Letter from a Practicing Physician
Dear Dr Farivar,
I was delighted to find your web site and to read its content - it is very
informative and well presented.
I am a General Practitioner in Western Australia with a special interest in
distressed babies. I am Medical Director of a clinic called the COMe HEAR Centre
- which is a multidisciplinary centre for children with Otitis Media and its
My major interest is in the relationship between the combination of GERD and
atopy - causing Eustachian tube dysfunction - with progress to recurrent early
OM and middle ear effusion.
I note with interest your comments about stopping cow's milk formula in infants
with reflux. This is usually my first line of management with distressed refluxing
babies - as I believe about 15% will stop refluxing if dairy products are withdrawn.
This also includes the mother stopping all dairy in her diet if the infant
is breast fed - we have a very high rate of breast feeding - which is extra
protection for these infants who are prone to ear infection.
I also note your comments about the risk of GERD causing ear infection and
would be interested in your references - I am aware that Kaufman included OM
as a risk factor of GERD - but I never found any references to this. I thought
that I was a voice in the wilderness talking about these relationships.
I believe that the combination of reflux and atopy is the basis of the problem
for many of my distressed babies. I believe that the refluxing acid and enzymes
irritate the opening of the ET [which is lower in the infant than in the adult]
and that the atopic disposition means that the tissues react excessively -
producing mucus and swelling and this interferes with ET function. I refer
to this condition as Eustachian Tube Irritation. The infants have a typical
pattern of behaviour - a desire to be upright, difficulty sucking at the breast
[? the vigorous sucking to get the 'let down' going causes ear pain - possibly
because the ET has difficulty maintaining the pressure in the middle ear at
atmospheric pressure]. This makes for discomfort lying down - so there are
often major sleeping difficulties as the longer the child is lying down the
greater the pain.
Many babies get relief from sucking a dummy [US pacifier], fist or thumb.
Strangely the worst of these infants are very distressed traveling in a car
- I don't understand the physiology / pathology of this. Many go on to develop
recurrent AOM and or glue ear - with many long term problems with speech development
and later school learning difficulties.
I have followed about 500 of these infants over some years. I also believe
that the incidence of ETI is much higher than the incidence of esophagitis.
I often see infants with reflux who have been tried on reasonable Medication
for the reflux and didn't improve - so were told that the reflux wasn't the
cause of the child's problems.
Looking after these infants is very time consuming
as their problems are often multifactorial - needing to deal with the reflux
often aspects of
the atopy and the middle ear problems as well. They tend to run an up and down
course - stirred up by URTIs, increases in reflux and immunisations. Infants
are very individual - some have more problems with the reflux, others with
atopic aspects and some have already outgrown the reflux but have ongoing middle
ear problems, language delay etc – so working with each child is different.
The best way to confirm the ear part of the problem is using a tympanometer
to show the ET pressure problems, effusion etc. The only article to support
my concept appeared in the Lancet in Feb 2002 From a group in the UK. This
examined the pepsin content of fluid from the middle ear taken when ventilation
tubes were inserted for children having tubes for persistent glue ear. They
found that 80% of the children had levels of pepsin that were 1000 times the
level in the blood - so postulated that reflux might be a significant cause
of glue ear. Their group was about 2 to 8 year olds I think. So how much more
likely are young infants to have this problem - with their shorter esophagus
and the high incidence of reflux.
I haven't ever been able to do a formal study of these infants - can't get
funding despite many attempts - and was told that trying to prove that A +
B causes C is not an accepted investigation design.
Hope I haven't bored you by this message - but I would be really interested
to hear your comments.
The COMe HEAR Centre
[Children's Otitis Media Centre]
Dodd St Wembley
Western Australia 6014