Alergi KAMAS

8/12/2019 Alergi KAMAS

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THE MANAGEMENT OF COWS

MILK ALLERGY


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INCIDENCE

Allergic Immunologic DivisionChildhealth Dept MedicalFaculty UI: 4 %.

- Atopic dermatitis infants :

45 %


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Diagnosis

1. Disease history2. Daily diet record

3. Skin Prick Test4. Specific Ig E with RAST(Radio Allergosorbent Test)

5. Elimination and provocation test


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Diet

Free of cows milk protein


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Breast milk

Provides : - Ideal nutritional, immunologic and physiologic nourishment for all newborn - Components of breast milk enhance natural defences and promote immunoregulation

Justify the AAP and European recommendationsfor exclusive and prolonged breastfeeding


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Feeding and Formula Options for Infants

with CMA

Breast milk with maternal diet restriction Soy-based formula

Extensively hydrolyzed formula (eHF)

Contains only peptides that have a MW


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Should Allergenic Foods Be

Restricted During Lactation ?


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No mummy, I dont like yourhyperallergenic milk


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Extensive hydrolysate CM protei

formula


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Technologies to Reduce the Allergenicity of

a Protein

Enzymatichydrolysis

Heating

Ultrafiltration

The lower the chain length and the smaller the molecular mass, thelower is the residual allergenicity of a protein / peptide


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Protein Hydrolysates: Different

Types

Allergenicity

intact protein pHF eHF Amino acids


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Soya protein formula As save alternative to CM formula in the

majority of infants with CM allergy after

screening documents indicate no coexisting soyallergy

Leung et al 2003


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AAP states, 'healthy full-term infants should be given soy

formula only when medically necessary,' but soy formula is still'safe and effective' when needed.


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PHYTOESTROGEN

ISSUES


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ScienceDaily (Aug. 16, 2001) Philadelphia, PA -- To understandwhether hormone-like chemicals in soy products may influence sexuadevelopment in children, researchers at the University of PennsylvaSchool of Medicine have revisited a study on soy-based infant formubegun over thirty years ago. Their results, published in this weeksJournal of the American Medical Association, reaffirm the safety osoy infant formula and offer evidence against the harmful effects osoy that have been presented in the popular media. According to thefindings, soy formula does not appear to lead to any more health orreproductive problems than cow milk formula.


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Consumption of soy formula instead of cow milk formula has no illeffect on reproductive or endocrinologic functions in young adulthoosaid Dr. Brian L. Strom and his colleagues at the University ofPennsylvania, Philadelphia.The relatively high doses of isoflavones-a subcategory ofphytoestrogens-consumed by infants, fed soy formula couldtheoretically impact hormone-dependent conditions such as maturatand reproduction. Phytoestrogens are plant-based compounds thatbind to estrogen receptors in adults, and few studies have addressethe long-term effects of significant phytoestrogen exposure. in

infancy, the researchers said.


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Exposure to these phytoestrogens early in lifemay have long-term health benefits Am J Clin Nutr 1998; 68 (suppl): 1453 S-61S

Soy isoflavones estrogen agonists, antagonists

or selective estrogen receptor modulators,depending on the conditions

Soy protein processed to contain lower levels ofisoflavones also provides significant health

benefits ( Badger TM et al, Fourth International Symposium ofsoy in Preventing and Treating Chronic Disease)


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Study in ChildHealth Dept.

Ciptomangunkusumo HospitalProportion of soy sensitization in CMA patients in this

study was 17.5%, which is similar to other studies in Asia,

and with low level of soy-specific IgE (0.48 kUA/L)

For clinical practice, soy protein could be used as an

alternative for cows milk-substitute in CMA patients


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Benefecial effect soy isoflavones in

food allergy

anaphylactic symptoms

antigen specific-antibody

mast cell degranulation

Possible mechanism:

Suppression dendritic cell activation and maturation

Subsequent regulation of CD4+T cell and NK cell

function preventing over- skewing Th2 function


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AMINO ACID BASE

FORMULA


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20 cal/oz Formulas in the US Average cost/oz

Partially hydrolyzed whey/casein $0.15

Partially hydrolyzed soy $0.15

Extensively hydrolyzed casein(Alimentum, Nutramigen, Pregestimil)

$0.24

Amino acid(Elecare, Neocate)

[30 cal/oz: Neocate Jr, EO28 Splash, Elecare]

$0.34

[$0.55-0.85]

Hydrolyzed and Amino Acid-based Formulas Available in the U.S.

Milk and soy-based formulas 0.15Stacie M. Jones, M.D.Professor of PediatricsUniversity of Arkansas for Medical SciencesArkansas Childrens Hospital


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Guidelines for the use of infant formulas to treat cows milk

protein allergy: an Australian consensus panel opinion

Andrew S Kemp,* David J Hill,* Katrina J Allen, Kym Anderson, Geoffrey P Davidson, Andrew S

Day,Ralph G Heine, Jane E Peake, Susan L Prescott, Albert W Shugg and John K Sinn


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Three types of infant formula (soy, extensively hydrolysed and

amino acid) may be appropriate for treating cows milk protein

allergy. Selection of a formula depends on the allergy syndrome to be

treated.

Extensively hydrolysed formula is recommended as firstchoicefor infants under 6 months of age for treating

immediate cows milk allergy (non-anaphylactic), food

protein-induced enterocolitis syndrome, atopic eczema,

gastrointestinal symptoms and food protein-induced

proctocolitis.


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Soy formulais recommended as first choice for infants over 6

months of age with immediate food reactions, and for those with gastrointestinal symptoms or atopic dermatitis in the

absence of failure to thrive.

Amino acid formula is recommended as first choice in

anaphylaxis and eosinophilic oesophagitis.

If treatment with the initial formula is not successful, use ofan alternative formula is recommended

MJA 2008; 188: 109112


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Budget Impact of Managing CMA

UK study of 18,350 infants with new diagnosis ofCMA

Used computer-based modeling to evaluate costs of

CMA management during first year of life

Initial Treatment: 60% soy, 18% eHF, 3% AAF

Cost estimates of managing CMA

1,381 per patient

25.6 million annually for cohort identified

Sladkevicius E, et al. J Med Economics 2010;13:119-128

S b i I f F l


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Substitute Infant Formulas

Soy (confirm soy IgE negative)

90% tolerance in IgE-CMA

Amino acid-based formulas

Lack allergenicity

Partial hydrolysates

Not hypoallergenic!Stacie M. Jones, M.D.Professor of PediatricsUniversity of Arkansas for Medical

SciencesArkansas Childrens Hospital


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