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Kelompok 11

Get thatcow milk

away fromme,

please.

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p

No Nama NIM Peran

1 Edward Adisaputra Atmodjo 405070139 Leader

2 Ell 4050700!1 "e#retar

3 $ristian %on&so 40507013' "#ri(er

4 )eine#ia 40507003! Mem(er

5 *asri Larasati +tami 4050700'7 Mem(er

' Melisa 405070079 Mem(er

7 ,aria Putri )oman 4050700!7 Mem(er

! -ulian 405070095 Mem(er

9 Mar#ella ,ian 40507009' Mem(er

10 Lu.i 405070107 Mem(er

11 /uliana 405070135 Mem(er

12 ristie ind ) 405070137 Mem(er

GROUP 11

Fasilitator : Dr. Hendra

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Case 1BGet That Cow Milk Away rom Me,

Please!!"o# recei$e a call from Mrs. Melati, mother of Rosa, apre$io#sly healthy %&mo'th&ol( )irl. or the past * (ays,Rosa (e$elope( a' occ#lt +lee(i') a'( m#co#s i' thestool accompa'ie( +y a mo(erate (e)ree of emesis.owe$er, her temperat#re has'-t i'crease(, 'oa+(omi'al crampi') or colic, +#t to(ay she seems a +it

pale a'( more irrita+le.U'fort#'ately, Mrs. Melati (i('-t +reastfee( Rosa a+o#ta week a)o, a'( )i$e her re)#lar cow milk form#la.hile yo# are (isc#ssi') her family history, Mrs. Melatireports that Rosa-s +rother a'( sister are ha$i') foo(aller)y, a'( her / years ol( +rother is asthmatic as well

as his father. The mother ass#me( that he has thesame (airy pro(#ct aller)y like his * years ol( sister.

"o# tell her to +ri') him for f#rther (ia)'ostici'$esti)atio' a'( call the lactatio' cli'ic for aco#'seli') appoi'tme't i' or(er to ret#r' to e0cl#si$e+reastfee(i').

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O

20plai'i') mecha'ism a'( etiolo)y of occ#lt +lee(i')i' i'fa't

20plai'i') mecha'ism a'( etiolo)y of emesis i'i'fa't

20plai'i') mecha'ism a'( etiolo)y of m#co#s i' thestool i' i'fa't

20plai'i') the most likely (ia)'osis 3(i4ere'tial(ia)'osis5

20plai'i') f#rther (ia)'ostic i'$esti)atio's to co'6rmthe (ia)'osis

20plai'i') pre(isposi') factors 20plai'i') complicatio's associate( with the (isease 20plai'i') treatme't of the case 20plai'i') e(#catio' for patie't-s mother

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1. 7ali$ary )la'(s%. Paroti(*. 7#+ma'(i+#laris 3lower 8aw59. 7#+li')#alis 3#'(er the to')#e5:. oral ca$ity./. 7oft palate ; phary'0

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2mesis

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#'ctio'

omiti'), as a +asic physiolo)icprotecti$e mecha'ism, limits thepossi+ility of (ama)e from i')este(

'o0io#s a)e'ts +y emptyi') theco'te'ts of the stomach a'( portio'sof the small i'testi'e.

a#sea a'( $omiti') may represe't atotal&+o(y respo'se to (r#) therapy,i'cl#(i') o$er(osa)e, c#m#lati$ee4ects, to0icity, a'( si(e e4ects.

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Mecha'ism

omiti') i'$ol$es two f#'ctio'ally(isti'ct me(#llary ce'ters the $omiti') ce'ter

i' the (orsal portio' of the retic#lar formatio' ofthe me(#lla 'ear the se'sory '#clei of the $a)#s.

the chemoreceptor tri))er Do'e. i' a small area o' the Eoor of the fo#rth $e'tricle,

where it is e0pose( to +oth +loo( a'(cere+rospi'al E#i(. Ft is tho#)ht to me(iate the

emetic e4ects of +loo(&+or'e (r#)s a'( to0i's. respo'(s to '#mero#s chemicals a'( hormo'es,

i'cl#(i') (opami'er)ic, a%&a(re'er)ic, a'( opioi(a)o'ists, a'( car(iac )lycosi(es, cytoto0i's, a'(C#7O9.

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Structures Receptors Agonist Antagonist

Area postrema D2 Apomorphine Antidopaminergicdrugs

CTZ L-DOPA

Vestibular nuclei ! "# Cholinomimetics $copolamine

%& tractus solitarius "istamine Dramamine

Vomiting center Cholinomimetics'e&g&! ph(sostigmine)

$copolamine

Vagal sensor(ner*eendings

+-"T, $erotonin Ondansetron

ranisetron

Tropisetron

Receptors and neurotransmitters involved inmediating vomiting

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Treatme't Anticholinergics

The o'ly a'ticholi'er)ic to ha$e +ee' show' to ha$e a'ya'tiemetic #ality is hyosci'e. Ft may +e of #se i' patie'ts forwhom the mai' stim#l#s is $esti+#lar 3that is, 'a#sea a'( $omiti')ca#se( +y mo$eme't or ear, 'ose, a'( throat s#r)ery5. Fts mai'#se, howe$er, is 'ow i' palliati$e care where it is #se( to (ry #pperairway secretio's a'( ease +reathi') at the e'( of life.

Antihistamines7e$eral (r#)s i'hi+it the actio' of histami'e at the 1sy'apticpathways, which are pre(omi'a'tly i'$ol$e( i' si)'alli') from the$esti+#lar ce'tre, +#t o'ly cycliDi'e is #se( to treat postoperati$e'a#sea a'( $omiti'). as few si(e e4ects. Commo' mil( si(ee4ects are a co'se#e'ce of its a'tim#scari'ic actio's a'( i'cl#(ese(atio' a'( (ry mo#th.

Steroids7teroi(s s#ch as (e0amethaso'e may +e )i$e' preoperati$ely asprophyla0is i' patie'ts with a hi)h risk of 'a#sea a'( $omiti').7teroi(s act +y re(#ci') i'Eammatory oe(ema a'( alteri') ce'trala'( peripheral respo'si$e'ess to proemetic compo#'(s s#ch asa'aesthetics a'( a'al)esics. They ca' also +e #se( as a last li'e

resc#e treatme't.

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Dopamine antagonistsThese pharmace#ticals, for e0ample prochlorperaDi'e, haloperi(ol, a'(metocloprami(e, ha$e +ee' #se( as a'tiemetics for ma'y years. Theywork +y i'hi+iti') the acti$ity of (opami'e at the @%receptor i' thechemoreceptor tri))er Do'e, there+y limiti') the emetic i'p#t to theme(#llary $omiti') ce'tre.Certai' other a'tipsychotics, especially haloperi(ol, are ofte' #se( i'palliati$e care to treat 'a#sea a'( $omiti') ca#se( +y mali)'a'cy. ow(oses of haloperi(ol, s#ch as 1 m) o'ce a (ay, are e4ecti$e a'( are thetreatme't of choice for 'a#sea a'( $omiti') ca#se( +y i'testi'alo+str#ctio'.Metocloprami(e closely resem+les the phe'othiaDi'es +#t has a limite(

role as a' a'tiemetic for postoperati$e 'a#sea a'( $omiti'). Ft ise4ecti$e i' certai' setti')s, s#ch as emesis associate( with hepatic(isease, +#t has +ee' show' to +e i'e4ecti$e i' ma'y trials for thetreatme't of postoperati$e 'a#sea a'( $omiti') a'( sho#l( 'ot +eco'si(ere( witho#t se'ior i'p#t. Beca#se it also i'creases )astroi'testi'almotility, it sho#l( 'e$er +e co'si(ere( i' patie'ts where +owelo+str#ctio' is possi+le.

Serotonin antagonistsO'(a'setro', )ra'itetro', a'( tropisetro' i'hi+it the actio' of seroto'i'at the :&hy(ro0ytryptami'e * 3:&T*5 receptor i' the small +owel, $a)#s'er$e, a'( chemoreceptor tri))er Do'e. They therefore (ecrease a4ere't$isceral a'( chemoreceptor tri))er Do'e stim#latio' of the me(#llary$omiti') ce'tre. These (r#)s were (e$elope( for #se with chemotherapya'( ha$e +ee' show' i' trials to +e the most e4ecti$e of the c#rre'tlya$aila+le a)e'ts for +oth pre$e'tio' a'( treatme't of postoperati$e

'a#sea a'( $omiti').

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@ia)'ostic Tests a'( Cli'ical 7#spicio' for Patie'ts with a#sea a'( omiti')

Test Clinical suspiciona+oratory tests

Complete +loo( co#'t e#kocytosis i' a' i'Eammatory process, microcytic a'emia from am#cosal process

2lectrolytes Co'se#e'ces of 'a#sea a'( $omiti') 3e.)., aci(osis, alkalosis, aDotemia,hypokalemia5

2rythrocyte se(ime'tatio' rate F'Eammatory process

Pa'creatic;li$er e'Dymes or patie'ts with #pper a+(omi'al pai' or 8a#'(icePre)'a'cy test or a'y female of chil(+eari') a)eProtei';al+#mi' Chro'ic or)a'ic ill'ess or mal'#tritio'7peci6c to0i's F')estio' or #se of pote'tially to0ic me(icatio's

Thyroi(&stim#lati') hormo'e or patie'ts with si)'s of thyroi( to0icity or #'e0plai'e( 'a#sea a'($omiti')

Ra(io)raphic testi')7#pi'e a'( #pri)ht a+(omi'al ra(io)raphy Mecha'ical o+str#ctio'

#rther testi')2sopha)o)astro(#o(e'oscopy M#cosal lesio's 3#lcers5, pro0imal mecha'ical o+str#ctio'

Upper )astroi'testi'al ra(io)raphy with +ari#mco'trast me(ia

M#cosal lesio's a'( hi)her&)ra(e o+str#ctio'sI e$al#ates for pro0imallesio's

7mall +owel follow&thro#)h M#cosal lesio's a'( hi)her&)ra(e o+str#ctio'sI e$al#ates the small +owelto the termi'al ile#m

2'teroclysis 7mall m#cosal lesio's, small +owel o+str#ctio's, small +owel ca'cerComp#te( tomo)raphy with oral a'(

i'tra$e'o#s co'trast me(iaO+str#ctio', optimal tech'i#e to localiDe other a+(omi'al patholo)y

Gastric emptyi') sci'ti)raphy Gastroparesis 3s#))esti$e5C#ta'eo#s electro)astro)raphy Gastric (ysrhythmias

A'tro(#o(e'al ma'ometry Primary or (i4#se motor (isor(ersA+(omi'al #ltraso'o)raphy Ri)ht #pper #a(ra't pai' associate( with )all+la((er, hepatic, or

pa'creatic (ysf#'ctio'Ma)'etic reso'a'ce ima)i') of the +rai' F'tracra'ial mass or lesio'

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Complicatio'

20cessi$e $omiti') ca' lea( to lar)elosses from the stomach of the watera'( salts that 'ormally wo#l( +e

a+sor+e( i' the small i'testi'e. Thisca' res#lt i' se$ere (ehy(ratio',#pset the +o(y-s salt +ala'ce, a'(

pro(#ce circ#latory pro+lems (#e toa (ecrease i' plasma $ol#me.

The loss of aci( from $omiti') res#lts

i' a meta+olic alkalosis.

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Occ#lt Blee(i')

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Occ#lt +lee(i')

The (i)esti$e or )astroi'testi'al 3GF5tract i'cl#(es the esopha)#s, stomach,small i'testi'e, lar)e i'testi'e or colo',rect#m, a'( a'#s. Blee(i') ca' come

from o'e or more of these areas, thatis, from a small area s#ch as a' #lcero' the li'i') of the stomach or from alar)e s#rface s#ch as a' i'Eammatio'of the colo'. Blee(i') ca' sometimes

occ#r witho#t the perso' 'otici') it.This type of +lee(i') is calle( occ#lt orhi((e'. ort#'ately, simple tests ca'(etect occ#lt +loo( i' the stool.

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o#r ways GF +lee(i') ca' +ere$eale( i'

315 hematocheDia, that is, the passa)e of +ri)ht re( +loo(per rect#m, either isolate( or mi0e( with stools,i'(icati') a' ori)i' low i' the )astroi'testi'al tract, mostcommo'ly the colo'.

3%5 mele'a, that is, the passa)e per rect#m of +lack, tarry,

a'( fo#l&smelli') stools, i'(icati') a so#rce of +lee(i')from a+o$e the ileocecal $al$e. Mele'a ca' also +e see'i' cases of +lee(i') from the pro0imal lar)e +owelpro$i(e( that the colo'ic tra'sit time is slowI

3*5 occ#lt )astroi'testi'al +lee(i'), with symptoms limite(to pallor or fati)#e, (etecte( +y (isco$ery of iro'

(e6cie'cy or iro' (e6cie'cy a'emia or +y testi') for theprese'ce of fecal +loo(I395 symptoms of se$ere +loo( loss s#ch as malaise,

tachycar(ia, or e$e' profo#'( shock witho#t a'yo+8ecti$e si)' of +lee(i').

