The benefits of soy formmula in the management of cma


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The benefits of soy formmula in the management of cma

  2. 2. Pendahuluan The process will continue in the lives of babies Sensitization to another food proteins wouldotherwise occurProf DR Dr Ariyanto Harsono SpA(K)Cows milk is generally the firstallergen in infantsonce responses to cows milk IgE occurs
  3. 3. Prevention is very importantAllergy Prevention: Primary Secondary Tertiary3Adjusting Solid Foods to Milk formula usedOther Suplement yang: LCP, vitamines, micronutrientSoy Formula has a positive effect on immunity andAllergy
  4. 4. Aktivasisel-selImuno-kompeten•Sel T•Sel B•Sel Mast•SelLanger-hansAktivasisel-selstruk-tural•Selendotel•SelepitelAktivasi danRekruitmen•Sel Mast•Eosinofil•BasofilPelepasanmediatorKerusakanepitelStimulasineuralDilatasi &peningkatanpermeabilitasvaskulerlBronkokonstriksiPerbaikanepitel•Proliferasifibroblast•Deposisikolagen•Hipertropi/hiperplasia otot polos•EkspansivaskulerPenyempitansaluran nafasbawahSymptomalergiBronkushiper-reaktifALERGENA B C D EAirwayremodellingPrimary Prevention Secondary PreventionTertiary PreventionJ Allergy Clin Immunol 2005;116:3-14Prof DR Dr Ariyanto Harsono SpA(K)4Imunopathology of allergy
  5. 5. AgAPC MHC-II Th0IL-12/ IL-1Th-2Th.1IL-1 IL-2, IFN-γB-CellIL-4IL-5SEL PLASMASEL MEMORIIL-6IL-10AAKTIVAtion of IMMUNOCOMPETENce CELLS byANTIGENMemory CellsProf DR Dr Ariyanto Harsono SpA(K) 5
  6. 6. BACTIVATION of STRUCTURALCELLSNature Rev Immunol 2003; 3: 867-78EosinophilEosinophilProf DR Dr Ariyanto Harsono SpA(K) 6
  7. 7. CMEDIATOR RELEASEProf DR Dr Ariyanto Harsono SpA(K) 7
  8. 8. Granule contents:Histamine,TNF-αProteases, HeparinLipid mediators:ProstaglandinsLeukotrienesCytokine production:Specifically IL-4, IL-13Prof DR Dr Ariyanto Harsono SpA(K) 8
  9. 9. D EFFECT of MEDIATOR RELEASE to TARGET ORGANNature Rev Immunol 2004: 3:234-237Prof DR Dr Ariyanto Harsono SpA(K) 9
  10. 10. Kehamilan = “Th2-disease”*Anti-oxydants*Avoid tobacco smokePrimary Prevention: Gestational ageProf DR Dr Ariyanto Harsono SpA(K) 10
  11. 11. • Exclusivebreastfeeding• Maternalhypoallergenic diet• Delay solid foods• pHF if not breastfedProf DR Dr Ariyanto Harsono SpA(K) 11
  12. 12. Primary prevention with MilkFormulaPartially hydrolyzedformulas:pHF FORMULAProf DR Dr Ariyanto Harsono SpA(K) 12
  13. 13. TargetOrganIgE-mediated disorder Non IgE-mediateddisorderSkinGastro-intestinalRespiratoryTractMulti-systemUrticaria and angioedemaAtopic DermatitisOral Allergy SyndromeGastrointestinal anaphylaxisAllergic eosinophilicgastroenteritisAsthma; Allergic RhinitisFood-induced anaphylaxisFood associated, exercise-induced anaphylaxisAtopic DrmatitisDermatitis HerpetiformisProctocolitisEnterocolitisAllergic eosinophilic-GEEnteropathy syndromeCeliac DiseaseGI HaemorrhageHeiner SyndromeClinical ManifestationE SymptomsProf DR Dr Ariyanto Harsono SpA(K)13
  15. 15. CE SymptomsProf DR Dr Ariyanto Harsono SpA(K)15Oral allergy syndrome
  16. 16. Prof DR Dr Ariyanto HarsonoSpA(K) 16Rinitis Alergika
  17. 17. Prof DR Dr Ariyanto HarsonoSpA(K) 17Atopic Dermatitis
  18. 18. 18Prof DR Dr Ariyanto Harsono SpA(K)Urticaria
  19. 19. Prof DR Dr Ariyanto Harsono SpA(K) 19Quinke’s oedemQuinke’s oedem
  20. 20. Prof DR Dr Ariyanto Harsono SpA(K) 20Quinke’s oedem
  21. 21. Prof DR Dr Ariyanto HarsonoSpA(K)21Larynx oedem
  22. 22. Prof DR Dr Ariyanto Harsono SpA(K) 22Fixed Skin Eruption
  23. 23. Asthma Prof DR Dr Ariyanto HarsonoSpA(K) 23
