10 food allergy untad

7/24/2019 10 Food Allergy Untad

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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#$!

2


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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

5


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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

-

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

'4


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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

'5


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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

10 food allergy untad

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