Sleep: Medical Issues
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Editorial: Sidney M. Baker, M.D.

bakerDr. Baker is a former faculty member of Yale Medical School, where he received his medical and specialty training in pediatrics. He also is a former director of the Gesell Institute of Human Development. He is the author of Detoxification and Healing, Child Behavior (with Ilg and Ames), and We Band of Mothers: Autism, My Son & the Specific Carbohydrate Diet with Judith Chinitz. A founding member of the Defeat Autism Now! movement, Dr. Baker is also the coauthor, with Jon Pangborn, Ph.D.,of Autism: Effective Biomedical Treatments.

 

Individuality: Each person has different needs

The individuality of every living thing is a fundamental scientific fact. The individual, not the disease, is the target of steps toward healing. Parents, therapists, and physicians aim to fill each child’s unmet needs to avoid bad and get good things. Intuition, common sense, brief trials, lab tests, and every detail of each person’s story help tailor the steps that favor Nature’s buoyant impulse toward growth and healing. The bad things are toxins and allergens. The good things are nutrients, accessory nutritional factors, light, love, and rhythmic integration.

Rhythmic integration: We all have the same need

The facts of rhythmic integration are the same for every one of us, no matter how special we may be in every other way. We all should be dancing to the same beat beginning with the day-night cycle of earth.
We can talk and think usefully about how various individuals fit within a spectrum. When it comes to needs we each have to mesh the rhythms of our bodies; the rules are just like those of music. Those rules permit a little give-and-take but not to the extent that you step on your dance partner’s foot, march out of step, or sing off key.
When you are out of synch in the different rhythms of molecules, brain waves, heartbeats, respiration, digestion, and the 90-minute cycles of “ups and downs” within the day-and-night cycles, something is wrong. Imagine the sound of an orchestra in which the vibrations of the strings, the beat of the drums, and the conductor’s baton all fit together in ways that are right and the human ear can spot the trouble when something is out of synch.
Any sound other than quiet breathing coming from your child after bed time is trouble. Frequent or recurring crying, screaming, banging, giggling, or silly laughter is a signal to change something. Even just being awake after bed time is enough for you to consider the following options.
Pain
The first consideration when we confront “behaviors” in our kids is pain. The mostly likely origin of pain has to do with the digestive tract not moving food and feces “south” in an orderly way. “Orderly” means waves—rhythms, right? And the problem may be anywhere from the esophagus (as in reflux) to the anus, with cramps and constipation constituting the main expression of inflammation. The inflammation may be in the bowel itself or in the centers of the mid-brain where the regulatory (rhythmic) functions of the digestive system—and all the other automatic functions of the body—are controlled. Of all the excruciating pains that we humans may endure, intestinal cramps lead the list of the ones in which the causes turn out to be not nearly as scary as they feel but usually self-limited and benign.
Let’s say that you are confronted with a child (or an adult) with a sleep problem in which periodic abdominal pain is a suspected factor. The safest bet would be to apply a magnesium cream or oil (which is not actually made with oil but feels so) to the skin. Two brands can be ordered on the Internet and others are available from pharmacies and suppliers of supplements to the autism community. Magnesium is absorbed through the skin and will help relieve cramping and “neuromuscular irritability” of many kinds found in the following list. (Note that this is my whole checklist, just so you get the whole “up tight” picture as it presents in people of various ages.)

Skeletal muscle:
Muscle cramps, including backache, neck pain, tension headache, temporomandibular joint dysfunction
Muscle twitches—facial twitches are common
Restless legs
Muscle tension
Muscle soreness
Chest tightness or a peculiar “I can’t seem to take a deep breath” or “I have to think about my breathing” that is often interpreted as hysterical. In children, this symptom is often seen as sighing.
Tics—as in children whose parents are told, “He doesn’t have Tourette’s syndrome, but I think it will develop.” All such children have responded to magnesium in my experience.
TMJ (temporomandibular joint) problems
Other muscles:
Constipation
Anal spasms—such as waken people at night
Urinary spasm
Difficulty swallowing or “lump in throat,” “globus hystericus”
Difficulty with adjusting to oncoming bright headlights because of spasm of the muscles that fine-tune pupillary diameter
Cold hands and feet due to vasospasm
Loud noise sensitivity due to abnormal tension on the stapedius muscle
Endometriosis due to “constipation” or reverse peristalsis of Fallopian tubes
Menstrual cramps
Asthma / Wheezing from constriction of bronchial muscles

