1. 아토피피부염 치료를 위한 식품영양적 접근 성균관대학교 의과대학 한영신

2. 증례 1 말라스무스

3. Case 1 Age12 month Diagnosis Marasmus Atopic Dermatitis Height68cm (<3 percentile) Weight5.9kg (<3 percentile) Birth Height50cm (25-50 percentile) Birth Weight3kg (25 percentile) Height historyNot available Weight history 5.4kg at 3 months (10-25 percentile) Biochemical values MCV 81.4 fl/RBC, MCH 28.6 pg/RBC, MCHC 35.1 g/dl/RBC WBC 6.48x10 3, Hemoglobin 11.7 g/dl, Hematocrit 33.3 % Total protein 6.2 g/dl, Albumin 4.4 g/dl, Ca 9.1 mg/dl Total IgE(U/ml)146 IgE on food protein(U/ml) Soy 0.45, Milk 0, Egg White 0, Wheat 0.5 Characteristics of patients

4. Age (months) Diet of case 1 3Stop 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 diet prior to admission

5. Age (month) Energy (kcal) Protein (g) Carbohyd rate (g) Fat (g) Calcium (mg) Phosphor us (mg) Iron (mg) Zinc (mg) 3-634111.8673.9833053.53.2 7-840313.9794.7913594.03.5 9-1047117.4907.01044224.73.9 RDA50020 30020064 RDA75020 300 84 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) 3-61550.40.25.00.50982201.7 7-81550.40.25.80.601082201.9 9-101550.50.26.50.601282202.3 RDA3500.30.430.2 10050103 RDA3500.40.550.4 7035104 Past nutrient consumption prior to admission

6. 증례 2 콰시오커, 구루병

7. Case 2 Age9 month Diagnosis Kwashiorkor, Richets (Hip & Pelvis) Atopic Dermatitis, Edema, Convulsion Height67cm (3 percentile) Weight8.4->7.4kg (3 percentile) Birth HeightNot available Birth Weight2.73kg (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 MCV 71 (70-96), MCH 22.3 (23-31), MCHC 31.4 (30-36) WBC 17660x10 3 (6x10 3 -15 x10 3 ), Hemoglobin 10.7 (10.5-13.5), 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) Total IgE(U/ml)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 Characteristics of patients

8. Age (months) Diet of case 2 3.2Stop 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 diet prior to admission

9. Age (month) Energy (kcal) Protein (g) Carbohydra te (g) Fat (g) Calcium (mg) Phosphor us (mg) Iron (mg) Zinc (mg) 3.2-562020.81217.6755445.13.6 6-765825.612312.3864915.23.6 854919.51028.61704575.53.1 RDA50020 30020064 RDA75020 300 84 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) 3.2-500.60.27.80.8096002.4 6-700.50.26.30.60123002.2 8470.40.25.80.61.0912.30.62.1 RDA3500.30.430.2 10050103 RDA3500.40.550.4 7035104 Past nutrient consumption prior to admission

10. Dietary management of food hypersensitivity FOOD ELIMINATION NUTRITION

11. Food Elimination Diet A definitive diagnosis Strict elimination of the offending food allergen(s) is the only proven therapy for food hypersensitivity

12. Complete avoidance is critical Food Elimination Diet 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

13. 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

14. Treatment Single food avoided Several foods avoided A few food allowed Duration Short term Long term

15. 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

16. 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

17. 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.

18. 1. 체위상태 : 체중 (5.9Kg,3 이하 ), 신장 (68cm,3 이하 ) 2. 출생 및 가족력 :3Kg 3. 질병력 : 과거병력 (2 개월경 Atopic Dermatitis) 현병력 (Malnutrition,Atopic Dermatitis,Diarrhea) 4. 영양 - 영양내력 : 생후 4 개월 ( 우유 끊음, 미음과 효소물과 차, 한의원치료 ) 생후 7 개월 ( 오곡미음을 농도를 다소 진하게 ) 생후 8 개월 ( 두유 feeding) 생후 1 년 (HA-21/Hope D) 5. 검사 :Total IgE (146), CAP 콩 0.45, 밀 0.5 영양평가

19. 섭취영양분석 항목식사량열량 (Kcal) 단백질 (g) 수유두유 100cc 603 식사 오곡미음 180-200ml x 4-5 times 효소물 100-150ml 야채쥬스 60-100ml 섭취량 47117 요구량 75020 증례 2: 비만

20. 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 good- quality protein is compromised. Substitute formulae 1) Soy protein-based formulae 2) Partially hydrolyzed formulae (atocare) 3) Extensively hydrolyzed formulae (Ha)

21. 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. n=183 n=41(18.3 %) Prevalence of soy protein sensitization in cow milk protein-sensitive children

22. SPECIAL DIETARY CONSIDERATIONS Maternal Diet Restriction for Breastfed Infants

23. 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

25. 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.

26. 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.

27. 감사합니다.