10 food allergy untad
TRANSCRIPT
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Diagnosis and Management
of Food AllergySumadiono
UKK ALERGI IMUNOLOGI IDAI
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Learning Objective
Review defnition, classifcation o ood!"e#sensitivit! and ood alle#$ens in cild#en
Di%e#entiate&etween I$E'mediated, cell'mediated and mi(ed I$E' and cell'mediatedood'#elated diseases in di%e#ent o#$ans!stems
Discuss te dia$nosiso ood alle#$! andte limitations o dia$nostic tecni)ues
Review te t#eatment o ood alle#$!
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Defnition
Adve#se #eaction to ood*
An! a&no#mal clinical #es"onse att#i&uted to in$estion,contact o# inalation o an! ood, a ood de#ivative o# aood additive
+ood intole#ance*
an adve#se "!siolo$ic#es"onse to a ood and ma! &e due to ine#ent"#o"e#ties o te oodo# to ca#acte#istics o te ostMa! not &e #e"#oduci&le, and a#e oten dose de"endent
+ood alle#$!*
an a&no#mal immunolo$ic #es"onseto a oodtat occu#s in a susce"ti&le ost -ese #eactions a#e#e"#oduci&le eac time te ood is in$ested and a#e oten
not dose de"endent 3
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Classifcation
Allergology International 2009; 58: 457-4664
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Main dominant ood allergensin some countries
USA & UK
Milk
Egg
Peanut
Tree Nuts
Seafood
FRANCE
Egg
Peanuts
Milk
Mustard
ITALY
Milk
Egg
Seafood
ISRAEL
Milk
Egg
Sesame
SINGAPORE
irds Nest
SeafoodEgg
Milk
AUSTRALIA
Milk
Egg
Peanuts
Sesame
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The most common ood !llergen in"reschool and elementar# school childrenare$
Mil., e$$ wites, e$$ !ol.s%seaoodand tomatoes
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/a#acte#istic o +ood Alle#$enSensiti0ation
in 1OG1AKAR-A
No Alle#$ens 1es 234 '( mil. 56 2774
2( e$$ wites 58 2754
3( e$$ !ol.s 55 29844( fsh ) *'()+5( s#im" 67 255:4,( "eanuts ; 25=4)( bee - & *'(,+-( chic.en '/ & *'(,+
)
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/a#acte#istic o +ood Alle#$enSensiti0ation
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No Allergens Yes (%)
10. rice 1 (0.2)
11 . corn 1 (0.2)12 . soy 10 (2.2)
13. wheat 5 (1.1)
14. apple 7 (1.6)
15. tomatoes 17 (3.8)16. guava 5 (1.1)
17. oranges 8 (1.8)
18. ananas 8 (1.8)
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0athogenesis based1diseasemaniestation
I$E I$E?Non'I$ENon'I$E
U#tica#ia?an$ioedem
aRinitis ?AstmaAna"!la(is
O#al alle#$ic
s!nd#omeGast#ointestinals!m"toms 2GI-4
Ato"icde#matitis
osino"hilic
gastro1intestinaldisorders
@#otein'induced
"#octocolitis?ente#ocolitis
Celiac disease
Contact dermatitiser"etiorm dermatitiseiners s#ndrome
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Diagnosingood !llerg#
11
Alle#$! isto#!
/linical Si$ns and S!m"toms
S.in -est
2s.in "#ic. test, ato"! "atc
test4 Se#um s"ecifc I$E test 2RAS-4
Elimination B @#ovocation test
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Medical isto#!
Adapted from Adverse Reactions to Foods Committee,Spanish Society of Allergy and Clinical Immunology
1 #m"toms described b# "atient
1 Length o time bet6een ingestion anddevelo"ment o s#m"toms$ immediate$
minute to 2 hours suggestive or 7g mediated
1 everit# o s#m"toms 1 re8uenc# o s#m"toms
1 Time rom last e"isode 9o diagnostic anal#sis *s.in tests% s"ecifc 7g in serum% etc+
is o value i it is inter"reted 6ithout reerence to medical
histor# '2
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+ood * Identifcation o ood
1 o6 ood 6as "#e"a#ed 1 :uantit# ingested
1 @#evioustolerance 1 Cross1reactions 6ith other ood
1 idden oods% additives% contaminants
Ote#s*
1 !ge at onset o s#m"toms
1 Other actors *eg% brought on b# e;ercise+1 0ersonal and amil# histor# o ato"ic
diseases1
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Ato"ic ec0ema =enerall# begins in earl# inanc# Characteri>ed b# t#"ical distribution%
e;treme "ruritus% and chronicall# rela"sing
course
Clinical maniestation
/utaneus maniestation
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Acute U#tica#ia and
An$ioedema*! The most common s#m"toms o ood allergicreactions
! The e;act "revalence o these reactions is
un.no6n! !cute urticaria due to contact 6ith ood is alsocommon
/#onic U#tica#ia*! ood allerg# is an inre8uent cause o chronicurticaria and angioedema
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Res"i#ato#!
