Does gastroesophageal reflux disorder (GERD) lead to middle ear infections in young children? Otitis media (OM) or ear infection, has the highest incidence, 62.9 percent, among all medical conditions in children younger than age five. Recent studies have suggested that GERD may cause OM.
Previous research into GERD revealed that regurgitation of breast-milk or formula was reported in half of 0- to 3-month-olds, peaked at 67 percent at four months of age, and decreased dramatically to five percent at 10 to 12 months of age. An analysis of children who had undergone a myringotomy found that the fluid in the middle ear (effusion) of four of five cases of ear infection in children aged two to eight years tested positive for pepsin or pepsinogen, a digestive enzyme, in concentrations that were roughly 1000 times higher than those found in serum (a fluid in the blood). In addition, they found no evidence of pepsin production in three middle ear specimens, leading to a conclusion that pepsin found in middle ear effusions was probably due to the reflux of gastric contents rather than material in plasma (a fluid in the blood).
Other studies have confirmed an association between gastric contents and middle ear effusion. However, association does not equal causation, especially in OM where the cause of the infection is usually multifactorial.
A new study has been completed that set out to investigate the causal relationship of GERD and OM by 1) confirming the finding of pepsin/pepsinogen in the middle ear fluid of children undergoing myringotomy and tube placement for chronic or recurrent OM; and 2) querying parents about symptoms that suggest the presence of GERD in these children. The authors of “Association of Reflux with Otitis Media in Children” are Judith E. C. Lieu MD, P. Ganesh Muthappen, and Ravindra Uppaluri MD, PhD, all from the Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO. Their findings are being presented on September 21, 2004, at the American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting & OTO EXPO, being held September 19-22, 2004, at the Jacob Javits Convention Center, New York City, NY.
Methodology:
The prospective observational study included 34 children, aged seven months to seven years, recruited from the clinical practice of the Division of Pediatric Otolaryngology at St. Louis Children’s Hospital. Middle ear fluid samples were collected from 22 children; a total of 36 samples were tested. Researchers were usually able to collect at least 100 microliters of middle ear fluid per ear.
The subjects were required to have a history of recurrent otitis media (ROM) or chronic otitis media with effusion (OME) and meet the criteria for placement of tympanostomy tubes. OME was defined as the presence of middle ear fluid for at least 3 months documented by physical examination or Type B tympanogram in at least one ear. Those excluded from the study ROM had a medical history of disorders known to be associated with an increased prevalence of ROM, OME, or gastroesophageal reflux disease (GERD).
Outcomes of the research included measurement of Pepsin/pepsinogen in middle ear fluid: Middle ear fluid samples were examined for the presence of pepsin using a proteolytic enzyme assay and ELISA specific for pepsinogen I.
Parents of the children were asked about current symptoms that may be suggestive of gastroesophageal reflux, using validated questionnaires. These questionnaires included the Infant Gastroesophageal Reflux Questionnaire (I-GERQ) for children two years old and younger, and the GER3-9P for children age three to seven years.
Results: