This is a guest article by Dr. Russell A. Faust, PhD, MD, FAAP, who blogs at Boogor Doctor. Recently, I asked him if there was a link between milk allergy and chronic ear infections. His article below offers an excellent understanding of what an ear infection is and why it is commonly seen in young children.

Russell A. Faust, PhD MD FAAP PhD – Molecular and Cellular Biology, University of Washington MD Otolaryngology, University of Minnesota Fellowship training in Otolaryngology at Johns Hopkins University Faculty appointments at Ohio State University and Wayne State University Contributor and instructor for Baby Boot Camp Nutrition Solutions program Expertise: pediatric ENT care, rhinitis and sinusitis, minimally invasive surgery for children Books: Robotics in Surgery Website: Boogor Doctor Twitter: @boogordoctor Contact: via website

Do milk allergies cause ear infections?

Without giving a straight “yes” or “no” answer, the following describes the factors that link food allergies (specifically milk) and otitis media, in a 1-2-3-4 stepwise fashion.

Otitis media is a complex disorder, and I want to simplify this link as much as possible. Please write and let me know whether I have succeeded:

As a pediatric boogor doctor, I see plenty of ear infections – Otitis media is what we call the disorder in medicine. It is affected by both inherited and environmental factors.

(1) The highest incidence of otitis is among infants and toddlers.

This is the first factor to keep in mind: the age group – infants and toddlers.

Some Definitions

Let’s define some basic terms before going further. Otitis media is inflammation of the middle ear space (see Figure).

Eustachian tube (the blue arrow) and middle ear cavity (bright pink)

Acute otitis media (AOM) is acute infection of the middle ear. Signs and symptoms are usually rapid in onset, and include fever, earache, and purulent fluid in the middle ear (pus). No signs and symptoms are universally accepted as definitively proving the diagnosis.

Otitis media with effusion (OME) is inflammation of the middle ear with a collection of fluid in the middle ear space.  This fluid may be thin and watery, thick mucus, or pus – any of these, just fluid, but without acute symptoms.

Chronic otitis with effusion (COME) is the label given to OME when it has been present for more than 3 months.

Hearing

The ear simply does not function when the middle ear space if full of fluid – hearing is reduced in the presence of middle ear fluid. When the fluid clears, hearing (nearly always) returns 100%. More on this in a little bit.

Some Anatomy

The middle ear cavity is normally air-filled. Anything else is considered pathology. Air or any gas within a closed cavity will be absorbed by the body. I don’t remember all of my partial-pressure formulas from physics classes, but if there is no way to get air into the middle ear cavity, this absorption will create a vacuum.

Let’s look at the Figure. The way air normally gets into the middle ear is through the Eustachian tube.

So here is the problem for infants and toddlers: the Eustachian tube is floppy.

Ever notice how a baby’s ears are soft and almost floppy? The cartilage inside is young and soft – just like the cartilage around their Eustachian tubes. So young Eustachian tubes are more floppy than mature Eustachian tubes.

Hence, infants and toddlers don’t get air into their middle ears very well.  The result is:

(2) “Eustachian tube dysfunction” (ETD)

That’s the term for Eustachian tubes that don’t work normally. This is the second factor in the link between milk and otitis.

We can relate to what ETD feels like, at least for s short while – we are all familiar with the sensation in our ears from traveling in a plane, or going rapidly up or down many floors in a fast elevator. It feels like pressure, and our ears feel “stuffy” and our hearing is muffled.

When the Eustachian tubes don’t work normally, a vacuum is formed in their middle ears, this draws fluid in from surrounding tissues – OME.

This fluid can become infected –AOM, potential COME. This is one reason why infants and toddlers have a higher incidence of otitis media.  Another reason is their immature immune systems – their immune systems are just not as wise and experienced as an adult’s, so they may be unable to fight off those infections.

Inflammation

We have seen that the Eustachian tubes in toddlers and infants are floppier than older children and adults. In addition to this given tendency to collapse, ANYthing that adds inflammation will make the collapse worse.

