alergi kamas
TRANSCRIPT
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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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