European Society of Sleep Technologists Useful resources: Is Your Medication Making You Lose Sleep? www.everydayhealth.com/sleep/medications-that-affect-sleep.aspx How medication and alcohol disrupt sleep www.webmd.com/sleep.../guide/drug-alcohol-related-sleepproblems National Sleep Foundation--Information on Sleep Health and Safety www.sleepfoundation.org

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

UPPER RESISTA

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Steven Y. Park, M.D. 46

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

AIRWAY ANCE SYNDROME:

COMMON THAN YOU THINK A woman suffering from chronic fatigue and years of poor sleep

I recently saw a 50-year-old woman who complained of many years of intense fatigue, poor quality sleep, and an inability to focus and concentrate during the day. Of note, she underwent multiple dental extractions when she was younger while undergoing orthodontics. She tried hormonal replacement therapy, but did not find this helpful. During sleep, she wakes up quite frequently, and never feels like she gets refreshing deep sleep. She also has cold hands and low blood pressure. She sometimes snores. Her examination revealed a very high arched hard palate, narrow jaws, a small mouth with four missing bicuspids and four missing wisdom teeth. She also has a severely deviated nasal septum to the right and flimsy nostrils. After placing a tiny flexible fiber-optic camera through her nose and into her throat, I saw that her soft palate collapsed significantly, and the space behind her tongue was very narrow, to the point of almost complete obstruction.

Not really sleep apnea

Her history and examination were consistent with classic obstructive sleep apnea, which is a common condition where one stops breathing repeatedly throughout the night due to throat closure. It’s estimated that about 25 percent of men and 10 percent of women have this condition. Untreated obstructive sleep apnea has been shown to significantly increase your risk of hypertension, diabetes, weight gain, heart disease, heart attack, stroke and car accidents. She eventually underwent a home-based sleep study, which revealed that she stopped breathing 10 times an

hour. However, when we submitted the paperwork for a CPAP titration study, it was denied due to the fact that her levels were not severe enough to have a diagnosis of sleep apnea. Looking back on her sleep study, her apnea-hypopnea index (AHI) was 4. The number that we used (10) to determine that she needed treatment was the RDI, or respiratory disturbance index. Not too surprisingly, her insurance company used an AHI threshold of 5 as a cut-off line for coverage. The problem with using an AHI score only is that it doesn’t measure the more subtle obstructions that are commonly seen.

A sleep study, explained

An apnea is scored on a sleep study when you have at least 10 second or longer pauses in your breathing, with greater than 90 percent diminished airflow. A hypopnea means you have at least 30 percent diminished airflow, along with a 4 percent lowering in your oxygen levels. Another variation of hypopnea is defined as at least 50 percent diminished airflow, along with either a 3 percent drop in your oxygen levels, or an arousal with your brain waves from deep to light sleep. If you don’t quite reach 30 to 50 percent, but it lasts more than 10 seconds and you have an arousal, that’s called a respiratory related event arousal, or RERA. The RDI incorporates these .

RERAs into the AHI score

To officially become diagnosed with obstructive sleep apnea, your AHI has to be 5 or more. If it’s below 5, then you’re out of luck, and your insurance company won’t pay for any treatment options. However in the sleep medicine community, RDI is used interchangeably with the AHI. Many sleep physicians consider the RDI as a more sensitive indicator of patient’s symptoms.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Beyond apneas and hypopneas

