1. 1
Penatalaksanaan Alergi Makanan
Pada Anak
Prof DR Dr ARIYANTO HARSONO SpA(K)
Lab/SMF Ilmu Kesehatan Anak
FK Unair/RSUD Dr. Soetomo

2. 2
Pendahuluan
• The American Academy of Allergy and
Immunology
– Alergi Makanan : Reaksi imunologi yang
menyimpang terhadap makanan, sebagian
besar reaksi ini melalui reaksi hipersensitifitas
tipe I

3. Food Hypersensitivity: reaksi terhadap makanan
dengan dasar reaksi tipe II, III, IV
Food Intolerance: reaksi terhadap makanan dengan
dasar reaksi non imunologi
Contoh:
Toksik
 Metabolik
 Idiosinkrasi
3Prof DR Dr Ariyanto Harsono
SpA(K)

4. 4
Patofisiologi
• Alergen Makanan
– Protein, glikoprotein, polipeptida
– BM > 18.000 dalton
– tahan panas
– tahan enzim proteolitik

5. Prof DR Dr Ariyanto Harsono
SpA(K)
5

6. 6
patofisiologi
• Pada ikan : alergen M
• Pada telur : ovomucoid
• Pada susu : betalaktoglobulin (BLG)
alfalaktalbumin (ALA)
bovin serum albumin (BSA)
bovin gama globulin (BGG)

7. 7
Cow's milk
-caseins
Whey
ασ1-Casein,
ασ2-Casein
β-Casein
κ-Casein
β-Lactoglobulin
α-Lactalbumin
Exposure of allergen

8. 8
patofisiologi
• Pada kacang tanah : Arachin
Conarachin
• Pada permunian : Peanut I
Glicoprotein
180.000 dalton

9. 9
patofisiologi
• Pada udang :
– alergen I (21.000 dalton)
– alergen II (200.000 dalton)
• Pada gandum :
– albumin
– pseudoglobulin
– euglobulin

10. 10
1. Genetic: Atopy
2. Exposure
3. Mucosal Barrier
Immunology Paradigm
Factors Of Allergy Development

11. Prof DR Dr Ariyanto Harsono
SpA(K)
11

12. a, b, c, d : HLA DR
e : HLA DM
f : HLA DM CIITA
Genetic

13. 13
patofisiologi
• Paparan awal
– sel yang berperan
• sel penyaji antigen
• sel T
• sel B

14. 14

15. 15
Macrophage are
abundant in the
lamina propria of the
villi.
Function:
1.Phagocytosis
2.Immune regulation
by cytokines
release
3.APC
Goblet Cells

16. Aktivasi
sel-sel
Imuno-
kompeten
•Sel T
•Sel B
•Sel Mast
•Sel
Langer-
hans
Aktivasi
sel-sel
struk-
tural
•Sel
endotel
•Sel epitel
Aktivasi dan
Rekruitmen
•Sel Mast
•Eosinofil
•Neutrofil
•Basofil
Pelepasan
mediator
Kerusakan
epitel
Stimulasi
neural
Dilatasi &
peningkatan
permeabilitas
vaskulerl
Bronkokonstriksi
Perbaikan
epitel
•Proliferasi
fibroblast
•Deposisi kolagen
•Hipertropi/hiperp
lasia otot polos
•Ekspansi vaskuler
Penyempitan
saluran nafas
bawah
Symptom
alergi
Bronkus
hiper-reaktif
A
L
E
R
G
E
N
A B C D E
Imunopatologi alergi
Airway
remodelling
16
Prof DR Dr Ariyanto Harsono
SpA(K)
Trigger

17. Macam Reaksi
• Reaksi tipe cepat (Rapid onset reaction)
• Reaksi tipe lambat (Delayed onset Reaction)
• Target organ:
– Mengenai 1 atau lebih organ tertentu
– Contoh :
• Paru : asma bronkial
• Hidung : rinitis alergika
• Kulit : urtikaria, dermatitis atopik
• Kardiovaskuler : renjatan anafilaktik
17Prof DR Dr Ariyanto Harsono
SpA(K)