  24. 24. ArthropathyProf DR Dr Ariyanto Harsono SpA(K) 24
  25. 25. VasculitisProf DR Dr Ariyanto Harsono SpA(K) 25
  26. 26. Otitis Media SerosaProf DR Dr Ariyanto Harsono SpA(K) 26
  27. 27. Secondary PreventionExtensively Hydrolyzed FormulaFormula Soy Isolate27Prof DR Dr Ariyanto Harsono SpA(K)
  28. 28. Prevensi SekunderExtensively Hydrolyzed FormulaFormula Soy Isolate28Prof DR Dr Ariyanto Harsono SpA(K)
  29. 29. History• Early 1900 preparation based on “soy-protein”for treatment of CMPA (in USA)• Since1960 :composition better adapted to infant nutritional needs• 2000 : infant formula based on soy fulfillsEuropean Directives and legislation forinfant feedingProf DR Dr Ariyanto Harsono SpA(K) 29
  30. 30. Soy protein isolate instead of soy-cereal• Previously: soy concentrate (protein content 70 %)Now : isolate (95% protein) Dupuy et al,1994• Addition of + methionine, + carnitine, + taurine,+Fe, +Zn, +Ca, + P Heating to destroy « anti--protease activity » for over 90 %Prof DR Dr Ariyanto Harsono SpA(K) 30
  31. 31. WHO Committee on Nutrition / AAP:Indications of Soy Infant FormulaCows milk allergy (CMA)• For ages 6-12 months->• For ages 0-6 months (necessary doctordecisions in accordance with ESPGHAN2010 Guideline)Lactose intolerancegalactosemiafamily VegetarianProf DR Dr Ariyanto HarsonoSpA(K)31
  32. 32. Other indications for soy infantformula• Cultural: traditional dietary habits• Economic• Religious (sometimes pork enzymes usedto hydrolyse in eHF?)• PhilosophicalProf DR Dr Ariyanto Harsono SpA(K) 32
  33. 33. PhytoestrogenBiological consequences of soy-rich dietshave been attributed to the presence ofsoy isoflavones, which are members of thephytoestrogen family.Phytoestrogens are plant-derived,estrogen-like compounds capable ofinteracting with the estrogen receptors ERand ERβ because their structureresembles that of the endogenoushormone 17β-estradiol.J. Clin. Invest. 2006 116:16-19Prof DR Dr Ariyanto Harsono SpA(K) 33
  34. 34. Phytoestrogen...Four groups of phenolic compounds are classifiedas phytoestrogens:isoflavones,stilbenes,coumestans, andlignans.The main isoflavones, found mostly in soybeans,are: genistein, daidzein, and glycitein.J. Clin. Invest. 2006 116:16-19Prof DR Dr Ariyanto Harsono SpA(K)34
  35. 35. Phytoestrogen...Several epidemiological studies haveconcluded that phytoestrogens confer:cardioprotection by downregulatingcardiovascular disease risk markers,consistent improvement in endothelialfunctionantioxidant activity. J. Clin. Invest. 2006 116:16-19Prof DR Dr Ariyanto Harsono SpA(K) 35
  36. 36. H2OProf DR Dr Ariyanto HarsonoSpA(K)36
  37. 37. Phytoestrogen...Soy product consumption has beenassociated with the following:reduced serum cholesterol levels viareductions in total and low-densitylipoprotein levels;vasodilatory activity under certainconditionsenhanced activity of certain antioxidantenzymes to increase antioxidant activities.J. Clin. Invest. 2006 116:16-19Prof DR Dr Ariyanto HarsonoSpA(K) 37
  38. 38. • symptoms of menopause• Prevention of obesity• Soy intake is related to a lower body massindex in adult womenMaskarinec G. Eur J Nutr 2008;;47:138-ˇ44Prof DR Dr Ariyanto Harsono SpA(K) 38
  39. 39. Prof DR Dr Ariyanto Harsono SpA(K) 39
  40. 40. A high intake of Soy and Isoflavones maybe associated with a reduced prevalenceof allergic RhinitisJ Allergy Clin Immunol 2005;115:1176-83Prof DR Dr Ariyanto Harsono SpA(K) 40
