Download 아토피피부염 치료를 위한 식품영양적 접근

아토피피부염 치료를 위한
식품영양적 접근
성균관대학교 의과대학
한영신
증례 1 말라스무스
<체중(5.9Kg,3백분위수이하),신장(68cm,3백분위수이하)인 12개월령 남아>
Characteristics of patients
Case 1
Age
Diagnosis
12 month
Marasmus
Atopic Dermatitis
Height
68cm (<3 percentile)
Weight
5.9kg (<3 percentile)
Birth Height
50cm (25-50 percentile)
Birth Weight
3kg (25 percentile)
Height history
Not available
Weight history
5.4kg at 3 months
(10-25 percentile)
Biochemical values
Total IgE(U/ml)
IgE on food
protein(U/ml)
MCV 81.4 fl/RBC, MCH 28.6 pg/RBC, MCHC 35.1 g/dl/RBC
WBC 6.48x103, Hemoglobin 11.7 g/dl, Hematocrit 33.3 %
Total protein 6.2 g/dl, Albumin 4.4 g/dl, Ca 9.1 mg/dl
146
Soy 0.45, Milk 0, Egg White 0, Wheat 0.5
Past diet prior to admission
Age
(months)
3
Diet of case 1
Stop formula
3-6
Mixed grain porridge (very light)
180-200ml x 4-5 times
Enzyme water
Persimmon leaf tea 100-150ml
vegetable juice 60-100ml
7-8
Mixed grain porridge
(concentrated)
180-200ml x 4-5 times
Enzyme water
Persimmon leaf tea 100-150ml
vegetable juice 60-100ml
9-10
Mixed grain porridge
(concentrated)
180-200ml x 4-5 times
Enzyme water
Persimmon leaf tea 100-150ml
vegetable juice 60-100ml
Soy milk 50ml/day
Past nutrient consumption prior to admission
Age
(month)
Energy
(kcal)
Protein
(g)
Carbohy
drate
(g)
Fat
(g)
Calcium
(mg)
Phosphor
us
(mg)
Iron
(mg)
Zinc
(mg)
3-6
341
11.8
67
3.9
83
305
3.5
3.2
7-8
403
13.9
79
4.7
91
359
4.0
3.5
9-10
471
17.4
90
7.0
104
422
4.7
3.9
RDA
500
20
300
200
6
4
RDA
750
20
300
300
8
4
Vit
A
(RE)
Vit
B1
(mg)
Vit B2
(mg)
Niacin
(mg
NE)
Vit B6
(mg)
Vit B12
(μg)
Folic
acid
(μg)
Vit C
(mg)
Vit D
(μg)
Vit E
(mg)
3-6
155
0.4
0.2
5.0
0.5
0
98
22
0
1.7
7-8
155
0.4
0.2
5.8
0.6
0
108
22
0
1.9
9-10
155
0.5
0.2
6.5
0.6
0
128
22
0
2.3
RDA
350
0.3
0.4
3
0.2
100
50
10
3
RDA
350
0.4
0.5
5
0.4
70
35
10
4
증례 2 콰시오커, 구루병
Characteristics of patients
Case 2
Age
Diagnosis
9 month
Kwashiorkor, Richets (Hip & Pelvis)
Atopic Dermatitis, Edema, Convulsion
Height
67cm (3 percentile)
Weight
8.4->7.4kg (3 percentile)
Birth Height
Not available
Birth Weight
2.73kg (3-10 percentile)
Height history
61.5cm at 100days (50-75 percentile)
65.6cm at 7 months (3-10 percentile)
Weight history
6.4kg at 100 days (50-75 percentile)
7.6kg at 7 months (25 percentile)
Biochemical values
Total IgE(U/ml)
MCV 71 (70-96), MCH 22.3 (23-31), MCHC 31.4 (30-36)
WBC 17660x103 (6x103-15 x103), Hemoglobin 10.7 (10.513.5), Hematocrit 34.1 (33-39), Total protein 4.9 (5.9-7.0)
Albumin 2.9 (3.4-4.2), Ca 4.6 (8-11)
10230
IgE on food
protein(U/ml)
Soy 101, Milk 101, Egg White 101 , Pork 2.52, Beef 4.82
Chicken 3.21
Alternative
Therapy used
Sauna Therapy at 8-9 month
Past diet prior to admission
Age
(months)
Diet of case 2
3.2
Stop formula
3.2-5
Mixed grain porridge
250ml x 6 times/d
=>mixed grain powder
6kg/month
6-7
Mixed grain porridge
250ml x 4 times/d
=> mixed grain powder
4kg/month
soy milk 200ml
cooked rice 1/2 bowl
8
Mixed grain baby porridge
180ml x 4 times/d
cooked rice 1/2 bowl
Past nutrient consumption prior to admission
Age
(month)
Energ
y
(kcal)
Protein
(g)
Carbohydr
ate
(g)
Fat
(g)
Calcium
(mg)
Phosphor
us
(mg)
Iron
(mg)
Zinc
(mg)
3.2-5
620
20.8
121
7.6
75
544
5.1
3.6
6-7
658
25.6
123
12.3
86
491
5.2
3.6
8
549
19.5
102
8.6
170
457
5.5
3.1
RDA
500
20
300
200
6
4
RDA
750
20
300
300
8
4
Vit
A
(RE)
Vit
B1
(mg)
Vit
B2
(mg)
Niacin
(mg
NE)
Vit
B6
(mg)
Vit
B12
(μg)
Folic
acid
(μg)
Vit
C
(mg)
Vit D
(μg)
Vit E
(mg)
3.2-5
0
0.6
0.2
7.8
0.8
0
96
0
0
2.4
6-7
0
0.5
0.2
6.3
0.6
0
123
0
0
2.2
8
47
0.4
0.2
5.8
0.6
1.0
91
2.3
0.6
2.1
RDA
350
0.3
0.4
3
0.2
100
50
10
3
RDA
350
0.4
0.5
5
0.4
70
35
10
4
Dietary management of
food hypersensitivity
FOOD
ELIMINATION
NUTRITION
Food Elimination Diet
A definitive diagnosis
Strict elimination of the offending food
allergen(s) is the only proven therapy for
food hypersensitivity
Food Elimination Diet
Complete avoidance is critical
Milk allergy
Dairy product: Milk, yogurt, cheese, pizza, cream,
butter. Ice-cream
Products with milk: Chocolate, caramel, soft candy,
pudding, cream soup, custard