(3) Any inflammation of the lining of the Eustachian tube can worsen ETD.

This is the third factor in the link between milk allergy and otitis:

Inflammation worsens collapse of the Eustachian tubes.  Chronic inflammation can increase the risk of otitis.

What can cause inflammation of the Eustachian tubes?

• Viruses, Bacteria
• Reflux
• Allergies – hayfever
• Allergies – food allergies
• Air Pollution – most commonly tobacco smoke, but any airborne irritant
• Chemical irritants – example: chlorinated pool water

For infants and toddlers, upper respiratory infections (URI) with viruses is the most common cause of inflammation that causes ETD.

Reflux (regurgitation of gastric contents) in babies and infants. Medical studies have shown that reflux can cause otitis media.

Allergic Effects

Studies that have looked for a link between otitis and allergies suggest that there is a link between allergies to milk and COME.

If we think about it, this link should not be surprising:

Remember, any inflammation, like allergies, will worsen Eustachian tube dysfunction in our age group with ear infections – infants and toddlers.

What is the most common allergy found in infants and toddlers? Allergies to the airborne allergens (the things that we react to) don’t really develop until later. In this age range, the most common allergic reactions are to foods.

(4) What is the most common food allergy in infants and toddlers?

Right: Dairy – milk and eggs. This is our fourth and final link between milk allergy and otitis.

So yes, there is a link between milk allergies and ear infections, but no, milk does not cause ear infections. Not any more than an allergy to grass or flowers causes ear infections.

Note that in those people who do respond to milk allergens, it often thickens their mucus secretions. This is not a good effect when we are talking about Eustachian tube function – thicker mucus makes it harder for the Eustachian tubes to work normally.

So, to recap:

1. Otitis is common in infants and toddlers
2. Eustachian tube dysfunction is common in infants and toddlers, and increases risk of otitis
3. Inflammation of the Eustachian tubes, including inflammation from allergies, increases risk of otitis
4. The most common food allergy in infants and toddlers is milk

What Can You Do With This Information?

Well, for starters, if your little boogorhead has recurrent ear infections, consider eliminating dairy from their diet for a few weeks. A good place to start is the recent article Preventing Food Allergies on Littlestomaks. When it is time to visit a doctor, try to visit a pediatric boogor doctor (Ear, Nose, & Throat specialist). Yes, any ENT doctor can place ear tubes to treat recurrent ear infections. You will find that a pediatric ENT doctor’s office will be more “kid-friendly” – their waiting rooms are usually full of books and toys for children of all ages, their nurses are devoted to the care of children, and their medical instruments are kid-sized. Not to mention that the docs themselves have devoted their lives to the care of children, exclusively.

During that visit, they may obtain a hearing test, they may consider allergies, or reflux, among many other potential factors for causing your child’s otitis. Be patient. Otitis media is a complex disorder, influenced by hereditary and environmental factors, and it can take awhile to sort it all out.

Hearing

As an integrative holistic pediatric ENT specialist, my goal is to combine the best of conventional and alternative medicine to get my patients healthy. As a result, I am ultra-conservative with regard to surgery, especially for things like otitis media. The balance between aggressive and conservative can be tricky.

I waited too long to have my first son’s COME treated (he never complained, had no acute infections, just fluid), and his start of speech was delayed due to the reduced hearing while the fluid was in his middle ears.  So – get it evaluated by a specialist, get it treated if necessary.

My son got his set of ear tubes (the only way to eliminate the chronic fluid in the middle ear cavity), hears normally now, and his speech has taken off (can’t shut him up, wouldn’t want to).

©2010 Littlestomaks.com

Ask The Expert is a weekly column on Littlestomaks.com. The idea is to have a reader-submitted question answered by a nutrition expert or a pediatrician. Feel free to submit your question in the comments section below.

