This is a guest article by pediatric ENT specialist Dr. Russell A. Faust, who blogs at Ask the Boogor Doctor.

We adults with reflux know it as heartburn. Other symptoms include burping and sour taste. That sour taste is regurgitation of stomach contents to the back of the throat (yuk!).

It’s called gastro-esophageal reflux (GER), and more than 135 Million, or about 44% of Americans, have reflux at least every month.

Babies, Infants, Children

We know reflux in babies and infants as “spitting up,” and we can all recognize the spitty baby from the white curds on their chin.

Most of these babies will outgrow their reflux without harm, and without intervention. Most will never have symptoms.

A small minority of infants and children with reflux will experience symptoms. Symptoms of reflux in children can be stealthy. They almost never complain of heartburn. The symptoms that they experience are usually indirect – they cough, wheeze, have chronic throat-clearing, recurrent bronchitis, or chronic sinusitis.

This is when simple GER becomes GER Disease, or GERD.

What I wanted to review here today is a connection that does not seem intuitive – that between reflux and sinusitis.

How in the World Can Reflux Cause Sinusitis?

Similar to the link between reflux and ear infections, there are two schools of thought on this connection:

1. The first is based on a theory called the Unified Airway Model. This theory states that, because the upper aero-digestive tract is derived of the same lining, any inflammation occurring anywhere in that tract will stimulate the other areas also. Simply put, otitis can cause sinusitis, can cause asthma, etc. There is pretty good scientific support for this theory.
2. The second thought it that if reflux reaches the back of the throat and lining of the nose, the resulting inflammation and swelling can cause sinusitis. There is pretty good scientific support for this theory too:  studies have found gastric enzymes inside the middle ears (in cases of chronic otitis), or inside the sinuses (in cases of chronic sinusitis). This is pretty direct evidence that gastric contents has been regurgitated up to that level of the upper airway (not a pretty thought).

What is the Clinical Evidence for a Connection?

A study reported in 1999 (Bothwell) found that 89% of their pediatric candidates for sinus surgery were able to avoid surgery simply by treating for reflux.  89% avoided surgery!!

A study published one year later (Phipps) reported that 63% of children with chronic sinus disease had reflux, and that sinusitis improved in 79% of them when their reflux was treated.

That same year (2000), another group (Yellon) reported an even stronger correlation between reflux esophagitis and sinusitis:  When they looked at the esophagus (food swallowing tube leading to the stomach) they found inflammation of the esophagus (esophagitis) in 100% of the children with sinusitis. That is, in their study every child with sinusitis had reflux esophagitis.

These correlations do not prove that reflux causes these symptoms, but there is strong implication.

What Can You Do With This Information?

Other symptoms to raise suspicion for GERD include:

• Cough, worse at night
• Wheezing, worse at night
• Choking at night
• Stomach ache, worse in the morning
• Chronic throat-clearing, worse in the morning
• Recurrent bronchitis
• Recurrent and chronic sinusitis
• Failure to thrive (difficulty gaining weight)

If your little monkey has chronic sinusitis, or any of these other symptoms, reflux should be considered as a contributing factor. Improving, or even eliminating, the symptoms might simply be a matter of treating the reflux. It still amazes me that I “cure” asthma or sinusitis in my clinic when I recognize reflux as the major causative actor and treat it.

Ask your pediatrician or pediatric boogor doctor about it.

Finally, Jan Gambino’s book, Reflux 101, is a great place to start if you have questions reflux in your infant or child, and what you can to do about it.

Next month I am reviewing how we test for reflux, and treatment options for reflux (conventional and alternative), and I invite y’all to come visit.

Resources:

1. Nelson, Chen, Syniar, Christoffel. Prevalence of symptoms of gastroesophageal reflux in infancy. Archives of Pediatric and Adolescent Medicine 151: 569-72; 1997.
2. Stroh BC, Faust RA, Rimell FL: Results of Esophageal Biopsies Performed During Triple Endoscopy in the Pediatric Patient. Archives of Otolaryngology – Head and Neck Surgery, 124: 545-549; 1998.
3. Bothwell M, Parsons D, Talbot R, Barbero G, Wilder B. Outcome of reflux therapy on pediatric chronic sinusitis.  Otolaryngology-Head and Neck Surgery. Vol. 121(3): 255-262; 1999.
4. Phipps CD, Wood WE, Gibson WS, Cochran WJ. Gastroesophageal reflux contributing to chronic sinus disease in children. Archives of Otolaryngology-Head and Neck Surgery. Vol. 126: 831-836; 2000.
5. Yellon RF, Coticchia J, Dixit S. Esophageal biopsy for the diagnosis of gastroesophgeal reflux-associated otolaryngologic problems in children.  American Journal of Medicine. Vol. 108: 131s-138s; 2000.

©2010 Littlestomaks.com

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

In her recent article Vaccine for ear infections soon to be on the market,  Chicago Family Health Examiner Jasmine Jafferali, MPH, wrote that the underlying cause of chronic ear infections in children could be milk allergy. I was so intrigued by this suggestion that I contacted her to address this idea in a Question-Answer format for my blog. If your child is suffering from chronic ear infections and you are concerned about excessive use of antibiotics, this article is a must read for you! Let me know what you think!

Question: You have said that milk allergy is an underlying cause for chronic ear infections. Can you provide a credible reference to support this?

