DEPARTMENT OF CHILD HEALTH Faculty of Medicine — Universitas Padjadjaran be) aE Wor Wel dalle Baers Ce ste are]Cow’s milk is a foreign protein given to the baby who can't give breast milk First atopy disease in infant is cow's milk protein allergy (CMPA) Cow’s milk protein allergy incidency is 3-7% Approximately 30-45% child 1 years old have atopy dermatitis caused by cow's milk allergy= Immunologic reactions to cow's milk protein are mediated by the immune system, by two major mechanisms: IgE-mediated ii-|/-jenon-Ig=-mediated ® All other nonimmunologic reactions to cow's milk proteincanbecharacterizedas = Cow's milk intolerances: nonallergic hypersensitivities? DMS GAS et Wes EA VaR SM eC ad 2, Davis CM. Food allergies: clinical manifestations, diagnosis, and management. Curr Probl Pediatr er ee ae ee eeCNN Te eer eR a caton) ] eereue ea Auta) ) eM a eeen tuum) ) eau ) ene Seer ) eee te eee eet Food protein Patel ca) elec) Perens Piola erro rhinoconjunctivitis, Tia Ciro) it Morolgle lod Er MU oe te Tare timers Led oral allergy disease, dermatitis Sale [celui aa ced rou eyt (type |) hypersensitivity reaction. The late-phase reaction is dominated by lt T,,2. T-helper type 2 CD4 ceils.; Signals for IgE Fe receptor yr activation of Signals for 4 phospholipase Ae degranulation == » Signals for cytokine gene activation Membrane phospholipids Granule contents Secreted Arachidonic PAF * Histamine cytokines acid * Proteases * Chemotactic factors (ECF, NCF) Leukotrienes Prostaglandin By, Ca, DgVasodiation, increased vascular permeabity ‘Sirooth muscle spasm PAF Leukotriones C,,0,.&, [Nouiral proteases that activate complement and kinins rBloglansn, Leukotones Cy. De Ey Histamine Prostaglonsins PAF Cytokines, eg, TNF Loukorrone 8, Eosinophil and ewrephl chomatacte fates (nat defined biochemical) PAFWER tor teeter titel) Release of histamine and anaphylaxis ——____ C f intestinal ‘ontraction smooth muscle, leading to vomiting®and diarrhoea Antigen diffuses into blood vessels, leading to urticaria and/or anaphylaxis Local release of histamine Wheal and flare response Allergic rhinitis in upp APSF SARTO? airways (bronchial smooth muscle contractionejala alergi susu sapi dan eee iky Saluran cerna: Diare (53%); Kolik (27%) Site Urtikaria (18%); Dermatitis atopik (35%), Saluran napas: Asma (21%); Rinitis (20%), Umum: Anafilaksis (11%) er cUe Wr Mas cer aCe Rae Co_ Most cow’s milk protein-induced IgE-mediated allergic reactions occur within minute after ingestion & Typically, symptoms occur immediately after cow’s milk protein ingestion, resulting in Joe cee es aaa er Wl OR WR RUC ToL Tr eae gl) Pediatr Adolesc Health Care.2009;39:236-54> ai _ Generally slower in onset ( after ingestion) and,are primarily aeRtoneetrel in nature Examples: f Davis CM. Food allergies: clinical manifestations, diagnosis, and management. Curr Probl eee to aa UR ee exeMixed IgE and non-lgE mediated In the mixed disorders, the IgE and non-IgE mechanisms can work together to exacerbate diseases like Davis CM. Food allergies: clinical manifestations, diagnosis, and management. Curr Probl er Ee een Re Lek are ESPEO er anu we a a Cueto eeeIgE-mediated cow’s milk protein allergies (within minutes to 1 hours) cross-contamination hidden ingredients. Davis CM. Food allergies: clinical manifestations, diagn