Source: The LEAP study

Did you know that nearly 30% of children in the United States have some form of allergy and that the rate of allergic disease in children is on the rise?

I found this fact quite interesting – and troubling – as I read this article about childhood allergies. What is even more interesting is that the progression of allergic disease in children appears to follow a predictable pattern called the Allergic March.

It goes like this – first it starts with dermatitis (eczema), then to chronic gastrointestinal (GI) issues, then to chronic serous otitis media (ear infections), then to chronic rhinitis (stuffy nose) and finally to asthma.

The problem is that allergic disease doesn’t have a cure, and that is why, prevention is the only smart choice. It helps to know that the pattern of allergic disease is predictable, which is why, early signs of allergic symptoms like eczema and food allergy or sensitivity should be considered seriously.

Most babies in their first 1-2 years of life show sings of food sensitivity to certain foods such as egg, dairy, soy, rice and wheat. This is because their young immune systems are yet to mature and sometimes they get confused by different proteins in these foods. Good news is that, most children do grow out of these early issues by the time they reach age 5.

The news is not so good if there is a family history of allergy, which is why getting to know the allergic march is quite important. If either mom or dad – or both – have a history of allergy, the chances of their child developing an allergy can be as high as 50 -80%. If not diagnosed and prevented early, the allergic march is likely inevitable.

We have been interested in food allergy here on Littlestomaks, because it affects so many babies and toddlers. Although there is no reason to hit the panic button over a few episodes of vomiting and reflux, it is prudent to take them seriously when allergy runs in the family. Same goes for ear infections, which again are quite common in children. A link between milk allergy and ear infections, for example, is being reported in many cases. Talk to your doctor about the history of allergy in your family on a routine visit to treat an ear infection. For all you know, it might be the first step on the allergic march, which you can avoid with early intervention.

Here are a few nice links for more information:

The LEAP study
The Allergy March
Food Allergies on About.com
Pediatric food allergies on Today’s Dietitian

Do you have a child with food allergies? Share your story, we would love to hear from you!

©2011 Littlestomaks.com

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

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, published author and Reflux expert Jan Gambino explains why giving fruit juice to a child with reflux may cause problems.

Question: Is apple juice really all that bad for a child who has Gastroesophageal Reflux? What about orange juice?

Answer:

A toddler with Gastroesophageal Reflux may naturally limit her intake of all juices, including apple juice and orange juice due to the high acidity in these beverages. She may have discovered through trial and error that juice causes painful acidic backwashing into her esophagus and throat. In addition, the extra sugar and fluid in her stomach may cause bloating and discomfort. If your child with reflux craves juice despite the pain, you may need to limit juice intake, offer watered down juice or slowly switch to water only. If your toddler has severe Gastroesophageal Reflux Disease (GERD), the doctor may recommend total elimination of acid foods and drinks such as juice from the diet. It is always best to ask your doctor for advice on feeding your toddler with reflux.

My toddlers with reflux were also severely lactose intolerant so they were not eager to drink milk. Even lactose free milk and toddler nutritional beverages were not tolerated. They did like watered down apple juice but there was barely any nutritional benefit. Eventually, water became the beverage of choice and they had to get their nutrients from calcium rich foods and a multivitamin.

I know many parents are grateful to have toddler juices fortified with calcium and vitamins. While these beverages offer the advantage of dairy free calcium and other nutrients, the added sugar and risk of tooth enamel erosion associated with juice intake need to be taken into account. With concern about juice and soda consumption adding to the obesity epidemic all parents need to be concerned about juice intake and a healthy diet.

Whether your child has reflux or not, water or watered down juice is the best option to stay hydrated.

©2010 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.