18. VACCINATION
ACTIVATION
ANTIGEN
SPECIFIC B
CELL
GENERATION OF
MEMORY
ACTIVATED
CD4
+
Th-2 CELL IL-4
DIFFERENTIATION
& AFFINITY
MATURATION
ANTIBODY SECRETING
PLASMA CELLS
ANTIGEN
PROCESSING &
PRESENTATION
MHC Class II B CELL IMMUNOGLOBULINE
T CELL RECEPTOR ANTIGEN
B CELL
IL-5,IL-13
Cow’s Milk Protein
Cow’s Milk epitope

19. Granule contents:
Histamine,TNF-α
Proteases, Heparin
Lipid mediators:
Prostaglandins
Leukotrienes
Cytokine production:
Specifically IL-4, IL-13
19Prof DR Dr Ariyanto Harsono
SpA(K)

20. IgGIgG mediated: Kolik, Protein loosing enteropathy, Gastro-intestinal haemorrhage
Prof DR Dr Ariyanto Harsono SpA(K)
1
Unsoluble allergen

21. IgMIgM mediated: Kolik, Protein loosing enteropathy, Gastro-intestinal haemorrhage
Prof DR Dr Ariyanto Harsono SpA(K)
1
Unsoluble allergen

22. Prof DR Dr Ariyanto Harsono
SpA(K)
22

23. 23
paparan awal...

24. 24
patofisiologi
• Patologi yang timbul disebabkan :
– intereksi antar sel
– mediator
– sitokin

26. 26
patofisiologi
• Paparan selanjutnya
mulai berperan
– limfosit T
– netrofil
– eosinofil

27. 27
Paparan selanjutnya

28. Mast Cells and basophiles involve in allergic
reaction in the context of antigen-IgE complex

33. 33
Physiologic barriers Block penetration of ingested antigens:
Epithelial cells
Glycocalyx
Intestinal microvillus membrane structure
Tight junctions joining adjacent enterocytes
Intestinal peristalsis
Break down ingested antigens:
Salivary amylases and mastication
Gastric acid and pepsins
Pancreatic enzymes
Intestinal enzymes
Intestinal epithelial cell lysozyme activity
Immunologic barriers Block penetration of ingested antigens:
Antigen-specific s-IgA in gut lumen
Clear antigens penetrating gastrointestinal barrier:
Serum antigen-specific IgA and IgG
Reticuloendothelial system

34. 34
Intestinal Epithelial Cells (IECs)
Central regulatory role in
*Determining allergen absorption
*Pattern of uptake of ingested Ag
*Function as APC

35. Mucosal immunoglobulins
S-IgA: Non
inflammatory
Mucosal
protection
S-IgM similar to
Plasma
IgM, activates
complement and
phagocytes
IgG: Neutralization, potentially inflammatory,
Activates Complement and phagocytes
IgE: Adverse hypersensitivity states, parasite expulsion

36. IgA
Immunological Barrier
The role of B Cells

37. Component
(SC)
Dimeric

38. 38
mAb-IgA

39. 39
mAb-SC

40. Development of Cow’s Milk Allergy
Early introduction of food antigens
• stimulate production of IgE
• IgE-mediated response to an allergen
– result of a series of molecular & cellular
interactions
– Involving APC, T cells and B cells.
APCs present epitope
• MHC class II molecules to T cells;
peptide-MHC complex.
• "first signal" leads to:
– T-cell proliferation, differentiation
– initiation of "second"signal
These cells and their
products
• interact with B-cells
bearing appropriate
antigen-specific
receptors
• isotype switching
• generation of antigen-
specific IgE.

41. IgE in Relation to Cow’s Milk Allergy
• In atopic children
– early antigenic exposure ->
IgE production
– sensitisation of mast cells
• gastro-intestinal
• respiratory tracts.
• IgE production starts early
– primary immune response to food
– continue even when the allergen is
avoided by an elimination diet.
• Food IgE-antibody concentrations:
– increase to individual peak levels and
thereafter decline
– sensitised through breast-milk to foods
their mother have eaten
This explains
• infants already react to their first intake of
cow's milk formula
• Infants with onset of allergic to one food,
also at high risk of developing allergy to
other foods.