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Commo't ca#se

Eshopagus

i'Eammatio' 3esopha)itis5e'lar)e( $ei's 3$arices5tear 3Mallory&eiss sy'(rome5

ca'cerli$er (isease

Small intestine

(#o(e'al #lceri'Eammatio' 3irrita+le +owel(isease5

ca'cer

Stomach

#lcersi'Eammatio' 3)astritis5

ca'cer

Large intestine and rectum

hemorrhoi(si'fectio's

i'Eammatio' 3#lcerati$ecolitis5colorectal polypscolorectal ca'cer(i$ertic#lar (isease

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M#co#s i' the stool

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M#co#s i' the stool

The m#c#s i' the stool +eca#se where thereJs m#c#s,

thereJs i'Eammatio' a'( pro+a+ly colitis. The colitis ca' +e

(#e to a +acterial i'fectio' s#ch as 7almo'ella, 7hi)ella,

Campylo+acter, or Clostri(i#m (iKcile. irschspr#')Js(isease is a'other possi+ility +eca#se it ca' prese't as

colitis.

B#t the most pro+a+le e0pla'atio' is aller)ic colitis.

F' worki') #p s#specte( colitis, it recomme'(e( to take

emocc#lt test, a' a+(omi'al ra(io)raph 3ki('ey, #reter,

a'( +la((er5, a'( c#lt#ri') the stool for C. (iKcile.

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M#co#s i' the stool

The mecha'ism that ca#ses aller)ic colitis i' +reast&fe(

chil(re' is 'ot well #'(erstoo(.

O'e hypothesis is that mothers who eat (airy pass milk

protei' a'ti)e's i'to their +reast milk. Ra(ioimm#'oassay

st#(ies (emo'strate this phe'ome'o' +y showi') that Lyo#

ca' act#ally see cowsJ milk a'ti)e's i' motherJs milk.L

owe$er, the theory falls short i' e0plai'i') how the

pepti(e is a+sor+e( a'( (eposite( i'to the +reast milk.

A'other e0pla'atio' is that cytoki'es i' motherJs milk are

me(iati') the aller)y.

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oo( aler)ic

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Cow-s milk Protei'F'tolera'ce

Cow-s milk protei' i'tolera'ce is ahetero)e'eo#s (isor(er. The most commo'a'ti)e' i' cow-s milk are alpha lacto)lo+#li',casei', alpha lactal+#mi', +o$i'e ser#m al+#mi',+o$i'e alpha )lo+#li'.

The #a'tity of cow-s milk re#ire( to pro(#ce a'a($erse reactio' $aries. Most cow-s milk form#la&fe( i'fa'ts with cow-s milk protei' i'tolera'ce(e$elop symptoms i' the 6rst * mo'ths of life.The a)e of o'set of the 6rst symptoms i' +reast&

fe( +a+ies (epe'(s o' the a)e at which cow-smilk is 6rst i'tro(#ce(.

Pre$ale'ce st#(ies of i'tolera'ce to cow-s milkprotei' $ary from 1, > to

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Cow-s milk Protei'F'tolera'ce

Cow-s milk protei' i'tolera'ce ofte' lastso'ly a few mo'ths, a'( i' ma'y cases ithas (isappeare( completely +y the a)e

of 1% mo'ths, he'ce the 'ee( for milkchalle')e at the a)e of 1% mo'ths i'patie'ts who were (ia)'ose( i' i'fa'cy.Most chil(re' +ecome tolera't to cow-s

milk protei' +y the a)e of * years,altho#)h some (e)ree of i'tolera'cepersists, occasio'ally i'to a(#lt life, i' asmall '#m+er of patie'ts.

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Cow-s milk Protei'F'tolera'ce

7ymptoms of cow-s milk protei' i'tolera'ce omiti') is a commo' imme(iate symptom.

re#e't loose stools occ#r i' %:&

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Cow-s milk Protei'F'tolera'ce

@iscomfort, cryi') or irrita+ility are commo'a'( ma8or feat#res of cow-s milk protei'i'tolera'ce i' i'fa'cy, +#t it is 'ot clearwhether this represe'ts pai'f#l

hyperperistaltis of the )#t or (iscomfortassociate( with $omiti') or other symptoms.They may occ#r i' co'8#'ctio' with othersymptoms, partic#larly )astroi'testi'al

symptoms, or they may occ#r alo'e. Thesesymptoms #s#ally comme'ce withi' a' ho#rof cow-s milk protei' i')estio'.