This week, Dr. Douglas Husbands provides an update on nutritional supplements with practical application for the health of your children.

Question: What is the latest development in nutritional supplements for children?

Answer:

Hello everyone!  I’m delighted for my second opportunity to guest post here.  Since I just recently came back from the 2009 International and American Associations of Clinical Nutritionists Scientific Symposium, I’d like to share some information on nutrition supplements with practical application for the health of your children.

Vitamin D3

• Adequate to optimal levels of serum vitamin D levels in infants and children (between 30 to 60 ng/ml) are associated with decreased asthma and allergies, better brain development and healthy bone development.
• When visiting your pediatrician or Functional Medicine doctor, serum 25-hydroxyvitamin D levels should be measured.
• It is estimated that between 50,000 to 70,000 deaths per year from various causes could be prevented by having adequate blood vitamin D levels.
• Many infants and children could benefit from supplementing with 1000 to 2000 IU of vitamin D daily, particularly during the winter months, if they cannot tolerate fatty fish, if they are darker skinned, or if their serum vitamin D levels are below 30 ng/ml.

Probiotics

• Probiotics help decrease abnormal intestinal permeability, or “leaky gut”.
• The appendix’s function is now known.  It is a repository for beneficial bacteria (probiotics) for the GI tract.  Supplemental probiotics help replenish the repository after antibiotic use or from use of corticosteroid creams or inhalers.
• Abnormal intestinal permeability allows gut-derived antigen exposure to the bloodstream; thereby distant, seemingly unassociated autoimmune symptoms can arise from a “leaky gut”.
• Due to immature GI tract development, it is best that infants are breastfed for at least his/her first 12 months.
• Many pregnant women and breastfeeding mothers would do well to supplement with the probiotic strain Lactobacillus GG (aka Lactobacillus rhamnosus) at a dose of 4 billion/day and Vitamin D3 at a dose of 4000 IU/day for potentially decreasing likelihood of asthma, eczema, allergies, type 1 diabetes, and autoimmune disorders in their babies.

Curcumin

• Curcumin, a component of turmeric, has powerful anti-inflammatory properties to inhibit inflammatory mediators, exhibiting therapeutic potential in asthma (and other inflammatory disorders)

©2009 Littlestomaks.com. All Rights Reserved
Disclaimer – Information provided in Ask The Expert column on Littlestomaks.com is intended to give you general guidance on a question related to toddler nutrition. It is not meant to be treated as medical advice. You are welcome to contact this expert for a detailed consultation on your specific situation to determine what actions, if any, you should take regarding nutrition and health of your toddlers. We do not recommend you to take any action based solely on the information presented in this column. Experts have agreed to provide their professional opinion on toddler nutrition related questions on a voluntary basis and no compensation is offered to them by Littlestomaks.com.

I got interested in reviewing this book by Jan Gambino when I connected with her on LinkedIn and she mentioned that some of the picky eating habits of toddlers may be due to gastroesophageal reflux (GER) or gastroesophageal reflux disease (GERD). This peeked my interest because in most cases we assume that picky eating is a behavioral problem. In some cases, the underlying reason may be physiological leading to a behavioral issue. Parents of infants and toddlers with GERD are probably already sensitized to that, but for a lot of other parents this may not be so obvious.

GER is defined as the backwashing of food from the stomach into the esophagus (food pipe) and throat during or after a meal. GERD, on the other hand, is considered to be symptoms or complications of gastroesophageal reflux. Clinical signs of GERD in children include vomiting, poor weight gain, dysphagia (difficulty swallowing), abdominal pain, esophagitis and respiratory disorders.

Overview

Jan has written this book out of a personal struggle with her youngest daughter’s severe asthma and reflux problem, which took a lot of time to diagnose, treat and control. She even calls herself a Reflux Mom! The wisdom of her personal experience and what she learned working with other parents can be clearly seen in this book. What I really liked about this book was the Question-Answer format in a lot of sections which directly addressed common concerns. It is full of practical tips and relevant comments from parents, yet it manages to cover a lot of ground on advanced medical topics and medications for GERD. Amazingly, Jan has been able to pack a lot of details in just over 250 pages!