42. once IgE response to cow’s milk protein is
initiated
Prevention of food allergy using
hypoallergenic milk formula in the first
trimester of life is very important, because:
it progresses throughout the infant life
sensitisation to other food allergen may
develop

43. 43
Immunoglobulin Other Than IgE
IgG, IgM
1. Anaphylactoid
2. Malabsorption.
3. Protein Losing Enteropathy

44. Induction of Oral Tolerance
T-cells regulation:
1.Intra Epithelial Lymphocytes: extrathymically derived,
have limited TCR repertoir, capable of recognizing common
microbiologic Ags, and demonstrate predominantly cytolytic
functions
2.Lamina Propria Lymphocytes: thymicaly derived,
contributes to limiting TCR/CD3-mediated signals in the
mucosa
.

45. M Cell
Epithelial
Cell
Intra Epithelial
Lymphocyte
Lamina Propria
Lymphocyte

46. 46
IEL
LPL
CD3
Anergy/Tolerance

47. 47
Infiltrasi eosinofil...

48. 48
Gejala klinik
organ sasaran
• Kulit
• saluran napas
• saluran cerna
• Mata
• telinga
• kardiovaskuler

49. Target
Organ
IgE-mediated disorder Non IgE-mediated
disorder
Skin
Gastro-
intestinal
Respiratory
Tract
Multi-
system
Urticaria and angioedema
Atopic Dermatitis
Oral Allergy Syndrome
Gastrointestinal anaphylaxis
Allergic eosinophilic
gastroenteritis
Asthma; Allergic Rhinitis
Food-induced anaphylaxis
Food associated, exercise-
induced anaphylaxis
Atopic Drmatitis
Dermatitis
Herpetiformis
Proctocolitis
Enterocolitis
Allergic eosinophilic-
gastroenteritis
Enteropathy syndrome
Celiac Disease
Heiner Syndrome
Clinical Manifestation

51. 51

54. 54

57. Target organ Unusual Clinical manifestation
•Skin
•ENT
•Respiratory
•Gastrointestinal
•Multi system
Vasculitis; Fixed Skin Eruption
Chronic Serous Otitis Media
Chronic Pulmonary disease (Heiner Syndrome)
Hypersensitivity pneumonitis
Constipation; Gastroesophageal reflux
Irritability/Sleeplessness in infants; Arthropathy;
Nephropathy; Thrombocytopenia
Unusual Clinical Manifestation

61. 61

62. Diagnosis
• Anamnesis
• pemeriksaan fisik
• laboratorium
• uji eliminasi provokasi

63. diagnosis
• Step 1 : eliminasi
– eliminasi diet
– minimal diet 1 (modified Rowe’s diet 1)
– minimal diet 2 (modified Rowe’s diet 2)
– egg & fish free diet
– his own’s diet

64. Diagnosis...
Step 2
• Provokasi :-DBPCFC
-Open Challenge

65. Penatalaksanaan
• “The mainstay of treatment of allergic
disease is avoidance of allergen”
• allergen yang ditemukan dg uji eliminasi
provokasi harus disingkirkan sebaik
mungkin
• desensitisasi tidak dilakukan

66. Diet Eliminasi
1. Elimination Diet
2. Minimal Diet 1
3. Minimal Diet 2
4. Egg and Fish free
diet
5. His own Diet
Prof DR Dr Ariyanto Harsono SpA(K) 66

67. Diet Eliminasi
1. Elimination Diet
2. Minimal Diet 1
3. Minimal Diet 2
4. Egg and Fish free
diet
5. His own Diet
Prof DR Dr Ariyanto Harsono SpA(K) 67
Elimination Diet (BSTIK)
Alergen utama yang
harus dipantang selama
3 minggu
Buah
Susu
Telur
Ikan
Kacang

68. Diet Eliminasi
1. Elimination Diet
2. Minimal Diet 1
3. Minimal Diet 2
4. Egg and Fish free
diet
5. His own Diet
Makanan hipoalergenik
yang diperbolehkan:
 Nasi(Beras)
 Daging sapi
 Kelapa
 Kedelai
 Sayur
 Wortel
 Bawang
 Gula, garam
Prof DR Dr Ariyanto Harsono SpA(K) 68

