S

DIARRHEA
IN CHILDREN
DIARE PADA
ANAK

BADRIUL HEGAR
Pediatric Gastroenterology, Department of Child Health
University of Indonesia

ACUTE DIARRHEA
85%

PROLONGED DIARRHEA
(>7 DAYS )
10%

CHRONIC DIARRHEA
(14 DAYS)

5%

Diarrheal disease of rapid onset +/- accompanying sympt

such as nausea, vomiting, fever, or abdominal pain

Episode diarrhea per year

Episode per child per year

0
0-5

6-11

12-23

24-35

age (months)

36-47

48-59

EPIDEMIOLOGY

Hospital admissions (children < 5 years)

USA : 220.000 patient/year (10% of hospit.)
RSCM, Jakarta
- One Day Care (2001) : 1136 patients
Diarrhea : 65%

Etiologyc agents
Rotavirus (70-80% of infectious cases in developed word)
Bacteria : Salmonella, ETEC (++), Shigella (+),
Campylobacter, Yersinia enterocolica (Eropa)

Parasites : Giardia lamblia (++), candida

RSCM, Jakarta
40 Children (6 month - 3 year)
- acute diarrhea, mild-moderate dehydration
- Rotavirus 58.3%

Fecal analysis (RSCM, Jakarta)

200 children, diarrhea, hospitalization

gram neg bacteria infection

lactose malabsorption
candida infection
parasite infection

34.4%
23.1%
20%
2%

SCFA

CLINICAL MANIFESTATION
Lactose malabsorption
Nausea
Vomiting
Abdominal pain, cramps, distention
Flatulance
Diarrhea

 ACUTE DIARRHEA
common and costly clinical problem in chiIdren
self-limited disease with many etiology
treatment supportive preventing & treating dehydr..
PROBLEMS

Some physician do not know the standards for

rehydration therapy

Some physician do not necessarily use oral

rehydration therapy

 EPSGHAN (2997 infants, AD,mild-moderate dehydr)

84% ORS
36% lactose containing formula
43% full strenght formula
77% continuation breast-feeding
37% ORS after rehydration
drugs: smectite (22%), loperamide (-), bismuth (-)
AAP , ORS 60%
RSCM (Jakarta), ORS 70%

 Three specific issues

Methods of rehydration
Refeeding during and after rehydration
The use of antidiarrheal agent

American Academy of Pediatrics (AAP), 1996

The 9 Pillars of Good Treatment

1. Use rehydration solution
2. Hypotonic solution
3. Fast oral rehydration (3-4 hours)
4. Rapid realimentasi wit normal feeding
5. Special formula is unjustified
6. Diluted formula is unjustified
7. Continuation of breast feeding
8. Supplementation with oral rehydration sol.
9. No unnecessary medication

Penilaian
Lihat: Kead. Umum
Mata
Air mata
Mulut dan lidah
Rasa haus

A
Baik, sadar

B
* Gelisah,

rewel

C
* Lesu,

lunglai, tak sadar

Normal

Cekung

Ada

Tidak ada

Tidak ada

Basah

Kering

Sangat kering

Minum biasa
tidak haus

* Haus, ingin
minum banyak

* Malas minum atau

tidak bisa minum

Periksa Turgor kulit

Kembali cepat

* Kembali

Hasil pemeriksaan

Tanpa dehidrasi

D. Ringan/sedang

Dehidrasi berat

1 tanda * (+) 1 atau

lebih tanda lain

1 tanda * (+) 1 atau lebih

tanda lain

Rencana terapi B

Rencana terapi C

Terapi

Rencana terapi A

lambat

Sangat cekung & kering

* Kembali

sgt lambat

PLAN TREATMENT A

No dehydration
vomiting (-) continue age-appr diet
malabsorption (-) no specific diet
complex carbohydrate, fruit, vegetables
ORS ?