10 things I learned from this book I did not know before

One way for me to evaluate a book is to step back and think about new actionable knowledge I gain by reading it. Luckily we did not face any major problems with reflux when our twins were still infants. There were a couple of incidents of forceful vomiting when we were introducing solids, but then we backed off, took it slow and avoided problem foods. In that way, this book gave me a lot of new information which I did not know before from personal experience. Here are 10 nuggets I gleaned from my reading:

1. Reflux (GER) is common in infants and babies and usually disappears in early toddler years. But GERD is a chronic condition which needs treatment.
2. There are several million children with GERD in the US.
3. Reflux can cause ear infections in babies.
4. Reflux can be triggered by food allergy.
5. Reflux is very common in children with autism.
6. Reflux during infancy can lead to picky eating in toddlers.
7. There is something called a silent reflux when food and acid from the stomach enters the esophagus but doesn’t come out as vomit. It can cause a lot of pain, irritation or discomfort to the child.
8. Some babies and children with reflux can even get overweight.
9. Colic and reflux can occur together but they are not the same.
10. Breast milk minimizes reflux since it is easy to digest.

What I wish this book had more of

Although this book is very well organized and there is a lot of useful information, it could use a few pictures or visuals to make its contents more appealing and not so dry. It is more of a personal preference as I am a very visual person. I like to see charts, graphs and tables to quickly understand the data. I also like pictures or photos to make it even more personal.

Recommendation

Here are a few reasons you may want to consider getting this book:

1. You would like to know more about reflux so you can be prepared to handle your baby’s needs and are not surprised by normal episodes of reflux.
2. You feel exhausted by excessive fussiness at feeding times, sleep issues and slower than expected weight gain and suspect that you need to see a doctor about these problems.
3. Your child has been diagnosed with GERD and you feel completely at a loss about how to care for him.
4. You feel isolated, constantly challenged, emotionally drained and feel you are not able to cope with the needs of your child with GERD.
5. You would like to learn more about tests, medications, surgery options and resources about GERD.

Overall, I give it a big thumbs up!

Visit RefluxMom.com for more information on GER, GERD and how to purchase this book.

Ni Hao! Hope all of you are having a great week so far. This week is Food Allergy Awareness Week. This is the 12th year that the Food Allergy and Anaphylaxis Network (FAAN) has organized a week of awareness about food allergies. Check out their website for more details on how to get involved if you are interested. If your child has food allergies, I would love to have you leave a comment and share your tips for managing nutrition.

Here is another set of 5 nutrition related news and articles from this week that I found interesting. Feel free to share your opinions in the comments section.

Ready for your order? Now let me tell you about sodium in our special today…

When I am dining out, I am usually quite impressed by the ability of the server to rattle off details of their specials of the day. But did you ever wonder why they don’t tell you anything about salt as they try hard to make your mouth water by the fancy description of the recipe? Turns out that if they did, the shock value would be enough for you to simply say “no thank you” and walk out never to return again!

In their report “Heart Attack Entrees and Side Orders of Stroke“, researchers from the Center for Science in the Public Interest (CSPI) disclose that many of the popular menu items in chain restaurants have “dangerously high levels” of sodium. They examined 17 chain restaurants and found that 85 out of 102 meals had more sodium than a whole day’s worth (2300 mg) and several had more than 4 days worth of sodium! Among the top 10 saltiest meals -  Red Lobster’s Admiral Feast has over 7100 mg and Oliver Garden’s Tour of Italy lasagna with breadsicks, salad, dressing and a coke has over 6100 mg of sodium. Items on Kids menu are no better either with some containing as much as 2400 mg of sodium. CSPI estimates that reducing daily sodium intake by just 25% over the next 10 years could help save the US government over 9 billion dollars per year in direct medical costs.

