14 July 1997

1. Separation Anxiety
2. Strange Itchy Bumps
3. Gastroesophageal Reflux
4. Enlarged Lymph Node
5. Milk Allergy and Ear Infections
6. Milk Allergy and Ear Infections Revisited
7. Spitting Up
8. Gastroenteritis and Dehydration
9. Disclaimer

• Read Questions & Answers in Another Column

• Feature Article: Fecal Soiling: Few things can be more exasperating to parents than dealing with poop in the pants of an older child. This article will help parents facing soiled pants understand why it happens and the management of the problem.

Separation Anxiety

In a nursery or with a sitter she can cry for hours and won't eat. As soon as I get home she takes a bottle and is happy again. I have enrolled her in a Mothers Morning Out program for two mornings a week for about 3 hours each morning. I feel like she has to learn to be away from me for at least a little while.

Will she ever outgrow this? What else can I do?

-PT

Dear PT: Separation anxiety is a normal part of growing up. It usually starts between 6 and 8 months. It can be very upsetting to fathers when their children are not willing to go to them. In such situations I recommend that the fathers make a point of spending more time with their babies with the mothers.

Some babies have more extreme separation anxiety than others. It does get better with time, but may take as much as a year or two. It may help to ease your baby into new situations by getting her used to them and the other people in your presence. But whether or not your baby cries, you should take time for yourself. By seeing that you always come back she will learn that your absence is okay.

Sincerely,
Dr. Warren

I have considered everything from dry skin to scabies, but nothing seems to soothe or prevent these bumps. A couple years ago I was afflicted with shingles on the side of my neck- this was treated with acyclovir, and I only had one recurrence. The leg bumps remind me of the first itch of the shingle blisters, therefore, I am wondering if the two things are related?

Please let me know if you have any idea what is going on here.

Thank You.

-Tired of Scratching

Dear Tired: Your rash does not sound in any way related to shingles. Your physician may be unconcerned because he feels your condition is not serious; however, in providing you this reassurance, he is missing the point that you need some relief from your symptoms. Since rashes are almost impossible to diagnose without seeing them, I would suggest that you see a dermatologist the next time you have an outbreak.

Sincerely,
Dr. Warren

-Concerned Parent

Dear Concerned Parent : Zantac is helpful in the management of reflux symptoms because it decreases the acidity of gastric secretions; however it does not significantly alter the dynamics of reflux or decrease the spitting. Thickening the formula by adding rice cereal may help. So might keeping the baby upright for a longer time after feeding. If these measures are not sufficient you should consult a pediatric gastroenterologist who might recommend other medications such as Reglan or Propulsid.

Sincerely,
Dr. Warren

My 8-month old baby has a swollen lymph node. He has had it since we was 3 mos. old. It is about the size of a pea and it does not seem to be inflamed nor does it hurt him when I touch it. My pediatrician is aware of this - and she feels it every time we go for a routine visit. However, since I am quite worried about it, I was referred to a pediatric surgeon who had the same conclusions. I was even told that the lump may be there for several months (and even years). What do you think?

P.S. A 35 year old friend of mine still has hers to this day.

-anonymous

Dear Parent: It is not unusual for lymph nodes in the neck or the back of the head to swell in response to common upper respiratory virus infections. Once these lymph nodes have swelled, it may be possible to feel them for months to years. It is likely that they will enlarge with each new virus infection. A pea sized lymph node that isn't getting larger doesn't sound the least bit worrisome. Your pediatrician has been responsive to your concerns in seeking another opinion and she is being conscientious in checking it regularly. Since your baby is getting such good care, I think you can relax.

Sincerely,
Dr. Warren

I did not find any mention of food allergies as a possible cause of this condition in your pages. Our son was subjected to several changes at about 6 mo. and has been sick off and on, but mostly on, ever since. These changes included the cessation of breast feeding and substitution of formula, and attendance at day care. More recently regular cows milk was substituted for formula, and he is also eating a lot of solid foods. At this time he has fluid in the ears and some excema on his lower legs and, to a lesser extent, his arms. However, the excema was not noticed by his mother until very recently, and so did not seem to be especially or obviously correlated to the introduction of cows milk.

In my estimation he does not have any traditional allergies to the foods he is taking, but based on the pediatrician's information and other information I have found on the Internet, it appears that there is a strong possibility that he may indeed have some kind of "quasi-allergy" to one or more foods such as cows milk. Since this kind of allergy does not cause a violent reaction, it seems that many doctors prefer not to consider it as a cause of persistent otitis media.

His pediatrician pointed out that a diet change, if done with some appropriate planning, is risk-free, unlike surgery. However, it would require close cooperation between his mother and I to implement, and having tried it myself in the past I know it is actually quite a hassle to eliminate dairy products entirely since so many different foods contain them. Therefore I am looking for some additional supporting information on this before "hoisting it up the flagpole".

I also read your article on common myths, which seemed reasonable and informative, but the myths did not include the idea of quasi-allergies to food. Do you feel that this is another myth, or is there supporting research already done?