Jasmine: Dr. Greene, a prominent pediatrician,  has discussed a link to milk allergies and ear infections.  Up to 40 percent of kids who suffer from chronic ear infections has a milk allergy.  In fact a 1997 report on food allergies in the Journal of the American Medical Association found that cow’s milk allergies tend to hit children in their infancies, showing up as colic, acid reflux or eczema.  However many pediatricians are overlooking the possibility of food allergies, especially milk allergies to chronic ear infections.

Question: How can parents recognize the signs of food allergy and dairy allergy in particular?

Jasmine: Although a child can develop an allergy to almost any food, well over 90 percent of food allergies in children are caused by one of only six foods: milk, eggs, peanuts, wheat, soy, and tree nuts. The immediate symptoms of food allergies in babies and toddlers are irritability, colic, wheezing (sometimes asthma), a minor rash, chronic runny nose, or itchy eyes. These more immediate symptoms are less likely to occur than slower onset symptoms, which your baby can experience seven to 10 days after exposure to cow’s milk.  These more common symptoms include diarrhea (possibly with blood), abdominal cramps, vomiting, coughing, gagging, acid reflux, ear infections, runny nose, eczema and colic.

Food allergies is becoming more and more common in our children.  Parents are fearful and the information out there is confusing.  These findings are all consistent with the 2008 American Academy of Pediatrics guidelines that overturned previous recommendations by declaring that there is no evidence that delaying any food beyond 4 to 6 months helps prevent allergies at all — for healthy term children who are not already allergic.  However, many parents get quite excited introducing solids to their infants.  Remember, the main source of nutrition for an infant is breastmilk or formula for the first year of life and solid food is meant to be the supplement.  Look for signs that your baby is ready to eat solids.

Question: What kind of questions should parents ask when an antibiotic is prescribed?

Jasmine: If an antibiotic is prescribed some questions to ask are:

1. Is the infection bacterial or viral?  If viral, then antibiotics will not improve symptoms of the ear infection.  It is like being prescribed antibiotics for a cold.  Ask for possible alternatives.
2. Where is the location of the infection?  If the infection is in the middle ear, ask if waiting it out is an option and what you can do to help minimize their pain.  Eighty percent of ear infections will resolve on its own within 4 to 7 days without antibiotics.  WebMD wrote an article on this study back in 2005.
3. If my child must take antibiotics, can I give them some probiotics after the finished antibiotics to help replenish their good bacteria?  (remember antibiotics kills BOTH good and bacteria and you have replace the good back into the body)  Studies are showing the benefits of taking probiotics after antibiotic treatment and during cold and flu season.

Question: How can parents tell if they are exposing their child to excessive antibiotic use?

Jasmine: If you are in the doctor’s office for the third time in one year getting another round of antibiotics it is time to ask the long term effects of getting the antibiotics and start looking into the underlying cause for the chronic condition.  If your child is an infant, you may want to switch formulas where the formula is more broken down and easier for your baby to digest.  Or if you are breastfeeding looking at your own diet as possible issues.

Question: Can ear infections be treated without the use of antibiotics?

Jasmine: Often, an antibiotics is prescribed to treat the ear infection. According to the June 2009 British Medical Journal article, prescribing antibiotics leads to more ear infections.  In fact, if the children had taken antibiotics, there was a 63 percent chance they’d had at least one subsequent infection. The risk was only 43 percent for children who’d been given an inactive placebo.  Other studies show that it takes children only three days longer to recover from the middle ear infection without antibiotic treatment.  (see the WebMD article)

There are alternate treatments to chronic ear infections.  In fact, my own grandmother used some of these home remedies on us when we suffered from ear infections.

1. Warm compresses with a warm washcloth. Do not put the water in the ear and make sure the washcloth is not too hot.
2. Hyland’s ear drops is used with a confirmed diagnosed ear infection.  This can be purchased at your local drugstore or health food store.
3. Warm olive oil, or warm garlic infused olive oil: In test tube studies garlic has been found to have antibacterial, antiviral, and antifungal activity-garlic is a natural antiseptic!  Chop 2 garlic cloves and allow the small pieces to marinate in a half cup of olive oil for a day (if you can’t wait proceed to warming the oil over the stove).  Warm the oil slowly over the stove, it should be warm to your touch.  Get an ear dropper and put a few drops into the ear.  You may add a few more drops later in the day, the first round should do the trick.  This mix will last for about two weeks.  Many parents are turned off by this home remedy, however, there are plenty that use and swear by this method.
4. Echinacea – this is an herb which can safely and effectively boost the immune system.  Click on Dr. Greene’s guide to using Echinacea properly.
5. Chiropractic care – chiropractic adjustments to the skull and neck can improve middle ear drainage and decrease ear infections.  Many parents are finding relief going this route

Using a combo of the above will be helpful such as warm compresses and whichever remedy you choose.
WARNING – if you see any liquid or pus draining out of the ear, DO NOT PUT ANY OF THE ABOVE DROPS INTO THE EAR.

Question: Can you give suggestions to dairy alternatives if dairy allergy is found to be the cause of ear infections?

Jasmine: If you child has a confirmed milk allergy with an ELISA allergy testing, then eliminating all dairy can be a difficult transition for your child.  Finding the right dairy substitute is tricky.  Often kids allergic to dairy are often or have a hard time digesting soy.  As rice cereal was probably your child’s first food, rice milk is a nice alternative and easy to digest.  If there are no tree nut allergies, almond milk is another great substitute.  If you are concerned about your child getting the fat from the milk, you may add up to 1tsp of flax oil to the milk substitute.   There is now coconut milk yogurt and coconut milk ice cream which is both delicious and provides some great health benefits.  So Delicious is a wonderful brand and your child will not miss out.

©2009 Littlestomaks.com