Egg allergy
Breads: Cake, castera, soft cooki, waffle, pancake,
custard
Source: myonaise, salad dressing
Ice cream
어묵, 만두, 햄버거, 튀김옷이나 부침옷에 계란이 들어가는 음식
기타 계란성분이 함유되어 있다고 표시된 제품
Food Elimination Diet
How to survive on an Allergen Restricted Diet
Complete avoidance is critical
Keep a diet diary
Use fresh, unprocessed foods as much as possible
Read all labels
Substitute foods for eliminated foods
Hypoallergenic formula: Maeil Atocare, HA
Egg, milk substitute
Food Elimination Diet
Treatment
Single food avoided
Several foods avoided
A few food allowed
Duration
Short term
Long term
Nutritional Consequences of Elimination Diets
A food or a food group elimination
Nutrients that are potentially lost
Sometimes the removal of even a single food protein
requires that a large number of products with diverse
nutritional and social advantage be excluded from the
diet.
Wheat : as flour in baked goods may provide a
solution.
Rice
Success of elimination diets depends on adherence
and nutritional adequacy
NUTRITION
Growth Assessment
weight, length, weight to length
growth velocity: growth chart
Clinical symptom
Face, nail, hair
Dietary Intake Assessment
Younger than 6 months a 24-hour recall
Older than 6months 3-day diet record
NUTRITION
Dietary Needs
Nutrient requirements are similar to healthy children
Calories and Protein : Use of protein hydrolysates and/or
amino acid-based formulas may be necessary for children
older than 1 year, if sufficient intake of good-quality protein
is compromised.
Fats : essential fatty acid (EFA)
Carbohydrates
Vitamins, Minerals, and Trace Elements: When 1 food or
food group is eliminated, alternative sources of nutrients
that are consequently lost need to be identified.
영양평가
1.체위상태:체중(5.9Kg,3이하),신장(68cm,3이하)
2.출생 및 가족력:3Kg
3.질병력:과거병력(2개월경 Atopic Dermatitis)
현병력(Malnutrition,Atopic Dermatitis,Diarrhea)
4.영양
-영양내력:
생후 4개월(우유 끊음,미음과 효소물과 차,한의원치료)
생후 7개월(오곡미음을 농도를 다소 진하게)
생후 8개월(두유 feeding)
생후 1년 (HA-21/Hope D)
5.검사 :Total IgE (146), CAP 콩 0.45, 밀 0.5
증례2:비만
섭취영양분석
항목
식사량
열량(Kcal)
단백질(g)
수유
두유 100cc
60
3
섭취량
471
17
요구량
750
20
오곡미음 180-200ml x 4-5
times
식사
효소물 100-150ml
야채쥬스 60-100ml
Nutritional management Tips
A multivitamin and mineral supplement can also offer a
nutritional safety net : contaminated with milk
Use of a complete formula
Use of substitute formulas may be necessary for
children older than 1 year, if sufficient intake of goodquality protein is compromised.
Substitute formulae
1) Soy
protein-based formulae
2) Partially
hydrolyzed formulae (atocare)
3) Extensively
hydrolyzed formulae (Ha)
Prevalence of soy protein sensitization in
cow milk protein-sensitive children
n=41 (18.3 %)
CM(+), Soy(+)
CM(+), Soy(-)
n=183
The mean age of patients sensitized to both cow milk and soy
protein was 2.5 years. Most of them(n=34) had atopic
dermatitis. Prevalence was written in the parentheses.
SPECIAL DIETARY CONSIDERATIONS
Maternal Diet Restriction for Breastfed
Infants
Maternal Diet Restriction for Breastfed Infants
Transfer of substances from the maternal diet into
breast milk constitutes a potential route of exposure
of the breast-feeding infant.
Levels of allergens attained in breast milk
b-lactoglobulin, Ovomucoid, Ovalbumin, Gliadin,
Peanut
5 - 800 ng/ml
Time from ingestion to peak concentration
1 to 6 hours
Maternal Diet Restriction for Breastfed Infants
AAP suggestion
Restricting milk, egg, fish, peanuts, and tree nuts in the
maternal diet if symptoms of food allergy are noted in
the infant.
Prophylactic restriction of some food allergens is
suggested for infants at high risk for allergy
Lactating mothers who undertake restricted diets may be at
nutritional risk.
Quality of breast milk: preserved even at times of poor
nutrition, the composition is affected by maternal diet
Quantity of milk: decreased in a diet low in calories
and/or protein.
제안
식품관리는 진단, 치료, 영양지원 등 아토피피부염
관리 전반에 밀접한 관계를 가지고 있다.
아토피피부염 치료를 위해서는 의사와 식품전문가
(임상영양사, 연구자)가 팀을 이루어 관리하고 연구
해야 한다.
이를 위해 적절한 의료 시스템을 갖추고 체계적인
식품 관리가 이루어져야 할 것이다.
감사합니다.