-AG

Dear AG: I am not sure what a "quasi-allergy" would be. People have different types of allergic reactions and different degrees of allergic reactions. Since congestion in the nose and throat from any cause can contribute in a significant manner to middle ear problems there is no question that chronic congestion caused by allergy can contribute to middle ear problems; however, in the absence of congestion, I know of no mechanism by which allergies would have a specific effect on the middle ear and no study indicating that this occurs.

The idea that cow's milk causes middle ear and other health problems has enjoyed some popularity in the lay press, but I have yet to see any proof. True, cow's milk was meant for cows, but which of the foods humans consume except for human milk was designed for humans. If allergy were at the root of many middle ear problems, shouldn't other foods be implicated as often as cow's milk? Many children who seem to have "problems" with cow's milk had no problems when they were on formula made from cow's milk.

The switch from breast to bottle may sometimes contribute to middle ear problems in another way. Some infants drink their bottles flat on their backs which can result in milk entering the Eustachian tube during a swallow and causing inflammation.

Day care, with its increased exposure to upper respiratory infections is most likely the most significant factor in your son's increased middle ear problems. If recurrent colds have led to persistent fluid and recurrent ear infections, long term low dose antibiotics to prevent reinfection may help to avoid surgery.

RAST testing can be helpful in diagnosing food allergies, but many allergists consider RAST testing useful only as confirmation when there is clinical evidence of allergy. The gold standard for allergy testing is skin testing although I've never seen it done for foods. Generally, elimination diets are used to treat and confirm food allergies. They can be quite a hassle, but as your pediatrician has pointed out, as long as your child is kept on a nourishing diet, elimination of a particular food is risk free.

Sincerely,
Dr. Warren

Since you mentioned the lack of supporting research on this, the one study I found so far that may apply to the question of food allergies and otitis was originally published in the Annals of Allergy, Volume 73, September 1994 by T Nsouli M.D. et al. See the URL (article no longer available) or search the net for "otitis media" + "allergy" for more details. In the paper they reported a significant statistical association between food allergy and recurrent otitis media among 104 unselected patients ranging in age from 1.5 to 9 years. I am not adept at this area of research, but I was wondering whether this was a significant study and whether there are others that are similar.

Regards,

-AG

Dear AG: I tried to look at the web site you suggested and found the page empty. Perhaps it is being revised. But in an effort to find the kind of information you are looking for I looked a little further and found a Web site by David Hurst, M.D. at http://home.earthlink.net/%7Emeear/ which discussed allergy and middle ear fluid in great detail.

Remember, I did agree that allergy can contribute in a significant way to middle ear problems although I questioned the mechanism if there were no nasal congestion. Dr. Hurst makes a good case for a mechanism, but I still have some difficulty with the idea of middle ear problems being the ONLY allergic manifestation, especially in the majority of children. And I fail to see why cow's milk is considered the most likely allergen. Yes, cow's milk may be the problem in some cases which is why I agreed that eliminating milk from your son's diet might be worthwhile as long as he continues to receive a nutritious diet. But since child nutrition often becomes an issue where milk is the only source of protein that some children consume, I'm still inclined to approach milk as a good food rather than the likely cause of most ills.

In any event, you should look at Dr. Hurst's site. It is chock full of information. Dr. Hurst's bias is evident in his opening statement: "This Web Site presents the proof that persistent fluid in a child's (or adult's) middle ear is the result of allergy and not infection. It is designed to tell parents and physicians how they can know for sure that allergy is responsible for their child's ear disease - and what to do about it." Most of my colleagues do not believe that persistent middle ear fluid represents infection and therefore only treat with antibiotics in those children who have recurrent infection. However, there are many possible contributing factors to middle ear fluid besides allergy, so it appears to me that Dr. Hurst is on somewhat of a soap box about allergy and middle ear fluid. As a point of interest, last year there was a study that showed that middle ear fluid is not always sterile, containing small amounts of bacteria. I'm not aware of another study confirming these results or any recommendations based on this study.

Sincerely,
Dr. Warren

Is this normal ? Can I do anything to help her ? She seems to be happy and healthy otherwise, and this vomiting doesn't seem to upset her. (She is gaining weight).

I'd appreciate your advice as I spend my time washing her, her clothes and her bed-linen ! Thanks,

-GD

Dear GD: It sounds to me like you're describing normal spitting up. Some babies spit more than others, and it can mean a lot of laundry, but as long as the baby is happy, has a good appetite, and is gaining weight well, there is no need to worry or do anything about it.

Sincerely,
Dr. Warren

Thanks

-LAF

Dear LAF: The main risk to intestinal viruses is dehydration because of fluid losses through vomiting and diarrhea. Once the vomiting is controlled, if the fluid intake is good and includes some salts such as Pedialyte, dehydration should be avoided. The body can go a much longer time without food than it can without fluids.

Since most children with intestinal viruses lose their appetites it is best not to push food as that may make them vomit. It would be unlikely that your child would get severely ill from lack of food during the time it will take for his appetite to return; however, if you don't like the way he looks, you should have him seen by his doctor. In the meanwhile, continue to offer him plenty of fluids, and remember, those fluids have some calories too.

Sincerely,
Dr. Warren

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