Dr. Kurt Barrett's GERD Blog - Pediatric-illness

Otitis Media in Infants and Young Children

nospam@example.com (Kurt Barrett, D.O.) — Sun, 14 Jun 2009 05:04:01 -0700

I have recently encountered a rash of youngsters whom have been treated repeatedly, 5-7 times in the FIRST YEAR of life for recurrent (persistent??) "ear infections". YES they need antibiotics for the fever and presumed bacterial infection BUT why do they not get beyond this?
Consider the following November 2008 information:

Gastric pepsin in middle ear fluid of children with otitis media: clinical implications.
He Z, O'Reilly RC, Mehta D.
Division of Pediatric Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.

"Gastroesophageal reflux and extraesophageal reflux have been postulated to be involved in the pathogenesis of otitis media. This is supported by recent studies revealing the presence of gastric pepsin in the middle ear space of children with otitis media but not in control patients without otitis media. Reflux's role in otitis media appears to be most pronounced in younger children and those with purulent effusions."

My take is that over 80% of the children with these ongoing ear problems likely have GERD, the unwanted reflux of gastric contents. GERD results in gastric contents arriving in the middle ear creating an environment favorable for bacterial colonization and growth with resultant infections. When the cause is GERD sucessful treatment for GERD should result in dramatic reduction in the manifestations of ill health. Often sleep and mood improve concurrent with the absence of ear pain (otalgia, ear ache, is COMMONLY caused by gastric reflux).
It is beyond the scope of the study reported but realize that chronic ear infections may be the only recognized complaint or only one of many problems that result in both chronic and acute illness. Asthma, recurring sore throat, "sinus problems", hoarseness/voice problems,clearing of the throat, runny nose and cough are all OFTEN caused by GERD.

Gastroesophageal Reflux in CF Not Caused by Cough

nospam@example.com (Kurt Barrett, D.O.) — Sun, 14 Dec 2008 18:03:45 -0700

"Gastroesophageal reflux (GER) is prevalent in patients with cystic fibrosis (CF), but it does not appear to be brought about by coughing; in fact, the converse may be the case, Belgian investigators report in the August issue of Gut."

Reuters Health Information, August 2008

More independent suggestion that GERD plays a surprisingly common role in many pulmonary diseases. At the very least, it seems likely to me, the autonomic (vagal) stimulus-response from gastric reflux complicates the associated pulmonary problems.

Pediatric GERD and Asthma

nospam@example.com (Kurt Barrett, D.O.) — Sat, 13 Dec 2008 13:28:32 -0700

November 11, 2008 (Seattle, Washington) Treatment of gastroesophageal reflux disease (GERD) improves lung function in children with persistent asthma". This according to a presentation here at the American College of Allergy, Asthma & Immunology 2008 Annual Meeting. They fail to endorse a "cause and effect" relationship but acknowledge the significance of therapeutic challenge. If the child skin tests negative for allergies they embrace a trial of GERD therapy. I certainly agree. My experience is that many asthmatics can benefit from high dose antisecretory medications trial and lifestyle changes.

Pacifiers Reduce SIDS Occurence

nospam@example.com (Kurt Barrett, D.O.) — Fri, 06 Jun 2008 19:26:20 -0700

_The 1994 "Back to Sleep" campaign, to place infants on their back for sleep, has helped reduce the incidence of Sudden Infant Death Syndrome (SIDS)
-In November 2005, the American Academy of Pediatrics (AAP), recommends offering a pacifier to infants 1 month until 1 year of age at sleep and nap time to reduce the incidence of SIDS
-AAP expert comittee on SIDS terms the evidence that pacifier use prevents SIDS "compelling"
-The "compelling" evidence includes a 92% reduction in SIDS
-There are many theroies but no agreed-upon mechanism in SIDS
-My opinion:
---sucking the pacifier stimulates salivary production and swallowing
---this causes clearing of gastric contents from the esophagus and normalization of the pH and internal environment of the esophagus
---in certain infants the presence of gastric reflux in the esophagus triggers a massive vagal nerve response intended to protect the person
---an unintended consequence of the "automatic" protective response is cardiovascular collapse likely triggering cardiac arrythmia and cardiac arrest in an otherwise healthy infant

-Offer the pacifier when the infant sleeps or naps
-Do not flavor, force, alter or reinsert the pacifier; it's almost as if the child intuitively responds...
-Even if we don't know the "why" this is inexpensive and safe, why not ? (You might save a life)

