Sumadiono

Pediatric Department
Faculty of Medicine
Gadjah Mada University
Yogyakarta1
Allergen TYPE-I

IgE

2
 ALLERGIC DISEASES :
• Impact on the quality of
life
• Impact on work and school
• Economic burden
• Fatal?

Worldwide Variation in 12-month (ISAAC)

Lancet 1998
3
Incidence of different types of allergic
diseases by age

4
non IgE mediated 5
 DUST MITE

INHALANT ALLERGEN 6
INHALANT ALLERGEN
Correlation Between Exposure and
Sensitization to Cockroach
in Asthmatic Patients

• SPT positive to cockroach: 52 %

• Positive SPT result of American Cockroach in

American Cockroach exposure: 75 %

• Positive SPT result of German Cockroach in

German Cockroach exposure: 40 %

7
 POLLEN
MOLD

INHALANT ALLERGENS 8
DOG?

CAT?

9
 FOOD ALLERGENS
35 29
30
22
25 1818
20 15 16 15
12 13
15 8 9 87
10 6 4
5 0
0
ur

itif
su

ah

al
n

an
ng
i ka
l

re

ad
te

su

bu

r
ca

yu
se
ka

sa
anak
child dewasa
adult

10
Prevention

11
SKIN PRICK TEST
ALLERGEN ?
12
 IgE TOTAL
J SENSI/SPESIFISITY: 57%/67%
J PARASITE INFECTION

J IgE SPECIFIC:
80%
13
 THE MANAGEMENT of ALLERGIC
DISEASES

ALLERGEN AVOIDANCE

ENVIRONMENTAL CONTROL

MEDICAMENTOUS

IMMUNOTHERAPY

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15
16
 PHARMACOTHERAPY;
5 ANTIHISTAMIN SISTEMIC,
LOCAL
5 CORTIKOSTEROID SISTEMIC,
LOCAL
5BRONCHODILATOR
5 SYMPHATOMIMETIC
5 PARASYMPHATOLITIC
17
Immunotherapy

Reduced
allergen-specific
IgE

Increase
“Blocking” IgG
antibodies

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19
 Allergic March

ATOPY

FOOD ALLERGY

ATOPIC
DERMATITIS

ASTHMA

ALLERGIC
RHINITIS
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CHILDHOOD FOOD ALLERGY

21
 PREVALENCE & BURDEN

Food Allergy in Infants and

Children

Food allergy afflicts an increasing number

of infants and children and is associated with
both
clinical and familial burdens

 recommendations to
prevent and treat food allergy
.

(Pediatrics, 2003) 22
 ADVERSE FOOD REACTION

Toxic
Non Toxic
e.g. a) Scombroid Poisoning
b) bacterial contaminaton

Intolerance
Immune
(nonimmune)
a) pharmacologic
b) enzymatic
IgE Non IgE
c) undefined
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 Most Common Food Allergens
• Cow’s milk  Begins in the first 1 to 2 yr of life

• Eggs
infants
• Peanuts
• Soy
• Wheat
• Fish
• Treenuts
• Shellfish
Burks AW et al. J Pediatr 1998
24
How is Milk Allergy Diagnosed ?
- Clinical Features
- Blood or skin test: (detect IgE)

- Elimination
Elimination--Challenge Test
 relief of symptoms on the removal of milk
 recurrence of symptoms when re-introduced

Skin Prick Tests

SPT can be used, especially accurate in the young child

Blood Tests ("CAP RAST")

This tests for milk protein
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 CLINICAL FEATURES

a) Temporal relationship with ingestion of food.

Symptoms within minutes to 2 hours

b) There is no concept of “additive effect”

c) Symptoms/signs could be subtle to catastrophic

d) May appear to involve one organ system, but in

reality, in most cases, there is multisystem
involvement
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(Joint(Joint FAO/WHO Expert,
FAO/WHO Expert, 2001)
2001)
27
Recommendations
for Primary Prevention
in High-
High-risk infants

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 PREVENTION OF CMA
Newborn Baby (High Risk)

Maternal pregnancy diet Not recommended

Exclusive breastfeeding
Maternal lactation diet
Supplemental calcium and vitamins
Avoid soy formulas
Partial Hypoallergenic
formula 29
Extensively hydrolyzed

Partially hydrolyzed

Soya 30
 MANAGEMENT OF CMA
DIAGNOSIS OF CMA

Cow’s Milk Avoidance

Soy formula

Extensive hydrolysate
Elemental amino acid
Partial Hydrolysate must be avoided
No Goat's milk 31
 Extensive hydrolysate
- This formula should be given for the first time
to patients with mild – moderate CMA
- Expensive
- Taste <<

Elemental amino acid

- This formula should be given for the first time
to patients with SEVERE CMA
- VERY Expensive
- Taste <<
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 Conclusion for CMA

