Sumadiono

- Staf Dept IKA FK UGM

- Komisi Evaluasi Kolegium IKA

- Anggota APAPARI Board (Asa Pasific Ascociation of

Pediatric Allergy, Respirology and

Immunology)

- Ketua Peralmuni Cabang DIY

- Ketua IDAI Cabang DIY

Update on Cows Milk Protein Allergy

Management

New evidence in
formula selection

ALLERGY GLOBAL ARISING

DISEASES

Characteristic of Allergic
Diseases
In Children in Yogyakarta
(2014)
33.8%
1. AR:
Allergic
Rhinitis
17.3%
9.1%

2. DA:
Dermatitis
Atopic
3. Asthma

N:

Characteristic of Allergen Sensitization in Children

in Yogyakarta (2014)
No Allergens %
1.

house dust mite

2.
3.
4.

shrimp
11.8 %
crab 10.9 %
cocroach
8.7%

5.

dog

8.4%

6.

cat

7.6%

7.

tree

4.2%

8.

cotton

8.

grass 3.8%

9.

tomatoes

4.0 $
3.8 %

10. milk

3.3 %

11 . pineapple

3.1 %

12. egg whites 3.1 %

13. egg yolks
2.4 %
14. soy
15.. fish

2.2 %
1.8 %

21.3%

Exclusive breastfeeding practice

during 6 months

Exclusive breast feeding

Partially breast
feeding

Mostly breast feeding

No breast feeding

with increasing age of baby

Exclusive breast feeding: tend to decrease

CMPA-suspected
symptoms

Apps JR and Beattie RM, BMJ 2009:339:b2275

Milk Formulas & Indications

No

Protein

Lactos Fat
a

1. Partially
H.

Partially N
H

2. Free
Lactose,

Indication

Prevention

0%/
N
Glucos
a
polym
er

Lact.
Intolerance
Diarhea

3. Extensive Extensiv N
H.
e casein

Prevention
CMA

4. Extensive Extensiv N
&
e Casein

MCT55 CMA
%
Fat Malabs

RECOMMENDATION
Indonesia Paediatrion Association
(IDAI)

DIAGNOSIS AND MANAGEMENT

OF COWS MILK PROTEIN ALLERGY

Allergy Immunology Working

Group
Gastrohepatology Working Group
Nutrition and Metabolic Diseases
Working Group

Indonesian CMA Management

Recommendation
Exclusive Breast Feeding Group
Continue Breast feeding
2013/2014
Mother: Avoid Cows Milk Protein (minimum 6
month)
Cows Milk Formula Group

Baby: Avoid Cows Milk

Replace eHF Mild-Moderate (min. 6 month)
Amino Acid Formula Severe (min. 6 month)
SOY FORMULA :
If: Cost, Availability, Taste

(start from early life with education)

AVALABILITY

Amino Acid Formula

: -- +
Extensive Hydrolize Formula
:+
Partiall Hydrolize Formula : +
Cows Milk Formula
: +++
Soy Formula
: ++

TASTE
Amino Acid Formula
: Verry bitter &
fishy
Extensive Hydrolize F. : Very bitter
Partiall Hydrolize F.
: Bitter
Soy Formula
: Quite nice
Cows Milk Formula : Nice

Cost of Milk Formula

Indonesian Income
per Capita: Rp.
85.000/day

Cost of Milk Formula

Europe Income
per Capita ??

9/14/2011

Soy Allergy ?
10%

Aluminium
Kandungan AL > pada formula kedelai > formula susu
sapi dan ASI.
Formula kedelai 200 mL/kg/hari hanya <0,5 mg/kg/hari.
Msh << tolerable intake ( FAO/WHO): 1 mg/kg/hari
American Academic Pediatric (AAP): bukan masalah
keamanan bagi bayi kecuali pada bayi prematur atau bayi
dengan gagal ginjal.
ESPGHAN Committee on Nutrition. J Ped Gastroenterol Nutr. 2006;42:352-61
Vandenplas Y, Castrellon P G, Rivas R, Gutierrex C J, Garcia L D, Jimenez J E, Anzo A,
Hegar B, Alarcon P. British Journal of Nutrition 2013 1:21

Soy Nutrtition?

Similar in Normal & Developmental in Term

Infants, Comparation: Soy Formula & Milk
Formula

Fitoestrogen ??
Isoflavon dalam bentuk genistein, daidzein dan glycitein
dampak perk seksual, reproduksi, neuroendokrin,
neurobehaviour, dan fungsi tyroid.
Pada kajian ilmiah: fitoestrogen dalam kedelai efek
estrogen yang lemah.
Kajian metaanalis:
pola pertumbuhan, metabolisme, tulang, reproduksi,
endokrin, sistem imun, dan fungsi neurologi sama susu
formula sapi

Susu formula isolat protein kedelai

merupakan alternatif
ESPGHAN Committee on Nutrition. J Ped Gastroenterol Nutr. 2006;42:352-61
Lancet 1997; 350;815-6

Fitat ??
Isolat protein kedelai mengandung fitat
sebesar 1-2%, yang dapat mengganggu
absorpsi mineral dan trace elements.
Reduksi kandungan fitat telah dilakukan
pada semua produk formula dengan
isolat protein kedelai
sehingga meningkatkan absorpsi
dan availabilitas zink, tembaga, dan
mineral lain .

UPDATE on CMPA management

IDAI 2009

IDAI 2014

Background:
human resources, SPT availability, formula selection: taste, access
and financial aspects

INDONESIA DATA

The safety of a soy-based infant formula in

infants with suggestive CMPA

CMPA - Symptoms
Indonesian Data

Body systems affected in an observational study among Indonesian infants above 6 months with
symptoms suggestive adverse reaction to cows milk protein, 2011-2012

Post Marketing Observational Study results, 2011-2012. Data on file

Results symptoms
resolution

Post Marketing Observational Study results, 2011-2012

Results safety analysis

From 535 subjects measured for safety evaluation:

the soy-based formula was well tolerated in

most subjects (86.0 % subjects).

No serious adverse event reported during the

study period.

Since there was no spontaneous adverse event reported in the

CRFs, adverse events were documented if there is new event(s)
appear in the later visit that is not exist in previous visit, which does
not necessarily have a causal relationship with the study formula.

Post Marketing Observational Study results, 2011-2012

Conclusions

Complete avoidance of cows milk is a key

management of CMPA, and formula selection should
consider to
Type of CMPA
Taste / palatability, access/availability,
affordability/financial
Isolated soy protein based formulas provide good
safety and tolerability profile
Low prevalence of soy allergy in CMPA patients
(especially in igE mediated CMPA)
Indonesia data : a soy-based formula is well tolerated
with high parental acceptance

31

Label Reading
Milk
Milk
Artificial butter flavor, butter, buttermilk
Casein (rennet), caseinates (calcium, magnesium,
potassium, and sodium)
Ghee
Hydrolysates (casein, milk, protein, and whey)
Lactalbumin, lactoglobulin, lactose (may contain),
lactulose
Milk solids, milk powder, nonfat dry milk powder
Whey
Label ingredients that may indicate the presence of
milk protein
Chocolate
32
Flavorings (artificial, caramel, and natural)