Pengantar lunch simposiumalergi dan imunologi

pada anakPrevalensi & Pencegahan

Sofyan IsmaelIkatan Dokter Anak Indonesia

Dalam rangka desiminasi Forum Nasional Sadar Alergi (ForNASA)

DIAGRAM KERANGKA KONSEPTUAL PROSES TUMBUH KEMBANG ANAK

LINGKUNGAN

INDIVIDU

GENETIK / HEREDOKONSTITUSIONAL

TUMBUH - KEMBANG

FETUS NEONATUS BAYI ANAKREMAJA

KEBUTUHAN DASAR ANAK

ASUH ASIH ASAH

Ibuo Pendidikano Gizi (Early Life

Nutrition)o KB

Exclusive Breathfeeding

MPASI Imunisasi Pengobatan (oralit)

Anggota keluargao Ayaho Saudara

Rumah Suasana rumah

Lingkungan tetangga

Sarana bermain

Fasyankes (Dokter)

Sistem Pendidikan Nasional

Lembaga Riset

Kebijakan Pemerintaho KEMKESo Kemendikbudo Kemenag, dll

Sosial budaya masyarakat

Lembaga non pemerintah

ForNASA MIKRO MINI MESO MAKRO

Ibuo Pendidikano Gizi (Early Life Nutrition)

o KB

Exclusive Breastfeeding Utilisasi Growth Chart Makanan Pendamping ASI Imunisasi Pengobatan sederhana

(oralit) Air bersih

MIKRO

Primary preventionin allergy

WHO / WAO meeting on thePrevention of Allergy and Allergic Asthma, Geneva, 8-9 January 2002

• Over 20% of the world population is atopic

• Asthma occurs in 10-15% of the paediatric population

• Asthma affects approximately 150 million people worldwide

Atopic Dermatitis : Significance

• May be the first step in the Allergy March:the relationship between allergic manifestations throughout life

– Approximately 75- 80% of atopic dermatitis

patients develop allergic rhinitis– More than 50% of atopic dermatitis patients

develop asthma

Leung DY - J Allergy Clin Immunol - 01-DEC-2003; 112(6 Suppl): S117Spergel J Allergy Clin Immunology 2003; 112 (6 Suppl): S 118-27Leung DY - J Allergy Clin Immunol - 01-DEC-2003; 112(6 Suppl): S117Spergel J Allergy Clin Immunology 2003; 112 (6 Suppl): S 118-27

The Allergic March

Cantani, 1999 Invest Allergol Clin Immunol 9(5)- 314-20 Cantani, 1999 Invest Allergol Clin Immunol 9(5)- 314-20

Atopic, GI and dermal allergy

Atopic, GI and dermal allergy

Allergic asthmaAllergic asthma

Lower respiratory tract (wheezing)

Lower respiratory tract (wheezing)

Upper respiratory tract (rhinitis, rhino-conjunctivitis, allergic otitis

media)

Upper respiratory tract (rhinitis, rhino-conjunctivitis, allergic otitis

media)

(50 %)

(75-85 %)

Allergy is a chronic disease

Adapted from Holgate S Church MK eds. Allergy. London: Gower Medical Publishing 1993

Atopic Dermatitis : Significance

• Healthcare Costs in the U.S.–1.6 billion (conservative) –3.8 billion (all inclusive)

Ellis CN, Drake et al. J Am Acad Derm 2002, 46: 361-70Ellis CN, Drake et al. J Am Acad Derm 2002, 46: 361-70

Preventing Pediatric Allergy• Allergy, particularly atopic dermatitis,

is a significant health issue – High incidence in developed countries– Increasing incidence and prevalence– High costs – Impact on quality of life– Allergy March may greatly magnify the

problemPrimary Prevention is a PriorityPrimary Prevention is a Priority

Good Clinical Governance (Tata kelola klinis yang baik)

Atopic dermatitis

Prevalence ?