69. Diet Eliminasi
1. Elimination Diet
2. Minimal Diet 1
3. Minimal Diet 2
4. Egg and Fish free
diet
5. His own Diet
Makanan hipoalergenik lain
yang diperbolehkan:
 Kentang
 Daging kambing
 Jagung
 Kacang merah
 Sayur
 Wortel
 Bawang
 Gula, garam
Prof DR Dr Ariyanto Harsono SpA(K) 69

70. Diet Eliminasi
1. Elimination Diet
2. Minimal Diet 1
3. Minimal Diet 2
4. Egg and Fish free
diet
5. His own Diet
Diet ini digunakan untuk
gejala alergi pada kulit.
 Telur
 Ikan
dipantang selama 3
minggu
Prof DR Dr Ariyanto Harsono SpA(K) 70

71. Diet Eliminasi
1. Elimination Diet
2. Minimal Diet 1
3. Minimal Diet 2
4. Egg and Fish free
diet
5. His own Diet
Diet ini digunakan untuk
gejala alergi hirupan
pada saluran nafas, pada
uji kulit debu rumah dan
tungau positif,
anamnesa positif.
Makanan yang
disebutkan oleh pasien
sendiri yang dipantang
selama 3 minggu
Prof DR Dr Ariyanto Harsono SpA(K) 71

72. Makanan Pengganti
Buah
Susu
Telur
Ikan
Kacang
 Sayur
 Kentang
 Wortel
 Nasi
 Teh
 Susu Formula HA/Soya
 Kue mangkok, lapis, bikang
 Daging sapi, hati,paru, otak.
 Tahu, tempe, kecap
Prof DR Dr Ariyanto Harsono SpA(K) 72

73. PENATALAKSANAAN
Pencegahan Primer
Pencegahan Sekunder
Pencegahan Tertier (Therapy)
Imunoterapi
Diet
Pharmalogic therapy
Beta-2 agonis
Xanthine derivative
Corticosteroid
Antagonist H1 generasi IIProf DR Dr Ariyantoarsono SpA(K) 73

74. PENATALAKSANAAN
Pencegahan Primer
Pencegahan Sekunder
Pencegahan Tertier (Therapy)
Imunoterapi
Diet
Pharmalogic therapy
Beta-2 agonis
Xanthine derivative
Corticosteroid
Antagonist H1 generasi IIProf DR Dr Ariyantoarsono SpA(K) 74

75. Kehamilan = “Th2-disease”
*Anti-oksidan
*Hindari asap rokok
*Probiotik trimester
Pencegahan Primer: Masa Kehamilan
75
Prof DR Dr Ariyanto Harsono SpA(K)

76. • ASI Eksklusif
• Diet eliminasi untuk
ibu
• Formula HA
• Tunda makanan padat
Prof DR Dr Ariyanto Harsono SpA(K) 76

77. Pencegahan Primer dengan susu
Formula
FORMULA H.A.
Partially hydrolyzed
formulas: BUBUR SUSU
BISKUIT SUSU
X
X
77Prof DR Dr Ariyanto Harsono SpA(K)
BISKUIT/BUBUR SUSU HA V

78. PENATALAKSANAANPencegahan Primer
Pencegahan Sekunder
Pencegahan Tertier (Therapy)
Imunoterapi
Diet
Pharmalogic therapy
Beta-2 agonis
Xanthine derivative
Corticosteroid
Antagonist H1 generasi IIProf DR Dr Ariyantoarsono SpA(K) 78

79. Pencegahan Sekunder dengan susu
Formula
FORMULA E.H.A.
Extensively
hydrolyzed
formulas:
BUBUR SUSU
BISKUIT SUSU
X
X
79
Prof DR Dr Ariyanto Harsono SpA(K)
BISKUIT SUSU/Bubur susu HA X

80. Prevensi Sekunder dengan susu
Formula
Soy formulas:
BUBUR SUSU
BISKUIT SUSU
X
X
80Prof DR Dr Ariyanto Harsono SpA(K)
BISKUIT SUSU/BUBUR SUSU HA X

