S

DIARE PADA ANAKDIARRHEA IN CHILDREN

BADRIUL HEGARPediatric Gastroenterology, Department of Child Health

University of Indonesia

PROLONGED DIARRHEA(>7 DAYS )

Diarrheal disease of rapid onset +/- accompanying sympt such as nausea, vomiting, fever, or abdominal pain

85%

10%

5%CHRONIC DIARRHEA

(14 DAYS)

ACUTE DIARRHEA

0

1

2

3

4

0-5 6-11 12-23 24-35 36-47 48-59

age (months)

Ep

iso

de

pe

r c

hild

pe

r ye

ar

Episode diarrhea per yearEpisode diarrhea per year

•Hospital admissions (children < 5 years)

– USA : 220.000 patient/year (10% of hospit.)

– RSCM, Jakarta- One Day Care (2001) : 1136 patients

Diarrhea : 65%

•Hospital admissions (children < 5 years)

– USA : 220.000 patient/year (10% of hospit.)

– RSCM, Jakarta- One Day Care (2001) : 1136 patients

Diarrhea : 65%

EPIDEMIOLOGY

• RSCM, Jakarta

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

Etiologyc agents

• Rotavirus (70-80% of infectious cases in developed word)

• Bacteria : Salmonella, ETEC (++), Shigella (+),

Campylobacter, Yersinia enterocolica (Eropa)

• Parasites : Giardia lamblia (++), candida

Fecal analysis (RSCM, Jakarta)

200 children, diarrhea, hospitalization

• gram neg bacteria infection 34.4%• lactose malabsorption 23.1%• candida infection 20%• parasite infection 2%

200 children, diarrhea, hospitalization

• gram neg bacteria infection 34.4%• lactose malabsorption 23.1%• candida infection 20%• parasite infection 2%

SCFA

CLINICAL MANIFESTATIONLactose 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 (-)

• 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%

American Academy of Pediatrics (AAP), 1996

• Three specific issues – Methods of rehydration– Refeeding during and after rehydration– The use of antidiarrheal agent

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

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

Lihat: Kead. Umum

Mata

Air mata

Mulut dan lidah

Rasa haus

Periksa Turgor kulit

Hasil pemeriksaan

Terapi

Baik, sadar

Normal

Ada

Basah

Minum biasa tidak haus

Kembali cepat

Tanpa dehidrasi

Rencana terapi A

* Gelisah, rewel

Cekung

Tidak ada

Kering

* Haus, ingin minum banyak

* Kembali lambat

D. Ringan/sedang

1 tanda * (+) 1 atau lebih tanda lain

Rencana terapi B

* Lesu, lunglai, tak sadar

Sangat cekung & kering

Tidak ada

Sangat kering

* Malas minum atau tidak bisa minum

* Kembali sgt lambat

Dehidrasi berat

1 tanda * (+) 1 atau lebih tanda lain

Rencana terapi C

Penilaian A B C

PLAN TREATMENT A

• No dehydration • vomiting (-) continue age-appr diet• malabsorption (-) no specific diet

• complex carbohydrate, fruit, vegetables• ORS ?

• 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 weightor

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

Continued feeding or early resumption

Umur < 1 tahun 1-5 tahun > 5 tahun dewasa

Total ORS 300 ml 600 ml 1200 ml 2400 ml

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

Na K Cl HCO3

Electrolite composition

Liquid Na+ K+ HCO3 Carbohy (g/L) mOsm/BW

Cola 2 0.1 13 50-150 gluc, fruc 550

Ginger ale

3 1 50-150 gluc, fruc

Apple Juice

3 20 100-150 gluc, fruc

Chicken Broth

250 5 0

Tea 0 0 0

Gatora

de

20 3 45 gluc, other sug

PLAN TREATMENT C

• Severe dehydration, IVFD

Reevaluate every 1-2 jam ORS After 6 hours (infants) or 4 hours (child)

reevaluate plan treatment A,B,C

Age Ist treatment

30 ml/BW in

2nd treatment

70 ml/BW in

Infant < 12 months 1 hour 5 hour

Child > 12 months ½ - 1 hours 2 ½ - 3 hours

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

Na K Cl HCO3

Electrolite composition

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)

• 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

• 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 Parent’s 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