Isn’t it ironical that even with so much salt in the meals, they still have the salt and pepper shakers on each table?

When eating out, ask for the low salt version of the dish you want to order. Same goes for fat, cholesterol and sugar. If enough customers start asking for healthy food, I think restaurants will change their menu to favor healthy recipes.

If Cheerios^® claims to lower cholesterol, should it be considered a “drug”?

The FDA certainly seems to think so. This week, they sent a warning letter to the CEO of General Mills informing him of “serious violations of the Federal Food, Drug and Cosmetic Act” by the promotion of Cheerios® Toasted Whole Grain Oat cereal as cholesterol lowering. That would qualify it to be a drug they reasoned, because it seems to treat a medical condition for which drugs are prescribed. In the eyes of the FDA, it counts as an unapproved use since the product has not been evaluated by the FDA for safety and efficacy. Drug approval takes very long and requires a very strict quality control in manufacturing. This could turn out to be quite serious for General Mills who may have to withdraw this claim or modify it to comply with the regulations.

Another claim that FDA found troublesome was that “heart-healthy diets rich in whole grain foods can reduce the risk of heart disease”. Seems like they conveniently forgot to include fruits and vegetables in this claim, which together with a diet low in fat and cholesterol lower the risk of heart disease. Whole grains or dietary fiber is only one factor.

We personally like Cheerios -  it is a brand I have written about favorably in the past. But I am glad that FDA is sensitive to such over-ambitious claims cited in their warning letter. It is not uncommon to see health-related claims on products – for example, nutritional supplements make all kind of claims – but then they are also required to add that their claims have not been evaluated (and approved) by the FDA.

Will this affect your decision to by Cheerios or other products from General Mills? Weigh in.

HIV and safety of breast milk

Imagine the heartbreaking dilemma of a woman with HIV wanting to feed her baby with breast milk. Now imagine that this woman lives in a poor country, where women like her are routinely told not to breastfeed and formula is not affordable.  What are her options? Should she let her baby grow up without the benefit of breast milk, or in the worst case, even die of early childhood diseases?

It  is a sensitive topic; something a lot of us are fortunate enough not to have to worry about. Yet, the problem cannot be ignored if we want all children to grow up healthy. I was pleased to read about the efforts of researcher Sera Young of UC Davis, who is helping women of Tanzania learn a protocol to pasteurize breast milk by flash heating without affecting its nutritional value. Even though the WHO recommends HIV-positive to pasteurize breast milk,  no one in those countries knows how to do it. This project is a great start in that regard. And it is encouraging to note that the acceptance level is very high. The challenge will be to ensure that the pasteurization protocol is properly followed so that the breast milk is safe and still maintains its nutritional value. It is one thing to do it under the watchful eyes of a researcher, and something else to do it everyday on your own. But I do hope that it works in future at a much larger scale.

Link between obesity and food allergy?

This is what you could call a double whammy! Not only do we have rising rates of childhood obesity, we also have an increase in the number of early childhood food allergies and sensitivity to various foods. Now researchers from the University of North Carolina, Chapel Hill, have uncovered a link between obesity and high levels of IgE (antibody associated with an allergic response) based on the 2005 – 2006 NHANES data. Although, they are careful not to draw too many conclusions, it hasn’t taken all that long for people to ask the question “Is obesity fueling food allergies“? It is hard to say if high BMI and obesity is a cause of food allergy, or simply a common feature. Also, is there even a common cause between the two? Hard to say – because even though poor nutrition is linked to high BMI, we cannot say for sure that it also causes food allergy or intolerance. Could it be that the child’s parents have allergies? Could it be that they introduced these foods too early when the child’s digestive system was not fully developed? Just by looking at the survey data and drawing conclusions based on a statistical analysis does not mean that obese children are more likely to develop food allergies.