Per ascoeee cca 7) 4 aesNon-lgE-mediated or mixed IgE and non- IgE-mediated 1 hours up to days eke Mee er mee Semen aaaDC Ce ae UO CUS eAlar)Infants and young children Older childrenweight loss or failure to thrive non-IgE-mediated allergy or gastrointestinal enteropathies (<1 hours) (1 hours up to days or chronic) and management. Curr ProblDiagnosis of Co Milk Protein Allergy an IgE-mediated cow’s milk protein allergy 5 a non-lgE-mediated cow's milk protein allergy Davis CM. Food allergies: c Ee ICUE uae aa Sera een ker cDiagnostic Testing Methods Same aire serum-specific IgE test Pree Reet r s, diag eu ua aeag Pediatr Adolesc Health Care.epidermis. dermis, ‘subcutaneous fatIntracutaneous prick Can be read after 20 minutes ASE.) OC CT ecm creel SIC) No age restriction But measures only ...Intracutaneous prick Can be read after 20 minutes Vesicle size determines reaction Safe No age restricSkin testing to foods has ag) negaive : Nelli but an overall positive predictive value (PPV) of only 50% While a negative skin test response can be very useful in ruling out food allergy, a positive skin test response is much less helpful in deciding when a patient should undergo ere ltarel (J Allergy Clin Immunol Volume 114,number 1,2004)gE RAST Simple blood test Many allergens available (Semi) quantitative Safe No age restriction But measures only ....Beers) iit) (cmo)olorem (cae - Many allergens available + (Semi) quantitative Pansr-](-3 - Noage ay a yar Ne orFood-specific IgE levels are also often used and 2 previous studies by Sampson and coworkers established the 90’.,ancd 95% PPVs for milk, egg, Peer T TU eee MCL ele mm CM EU CM CTCL determining when a patient’ s food-specific IgE levels is so high that a challenge is unnecessary. (J Allergy Clin Immunol volume 114,number 1,2004)| Table. Predictive value of food allergen specific IgE level Allergen 95% predictive level PPV (kIUA/L) | Egg iW, > Infant < 2 years 2 Milk 15 > Infant s 2 years 5 Peanuts 14 Fish 20 Tree nuts Als) Soya 30 Wheat 26 Davis CM. Food allergies: clinical manifestations, diagnosis, and management. Curr Probl Pi Ae eRe ei ReiseSuggested predictive values of SIGE and SPT for selected food allergens Ea ey PPV 95% (>2 years old) (<2 years old) [loa eit Cas ire lg ek en 8 nC COU Pu) Pare) a) OU) iil v4 eonicut) history) be) (unconvincin Ps) Lay 20 NA ere eetExample (Cow's milk: >15 kUA/L (>2 years); >5 KUA/L (<2 years) Likelihood of clinical allergy from specific IgE (KU/L) Intermediate High (215) (0.35 to <15) Low, eg non-Ig€ | No Possible allergy Possible allergy =| Harus dilakukan uji eliminasi dan provokasi J Clin Invest. 201Cow’s Milk Protein Allergy Management in IndonesiaManagement of Cow’s Milk All 5 the avoidance C Colo ASM ta Lertcl elise] anaphylaxis generalized urticaria epinephrine De ace erie aus a Pt uke) cee aksManagement of Fo PN Sod @ Topical corticosteroids 7] systemic corticosteroids Pee Ago orl r Ie rae Un aac Pediatr Adolesc Health Care.Breet ry ASS Gear iueea Pet sapi dan eee) elie icy sesuai indikasi ear) Breer iri) Price) Rett iclg Bia Ly Cee) tart 1 Bila ada masalsh dana den ketersediaan Perera ec ener formula tsolat protein kedelal dengan disertal edukas! bahwa cone arc en een ce ied eres Berikan eHF [| Berikan AAConformational Epitope Sequential =i) Ce) ot-) DIDI — WIT