81. Prevensi Sekunder dengan susu
Formula
Amino Acids:
BUBUR SUSU
BISKUIT SUSU
X
X
81Prof DR Dr Ariyanto Harsono SpA(K)
BISKUIT SUSU/BUBUR SUSU HA X

82. PENATALAKSANAANPencegahan Primer
Pencegahan Sekunder
Pencegahan Tertier (Therapy)
Imunoterapi
Diet
Pharmalogic therapy
Prof DR Dr Ariyantoarsono SpA(K) 82

83. Penatalaksanaan…..
• Eliminasi makanan setelah uji provokasi
• Diberi petunjuk makanan pengganti
– Pengganti Susu Sapi:
• Susu formula hidrolisat kasein
• Susu formula hidrolisat whey
• Susu formula kedelai
– Pengganti Buah: sayur
– Pengganti telur, ikan, ayam: daging sapi/kambing
• Jika diet tidak bisa dilaksanakan harus diberi pengobatan simtomatis
83Prof DR Dr Ariyanto Harsono
SpA(K)

84. PENATALAKSANAANPencegahan Primer
Pencegahan Sekunder
Pencegahan Tertier (Therapy)
Imunoterapi
Diet
Pharmacologic therapy
Prof DR Dr Ariyantoarsono SpA(K) 84

85. penatalaksanaan
• Tujuan penatalaksanaan
– frekuensi serangan
– intensitas serangan
– penggunaan obat
– hari bolos sekolah
– kualitas hidup

86. 86
penatalaksanaan
• Makanan pengganti (substitusi)
– susu : formula hidrolisat whey
formula hidrolisat kasein
formula kedelai
– buah : sayur
– telur/ikan : daging sapi
daging kambing
tahu tempe

87. 87
penatalaksanaan
• Makan direstoran tidak aman
• Dianjurkan melakukan “label reading”
• pada bayi, ibu juga harus ikut eliminasi

88. 88
penatalaksanaan
• Farmakoterapi
– tidak bisa menggantikan eliminasi alergen
– mengurangi gejala ringan tapi menutupi gejala
awal kulit

89. Obat-obatan dan yang digunakan untuk mengobati
alergi dapat dibagi menjadi kelompok besar:
1. Obat yang menghambat aktivitas bahan kimia yang
dilepaskan dalam tubuh selama reaksi alergi: - antihistamin
dan antagonis leukotriene;
2. Obat yang mengendurkan otot di saluran udara dari paru-
paru, atau mengecilkan jaringan padat, atau membalikkan
efek dari bahan kimia yang dilepaskan selama reaksi alergi: -
bronkodilator, dekongestan dan epinefrin; anti acetylchloline
3. Obat-obatan yang mencegah aktivasi sel yang terlibat dalam
reaksi alergi: - agen anti-alergi: kromolin, ketotifen
4. Obat yang memiliki efek yang lebih umum dalam
mengurangi peradangan: - kortikosteroid;
5. Terapi yang memodifikasi respon imun: - imunoterapi
alergen. Prof DR Dr Ariyanto Harsono
SpA(K)
89

90. 90
penatalaksanaan
• Cromolin, nedocromil
– penggunaan pada asma
• asma ringan
• asma latihan
• gejala GI
• dermatitis atopi

91. 91
penatalaksanaan
• Glukokortikoid
– digunakan pada penderita alergi makanan
dengan gejala
• asma
• rinitis alergika
• anafilaksis

92. 92
penatalaksanaan
• Beta adrenergik agonis
– beta 2 agonis
• untuk asma
– epinefrin
• untuk renjatan anafilaksis

93. 93
penatalaksanaan
• Metilxantin
– sebagai bronkodilator
• Antagonis kolinergik
– untuk pengobatan tambahan pada penderita
dengan gejala asma, rinitis alergika

94. 94
penatalaksanaan
• Leukotrien antagonis: Montelukast, Zafirlukast
– untuk gejala asma
• kombinasi dengan xantin dan beta 2 agonis

95. penatalaksanaan
• H1 reseptor antagonis
• Generasi II
– efek samping CNS ( - )
– dapat digunakan mulai 6 bulan
– dapat digunakan dalam jangka lama
– efektif untuk
• urtikaria kronik
• rinitis alergika
• dermatitis atopik
• asma ringan