Support Share Our Strength’s Great American Bake Sale

If you love to bake and would like do some good at the same time, you have a great opportunity to help end childhood hunger. Can you believe that 500,000 more children live in poverty now compared to an year ago and 16 million children rely on food stamps? Personally, I find this statistic embarrassing in our land of plenty! Now, Share Our Strength is running their Great American Bake Sale campaign where you can get involved – the proceeds of your bake sale will go to fund after-school and summer feeding programs in your community and across the country.

You can also support them by blogging about it, or even contributing a recipe to their virtual bake sale! They will raise money by selling eBooks of recipes.

The only thing I will add is that even though this campaign is sponsored by Domino and C&H sugar, try to go low on sugar! Leave a comment if you decide to contribute.

Enjoy your weekend!

Photo source – Davichi on Flickr
©2009 Littlestomaks.com

Happy Friday! Check out these interesting nutrition related articles and drop a comment if you would like to share an opinion.

Carrots are boring but what about X-ray vision carrots?

It appears that giving veggies interesting and creative names might work if you would like your kids to try them more. In a recent study, 4-year old preschoolers ate twice as many carrots when they were presented as “x-ray vision carrots” compared to just “carrots”. That is amazing! I guess it might work with fruits too although they were not included in this study. Creating an experience of fun with veggies worked for @MommyMellie, who wrote in her guest post on this blog about how carrots, broccoli  and finger paint got her child to tolerate veggies and even like them. So, let your imagination go wild and have fun with fruits and veggies. Here are some more tips on helping your kids eat more of them.

“Organic” stamp does not mean food safety

Remember the recent outbreak of salmonella from the peanut plants in Texas and Georgia? Turns out, they also had the “organic” certification from the USDA according to this article in the New York Times! This is a good time to remind ourselves that organic certification does not imply food safety, even though you may expect it because you pay top dollar for these foods. Just like every other government program, the process of getting and maintaining the organic certification has become a beuareucratic mess. It took the private certifier for the Peanut Corporation of America nearly 7 months to report the problem to the USDA. By then, several people had been infected and many foods were on the recall list. In my opinion, these inspectors should also lose their license!

Does it mean you should give up on buying organic? Certainly not. However, it is probably a good idea to understand what the label means and not make any assumptions.

Getting a blood test for food allergy? Watch out for misdiagnosis

Seems like a lot of people are getting a blood test for detecting food allergies in their children. And in a lot of cases, kids and adults alike are getting diagnosed with allergies they don’t really have. In one case according to this article, a young boy was put on feeding tube because blood tests indicated he was allergic to everything! After doing a food challenge, doctors were able to introduce 20 foods into his diet. This is an extreme example for sure, however there is an increase in the number of misdiagnosed food allergies when blood tests are used. A 2003 report in Pediatrics reported that positive result on a blood allergy test correlated with less than 50% of real food allergy. If the blood tests show a huge positive allergy response, it is best to contact a specialist. Introduce new foods slowly and watch of any allergic reactions.

Do you have any experiences with food allergies in your kids?

Open your eyes to healthy eating habits

March is “Save Your Vision” month sponsored by the American Optometric Association (AOA). Most people already know that carrots are good for eyes because they supply the beta-carotene needed for night vision. There are several other key nutrient for long term eye health which are not that commonly known. Accordinng to AOA’s  Diet and Nutrtion website, researchers have now linked nutrients such as lutein, zeaxanthin, vitamin C, vitamin E, essential fatty acids and zinc to reducing several eye diseases. Foods such as spinach, kale, citrus fruits, nuts, whole grains, fish and supplements can provide all of these nutrients. This is a good reminder to try various foods with your toddler so he can get a balanced diet. Most toddlers are picky eaters, so you can also consider a daily multivitamin supplement.

Enjoy lentil soup

Our twins have now developed a taste for lentil soup. Check out our simple lentil soup recipe! Hope your toddlers find it as appealing as ours.

Enjoy your weekend!

Image source: orangeacid on Flickr
©2009 Littlestomaks.com