Ld Conformational Epitope Sequential Epitope Conformational epitopes are destroyed when the native shape of a protein is altered -e.g, by cooking or hydrolysis- whereas sequential epitopes are not affected. RU LMHypoallergenic Formula Heating Enzymatic hydrolysis Ultrafiltration Protein in hypoallergenic formula is hydrolized into peptides and short chain amino acidsiS PeeUte lig extensively synthetic hydrolyzed hydrolyzed ue Tal) Protein or peptide with shorter peptide chains and smaller molecule has a lower allergenicityFormula Hidrolisat cMP CMP Extensively Partially hydrolyzed hydrolyzedaE Pale tae) eure) ee ael| hipoalergenik pada 90% anak dengan alergi FTV Vt le)] Formula pengganti pada anak alergi susu sapi Formula peice Pa : ‘ untuk pencegahan be Peer at) sebagian PerelFormula hipoalergenik Ars Formula terhidrolisat sempurna Formula asam: amino _ bebasIDAI Recommendation REKOMENDAS! RECOMMENDATION {RATAN DOKTER ANAK INDONESIA Te eerste eT eh Tea) MANAGEMENT OF COW’S MILK PROTEIN Evans toy Oo Per neat eedAlgoritma diagnosis dan tatalaksana ASS dibagi berdasarkan 2 keadaan, yaitu: Tee VIRCu Ruta ees) Pap aR ae RO)ere J See eed oe Riwayat kelarga (faktor risiko) | CO ee ASS berat ro) E Peer gurgitasi berulang, muntah, diare, ees a rena eta a See ue are) . alopati karena kehilangan protein, (er Prey tne ete re, oa ao ee ee] Kolk persisten (3 jam perhariiminggu | any : rat dengan anemia- hipoalbuminemia Pee ee ey ere nia defisiensi besi ruksi bronk een eeeSas aCe ny ASS berat eee ea! Te ee i ae +6 Pe Re Me ery an darah di ee Per eer ayBC aCe Cee ee eae el Perea ret Pee eee Cees Re an emue Renee SUTTER eR ALTO elo Rens Lag [Wa 1}Systematic Review with Meta-Analysis Safety of soya-based infant formulas in children Yvan Vandenplas!, Pedro Gutierrez ( as, Carls Jimenez i Effect of Soy Infant Formula |Z p | 2m] P [On weight gain 138] 0.1700| 89.30] 0.0001 [On height gain 1,02| 0.3000] 93.20] 0.0001 JOn haemoglobine value 0.74| 0.4600| 73.70| 0.0020] [On serum Zn value 0.86| 0.3900] 45.70] 0.1400] |On total Calcium value 231) 0.0200} 69.90] 0.0050] [On bone mineral content (gm/em2) | _0.61| 0.5400] _94.30| 0.0001 [On polio antibodies 0.17] 0.8600] 97.80] 0.0001 [On diphteria antibodies 0:86] 0.5400] 96.90] 0.0001 1On infectious episodes/child 2.25] 0.0240} 89.90] 0.0001 lOn genistein level in serum 10.67] 0.0001{ 0.00] 0.8070} [On daidzein level 7.68 0.0010] 57.80] 0.0680 [On age of menarch 2.07| 0.0400] 84.40] 0.0002 a TalePoe e mele) Systematic Review with Meta-Analysis Safety of soya-based infant formulas in children Yean Vandenplas!s, Pedio Gutierrez Castrellon’, Rodolfo Rivas’, Carlos Jimenez Gutiére ICE TC meetin hac lem ercaNne Mele E) ale rool 4 negatif terhadap fungsi reproduksi dan endokrin, termasuk juga peda sistem imun dan kognitif. Sehingga formula soya aman diberikan dan juga dapat mendukung Stet kembang Si Kecil 2.07| 0.0400] 84.40] 0.0002Development of new guidelines & New IDAI recommendation (in progress): Considering the human resources, SPT availability, formula selection: taste, access and financial aspects @ Soy formula can be used for any age, with precaution for infants under 6 months old, the risk for soy allergy is higher than above 6 months-old. 3Cow’s Milk Allergy Prognosis -) Cow's milk allergy is a transient conditionThank you