PLAN TREATMENT B
Mild-moderate dehydration
ORS (the first 3 hours) 75 ml x body weight
or
Umur

< 1 tahun

1-5 tahun

> 5 tahun

dewasa

Total ORS

300 ml

600 ml

1200 ml

2400 ml

Reevaluate after 3-4 hours plan th/ A, B, or C

Continued feeding or early resumption

Electrolite composition
Na

Cl

HCO3

Cholera diarrhea
Non-cholera diarrhea

101
56

27
25

92
55

32
14

ORS WHO
Ringer Lactate
NaCl 0,9%
DG ana
NaCl 0,45%

90
130
154
61
77

20
4
0
18
0

80
109
154
52
77

30
28
0
27
0

Liquid

Na+

K+

HCO3

Cola

0.1

13

Ginger
ale

50-150 gluc, fruc

Apple
Juice

20

100-150 gluc, fruc

Chicken 250
Broth

Carbohy (g/L)
50-150 gluc, fruc

Tea

Gatora
de

20

45 gluc, other sug

mOsm/BW
550

PLAN TREATMENT C
Severe dehydration, IVFD

Age

Ist treatment
30 ml/BW in

2nd treatment
70 ml/BW in

Infant < 12 months

Child > 12 months

1 hour
- 1 hours

5 hour
2 - 3 hours

Reevaluate every 1-2 jam

ORS
After 6 hours (infants) or 4 hours (child)
reevaluate plan treatment A,B,C

Electrolite composition
Na

Cl

HCO3

Cholera diarrhea
Non-cholera diarrhea

101
56

27
25

92
55

32
14

ORS WHO
Ringer Lactate
NaCl 0,9%
DG ana
NaCl 0,45%

90
130
154
61
77

20
4
0
18
0

80
109
154
52
77

30
28
0
27
0

Remember
The dehydration categories are only
estimate
Should use all of the available clinical & historical
information
Not just the physical findings

Evaluation (clinical assessment)

A search for sign of cormobid conditions
factors
travel, animal/bird, day care, antibiotic

Characteristic
Blood : inflamatory bacterial disease aggressive
work up & intervention

Gross or occult blood in the stool

Shigella sp, Campylobacter sp, EHEC

ANTIMICROBIAL

Inappropiate antimicrobial treatment may

prolong the time taken to control diarrhea
disregulation of the intestinal microflora
antibiotic associated colitis
prolong the carier state (Salmonela)

ANTIMICROBIAL

suspected dysentri baciller

suspected cholera
giardiasis
amoebiasis

Laboratory assessment
Routine laboratorium testing is no longer

necessary
It may be helpful in individual patients
oral replacement treatment fail

Large number of leucocytes on fecal

indicate an inflammatory bacterial process
Culture ?

Breath Hydrogen Test

45 children, prolonged diarrhea
Increasing H2 excretion
Result : - 14/45 overgrowth bacteria

 LIMITATION OF ORS
Severe dehydration IVFD
Profuse diarrhea (>10ml/BW/hour) ORS
ORS composition could not decrease the
volume diarrhea

ORS duration, freq, volume diarrhea

Expectation versus Facts

in the Management of Infantile Diarrhea
EXPECTATIONS

FACTS

Self-limiting disease

Parents anxiety builds in the

presence of a long course of
diarrhea leading to a specific
request for effective drugs

ORS - The key treatment

ORS has no effect on either

the duration of diarrhea or
the volume of fluid loss
Agents that could be safe and
effective in reducing the duration of diarrhea would be a valuable therapeutic resource

 Therapeutic

strategy

Active search for the therapeutic strategy

has been conducted recent years

adsorbant, mucoprotector, antisecretory,
probiotic

Conclusion
Diarrheal disease is still common and serious
problem in children
The main treatment for diarrhea in children is
rehydration
Agent that decrease the freq, duration, volume of
diarrhea, save to children, and compatable to ORS
is considerably perspective

THANK YOU