  41. 41. Prof DR Dr Ariyanto Harsono SpA(K) 41Soy protein formulas in children: no hormonal effects in long-term feeding.48 children (mean age 37 months (range 7--96 months) 27boys, 21 girls) soy > 6 months 18 controlsbone age, urinary markers of bone metabolism, ␣serum levels of bone alkaline phosphatase, osteocalcin17beta--oestradiol, intact parathyroid hormonegirls: no signs/symptoms of precocious pubertyboys: no gynecomastiabone age within the normal range bone alkalinephosphatase, osteocalcin, 17beta--oestradiol, intactparathyroid hormone, urinary levels of the markers of bonemetabolism all within normal values.Giampietro PG;; J Pediatr Endocrinol Metab. 2004;;17:191--6
  42. 42. Prof DR Dr Ariyanto Harsono SpA(K) 42Soy protein infant formulae and follow-ˇon formulae:a commentary by the ESPGHAN Committee on Nutrition.Before 6 months Soy not recommended Extensive protein hydrolysates recommended if eHF not tolerated: amino-ˇacid based formulaAfter 6 months Soy can be used if tolerance first established Benefit: acceptability, cost…..Giampietro PG;; J Pediatr Endocrinol Metab. 2004 ;17:191--6J Pediatr Gastroenterol Nutr. 2006;;42:352-ˇ61
  43. 43. Prof DR Dr Ariyanto Harsono SpA(K)43
  44. 44. Goal of Secondary PreventionProf DR Dr Ariyanto Harsono SpA(K) 441. Morbidity2. Quality of life
  45. 45. Other Milk supplement* Lipid-soluble vitamin E has a capacity ofdefense against oxidant-inducedmembrane injury. Studies haveconsistently demonstrated beneficialassociations between dietary vitamin Eand ventilatory function, and few havedemonstrated beneficial association withasthma and atopy.Prof DR Dr Ariyanto Harsono SpA(K) 45J Allergy Clin Immunol 2005;115:1109-17.
  46. 46.  Water-soluble vitamin C provides anti-oxidantcapacity primarily by scavenging oxygen freeradicals and suppressing macrophage secretionof super oxide anions, therefore play a role inpreventing mucosal shedding caused bymediators released from eosinophils andoxydants. n-3 polyunsaturated fatty acid (Omega-3),eicosapantaenoic acid, and docahexaenoic acidmight have contributed to the decrease inasthma and atopic disease morbidity.Micronutrents: Fe, Zn, SeProf DR Dr Ariyanto Harsono SpA(K) 46J Allergy Clin Immunol 2005;115:1109-17.Eur Respir J 1997;10:6-12.
  47. 47. Arachidonic Acid (ARA)Phospholiphase ACyccloxygenase LipoxygenaseProstaglandineTXAProstacyclinLeukotriene ALeukotriene BLeukotriene COmega-3, DHAecosapantaenoicacidHETE,5-HETE, PAFPGD2/E2PGD3 LTC4LTC547
  48. 48. Prof DR Dr Ariyanto Harsono SpA(K) 48IMMUNOMODULATORY ANDIMMUNOSUPRESSIVE EFFECTS OF PUFAsPUFAs modulate :1. Cytokine production2. Lymphocyte proliferation3. Surface molecule expression4. Phagocytosis and apoptosis5. Inhibit natural killer (NK)cell activity
  49. 49. Prof DR Dr Ariyanto Harsono SpA(K) 49 N-3 PUFA are better than n-6 PUFA The ratio of n-3 to n-6 may be animportant factor in modulatinginflammation Increasing the ratio of n-3 to n-6 antiinflammatory effect especially withatopic disease
  50. 50. Prof DR Dr Ariyanto HarsonoSpA(K)50LC-PUFA and immune responseARA DHAProstaglandine D2/E2LtC4Push B cells to produce IgETh1 Responsepro-inflammatory anti-inflammatoryAntagonizes ARALTC5/PGD3/ProstacyclineProstaglandine E2
  51. 51. Prof DR Dr Ariyanto HarsonoSpA(K)51SeleniumEssential trace mineral that plays a role in the bodysdefense as an anti-oxidant and helps scavenge freeradicals that can cause tissue damageSelenium concentrations in breast milk duringlactation and decreased greatly influenced by maternaldiet.Infants who received soy formula with added seleniummay benefit from the addition of selenium to maintainoptimum levels of selenium.