But if you stop breathing 25 times an hour, but each episode is less than 10 seconds, then your AHI will be zero. This is the dilemma that many of my patients are stuck in. This problem was first described by Dr. Christian Guilleminault at Stanford University in the early 1990s. He described a group of young men and women who were tired and drowsy all the time, despite not having significant apneas or hypopneas on a sleep study. When he placed pressure catheters into the throat and esophagus, he found that they had progressive levels of partial inspiratory obstructions leading to brain wave arousals, but not meeting the criteria for apneas. He coined this finding upper airway resistance syndrome, or UARS. Many of these patients responded very well to CPAP, but could not stay on it permanently. Other researchers described various syndromes and symptoms that are common in patients with UARS. Cold hands and feet, low blood pressure, digestive problems, depression, hypothyroidism, TMJ and headaches were often seen in these patients. In my experience, people with UARS tend to be relatively younger and thinner. More often than not, one or both parents will snore heavily and have undiagnosed obstructive sleep apnea. Due to very small jaws and upper airway anatomy, these patients will not be able to sleep on the backs. As they get older and heavier, especially after menopause for women, they’ll progress into the more traditional features of obstructive sleep apnea.

Nasal passages

Many people also have very flimsy nostrils that will cave in during inspiration. This can be managed by using overthe-counter nasal dilator strips, internal nasal dilator options or surgery. A major reason for this problem is due to underdevelopment of the jaw structures. Notice how this patient had a very small oral cavity, which was aggravated by her dental extractions during orthodontics. It’s also been shown that the presence of bottle-feeding, thumb sucking, as well as eating soft foods can prevent proper jaw development and widening. As a result the hard palate does not descend fully, resulting in a high arched hard palate, and a narrow molar to molar distance. If the hard palate doesn’t come down, then the floor of the nose doesn’t come down, leading to a buckling of the nasal

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septum to one direction as it grows. Since the sidewalls of the nasal cavity follow the upper molars, the nasal cavity will be more narrow. Lastly, the angle between the septum and the nostrils will also be more narrow. This will predispose you to flimsier nostrils.

How stress Is created

As a result of these multiple sub-apnea or hypopnea arousals, a physiologic stress response is created, and your body goes into the classic fight-or-flight mode. It’s like you’re being chased by a tiger all the time. In this situation, your nervous system becomes over-sensitive, en garde, edgy and over-reactive to simple, normal stresses. You’ll become more sensitive to weather changes (temperature, humidity and pressure changes), chemicals, scents or odors. When you’re running from a tiger, the last thing you need to do is to reproduce, digest or have blood to go to your skin or extremities. All your energy and metabolism have to be shunted to your central core muscles, the heart and the brain. So you can see how in this situation, your digestive system can go haywire, your reproductive organs and hormones shut down, and even your hands and feet become cold. You can also imagine how this process can wreak havoc on your metabolism.

Dental options

If you have any degree of dental crowding or bite problems, you may consider seeing an orthodontist or oral-maxillofacial surgeon to expand your jaws, which can enlarge your breathing passageways. Under no circumstances should any of your teeth be removed, or jaws pushed back. There are now functional dental appliances that can expand your jaws significantly in three dimensions. Lastly, you can always consider the standard mandibular advancement device which pulls your lower jaw forward, thereby pulling your tongue forward.

Treat the patient, not the numbers

A great number of people will not officially meet the criteria for obstructive sleep apnea, but suffer from multiple obstructions and arousal at night due to narrowed upper airway anatomy. Unfortunately, most people are told they don’t have sleep apnea and that their symptoms are due to other medical or mental health causes. They will undergo years of health struggles

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Cold hands and feet, low blood pressure, digestive problems, depression, hypothyroidism, TMJ and headaches were often seen in these patients.

Treating UARS Treatment for this condition is essentially the same as that for obstructive sleep apnea. Options include CPAP, dental appliances and surgery. CPAP stands for continuous positive airway pressure, where a mask is used to apply gentle positive air pressure through the nose. Dental appliances in general pull your lower jaw forward, which pulls your tongue forward. Since most people with UARS are thin, weight loss is not an option. It is also important to make sure that nasal breathing is clear. By definition, people with UARS and obstructive sleep apnea have narrowed nasal passageways. This can be addressed with conservative options such as nasal saline, allergy medications and as a last resort, surgery.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012 until decades later when they do go on to develop obstructive sleep apnea, with some or many of the medical consequences of untreated obstructive sleep apnea. Whether or not you have obstructive sleep apnea, if you have obvious breathing problems due to narrowed throat passageways during sleep, it’s important to address it appropriately. In some cases, conservative options do help, but it never truly changes the anatomy. Most people will require CPAP, oral appliance, orthodontic therapy or surgery to find significant relief. The ultimate challenge is in finding a doctor that truly understands upper airway resistance syndrome. There are a growing number of dentists that are beginning

