ALLERGIC MARCH

Literature reading
Wahyu Murtiono.H
Department of Otorhinolaryngology-Head & Neck Surgery
Faculty of Medicine Padjadjaran University
Hasan Sadikin General Hospital
Bandung
2011

The ``allergic march':

The natural history of atopic diseases.
Characterized a typical sequence of
sensitization and manifestation of symptoms
Certain age period, persist over years or
decades, tendency for spontaneous remission
with age.
U. Wahn in:What drives the allergic march? Curr Opin Allergy Clin Immunol, 2002; 2: 55560.
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The Allergic March

EUGENE G WEINBERG, MB ChB, FCPaed, FAAAAIThe

allergic march

Prenatal sensitization
Multifactorial cause of allergy
Genetic constitution Environmental
Factors
* Still in debate.

Andrew H. Liu, MDThe Allergic March of Childhood

 Immune response start in week 20th of

pregnancy.
Amniotic fluid (+) house dust mite
allergen
Transplacental transport mechanism of
different allergen.
Andrew H. Liu, MDThe Allergic March of Childhood

Proposed mechanisms by which maternal exposure to bacteria protects against allergies in

offspring.

Holt P G , Strickland D H J Exp Med 2009;206:2861-2864

2009 Holt and Strickland

Postnatal beginning
Inhaled allergen and food allergen.
Exposure to allergen in early life in
genetically predisposed individual.
Airways allergic diseases (allergic rhinitis
and asthma) increased steadily in prevalence
to age 7years.

Andrew H. Liu, MDThe Allergic March of Childhood

Early atopic signs

Dermatitis,
Gastroesophageal reflux,
Chronic rhinorrhea
Recurrent wheezing

Lawrence D. Rosen, M.D. An Integrative Approach to Atopic Disorders in

Children DOI: 10.1089/act.2007.13201
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U. Wahn - Curr Opin Allergy Clin Immunol, 9

2002; 2: 55-560

 There may be areverse allergic march

where some atopic children first
present with asthma and only later on
develop eczema.

EUGENE G WEINBERG, MB ChB, FCPaed, FAAAAIThe allergic march

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Root of the Problem

The development of atopy early in
childhood is linked with the later
development of airways allergic
disease.
The problem of atopy begins when the
nascent immune system develops
aberrant immune responses to common
ubiquitous, and unavoidable exposures.
Andrew H. Liu, MDThe Allergic March of Childhood
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 Chronic ongoing exposures fuel inappropriate

prolonged injury and inflammation to the airways
aberrant repair of injured tissues.

Aberrant processes through critical periods

of postnatal lung growth and differentiation fully
developed lung may differ from the
normal lung.
This may underlie the persistent asthma phenotype.
Andrew H. Liu, MDThe Allergic March of Childhood
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The Iceberg Model

Understanding a new paradigm of care in
children with atopic disorders.
The tip:
The visible phenomena in atopic children (skin
rashes, vomiting, runny noses, and coughing).

Beneath:
Genomic predisposition
(familial and individual tendency to develop immune
dysregulation under certain environmental
circumstances).
Lawrence D. Rosen, M.D. An Integrative Approach to Atopic Disorders in Children DOI:
10.1089/act.2007.13201
13

Lawrence D. Rosen, M.D. An Integrative Approach to Atopic

Disorders in Children DOI: 10.1089/act.2007.13201

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Genetic factors:
During the first twenty years of life
The risk of developing atopic
symptoms correlated to the existence
of atopic disease in parents and
siblings.

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Allergens:
Food allergens
Respiratory inhaled allergens
(pollen, moulds, animal dander, mites).

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The environment:
Insufficient exposure to certain
infectious agents in early childhood
increase the risk of developing allergy
by disturbing the TH1/TH2 balance and
favouring the TH2 allergic mechanism.
Improved hygiene could be partly
responsible for this phenomenon.

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The hygiene theory

Nature may immunize
Against the development of allergic diseases and
asthma through :
infections and microbial exposures of the
1. Respiratory
2. Gastrointestinal tracts
3. The skin in early life.

U. Wahn - Curr Opin Allergy Clin Immunol,

2002; 2: 55-560

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 Skin sensitization lead to airway sensitization.

Disturb balance between Th1 and Th2
greater expression of Th2 and production of
cytokines.
* Induced IgE production and activate Eosinophil.

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The hygiene theory

Andrew H. Liu, MDThe Allergic March of Childhood

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The hygiene theory

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 Protective Th1 immune responses to microbial

exposures that begin immediately after birth and
after leaving the sterile environment of the mothers
womb.
When this process goes well, Th1-based immune
development prevents pro-allergic Th2 immune
development and atopy, thereby keeping
environmental exposures from becoming allergens.
Andrew H. Liu, MDThe Allergic March of
Childhood

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Th1 immune :

Improve host defense by inducing antiviral

mechanisms that keep respiratory viruses from
proliferating in respiratory epithelium and spreading
down the airways.

Responses during airways injury and inflammation

also inhibit aberrant repair processes that underlie
pathologic tissue changes in asthma.

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 Leading to greater expression of the TH2

features resulting from the secretion of the
cytokines IL-4, IL-5,IL-10 and IL-14.
These cytokines:
Induce IgE production
activate eosinophils leading to allergic
inflammation.
Eugene G Weinberg, MB ChB, FCPaedTHE ATOPIC MARCH
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Intervention and Prevention

The basis for a stratified approach to early
interventions.
Allergy testing is now recommended
from infancy
If food allergies are suspected to cows milk,
hens egg,peanut allergens
should be tested for specific allergies
irrespective of their age

Adrian Morris, MBChB, DCH, MFGPIS ALLERGY TESTING COST EFFECTIVE? Current Allergy &
Clinical Immunology, March 2006 Vol 19, No.1

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Prevention of atopy
Primary prevention :
The avoidance of early allergen exposure to certain
foods and inhalantsfrom birth.

The ETAC (Early Treatment of the Atopic

Child):
The role of cetirizine in delaying the atopic march.

Eugene G Weinberg, MB ChB, FCPaedTHE ATOPIC MARCH

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The use of probiotics

Cultures of beneficial bacteria :

Enhancing the microbial balance
Restore normal intestinal permeability and gut microecology.
Improve the immunological barrier function of the intestine.
Reduce the generation of proinflammatory cytokines characteristic
of allergic inflammation.

In the future may be used in the primary

prevention of the allergic march and asthma.
Eugene G Weinberg, MB ChB, FCPaedTHE ATOPIC MARCH
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CONCLUSIONS
Allergic diseases have now become the
most common group of diseases
among children.Treatment is mainly
based on preventing and/or controlling
symptoms

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 New promising treatments, such as the

administration of sublingual
immunotherapy.
In the future, it is anticipated that therapies
that modify the severity of atopic eczema in
infants and young children will decrease the
risk for the eventual development of allergic
disease and thus prevent the consequences
of the allergic march.
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 Intensive research is still required

before a potential cure for all allergic
children may eventually be developed.

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THANK YOU
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