Burden of disease

ClinicalGovernance

ClinicalGovernance

Clinical audits

Clinical audits

Education & Training

Education & Training

Riskmanagement

Riskmanagement

Account-ability

Account-ability

Research &development

Research &development

ClinicalEffective-

ness

ClinicalEffective-

ness

EBM

Babies with feeding challenges (30%-50%) # Feeding Intolerance # Cow’s Milk Protein Allergy

Problem

# Valid# Important# Applicable

EBM

Financial consequences Cost-benefit analysis

Cost-effectiveness analysis

Patient Safety

burden of disease

burden of disease

Mengapa prevalensi meningkat ?• Perubahan pola hidup

• Pola makanan• Polusi lingkungan

• Tata kelola klinis belum memadai

Genetic Factors A Positive family history for allergy

Both parent no allergies

One sibling with allergy

One parent with allergy

Both parent with

allergies

10 %

risk of allergy

20-30 %

risk of allergy

20-40 %

risk of allergy

60% - 80 %

risk of allergy

Koning,1996; Bousquet,2002Sensitivity 61 %; Specificity 83%

Risk of allergy

burden of disease

Primary prevention (risk factor !)

Exclusive breastfeedingpHF or eHF &

probiotic

Prevention in infant

Pencegahan dilakukan sebelum timbul gejala alergi, terutama pada bayi yang mempunyai

faktor risiko

burden of disease

Suppress disease expression after

sensitization

Secondary preventioneHF/AAF

Anak yang telah terpajan alergen, tetapi dengan manifestasi yang ringan, misalnya eksema dengan tujuan

untuk mencegah terjadinya asma dan rinitis

Prevention in infant

burden of disease

Treatment to avoidrecurrence of

symptom(clinical

manifestation)

Tertiary prevention

Elimination diet, eHF/AAF, Steroid, Antihistamine, Emergency treatment

Anak sudah terkena rinitis atau asma, dengan tujuan supaya penyakitnya tidak terjangkit kembali, tidak

bertambah berat, dan diupayakan tidak berlanjut sampai dewasa

Prevention in infant

Co-morbidities of allergic rhinitis

ClinicalGovernance

ClinicalGovernance

Clinical audits

Clinical audits

Education & Training

Education & Training

Riskmanagement

Riskmanagement

Account-ability

Account-ability

Research &developmentResearch &

development

ClinicalEffective-

ness

ClinicalEffective-

ness

EBM:# HTA

# Clinical guidelines# Clin pathways

# Algorithms# Protocols

# Procedures#Standing orders

Patient safety Audit medik

ValidImportantApplicable

Tata kelola klinis yang baik Kendali mutu

dan Kendali biaya

Rekam medik

P2KB

Persetujuan

Manajemen alergi

Recommendations regarding milk-formula

• Breastfeeding is highly recommended for high-risk infants, as exclusive breastfeeding is more protective than hydrolized formula. However, a hydrolyzed formula can be recommended for high-risk infants who cannot be completely breastfed.

• Cow’s-milk based formula should be avoided in the first 5 days of life as the administration of cow’s milk-based formula during the first 5 days in the newborn nursery increases the risk of specific sensitization.

Osborn DA, Sim J. Formula containing hydrolyzed protein for prevention of allergy and food intolerance infant. Cochrane Database Syst Rev. 2006(4):CD003664

Kjaer HF et al. The prevalence of allergic diseases in an selected group of 6-year-old children. The DARC birth cohort study. Pediatr Allergy Immunol. 2008 Dec:18(8):737-45

Grade A, Level 1

Grade C, Level 2

Why Clinical Practice Guidelines (CPG) on Food Allergy

OVER DIAGNOSISPerceived >>

True

TRIVIALIZED True food allergy can

be life threatening

UnsubstansiatedTests and

Treatments

Tujuan Clinical Practice Guidelines

• Meningkatkan kualitas pelayanan pada keadaan klinis dan lingkungan tertentu

• Mengurangi intervensi yang tidak perlu atau berbahaya

• Memberikan opsi pengobatan terbaik dengan keuntungan maksimal

• Memberikan opsi pengobatan dengan risiko terkecil

• Tata laksana dengan biaya yang memadai

Algoritme pencegahan alergi pada anak

(UKK Alergi 2015)

Sesudah lahirASI/pengganti ASI

ASI eksklusif 6 bulanBila ASI eksklusif tidak memungkinkan, beri

formula hidrolisat parsial atau ekstensif sampai 4-6 bulan Makanan padat

Makanan padat mulai diberikan pada anak usia 4-6 bulan secara bertahap

Restriksi diet terhadap makanan tertentu tidak diperlukan

LingkunganHindari pajanan asap rokok

Masa kehamilanTidak ada pantang makanan tertentu untuk

pencegahan penyakit alergi

Hindari pajanan asap rokok aktif dan pasif

ADA RISIKO