 Exclusive breastfeeding for at least 4-6 mo

 No pregnancy allergen avoidance diet

Partial Hypoallergenic Formula

 for primary prevention of milk allergy
 Extensive HF/ Soy formula
 for supplementation or for bottle-fed infants in CMA
 Weaning foods beginning at 6 months
- Partial Hypoallergenic formulae for primary prevention
- Solid food with soy for CMA high risk infant
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 Allergic March

ATOPY

FOOD ALLERGY

ATOPIC
DERMATITIS

ASTHMA

ALLERGIC
RHINITIS
34
 ATOPIC DERMATITIS

Chronic inflammation
on skin
35
in individual atopy
2-4 MONTH

CHEEKS,

REDISH
ITCHY
SCRACTHING

36
 DD:

1-3 YEARS
D. SEBOROIKA

SCABIES
IN THE
SKIN FOLD IHTIOCYTOSIS

HISTYOCYTOS
IS 37
DIAGNOSTIC Criteria
(Hanifin & Rajka, 1980) 3 Signs in MAJOR &
3 MINOR criteria
MAJOR criteria:
 1. Pruritus

 2. Spesific morphology and

distribution

 3. Ada Riwayat Atopi

 4. Kronik dan Kumat-kumatan 38

MINOR criteria:
 1. Xerosis
 2. Ichthyosis
 3. Skin test I:+
 4. IgE >>
 5. Dermatitis in early life
 6. Infection tendency
 7. Dermatitis in foot
 8. Nipple eczema
 9. Kheilitis
 10. conjungtivitis
 11. Denni-Morgan

39
 12. Keratoconus
 13. Catarac subcapsular anterior
 14. Orbital darkening
 15. Eritema Fasial
 16. Pityriasis alba
 17. Itchy
 18. Wool <<
 19. Perifollivular accentuation
 20. Food allergy
 21. Influenced by env./emotional factors
 22. White dermagraphism
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 Management of atopic dermatitis

Combination:

-Reduce the itchy

-Skin repair
-Inflammation treatment
-Elimination risk factors

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 Allergic March

ATOPY

FOOD ALLERGY

ATOPIC
DERMATITIS

ASTHMA

ALLERGIC
RHINITIS
42
ASTHMA BRONCHIALE

SUSPECTED:
WHEEZY,
EPISODIC,
NIGHT,
POST
ACTIVITY
ATOPY

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 ASTHMA BRONCHIALE
POSITIVE
RESPONSE
TO THE DD:
TREATMENT BRONCHIO-
LITIS
CROUP
SYNDROME
ASPIRATION
FIBROSIS
44
 Prevention of allergy
Infection

Allergen

Atopy Cigarete smoke, humidity

polutant
Genetic

Inflammation
Sensitisation Remodelling
hypsersensitivity

Primary Secondary Tertiary

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 Canadian asthma guidelines:
Asthma treatment continuum

+ Prednisone
µg
Additional therapy
0 500 1000 2000

Short/fast acting β2-agonist on demand

Environmental control and education — Treat associated conditions

Very mild Mild Moderate Moderately Severe

severe

Preclinical Intermittent Persistent

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*BDP-CFC=beclomethasone-chlorofluorocarbon Boulet LP, et al. Can Respir J 2001
 Allergic March

ATOPY

FOOD ALLERGY

ATOPIC
DERMATITIS

ASTHMA

ALLERGIC
RHINITIS
47
 ITCHY

RHINY NOSE

SNEEZE

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 ITCHY

RHINY NOSE

SNEEZE

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50
51
ITCHY

RHINY NOSE

SNEEZE

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LATE PHASE

Nasal Blockade
Mouth Respiration 53
 Allergic Conjunctivitis

ALLERGIC SHINERS
D-MORGAN LINE

54
AllergicConjunctivitis Palpebra type Allergic Conjunctivitis Limbal type
Salute sign 55
 56
Grimace
Classification of Allergic Rhinitis
Intermittent Persistent
symptoms symptoms
 <4 days per week  >4 days per week
 Or < 4 weeks  Or > 4 weeks

Mild Moderate-severe
 normal sleep One or more items
 normal daily activities  Abnormal sleep
 normal work an school  Impairment of daily
 no troublesome activities, sport, leisure
symptoms  Problems caused at school
or work
 Troublesome symptoms
ARIA Guidelines: Recommendations for
Management of Allergic Rhinitis
Moderate
Mild severe
Moderate
persistent persistent
severe
intermittent

Mild Intra-nasal steroid

intermittent
Local cromone
Leukotriene receptor antagonists

Second-generation nonsedating H1 antihistamine

Intranasal decongestant (<10 days) or oral decongestant

Allergen and irritant avoidance

Immunotherapy
ARIA = Allergic Rhinitis and its Impact on Asthma.
Bousquet et al. J Allergy Clin Immunol. 2001;108 (5 suppl):S147.