to understand the implications of having smaller jaws, but the medical community in general is not aware of these important issues, with a few exceptions. Also, insurance coverage issues can be challenging, but not impossible. If you suffer from the symptoms that I described above or if your doctor tells you that you only had mild sleep apnea and that all your symptoms are from other reasons, make the effort to find someone in your area who can help. ___________________________ Steven Y. Park, M.D. Department of Otorhinolaryngology-Head and Neck Surgery Montefiore Medical Center Assistant Professor, Otorhinolaryngology Albert Einstein College of Medicine

Seven Simple Steps to Sleep Better

So what are you to do if you don’t officially meet the criteria for sleep apnea and your insurance company won’t cover any of the treatments? I tell all my patients, whether or not they have sleep apnea, to start off with these seven basic steps:

1. Don’t eat any food within three to four hours of bedtime. When your breathing obstructs, you’ll create

vacuum forces that suction up normal stomach juices into your throat, causing you to wake up more frequently, and cause additional swelling and inflammation in the throat. This causes more throat collapse.

2. Don’t drink alcohol within three to four hours of bedtime. Alcohol relaxes your muscles and can aggravate more apneas and breathing pauses.

3. Do Keep your nose clear. Having a stuffy nose can cause your throat to collapse, like sucking through a flimsy straw while pinching the tip.

4. Don’t sleep on your back. Most people with these issues will naturally sleep on their sides or stomach,

but if for whatever reason you switched to your back (pregnancy, injury or even a dermatologist’s advice to prevent facial wrinkles), try getting off your back again. Your tongue collapses most when you’re on your back. When you add deep sleep and additional muscle relaxation, you’ll stop breathing and keep waking up.

5. Do Address and treat nasal and/or food allergies. This causes additional inflammation in the throat which can cause further throat narrowing.

6. Do Sleep with your head cocked back about 15 to 20 degrees. Extending you head back while sleeping supine can open up your airway significantly. This is why sometimes, contour pillows can help. However, if you prefer to sleep off your back, then this tip won’t help as much.

7. Do Practice deep-breathing exercises continuously. Anything that helps to relax your nervous system can

help to calm your overly stressed body during the day. It’s been shown that spending more time exhaling is more calming, since exhalation is controlled by the parasympathetic nervous system (the relaxing part of your involuntary nervous system), whereas inhalation is controlled by your sympathetic nervous system (the fight- or-flight response).

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Apria Healthcare is the nation’s leading & largest provider of comprehensive home healthcare products and services with a proven track record and leading market position across all home healthcare product lines. With over 550 locations Nationally, Apria Healthcare specializes in Sleep Therapy, Respiratory Therapy, Tube Feeding, and Home Medical Equipment services.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

At Alegent Health Sleep Disorders Services…we’re on a mission to provide you with a better night’s sleep. Fully accredited by the American Academy of Sleep Medicine (AASM), we offer four convenient metro locations: Immanuel One Professional Center 6828 North 72nd Street, STE 6100 Omaha, NE 68122 Lakeside One Professional Center 16909 Lakeside Hills Court, STE 110 Omaha, NE 68130 Mercy Hospital 800 Mercy Drive Council Bluffs, IA 51503 Midlands Hospital 11111 South 84th Street Papillion, NE 68046

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

OBSTRUCTIVE SLEE APNEA AND ORAL DENTAL DEVICES

Gary Lowder, D.D.S. 54

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

EP L/ S

and non-surgical treatment of obstructive {Conservative sleep apnea (OSA) through the use of dentally applied intra-

oral devices has been shown to be an effective alternative to continuous positive airway pressure (CPAP) therapy. Research has demonstrated the success of CPAP as the gold standard for treatment of OSA. However, many patients do not tolerate the use of CPAP. This is often due to difficulty adjusting to wearing a facemask and, at the same time, managing the connecting tubing while moderate to high levels of air flow through their nose and mouth during sleep.

