Information about GERD Symptoms, Diagnosis, Treatment options, and GERD Medication
 
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Irritable Bowel Syndrome (IBS)
 
 

 

 
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 sequelae.

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line of management with distressed refluxing babies - as I believe about 15% will stop refluxing if dairy products are withdrawn.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 [usually], 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.


Yours sincerely,

Renee Shilkin
Medical Director
The COMe HEAR Centre
[Children's Otitis Media Centre]

Dodd St Wembley
Western Australia 6014

 

 

 

 

 

         This is an educational site created by M. Farivar, M.D. The information provided is the author's opinion based on years of clinical experience and research.  You are advised to consult your own physician about the applicability of this information to your particular needs.  Also, keep in mind that symptom response to therapy does not preclude the presence of more serious conditions. 

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