  52. 52. Prof DR Dr Ariyanto HarsonoSpA(K)52Vitamin DVitamin D helps build and maintain boneVitamin D is a fat soluble vitamin serves as an importantbiological regulator of calcium and phosphorusmetabolismVit D deficiency can cause ricketsAAP Recommendations whole milk infant formula mustmeet IU/100 Vit D 40 kcal (258 IU / L)
  53. 53. Prof DR Dr Ariyanto HarsonoSpA(K)53Calcium and Phosphorus–Has an important function collectively they build bones and teeth.–Promotes nerve function and muscle–activation of the enzyme helps convert food into energy–Up until 1980 because of erratic absorption of minerals stabilitasuspension and the presence of excessive soy phytates Consequently several studies have shown that poor bonemineralization between infants who received cows milk formulacompared to infants receiving soy formula–Formulations of soy formula has been improved, so that theconcentration of calcium and phosphorus in serum and bonemineralization in infants who receive formula milk formula milkcows and donkeys–The ratio of calcium and phosphorus in the latest standard is 1.3:1 (ESPGHAN 2010)
  54. 54. Prof DR Dr Ariyanto HarsonoSpA(K) 54IronHas an important role for the development of thebrain in the early stages of life.Iron deficiency can cause anemia , can harm braintissue.The AAP recommends that infant formulasfortified with iron 4 mg - 12 mg / L
  55. 55. Prof DR Dr Ariyanto HarsonoSpA(K) 55• Zinc• Plays an important role in growth, brain and immunitydevelopment• Zinc plays an important role in normal growth,neurotransmitter in motor function• Zinc supplementation in infant formula may helpreduce the duration and severity of diarrhea.• Mild zinc deficiency has a characteristic growth isslower than normal.
  56. 56. The health implications of soyinfant formula• Soy formula composition meets US Food and Drug Administrationand AAP guidelines for vitamin, mineral, and electrolyte content andprovides 67 kcal/dL:Soy isolate protein plus L-methionine, L-carnitine, and taurine provide 2.45 to 2.8 grams per 100 kilocalories.• Fat consisting mostly of vegetable oils provides 5.02 to 5.46 gramsper 100 kilocalories.• Carbohydrate, consisting of corn maltodextrin, corn syrup solids,and sucrose, provides 10.26 to 10.95 grams per 100 kilocalories.• Soy formulas contain 20% more calcium and phosphorus than cowsmilk formulas and are fortified with iron and zinc because ofphosphorus, iron, and zinc binding.Prof DR Dr Ariyanto HarsonoSpA(K) 56Pediatrics: 1998 :101(1) : 148 -153
  57. 57. Prof DR Dr Ariyanto HarsonoSpA(K) 57Numerous studies have documented normal growthand development in term neonates fed methionine-supplemented isolated soy protein-based formulas. Average energy intakes in infants receiving soyprotein formulas also are equivalent to thoseachieved with cow milk formula. The serum albumin concentration, as a marker ofnutritional adequacy is normal, Bone mineralization also is equivalent to thatdocumented with cow milk-based formula. Additional studies confirm that soy protein formulasdo not interfere with the normal immune responses tooral immunization with polio vaccine.Pediatrics: 1998 :101(1) : 148 -153
  58. 58. Growth in Infants Fed Soy FormulasProf DR Dr Ariyanto Harsono SpA(K) 58
  59. 59. From the nutritional point of view, formulasbased on soy-protein have in comparisonwith cow milk based formula (eHF):•no advantages•no disadvantagesProf DR Dr Ariyanto Harsono SpA(K) 59
  60. 60. Conclusion Primary prevention with hypo-allergenic formulashould be started from the first trimester of life, donot wait for the symptoms of allergy. Food additivesshould also hypo-allergenic Secondary prevention using advanced hydrolyzedformula or formula Soy Isolate Other nutritional supplements: omega-3,ecosapentaenoic acid, DHA plays a role in immunemodulation of inflammatory mediators Anti-oxidants: Vitamin A, C, EVit D Micronutrients: Fe, Zn, Se In the full-term infants fed on Soy Formula goinggood growthProf DR Dr Ariyanto Harsono SpA(K)60
  61. 61. Prof Dr Ariyanto Harsono dr SpAKCURICULUM VITAETempat /tgl lahir : Kediri, 3- JuliAgama : IslamStatus Perkawinan: MenikahPendidikanS-1: Lulus Dokter : FK UNAIR, 1972S-2: Spesialis Anak : FK UNAIR, 1982S-3: Program Pascasarjana UNAIR, 2004Pendidikan tambahan : Sertifikat “Fellowship on Food Allergy”,Academisch Ziekenhuis Utrecht, Nederland, 1990-1991Jabatan sekarang : Guru Besar Ilmu Kesehatan Anak,Dep IKA FK UNAIR/RSU Dr.Soetomo, Surabaya.Konsultan Alergi/Imunologi: 199261
  62. 62. Thank YouProf DR Dr Ariyanto HarsonoSpA(K)62
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