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Dental OSA therapy is performed by a licensed dentist after appropriate referral from a collaborating sleep medicine physician who has diagnosed the patient’s OSA and is recommending the dental alternative. It is currently considered outside of the scope of the dental license to diagnose OSA or to order a sleep study. However, the dentist is the most qualified to provide oral appliance therapy following a proper referral. The oral appliance used is called a mandibular repositioning appliance (MRA). The title describes the function of the dental device. The lower jaw, mandible, is positioned forward of a normal resting position. This is accomplished by having the patient wear custom-fitted upper and lower orthodontic retainer-like devices that connect the upper and lower arches of teeth in a way that allows for posturing of the mandible to a forward position. In most patients, increased opening of the airway can be accomplished by this means. The degree of forward positioning and resulting airway opening can be controlled through various designs of adjustable connectors between the upper and lower retainers. Titration adjustment of the MRA to obtain optimum airway opening and increased airflow is incorporated into the design. The treatment of mild to moderate OSA with MRAs is listed in the American Academy of Sleep Medicine (AASM) guidelines as a reasonable alternative to CPAP. Additionally, patients who are CPAP intolerant have this effective treatment choice rather than no treatment or expensive and invasive surgical alternatives. The fact that CPAP has the greatest potential for improving blood oxygen levels becomes meaningless if the patient isn’t using it because they are intolerant to it.

dental intraoral and extraoral exam is necessary {Ato thorough determine if MRA therapy is advisable for the patient.{ Consideration must be given to the health of the supporting teeth and periodontal structures as well as the health of the temporomandibular joints and associated masticatory muscles and joint tissues. Forward posturing of the mandible involves all of these areas.

The effects on these tissues from mandibular advancement are usually transient but must be evaluated in follow-up clinical consultations in order to assure that possible negative side effects

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012 using a Thornton Anterior Positioner appliance (TAP of treatment do not occur. One such transient effect is III). The desaturation event index was reduced to less the awareness, after removal of the appliances upon than half that of no treatment. The obvious superior awakening, that the front teeth contact first when closing effectiveness of CPAP therapy is striking, as reflected the teeth together following a night’s wear of the appliance. in a SP02 (saturation) of less than 90 from three hours This usually resolves in less that 30 minutes and has no to one minute and 24 seconds. lasting consequences. The patient should be advised to report any negative side effects or new symptoms that last It is important to note that this is only one patient’s more than a few hours as a result of wearing the MRA. results and, although it reflects a norm, it is not the same for all patients using MRA therapy. Careful The MRA must be stable during wear and needs to follow-up testing by the referring sleep medicine be retentive in order to minimize its being dislodged physician or sleep lab is advised to allow for optimal from incidental mandibular movements. Most titration of the adjustable MRA. However, this follownew designs allow for some freedom of mandibular up testing should be postponed until the patient is movement while worn, thus allowing for swallowing able to maintain comfortable sleep while wearing the and minor functional movements during sleep. Ease of MRA. This author uses a time regimen sequence of : disengagement of the upper and lower trays from each other is also helpful for functional events such as yawning, coughing, sneezing, etc. 1. Follow-up evaluation at two weeks post delivery of the MRA to assess the tolerance, A common cofactor in sleep apnea patients is bruxing compliance and comfort levels of the patient of the teeth. This is usually evidenced by excessive wear 2. Another two weeks of continuous sleep-time patterns visible on both the anterior and posterior teeth. use The design selection of the MRA to be used in treatment 3. Digital pulse oximetry testing and titration if should reflect concepts of dental functional occlusion needed that reduce bruxing by focusing on anterior rather than posterior interarch contact of the dental arches. Optimum test results for effectiveness are best achieved if the patient is compliant and sleeping comfortably. To illustrate the comparative effectiveness of no treatment, MRA and CPAP: the following table of values, Snoring due to airway obstruction is usually as measured with digital pulse oximetry, on one patient is diminished or eliminated with MRA wear. When this helpful. {SEE GRAPH BELOW} is not the case, other possible causes of snoring related to nasal and/or sinus congestion should be assessed THERAPEUTIC COMPARISON TAP III vs CPAP and appropriately treated. The time spent below SPO2 (saturation) of 90 during sleep was reduced from approximately three hours to one hour Another important and effective use of MRA therapy