maniestationsAstma !n uncommon maniestation o ood allerg# ?suall# seen 6ith other ood1induced
s#m"toms
RinoconCunctivitis ?suall# seen during "ositive controlledchallenge tests% but occasionall# re"ortedb# "atients
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S!stemic #eaction*ana"!la(is?ana"!la(is
s!nd#ome +ood'induced ana"!la(is1 Ra"id'onset
1 Multi'o#$ans#stem involvement1 0otentiall# atal1 !n# ood% highest ris.$ "eanut% nut% seaood% mil.% egg
+ood'de"endent ' e(e#cise'induced1 !ssociated 6ith a "articular ood1 !ssociated 6ith eating an# ood
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I$E'mediated*
GI- maniestationO#al alle#$! s!nd#ome 2OAS4
licited b# a variet# o "lant "#oteins thatcross1react 6ith airborne allergens
@ollen allergic "atients ma# develo"s#m"toms ollo6ing the ingestion o vegetableoods$
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+ood alle#$! "#evalence in s"ecifc diso#de#s
Diso#de# +ood Alle#$!@#evalence
Ana"!la(is 76 ' 66 3O#al alle#$!s!nd#ome
96 ' ;63 in "ollenalle#$ic "atients
Ato"ic
de#matitis
763 in cild#en 2#a#e in
adults4
U#tica#ia 9>3 in acute 2#a#e inc#onic4
!sthma 5 1 ,B in asthmatic or ood '-
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intestinal walls wit eosino"ils
D#s"hagia% !bdominal "ain% @oo##es"onse to anti ' #eu( d#u$s
!lmost 5/B o "atients have other ato"ic
diseases Diagnosis is based on endosco"ic
fndin$s and bio"s# *'512/ eosino"hils"er igh 0o6er ield+
@io"s#$osino"hils F9>eosino"ils A 0
Rings
White plaquese!sin!phils"
Mi(ed I$E?Non'I$E mediated*GI- alle#$ic eosino"ilic diso#de#s
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Non'I$E mediated*
GI- ood "#otein induced s!nd#omes
2t!"icall! mil. and so! induced4
Ente#ocolitis Ente#o"at!@#octocolitis
A$e Onset* Inant Inant?-oddle#New&o#n
Du#ation* 59'98 mo H 59'98 mo 59mo
/a#acte' +ailu#e to t#ive Mala&so#"tionJlood! stools#istics Soc. illous at#o"! Nos!stemic si$n
Leta#$! Dia##eaEosino"il
Dia##ea'oa&-(egr$yn et al )ediatri#s 200*+a!atero Remon , et al Allergol Imm%no!athol 2005
Solid oods im"licated* fs, co#n, cic.en, tu#.e!,ve$eta&les
2'
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!llergens eliciting a 6heal o at least
7 mm $#eate#than the negativecontrol
0ositive "redictive accurac# 5/ BNe$ative "#edictive accu#ac! F
=6 3
Laborator# methods
S.in @#ic. -est
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@#ic.* Re"#oduci&le, sensitive,
non i##itantSkin tests0ric. to "ric. $ use ra6 or coo.ed ood( ighl# recommended orruits vegetables(
Commerciall# "re"arede;tracts are generall#inade8uate due to
instabilit# o the allergens
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Radioalle#$oso#&ent -est2RAS-4
en s.in testin$ is im"#actical .in disorder% drug inhibition% uncoo"erative
"atients
-o avoid s!stemic #eactions0rior histor# o
ana"!lactic #eaction, seve#e astma
Disadvanta$es
/ost, Dela!ed #esults 24
"ore convenience #or patient
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Radioalle#$oso#&ent -est 2RAS-4
1 Sensitivit! simila# to s.in "#ic.tests
1 =ood correlation 6ith other "rocedures
1 Ecienc#$ De"ends on the allergen
'Useul i disc#e"anc! e(ists &etweenisto#! and S@-
The use o 8uantitative measurements has sho6n to be
"redictive% or some allergens% o s#m"tomatic 7g1mediated ood aller25