Central nervous system:
Insomnia
Anxiety
Hyperactivity and restlessness, constant movement
Panic attacks
Agoraphobia
Irritability
Migraine

Peripheral nervous system:
Numbness
Other abnormal sensations including “zips,” “zaps,” vibratory and other peculiar sensations

Cardiovascular system:
Mitral valve prolapse
Palpitations
Arrhythmias
Vasospastic angina
Hypertension

Other:
Salt craving
Carbohydrate craving
Carbohydrate intolerance
Kidney stones

The digestive tract and liver get up and work on the night shift. Sleep is affected when that work doesn’t go smoothly for various reasons. One such reason is intestinal cramps. Intestinal cramps are, however, a subset of the long list (above)  of crampy (“up tight”) symptoms of neuromuscular irritability that are common in many people living in modern industrialized societies
The solution to the problem lies—in part—in supplementation with magnesium via lotions, baths of magnesium sufate (Epsom salts; one cup in a tub of warm water) or oral supplements that can be taken “to bowel tolerance” by starting with a daily dose of, say 150 mg at bedtime and working up until poops become too loose or frequent and then backing down to the point of comfort. A powdered form of magnesium citrate is found in the product called CALM. Magnesium is calming to the nervous system, but the aim of its use as I have described it is to ease painful muscle cramps in the intestine.

Pills
None of the steps I have outlined so far are specific to the autism spectrum. The point of view of ARI is to steer away from a pill-for-an-ill approach that tries to match a drug or other remedy to a disease or a symptom. Nevertheless, you might expect an article on sleep problems to suggest a sleeping pill. Would one ever give a sleeping pill (tranquillizer, sedative, or antihistamine) to a child with a sleep problem? Sure! Before surgery or dentistry, for special procedures and traveling problems, and in other unusual circumstances.
However, caution must be exercised against treating pain with sedation! Heavy tranquillizers and antipsychotic medication are misplaced without very careful consideration of pain as the cause of sleep problems and other “behaviors.”
Melatonin
Melatonin has a very high rating among treatments rated by thousands of parents responding to ARI’s parent surveys (www.AutismTreatmentSurvey.com). Its rating of 8.3 to 1 means that for every child in whom a negative effect was noted, more than eight benefited. No sedative, tranquillizer, antipsychotic or anticonvulsant comes anywhere close to such a rating and none of them are as safe as melatonin.
Benefits may be seen in some children given daytime doses, and with larger doses than might be considered needed for its role in supporting normal sleep. The high rating therefore includes a mix of children in whom the main result was improved sleep and others who had a wide-ranging set of positive responses.
As is the case with addressing unmet needs for magnesium, melatonin promotes real sleep. It is not a sedative but is produced normally in a sudden release from the brain in a burst that looks like a steeple when graphed over a 24-hour period. The peak of the steeple comes in the hours following midnight and acts as a kind of synchronizing signal, antioxidant gift and an anti-cancer aid to cells throughout the body.
Doses required to produce such a peak in a young adult may be less than 1 mg. If tiny doses (0.1 mg) are escalated slowly, occasional children and adults may benefit safely from daily intakes up to 20 mg! Responses to it can be evaluated over a matter of days. A very positive response with better sleep or many other benefits would justify continuing the trial, and a negative response or no response would dictate abandoning the trial.

