Sumadiono

Pediatric Department
Faculty of Medicine
Gadjah Mada University
Yogyakarta
1
Rising Prevalence
30

25

20

15 1979
1991
10

0
Asthma Rhinitis Eczema Total

• Aberg. Clin Exp Allergy.2

1995.95:815. Swedish Children
 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
non IgE mediated 4
Allergen TYPE-I HYPERSENSITIVITY

IgE

5
 Mediators produced by mast cells
Mediator category Mediator Function(s)

Preformed Histamine Increases vasc. permeability,

smooth muscle contraction
structure
Tryptase, acid hydrolase, Degrade microbial structure, tissue
cathepsin G, carboxypeptidase damage/remodelling

Lipid mediators Prostaglandin D2 Vasodilatation,

bronchoconstriction, neutrophil
produced on chemotaxis
activation
Leukotrien C4, D4, E4, PAF Prolonged bronchoconstriction,
mucus secretion, increased vasc.
permeability

Cytokines IL-3 Promotes mast cell proliferation

TNF-, MIP-1 Promote inflam./late phase reaction

IL-4, IL-13, and IL-5 Promote Th2 differentiation, and

6
eosinophil production
 RISK FACTORS
GENETIC:
ATOPY
BOYS
IgE >
CHROMOSOM MUTATION,
IMMUNE RESPONS DEFECT

ENVIRONMENTAL:
PREGNANT SMOKER
DIET
ALERGEN
7
INFECTION
 Allergic March
ATOPY

FOOD ALLERGY

ATOPIC
DERMATITIS

ASTHMA

ALLERGIC
RHINITIS
8
 POLLEN
MOLD

Cockroach

9
DUST MITE
DOG?

CAT?

10
 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
11
 10 Thailand
Allergy <<
9 (n=27)
8 Allergy >>
Singapore
CFU/g

7 (n=62)
6
5
4
3
2
1
0
LAB Coliforms Enterococci Staphylococci

Fig 1. Microbiota in faecal samples

12
(Lee Bee wah, 2005)
CHILDHOOD FOOD ALLERGY

13
 ADVERSE FOOD REACTION

Toxic a) Scombroid Poisoning

b) bacterial contaminaton
Non Toxic

Intolerance
Immune
(nonimmune)
a) pharmacologic
b) enzymatic
IgE Non IgE
c) undefined
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How is Milk Allergy Diagnosed ?
- Clinical Features
- Blood or skin test: (detect IgE)

- 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
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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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 SIGNS AND SYMPTOMS OF ALLERGIC
REACTIONS IN VARIOUS TARGET ORGANS

Skin: itchy red rash, hives, eczema,

allergic "shiners" (black eyes),
swelling of lips, mouth, tongue,
face or throat

Gastrointestinal tract:

Nausea, vomiting, diarrhea, gas,

bloating, or abdominal cramps
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Respiratory tract:
Runny nose, sneezing, watery eyes,
itchy eyes, nasal congestion, wheezing,
shortness of breath, or coughing
Laryngeal edema,
and/or dysphonia

Cardiovascular:
Anaphylactic/shock
Dizziness

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Recommendations
for Primary Prevention
in High-risk infants
(2005, ESPACI/ESPGHAN)

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 HIGH RISK for ALLERGY

Prediction of Allergy:
Family history/atopy: most useful
Risk: 38 - 58% (1 parent)
60 - 80% (2 parent)
sens/specificity: 45%/74%
Cord blood IgE:
sens/specificity: 26%/74%
Combination: sensitivity: 56%
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 Prevention of allergy

1. Primary Prevention
Before any IgE mediated disease has occurred
- Prenatal
- Post natal
2. Secondary Prevention
Futher sensitivities once IgE mediated
disease has developed

3. Tertiary Prevention
Prevention manifestation of allergic disease 21
 PREVENTION OF CMA
Newborn Baby (High Risk)

Maternal pregnancy diet Not recommended

Exclusive breastfeeding

Maternal lactation diet

Avoid soy formulas

Hypoallergenic formula
Delayed introduction of solid foods 22
Extensively hydrolyzed casein
Extensively hydrolyzed whey
Partially hydrolyzed whey
Soya 23
 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 24
ATOPIC DERMATITIS
In children

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 Sinonim
• Prurigo diathesique
• Prurigo Besnier
• Asthma-eczema
• Mycosis flexurarum
• Prurigo-eczema
• Prurigo simplex xhronica
• Neurodermatitis constitutionalis
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2-4 MONTH

CHEEKS,

REDISH
ITCHY
SCRACTHING

27
 DD:

1-3 YEARS
D. SEBOROIKA

SCABIES
IN THE
SKIN FOLD IHTIOCYTOSIS

HISTYOCYTOS
IS 28
 Atopic Dermatitis

Orbital
darkening

Kheilitis
Denni-Morgan
(pd infraorbital)

29
Pityriasis alba

Dermatitis in
hand and foot
Ichthyosis

Infection

30
From bitting & saliva

running nose & saliva

Lichenification,
excoriation foliculitis

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 DIAGNOSIS

3 Signs in MAJOR & MINOR criteria

• Skin test
- NEGATIVE: Eliminate the ALERGEN
- POSITIVE: < SPECIFIC

• Blood EOSINOFIL & IgE

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 DIAGNOSTIC Criteria
(Hanifin & Rajka, 1980)

MAJOR criteria:
 1. Pruritus

 2. Spesific morphology and

distribution

 3. Atopy hystory

 4. Chronic, exacerbation 33
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

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 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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36
37
 Asthma
Bronchiale

38
NATIONAL CONSENSUS for 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
40
 Asthma treatment continuum
A

+ Prednisone
D
C
µg
Additional therapy
0 500 1000 2000
B Short/fast acting β2-agonist on demand

E 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
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43
ITCHY

RHINY NOSE

SNEEZE

44
LATE PHASE

Nasal Blockade
Mouth Respiration 45
 Allergic Conjunctivitis

ALLERGIC SHINERS
D-MORGAN LINE

46
AllergicConjunctivitis Palpebra type Allergic Conjunctivitis Limbal type
Salute sign 47
 48
Grimace
49
 IgE TOTAL
 SENSI/SPESIFISITY: 57%/67%
 PARASITE INFECTION

 IgE SPECIFIC: 80%

50
SKIN PRICK TEST
ALLERGEN ?
51
Elimination
provocation

52
Education

53
Dance

54