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SLEEP METHOD AND DURATION

ROOM AIR (06:53:00)

TAP III (07:01:00)

CPAP @ 10CM (06:12:30)

Sleep Method and Duration Highest SPO2 Lowest SPO2 Mean SPO2 Desaturation Events<3 min. Desaturation Events>3 min. Time SPO2<90 Desaturation Event Index

97% 72% 89.4% 104 16 3:01:24 1:01:36 15.1 events/hr.

98% 77% 90.6% 51 11 0:58.16 0:23.48 7.3 events/hr.

98% 88% 93.1% 13 7 0:01:24 0:00:00 2.1 events/hr.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

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In cases of mild to moderate OSA, MRA therapy may be the initial treatment of choice.

is in combination with CPAP where the pressure setting is so high that air leakage around the mask interferes with tolerance and therefore compliance. In selected cases of such combination therapy, the added airway opening secondary to mandibular advancement has allowed for reduction of the air flow setting on the CPAP unit to tolerable levels without loss of effectiveness in maintaining optimum oxygenation. In summary, MRA therapy is not as effective as CPAP in establishing and maintaining optimum oxygenation of the blood. Every effort and avenue should be utilized for encouraging CPAP use where possible. When those efforts are exhausted and CPAP intolerance persists, or when the patient is CPAP compliant but airflow settings are excessive for optimum compliance, MRA is an effective and viable alternative or adjunct to therapy for OSA. In cases of mild to moderate OSA, MRA therapy may be the initial treatment of choice. Follow-up evaluation of effectiveness is crucial in order to ensure that adequate levels of oxygenation are established with MRA use. Annual re-evaluations for effectiveness of

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therapy are also recommended regardless of whether the patient is using an MRA or CPAP device. 1. Lavigne GJ, Cistulli PA, Smith MT. Sleep Medicine for Dentists: A Practical Overview; 2009 Quintessence Publishing Co. Inc.; 10:77-83. 2. Ibid: 10:79, Conclusion: 204. 3. Local Coverage Determination (LCD) for Oral Appliances for Obstructive Sleep Apnea (L28606), CMS National Coverage Policy, 09/01/2011 pp. 1-5. 4. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Dlin Sleep Med 2009;5:263-276. 5. McHorris WH, The Importance of Anterior Teeth, The Journal of Gnathology, Vol.1, No 1, 1982, pp 35. 6. Op cit. Lavigne GJ, 10:80. 7. Ibid. Conclusion: 204

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

A good nights

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Mental Illness and Sleep

It should be no surprise that there is a correlation between sleep dynamics and brain-based conditions, such as mental illness. People who live with psychiatric conditions like depression and bipolar disorder are aware that sleep difficulty is often a key and early sign of the re-emergence of their conditions. The advancing neurosciences of sleep and the brain itself have revealed a relationship between psychiatric disorders and sleep. Let’s look at some psychiatric illnesses and their relationships with sleep disorders.

RE S S ION P E D

PHREN O Z I H I

Sleep changes are one of the nine symptoms in the DSM 4TR for major depression. One estimate is that 80% of individuals with depression report sleep difficulty.

