S

DIARRHEA IN CHILDREN
DIARE PADA ANAK

ASWITHA D BOEDIARSO
Pediatric Gastroenterology, Department of Child Health
University of Indonesia
 ACUTE DIARRHEA
85%

PROLONGED DIARRHEA
(>7 DAYS )
10%

CHRONIC DIARRHEA
5%
(14 DAYS)

Diarrheal disease of rapid onset +/- accompanying sympt

such as nausea, vomiting, fever, or abdominal pain
 Episode diarrhea per year
4
Episode per child per year

0
0-5 6-11 12-23 24-35 36-47 48-59
age (months)
 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 34.4%
lactose malabsorption 23.1%
candida infection 20%
parasite infection 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 A B C
Lihat: Kead. Umum Baik, sadar * Gelisah, rewel * Lesu, lunglai, tak sadar
Mata Normal Cekung Sangat cekung & kering
Air mata Ada Tidak ada Tidak ada
Mulut dan lidah Basah Kering Sangat kering
Rasa haus Minum biasa * Haus, ingin * Malas minum atau
tidak haus minum banyak tidak bisa minum

Periksa Turgor kulit Kembali cepat * Kembali lambat * Kembali sgt lambat

Hasil pemeriksaan Tanpa dehidrasi D. Ringan/sedang Dehidrasi berat

1 tanda * (+) 1 atau 1 tanda * (+) 1 atau lebih
lebih tanda lain tanda lain

Terapi Rencana terapi A Rencana terapi B Rencana terapi C

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 K Cl HCO3
Cholera diarrhea 101 27 92 32
Non-cholera diarrhea 56 25 55 14
ORS WHO 90 20 80 30
Ringer Lactate 130 4 109 28
NaCl 0,9% 154 0 154 0
DG ana 61 18 52 27
NaCl 0,45% 77 0 77 0
Liquid Na+ K+ HCO3 Carbohy (g/L) mOsm/BW

Cola 2 0.1 13 50-150 gluc, fruc 550

Ginger 3 1 50-150 gluc, fruc

ale

Apple 3 20 100-150 gluc, fruc

Juice
Chicken 250 5 0
Broth
Tea 0 0 0

Gatora 20 3 45 gluc, other sug

de
 PLAN TREATMENT C
Severe dehydration, IVFD

Age Ist treatment 2nd treatment

30 ml/BW in 70 ml/BW in
Infant < 12 months 1 hour 5 hour
Child > 12 months - 1 hours 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 K Cl HCO3
Cholera diarrhea 101 27 92 32
Non-cholera diarrhea 56 25 55 14
ORS WHO 90 20 80 30
Ringer Lactate 130 4 109 28
NaCl 0,9% 154 0 154 0
DG ana 61 18 52 27
NaCl 0,45% 77 0 77 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 dura-
tion of diarrhea would be a va-
luable 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