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"ecifc 7g ood !llergen
$ %lin &nvest. 2011'12182735
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"ecifc 7g
+ood Se#um I$Ealue 2.U?L4
E$$ ;>
9 !# old 9>
Mil. 56>
9 !#s old 6>
@eanut 58>
+is 9>>-#ee nuts 56>
From Sampson HA: JACI 107:891-896,2001' (oyano#)artine* +, arcia#Ara C, -ia*#.ena /), et al Clin 0p Allergy 2114$4#14$9,%""1&
'' arcia#Ara C, (oyano#)artine* +, -ia*#.ena /), et al/ACI 1"31!#19",%""1&
2&
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2)
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2*
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Elimination diets and ood callen$es
Elimination diets 25 ' < wee.s4*
1 liminate sus"ected oodAs% or1 0rescribe limited Feat onl#G diet% or1 lemental diet
O#al ood callen$e testin$*' @!sician su"e#vised' Eme#$enc! #oom medications must &eavaila&le
Eat an ave#a$e "o#tion o te "u#e oodwitin 6 min
Reco#d s!m"toms
O&se#ve "atient a minimum o 9 ou#s
3/
%"/ iagnosis
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+limi,
nation
-
rovo,
cation
%"/ iagnosis
istor
aing
ign -mptoms
in
ric est peci#ic&g+
/top
atchest&g+
"eiate
on &g+
"eiate
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Diagnosis o Non I$ E mediatedood h#"ersensitivitt#
istor#$ Timing o
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Un"#oven metods*
@#ocedu#es used in dia$nosis
and t#eatment tat lac.scientifc c#edi&ilit!
ave not &een sown to ave
clinical eQcac!
/omme#cial inte#ests
7nvalid tests
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7nvalid tests
Electrodermal Sin !est "#E$A test &ioresonance
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M t + d
M t + d
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Mana$ement o +ood
alle#$!Mana$ement o +ood
alle#$!
Correct diagnosis
Treatment o reactions
!voidance
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Eme#$enc! medicines
E"ine"#ine* d#u$ o coice o##eactions1 el1administered e"ine"hrine readil# available1 Train "atients$ 7ndications A techni8ue
Antiistamines* Seconda#! te#a"!
mergenc# "lan in 6riting1 chools% caregivers% mature siblings A riends
mergenc# identifcation bracelet
3&
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AvoidanceAvoidance
Mainsta! o t#eatment
Must be considered as a thera"eutic a""roach
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La&el Readin$
Mil.
Mil.
!rtifcial butter Kavor% butter%buttermil.
Casein *rennet+% caseinates *calcium%magnesium% "otassium% and sodium+
=hee
#drol#sates *casein% mil.% "rotein%and 6he#+
Lactalbumin% lactoglobulin% lactose*maycontain+% lactulose
Mil. solids% mil. "o6der% nonat dr#mil. "o6der
he#La&el in$#edients tat ma!indicate te "#esence o mil."#otein
Chocolate
lavorings *artifcial% caramel% and
natural+igh1"rotein Kour
E$$
!lbumin
gg *6hite% #ol.% dried% "o6dered%solids+
Ma#onnaise
La&el in$#edients tat ma!
indicate te "#esence o e$$"#otein
! shin# gla>e or #ello6 ba.edgoods
lavorings *artifcial and natural+
Lecithin
0ediatric allerg#$ "rinci"les and "ractice( 2nd
edition 3-
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il. l B di i
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No @#otein Lactos
a
+at Indication
'( @a#tiall!
@a#tiall!