Alka Seltzer Gold and activated charcoal (in sequence—not mixed together!)
A dose of Alka Seltzer Gold followed in at least 20 minutes by a dose of activated charcoal provides information gained from seeing it work that is worth almost as much as the relief it provides. The equivalent of “Alka-Gold” comes in the form of tri-salts —sodium, magnesium, and potassium bicarbonate powder and capsules—from various nutritional supplement suppliers and compounding pharmacies. Alka Seltzer Gold (not Cold) contains only sodium and potassium bicarbonate. Not to be taken immediately after a large meal, it is safe and makes just about everything better. It is absorbed from the intestine quickly into the bloodstream and results in a slight, transient adjustment (called an alkaline tide) of the acidity that is associated with just about everything that goes wrong with us acutely and chronically when we are sick.
A quarter of an Alka Seltzer Gold tablet for a toddler or two tablets for an adult, dissolved in a glass of water, is safe when given once or twice in a day to see its effect. In the context of sleep problems its first use is just to see if it does work. If it does—in, say, less than 35 minutes—then you’ve learned a lot and done some good. What you have learned is that there was something that didn’t agree with the person to whom it was administered. The good you have done is to find a temporary solution to the problem and take steps based on what you have learned.
Unless the Alka Seltzer Gold is an instant success by itself, the next step in the sequence comes with the administration of activated charcoal. It comes as tablets (crushable) or encapsulated in doses of 100 to 560 mg. For individuals who cannot swallow capsules, the powder can be taken carefully from the capsules to avoid getting the powder on your clothing. It is, however, washable. If administered as a powder it must first be mixed in water. (Grape juice frozen concentrate— undiluted or minimally diluted—is a vehicle for children needing a strong disguise of taste and color, provided they can tolerate an exceptional bit of sugar.) A recipient who is likely to chew a capsule should be given the charcoal as a liquid suspension (water or juice) to avoid the risk of inhaling the fine black powder.
Many parents and individuals with problems discover from the use of charcoal for die-off reactions that it works—as just described—under circumstances that include just having a “bad day” or reactions to stresses such as allergenic foods, too much sugar, or alcohol, not enough sleep, or even just being hungry and irritable. Similar to Alka Seltzer Gold or its generic equivalent, activated charcoal works as a kind of panacea.
The risk that activated charcoal will absorb important nutrients is minimized by using it only for short-term diagnostic and treatment purposes and keeping it at least an hour away from foods and other medications. For more information see http://www.emedicinehealth.com/activated_charcoal/article_em.htm.

Light and food
The circadian rhythm (circa “about” and dia “a day”) is found in every living thing on our planet. Scientists who study this day-night cycle use a German word “zeitgeber” (time-giver) to describe factors that influence the timing of that cycle, which is set to run just a little more than 24 hours.
It requires regular tweaking to keep us in synch with day and night so that our cycles of waking and sleeping fit with day and night. Caffeine, food, activity, and light each profoundly influence the timing of the body’s internal clock and push it forward or backward depending on the timing of exposure.
Studies of jet lag show that a small amount of light shined on the back of a person’s knee can influence how he or she adjusts to the time change in a flight from New York to Europe. In other words, a little bit of light goes a long way. The presence of only a small amount of light—coming into a child’s room from a street light, or from a tiny night-light—can cause a major disturbance of the quality and quantity of sleep. It takes only a small amount of intrusion of light in a bedroom to throw off the regular melatonin release that goes with a normal day-night cycle. Just getting up to use the bathroom in the middle of the night can throw you off unless the light is very dim and red. Nature is not forgiving on this point, so use a dim red night-light to avoid stumbling in the dark!
The influence of the timing of food presents another surprise. Protein in the morning and carbohydrates in the evening fit with and reinforce a normal day-night cycle. Are there individuals who adjust more or less well to shift work, or whose function deteriorates less when they are up at night or when they—as many do—eat carbs for breakfast and protein in the evening? Yes, but the rules of rhythm are the same for all of us. Are there some individuals who are intolerant of carbohydrates and thus may need to (temporarily) adjust the variety and timing of food intake? Yes, but sleep is favored by preceding intake of carbohydrate and day-time chemistry is supported by supplying protein in the morning. Does that mean that the habit of sweets for breakfast and meat for dinner is all wrong? Yup!

Food intolerance
Food figures in another way when it comes to sleep. Sleep disturbances in babies are often due to milk intolerance. By the same token, a trial of avoidance of each food in a child’s diet for at least five days should be undertaken in all children with sleep disturbances.
Strict avoidance followed by a challenge is the most efficient test. Hidden food sensitivity is the most common undiagnosed factor in children’s sleep problems once the other items I discussed earlier have been taken into consideration. It is a big subject, but it can be effectively tackled by making a link between food and symptoms of every sort. To do this, keep a food diary and list symptoms that worsen in the 1 to 24 hours following a particular food.