R DE R

POS T T R

44%

44% of outpatients with schizophrenia met criteria for insomnia.

R DI SOR A L DE O P I R B C S T RE I T A S S M U

Individuals with post traumatic stress disorder (PTSD) have “hyperarousal” symptoms (like flashbacks and nightmares) and feelings of numbness. They may also experience nightmares.

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Though there are clear connections between sleep and mental illness, it is not always common for practitioners at psychiatric outpatient clinics to coach their 63.5% patients in good sleep hygiene. During a survey done at a clinic in Ireland, 63.5% of patients reported that they did not discuss sleep hygiene with their 6.8% practitioners, while 6.8% of patients said they received sleep hygiene education. (The rest of the patients questioned could not recall having discussed sleep hygiene.)

32% Up to 20% of individuals who are affected by depression also have sleep apnea, and vice versa.

SLEEP HYGIENE

no sleep hygiene education

sleep hygiene education

9.7%

20% As indicated by one MMPI survey, 32% of obstructive sleep apnea patients had elevated depression scores.

One study found 100% of research subjects reported sleep-wake phase disorder, meaning their circadian rhythms were out of sync with the general population.

For people with bipolar disorder, a single night of sleep deprivation can increase the risk of a manic episode or can trigger hypomania, a mental state marked by intense activity but to a lesser degree than a full manic episode.

In a study of sleep apnea in psychiatric outpatients, 9.7% were diagnosed with the disorder.

In people with depression marked by at least two weeks of persistent symptoms as defined in the DSM 4, 80% reported having insomnia.

mania

hypomania

One study showed a 7% increase in mania and a 12% increase in hypomania.

Among Vietnam veterans, 52% of the PTSD patients had nightmares. (The civilian population has about a 3% incidence of nightmares.)

52%

12% increase

7% increase

96%

3% veterans

civilians

Among individuals who suffer from both PTSD and co-morbid panic disorder, 96% had nightmares. Copyright of the American Sleep and Breathing Academy, LLC

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SLEEP & WELLNESS MAGAZINE // SUMMER 2012

Mask usage and cleaning It is vitally important to find a mask that fits properly and is comfortable to wear. Philips Respironics is here to help. To select the right mask and to maintain its proper condition and fit, work closely with your homecare provider who can help you order what you need to succeed with your sleep therapy.

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tips

SLEEP & WELLNESS MAGAZINE // SUMMER 2012

from Philips Respironics

General tips • A nasal mask that covers your nose is most commonly used. But if you breathe through your mouth when you sleep, a full-face mask that covers both the nose and mouth may be a better option. • The smallest mask size that fits but does not pinch the nostrils should be used. • The mask should be fitted while you are in a sleeping position and with air blowing at the prescribed pressure through the tubing and mask. • The cushion of the mask should not be crushed against the face. • Mark the headgear straps with permanent marker to remember where they should be fastened. • Remove the mask by pulling it over your head or use the quick-release clip.

Daily care for your mask • For best results, the mask should be disassembled per the Instructions for Use. Remove the mask/nasal pillows from the headgear. Clean with warm, soapy water; rinse and let air dry. Avoid soap with moisturizers. • Never use bleach, alcohol or cleaning solutions that contain alcohol on the mask or nasal pillows. It can harm the mask. • Wash your face thoroughly before using your mask. • Inspect your mask. Replace the mask if the cushion becomes hardened or if any parts become damaged.

Even by following these tips, the natural oils in your face will interact with the mask, and, over time, the mask will lose its seal. Tightening the mask will often cause irritation, pressure sores and additional leaks. Replace the cushion or mask instead of tightening repeatedly. Medicare allows masks to be replaced as often as every three months; most other insurance payers allow for replacement every three to six months. As an informed healthcare consumer, you should be aware of the mask replacement benefits under your healthcare plan. If your plan does not meet your mask replacement needs, talk to your home healthcare provider.