N N @#evention
2( +#eeLactose%
N >3?Glucosa"ol!m
e#
N LactIntole#anceDia#ea
3( E(tensive(
E(tensive casein
N N @#evention,/MA
4( E(tensive
E(tensiv
e /asein
N M/-66
3
/MA, +at
Mala&s
Mil. +o#mulas B Indications
7ndonesian CM! Management
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;clusive @reast eeding =rou"
Continue @reast eeding
Mother$ !void Co6s Mil. 0rotein *minimum ,month+
7ndonesian CM! Management
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!mino !cid ormula $ 11
;tensive #droli>e ormula $
0artiall #droli>e ormula $
/ows Mil. +o#mula *
So! +o#mula *
AALAJILI-1
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!mino !cid ormula $ Ierr# bitter fsh#
;tensive #droli>e ( $ Ier# bitter
0artiall #droli>e ( $ @itter o# ormula $ :uite nice
%ow9s "il :ormula ice
T!T
/ost o Mil. +o#mula
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/ost o Mil. +o#mula
7ndonesian 7ncome"er Ca"ita$
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/ost o Mil. +o#mula
uro"e 7ncome
"er Ca"ita PP
-A'4A2/''
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o /llerg ;
10 ? paa #ormula eelai ? #ormula sususapi an /&.
:ormula eelai 200 m>ghari 'anya 0* mg+g+'ari.
"sh @@ tolerable intake( :/ABA), 1 mg+g+'ari
/merican /caemic eiatric (//) uan masalah
eamanan agi ai ecuali paa ai prematur atau ai
engan gagal ginCal.
ESPGHAN Committee on Nutrition. J Ped Gastroenterol Nutr. 2006;42:!2"6#
$anden%las &' Castrellon P G' (i)as (' Gutierre* C J' Gar+ia , -' Jimene J E' Ano A'
He/ar ' Alar+on P. ritis1 Journal o Nutrition 20# #:2#
/luminium
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o utrtition;
imilar in 9ormal Develo"mental in Term
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imilar in 9ormal Develo"mental in Term7nants% Com"aration$ o# ormula Mil.
ormula
Fit t --
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&so#lavonalam entu genisteinD aiEein an glcitein
ampa per sesualD reprousiD neuroenorinDneuroehaviourD an #ungsi troi.aa aCian ilmiah #itoestrogen alam eelai e#e
estrogen ang lemah.
=aCian metaanalispola pertumuhanD metaolismeD tulangD reprousiD enorinD
sistem imunD an #ungsi neurologi sama susu #ormula sapi
usu #ormula isolat protein eelai
merupaan alternati#
ESPGHAN Committee on Nutrition. J Ped Gastroenterol Nutr. 2006;42:!2"6#
,an+et #33; !0;5#!"6
Fitoestrogen --
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Fitat --
&solat protein eelai menganung #itatseesar 1,2
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#drol#>ed ormulas -aste @#o&lemHH
*Older babies
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;clusive @reast eeding =rou"
Continue @reast eeding
Mother$ !void Co6s Mil. 0rotein *minimum ,month+
g
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5&
Than.
#ou
T < l
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Tes
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Education o# "atient?ca#e $ive#
5Identi! alle#$en2( amiliari>e allergen in the diet
idden in$#edients
Labelling issues Cross contamination *shared e8ui"ment+
FCode 6ordsG *F9atural KavorG ma# be co6Js mil.+
3 @#ovide &alance diet* See.in$
assistance * Re$iste#ed dietician
0ediatric allerg#$ "rinci"les and "ractice( 2ndedition 5-
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/omme#cial +oods tat +#e)uentl!/ontain Une("ected Alle#$ens
+oods /ontainin$ Mil.@#otein
@reads and bread crumbsnglish muEnlavored crac.ers
9ondair# creamer7nstant noodle cu"sorbetso# cheeseaRes
Canned fsh@ab# oods 6ith mi;edingredients
Most mammalian mil.s cross1react 6ith co6Ss mil. *e(g(
shee"% goat+
+oods /ontainin$ E$$@#otein
gg substitutes *i(e( eggbeaters+
@ab# ood s"aghettiMarshmallo6 "astr# cream0astaaReshin# ba.ed goods *egg 6ash+ine *fned or clarifed 6ithegg 6hite+
0ediatric allerg#$ "rinci"les and "ractice( 2ndedition,/
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-#eatment ollow'u"
Re'evaluate or tolerance "eriodicall#
7nterval and decision to re1challenge$1 T#"e o ood allerg#1 everit# o "revious s#m"toms1 !llergen
!ncillar# testing1 .in "ric. testA