Reflux in Children

nospam@example.com (Kurt Barrett, D.O.) — Thu, 17 Aug 2006 17:26:39 -0700

Many pediatricians will confess that ALL infants have "reflux". They feel it's a matter of degree. The conventional wisdom is not to treat unless there is a problem...the pediatrician gets to define what constitutes a problem. Almost all consider gastroesophageal reflux (GER) as pretty innocent. The "D", signifying disease i.e. GERD, is left out because many pediatricians/family doctors do not automatically think of reflux as a disease. It is so common it seems automatically dismissed. The unfortunate result is many children plagued by this disorder thus go without treatment. Clinically it is almost certain infants and children have different symptoms than adolescent and adult patients. It has been demonstrated and confirmed that over 80% of children that need ear drainage tubes have "stomach juice" in the middle ear. This is the absolute truth (Dr. A. Tasker in 2002, findings confirmed by Dr. J. Lieu in 2004). The concept of "escaped" stomach acid causing problems remote to the digestive tract is yet to be widely received. In this case GERD is responsible for the infamous otitis media, ear infection or "fluid behind the ear drum". There is a huge debate about which antibiotic is best because all treatments to eradicate infection seem mediocre in long-term outcomes. It is perfectly clear to me that the infection is often a secondary event, actually a complication of the primary problem which is gastric fluid trapped in the middle ear. How did it get there? Stomach contents travelled past an incompetent check valve at the foot of the esophagus all the way to the oral cavity and right on up the eustachian tube where it lingers as a dangerous foreign invader. Thus trapped fluid stagnates and bacteria grow causing a bad situation to get worse as infection dominates the clinical picture. If the child does not manifest some severe, unusual digestive complaint the source of the problem (GERD) seems rarely, ALMOST NEVER, considered by the care givers, pediatrician or ear/nose/throat surgeon. Infants and children may spit-up, be "fussy eaters", throw up or complain of stomach pain yet never be considered for GERD testing or be a candidate for a therapeutic challenge with GERD medication (not sick enough?). Many other times no one has a clue that they suffer the consquences of GERD because it is infrequent for the child suffering acid reflux to manifest purely digestive complaints. More likely they will have trouble sleeping, snore, cough, wheeze, have sore throats (commonly in the morning), sinus problems, bad breath, constipation, "allergies" that are refractory to conventional therapy, difficulty in school, headaches and more. All caused by the body working fiercely to protect aginst the chemical spill of their home-grown hydrochloric acid. My clinical perception leads me to question the possibility of GERD in any child (or adult!) who has been "negative" when evaluated/tested in a conventional manner for a wide variety of problems.
A just completed study reveals that the tissue from infants/children esophagus remains abnormal long after the symptoms seem to have been "out grown".

Pediatrics-Illness in Infants

nospam@example.com (Kurt Barrett, D.O.) — Sun, 09 Apr 2006 16:27:42 -0700

Many pediatricians confess that ALL infants have "reflux". They feel it's a matter of degree. The conventional wisdom is not to treat unless there is a problem...the pediatrician gets to define what constitutes a problem. Almost all consider gastroesophageal reflux (GER) as pretty innocent. The "D", signifying disease i.e. GERD, is left out because many pediatricians/family doctors do not automatically think of reflux as a disease. It is so common it seems automatically dismissed. The unfortunate result is many children plagued by this disorder thus go without treatment. Clinically it is almost certain infants and children have different symptoms than adolescent and adult patients. It has been demonstrated and confirmed that over 80% of children that need ear drainage tubes have "stomach juice" in the middle ear. This is the absolute truth (Dr. A. Tasker in 2002, findings confirmed by Dr. J. Lieu in 2004). The concept of "escaped" stomach acid causing problems remote to the digestive tract is yet to be widely endorsed. In this case GERD is responsible for the infamous otitis media, ear infection or "fluid behind the ear drum". There is a huge debate about which antibiotic is best because all treatments to eradicate infection seem mediocre in long-term outcomes. It is perfectly clear to me that the infection is most often a secondary event, actually a complication of the primary problem which is gastric fluid trapped in the middle ear. How did it get there? Stomach contents travelled past an incompetent check valve at the foot of the esophagus all the way to the oral cavity and right on up the eustachian tube where it lingers as a dangerous foreign invader. Thus trapped fluid stagnates and bacteria grow causing a bad situation to get worse as infection dominates the clinical picture. If the child does not manifest some severe, unusual digestive complaint the source of the problem (GERD) seems rarely, ALMOST NEVER, considered by the care givers, pediatrician or ear/nose/throat surgeon. Infants and children may spit-up, be "fussy eaters", throw up or complain of stomach pain yet never be considered for GERD testing or be a candidate for a therapeutic challenge with GERD medication (not sick enough?). Many other times no one has a clue that they suffer the consquences of GERD because it is infrequent for the child suffering acid reflux to manifest purely digestive complaints. Often times they will have trouble sleeping, snore, cough, wheeze, have sore throats (commonly in the morning), sinus problems, bad breath, constipation, "allergies" that are refractory to conventional therapy, difficulty in school, headaches and more. All caused by the body working fiercely to protect aginst the chemical spill of their home-grown, made by the stomach, hydrochloric acid. My clinical perception leads me to question the possibility of GERD in any child (or adult!) who has been "negative" when evaluated/tested in a conventional manner for a wide variety of problems.
A just completed study reveals that the tissue from infants/children esophagus remains abnormal long after the symptoms seem to have been "out grown".

Pediatrics-Sudden Infant Death syndrome (SIDS)

nospam@example.com (Kurt Barrett, D.O.) — Tue, 04 Apr 2006 05:27:08 -0700

In October of 2005 the American Academy of Pediatrics (AAP) made a formal recommendation that infants age 1 month to 1 year be offered a pacifier when they nap or sleep. This strategy when coupled with the "Back to Sleep" initiative can reduce crib deaths by as much as 90%.
It has been suggested that SIDS may be an unfortunate convergence of sleep disordered breathing and gastric regurgitation. It makes sense to me that sucking on the pacifier allows the infant to clear the stomach contents from the esophagus thus preventing the "shock" to the baby from hydrochloric acid lingering in the esophagus.
Of course ALL the behaviors of creating a safe sleep environment for the infant also apply; this idea of offering the pacifier is in addition to lying the infant on their back, NOT allowing the infant to sleep in the parental bed, keeping the crib free of stuffed animals, etc.
They stress not forcing or flavoring the pacificer. It seems that just OFFERING the pacifier is the necessary step...the infant may or may not retain it...it suggests that the infant will inherently suck if that is "natures call".
Their is an informative abstract located at http://www.gerd.com/articles/abstracts/492.htm
Cardic Effects of Esophageal Stimulation: Possible Relationship Between Gastroesophageal Reflux (ger) and Sudden Infant Death Syndrome (sids)