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Cow-s milk Protei'F'tolera'ce

Cl#es to the (ia)'osis or cow-s milk protei'i'tolera'ce i' the history 7ymptoms occ#r, or are ma(e worse, soo' after

i')estio' of cow-s milk protei'. M#ltiple a4ecte(systems 3e.). )#t, chest a'( ski'5 make the (ia)'osis

more likelyI si')le symptoms make it most #'likely. 7ymptoms (ate from the time, or soo' after the time,that +reast&fee(i') was stoppe( or cow-s milk protei'was 6rst i'tro(#ce( i'to the (iet. 3fee(i') cha')es ofte'coi'ci(e with the o'set of atopic (isease, a'( (o 'otpro$e a ca#se a'( e4ect relatio'ship5.

A family history of cow-s milk protei' i'tolera'ce. The prese'ce of se$ere atopic (isease i' a' i'fa't #'(erthe a)e of 1% mo'ths.

The o+ser$atio' that spilli') cow-s milk o'to 'o'&ecDemato#s ski' ca#ses a' #rticarial rash.

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Cow-s milk Protei'F'tolera'ce

Maki') the (ia)'osis of cow-s milk protei'i'tolera'ce Most patie'ts whose symptoms comme'ce withi' a'

ho#r if cow-s milk i')estio' ha$e a positi$e ski'

prick test, +#t most of those whose symptoms occ#rmore slowly ha$e 'e)ati$e ski' prick test. As is thecase with more other e0amples of foo( i'tolera'ce,ski' prick test a'( RA7T 3ra(ioaller)osor+e'ttesti')5 are #'helpf#l +eca#se of the hi)h i'ci(e'ceof false positi$e a'( false 'e)ati$e res#lts. A 8e8#'al+iopsy is #''ecessary +eca#se it ca''ot replace the'ee( for milk elimi'atio' a'( challe')e, a'( thehistolo)ical cha')es see' i' the small i'testi'e are'ot (ia)'ostic for cow-s milk protei' i'tolera'ce.

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Cow-s milk Protei'F'tolera'ce

The proce(#re re#ire( to (ia)'ose cow-s milkprotei' i'tolera'ce is

A perio( of a$oi(a'ce 3% (ays for those with symptomsocc#ri') withi' a' ho#r of milk i')estio' 19&%= (ays forthose woth (elaye(&o'set symptoms5 ca#si') loss symptoms

Rec#rre'ce of symptoms o' rei'tro(#ctio' of cow-s milkprotei'

oss of symptoms after seco'( with(rawal of cow-s milkprotei'

Co'ti'#e( a+ateme't of symptoms with co'ti'#e( a$oi(a'ceof cow-s milk protei'

This strate)y m#st +e accompa'ie( +y re)#larattempts to i'tro(#ce cow-s milk protei', for e0ampleyearly, to see if the patie't has )row' o#t of thei'tolera'ce.

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Lactose

Intolerance

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Lactose Intolerance

Also calle( lactase (e6cie'cy #'a+le to f#lly (i)est the milk s#)ar3lactose5 i' (airy pro(#cts.

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Wo is at risk !or lactoseintolerance"

actose i'tolera'ce is a commo' co'(itio' that ismore likely to occ#r i' a(#lthoo(, with a hi)heri'ci(e'ce i' ol(er a(#lts. 7ome eth'ic a'( racialpop#latio's are more a4ecte( tha' others,

i'cl#(i') Africa' America's, ispa'ic America's,America' F'(ia's, a'( Asia' America's. Theco'(itio' is least commo' amo') America's of'orther' 2#ropea' (esce't.

F'fa'ts +or' premat#rely are more likely to ha$e

lactase (e6cie'cy +eca#se a' i'fa't-s lactasele$els (o 'ot i'crease #'til the thir( trimester ofpre)'a'cy.

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causes lactoseintolerance

The ca#se of lactose i'tolera'ce is +est e0plai'e( +y(escri+i') how a perso' (e$elops lactase (e6cie'cy.

Primary lactase (e6cie'cy (e$elops o$er time a'( +e)i'safter a+o#t a)e % whe' the +o(y +e)i's to pro(#ce lesslactase. Most chil(re' who ha$e lactase (e6cie'cy (o 'ote0perie'ce symptoms of lactose i'tolera'ce #'til late

a(olesce'ce or a(#lthoo(. Researchers ha$e i(e'ti6e( a possi+le )e'etic li'k to primary

lactase (e6cie'cy. 7ome people i'herit a )e'e from theirpare'ts that makes it likely they will (e$elop primary lactase(e6cie'cy. This (isco$ery may +e #sef#l i' (e$elopi') f#t#re)e'etic tests to i(e'tify people at risk for lactose i'tolera'ce.