Neurotransmitters
A rise in brain and blood levels of serotonin is associated with the night-time hours. Some individuals are quite sensitive to the supply of one of the key raw materials from which serotonin is made in our bodies. For them, a supplement of tryptophan produces a substantial benefit in mood and sleep.
Tryptophan is an amino acid. Proteins are made of amino acids. How does it work that eating protein in the morning is good for sleep at night? Unlike all the other amino acids taken in during the morning, meal tryptophan does not rise and fall in the blood as the day progresses. The body keeps it around for use in the evening.
Does that mean that supplements of tryptophan can be taken in the morning for the body to use later that day? Yes, but those for whom tryptophan is an aid to sleep will get the best results from taking it in the evening. In an adult, a dose of 500 mg of tryptophan (equivalent to 100 mg of the more readily available 5-hydroxy-tryptophan, 5HTP) can be tried to see if it improves sleep. The dose can be adjusted downward so that a 40-pound child could try a quarter to a half of that dose.
Could tryptophan cause an adverse reaction? In the 1990s, there was a sudden outbreak of a “new” disease called eosinophilic myalgia. It was traced to a bad batch of L-tryptophan that had come to the U.S. from a Japanese supplier. Tryptophan was taken off the market, but later returned. 5HTP was never suspected and remains available without a prescription.
Gamma-amino-buturic acid (GABA) is another small molecule with important roles in the brain. A particular product, GABA Calm, may produce a good outcome. Keep in mind, however, that the use of neurotransmitter-like molecules may produce unexpected consequences. Such consequences, like negative reactions to pharmaceuticals, tend to appear quickly and be unpredictable in a given individual. Given the choice of substances natural to the body’s economy, such as GABA and L-tryptophan, my preference for avoiding pharmaceuticals except in emergencies is strong.

Herbs
Chamomile, milk thistle (silymarin), kava kava, and valerian all have reported benefits.
Chamomile tea taken at bedtime has been in use for centuries. It does not taste bad, and it is soothing.
Milk thistle, which is used as a liver protective in the case of drug toxicity and mushroom poisoning, may exert its sleep-producing effects via its role as a promoter of basic steps in metabolism (raising levels of reduced glutathione, for example). When it works dramatically to correct insomnia in a child, I explain it by saying that the liver works on the night shift. If the liver is unhappy at night, it is more the cause of insomnia than the brain. Providing “support” for the liver can thus correct sleep problems.
Kava is in wide use. It is a calming herb and may be safe enough to use for a brief trial to see if it works like magic in a given person. Valerian is good, too, but it tastes so awful that it is pretty useless in kids.

Exercise
I hesitate to put exercise on this list because many of the kids I know are sufficiently anxious and hyperactive that they are already expending a lot of daily energy. However, it would be amiss to neglect mention of an approach that will promote sleep in just about anyone. Whether it takes the form of lots of swimming—the preferred exercise for most autistic kids I know—or a treadmill, or bike, or running, or dancing, exercise to the point of some degree of exhaustion is bound to be helpful to a child whose motor doesn’t want to quit at night.

Water and Music
A warm bath and the sound of a collection of the adagios of Mozart, Albinoni, Bach, or Beethoven under dim lights should never be ignored among the options for all children regardless of the labels they wear.

Summary
Sleep problems, like all others, call for actions aimed at understanding the underlying cause. The whole biomedical approach to chronically ill individuals invites a simple logic that I have described elsewhere in publications and videos. I call that logic “principle-based medicine.” It contrasts with “name-it, blame-it, tame-it prescription pad medicine” in that it rests on the scientific principles of individuality and rhythm.
Principle-based medicine is not a logic that you can easily turn to at 4 a.m. when your child has been up screaming, stimming, giggling, bouncing, or all of the above for three hours. But I hope the above list will offer you some useful guidelines for preventing or dealing with such nightmares of parenthood and child care.
And in closing, I encourage you to join the more than 6,000 members world-wide of Autism360.org. We offer actionable options based on the experience of others. Our service is without cost to you, thanks to the support of The Moody’s Foundation, Google, and others including ARI who believe in our mission to “let the data talk” in an exchange between individual and collective experience. Finally, do not fail to get and use the wonderful new book by my friend and colleague, Jon Pangborn, Ph.D., Nutritional Supplement Use for Autistic Spectrum Disorder. You can find it on Autism.com and on Amazon.com.

References:
Baker SM. Magnesium deficiency in primary care and preventive medicine: symptom profiles in relation to magnesium loading studies. Magnesium and Trace Elements, 1991-1992;10:251-262.
Baker SM. Principle based medicine. Journal of Integrative Medicine, 2011, Vol. 10, No. 5, 22-33.
Baker SM. Autism spectrum: new metaphor—new paradigm for chronic illness. North American Journal of Medicine and Science, July 2012, Vol. 5, No. 3, 193-97.
Baker SM. Autism 360: The development of an online database with patient-entered data. Integrative Medicine, Vol. 11, No. 1, Feb/Mar 2012, 18-26.
Baker SM, Milivojevich A. Gender differences among children with autism spectrum disorders: differential symptom patterns, global advances in health and medicine, in press.

 

Sleeplessness in Autism