7eco'(ary lactase (e6cie'cy res#lts from i'8#ry to the smalli'testi'e that occ#rs with se$ere (iarrheal ill'ess, celiac(isease, Croh'-s (isease, or chemotherapy. This type oflactase (e6cie'cy ca' occ#r at a'y a)e +#t is more commo'i' i'fa'cy.

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Two tests are commo'ly #se( to meas#re the(i)estio' of lactose.

H#drogen $reat Test.The perso' (ri'ks alactose&loa(e( +e$era)e a'( the' the +reath isa'alyDe( at re)#lar i'ter$als to meas#re the amo#'tof hy(ro)e'. ormally, $ery little hy(ro)e' is(etecta+le i' the +reath, +#t #'(i)este( lactosepro(#ces hi)h le$els of hy(ro)e'. 7moki') a'(some foo(s a'( me(icatio's may a4ect theacc#racy of the res#lts. People sho#l( check withtheir (octor a+o#t foo(s a'( me(icatio's that mayi'terfere with test res#lts.

%tool &cidit# Test.The stool aci(ity test is #se( for

i'fa'ts a'( yo#') chil(re' to meas#re the amo#'tof aci( i' the stool. U'(i)este( lactose creates lacticaci( a'( other fatty aci(s that ca' +e (etecte( i' astool sample. Gl#cose may also +e prese't i' thestool as a res#lt of #'(i)este( lactose.

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%#mptoms

@iarrhea the most commo'symptom

a#sea

A+(omi'al cramps

Bloati')

Gas

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' t#pes o! lactoseintolerance (ormal result o! aging !or some people )primar#

lactose intolerance*

Result o! illness or in+ur# )secondar# lactose

intolerance*

small i'testi'e (ecreases lactase pro(#ctio' after a'

ill'ess, s#r)ery or i'8#ry to yo#r small i'testi'e.

Ft ca' occ#r as a res#lt of i'testi'al (iseases, s#ch as

celiac (isease, )astroe'teritis or a' i'Eammatory +owel

(isease like Croh'Js (isease.

Condition #ou,re -orn it )congenital lactose

intolerance*

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Milk Aller)y

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Clinical T#pes o! /ilk&llergic Reactions

T#pe 1

7ymptoms start withi' mi'#tes of i'takeof small $ol#mes of CM.

Mai'ly ca#ses ski' pro+lems, ecDema or#rticaria 3hi$es5. May ha$e respiratory3r#''y 'ose, wheeDy chest5 or )astro&

i'testi'al 3$omiti') a'( (iarrhoea5symptoms.

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T#pe 0

7ymptoms start se$eral ho#rs after i'take ofmo(est $ol#mes of CM

Mostly symptoms of $omiti') a'( (iarrhoea.

T#pe ' 7ymptoms (e$elop after more tha' %?

ho#rs, or e$e' (ays after i'take of lar)e

$ol#mes of CM. 7ymptoms i'cl#(e (iarrhoea, with orwitho#t respiratory or ski' reactio's.

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Pre$e'ti$e 2(#catio'

GoatJs milk, rice milk, or almo'( milksare 'ot safe a'( are 'otrecomme'(e( for i'fa'ts.

People with lactosa i'tolera'ce sho#l(k'ow a+o#t foo( hi)h lactosa,e0 Brea( a'( other +ake( )oo(s,Processe( +reakfast cereals , F'sta'tpotatoes, so#ps, a'( +reakfast (ri'ks ,Mar)ari'e , #'ch meats 3e0cept thosethat are kosher5 , 7ala( (ressi')s ,Ca'(ies a'( other s'acks , Mi0es forpa'cakes, +isc#its, a'( cookies

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7#))estio'

e s#))est Rosa-s mother, Mrs. Melati,to ret#r' to e0cl#si$e +reastfee(i')a'( to stop )i$i') cow-s milk form#la

for Rosa.

#rther (ia)'ostic i'$esti)atio's are'ee(e( to co'6rm o#r (ia)'ostics.

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Co'cl#sio'

Accor(i') to the case, we ca'co'cl#(e that Rosa is ha$i'))astroi'testi'al (isor(er.

O#r ma8or te'(e'cies are lactosei'tolera'ce a'( cow-s milk protei'

aller)y.

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Refere'ces

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