1. Pemeriksaan penunjang pada DD nyeri perutAcute Abdominal Pain in ChildrenTABLE 1Causes of Acute Abdominal Pain in ChildrenGastrointestinal causes Genitourinary causes Drugs and toxinsGastroenteritis Urinary tract infection ErythromycinAppendicitis Urinary calculi SalicylatesMesenteric lymphadenitis Dysmenorrhea Lead poisoningConstipation Mittelschmerz VenomsAbdominal trauma Pelvic inflammatory disease Pulmonary causesIntestinal obstruction Threatened abortion PneumoniaPeritonitis Ectopic pregnancy DiaphragmaticFood poisoning Ovarian/testicular torsion PleurisyPeptic ulcer Endometriosis MiscellaneousMeckel’s diverticulum Hematocolpos Infantile colicInflammatory bowel disease Metabolic disorders Functional painLactose intolerance Diabetic ketoacidosis PharyngitisLiver, spleen, and biliary tract disorders Hypoglycemia Angioneurotic edemaHepatitis Porphyria FamilialCholecystitis Acute adrenal insufficiency Mediterranean feverCholelithiasis Hematologic disordersSplenic infarction Sickle cell anemiaRupture of the spleen Henoch-Schönlein purpuraPancreatitis Hemolytic uremic syndromeCopyright © 2003 by the American Academy of Family Physicians.This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Laboratory studies should be tailored to the patient's symptoms and clinical findings. Initial laboratory studies may include a complete blood cell count and urinalysis. A low hemoglobin level suggests blood loss or underlying hematologic abnormalities, such as sickle cell disease. However, a normal hemoglobin level does not exclude an acute massive hemorrhage for which the body has not yet compensated. Leukocytosis, especially in the presence of a shift to the left and toxic granulations in the peripheral smear, indicates an infection. Urinalysis can help identify urinary tract pathology, such as infection or stones. A pregnancy test should be considered in post-menarcheal girls.16

Plain-film abdominal radiographs are most useful when intestinal obstruction or perforation of a viscus in the abdomen is a concern. Chest radiographs may help rule out pneumonia. The most contentious issue in emergency medicine may be the usefulness of ultrasonography and computed tomography (CT) in patients with abdominal pain.17-20 CT likely is more accurate than ultrasonography.18 However, the experience of the operator and interpreter significantly affect the accuracy of both modes.19 In the emergency department, ultra-sonography probably is most useful in diagnosing gynecologic pathology such as ovarian cysts, ovarian torsion, or advanced periappendiceal inflammation.17,20 CT involves radiation exposure and may require the use of contrast agents. CT may be necessary if excessive bowel gas precludes ultrasonographic examination.

These will depend on differential diagnosis but may include the following. Many children need no investigations. urine MCS blood sugar for DKA electrolytes +/- LFTs Lipase (pancreatitis) urine pregnancy test/ quantitative beta hCG Imaging

o AXR if obstruction suspected. Not helpful in diagnosing constipation.o CXR if pneumonia suspectedo Ultrasound

May be requested after discussion with senior staff Is not clinically indicated for testicular torsion.

2. Penatalaksanaan umum nyeri perut ABC Early referral of patients with possible diagnoses requiring surgical management. Fluid resuscitation may be required (initial bolus 20ml/kg normal saline)

Establish and maintain intravenous access in sick children. Measure electrolytes and blood sugar if the patient appears dehydrated Keep patients fasting if surgical cause suspected Provide adequate analgesia – iv morphine may be required or  intranasal fentanyl

as initial analgesia in severe pain (see Analgesia and sedation) Consider a nasogastric tube if bowel obstruction suspected Consider IV antibiotics in surgical causes (discuss with surgeon first) Other investigations and management will be guided by clinical findings

Note: When transferring infants or children with possible surgical conditions, ensure analgesia, venous access and intravenous fluids as third space losses can be large and lead to haemodyanamic collapse.

Analgesia and behavioural strategies should be used in all children prior to painful procedures, with sedative drugs added where necessary. Sedative drugs are not a replacement for adequate analgesia, nor should they replace behavioural strategies (eg. calico dolls/play therapy) for reducing children's anxiety.

Analgesia

Paracetamol

20 mg/kg (max 90 mg/kg/day) orally or PR

Non Steroidal Anti-Inflammatory Drugs

naproxen 5 - 10 mg/kg (max 500 mg) 12 hrly orally or PR ibuprofen 2.5 - 10 mg/kg (max 600 mg) 6-8hrly orally

Opioids

oxycodone 0.1 - 0.2 mg/kg (max 5-10 mg) orally 4-6 hrly pethidine 1mg/kg i.m. or 0.25 - 0.5 mg/kg i.v. morphine 0.1 mg/kg i.m. or 0.05 - 0.1 mg/kg i.v.

Note:

Use i.v. if older child/adolescent with easy intravenous access . Titrate boluses (ie. give 1/2 of dose first to see effect, then repeat at 5 - 10 minute intervals

as required up to maximum total dose). Respiratory depression risk - reduce doses if combined with sedatives. May get delayed

respiratory depression after treating cause of pain. Multi-trauma - do not withhold but give with caution, particularly if hypovolaemic.

Sucrose

Oral sucrose has been shown to reduce pain in infants less than three months of age during minor procedures.Oral sucrose may be given to infants during procedures such as blood collection, IV insertion, eye examination and lumbar puncture.Sucrose may be more effective if given with a dummy as the dummy promotes non-nutritive sucking which contributes to calming.Other strategies which assist in calming infants and can be used as an adjunct to sucrose include feeding (if allowed), cuddling, and wrapping.Other appropriate local or systemic analgesic agents should be administered as required.

Dose:

Maximum 2mL (0.5mL for infants below 1500 grams) administered orally for each procedure.

Two minutes prior to a painful procedure, administer a small amount (around 0.25ml) of sucrose onto the infant's tongue. Offer a dummy if this is part of the infants care.

Continue giving remainder of sucrose slowly during the procedure for a total dose of 2ml, until the procedure is completed.

Stock bottles of 33% sucrose are available from Royal Children's Hospital Pharmacy Department.

Note:

Sucrose is only effective if given orally. There is no effect if given via an oral or nasogastric tube.

The addition of non-nutritive sucking enhances the analgesic effect of sucrose.

Specific uses of Analgesia

IV insertionTopical anaesthetic cream for 30 - 45 mins; distraction eg.calico dolls.Oral sucrose combined with non-nutritive sucking for infants under three months

Lumbar punctureTopical anaesthetic cream for 30 - 45 mins, 1% lignocaine with 25G needle.Oral sucrose combined with non-nutritive sucking for infants under three months

Removal of nasal/pharyngeal foreign bodyTopical phenylephrine (0.5%) & lignocaine spray (Cophenylcaine) or nebulised lignocaine (1.0%) 1ml in 3ml 0.9% NaCl.

EaracheTopical auralgin otic (lie ear up for 10 mins) or 1% Lignocaine 2 drops.

EyeTopical amethocaine 0.5% to examine; patch +/- atropine (to relieve iris spasm)Oral sucrose combined with non-nutritive sucking for infants under three months.

Regional anaesthesia (eg. Bier's block) - see Intravenous Regional Anaesthesia guideline.

Systemic analgesia - see nitrous oxide section below

Sedation - Midazolam

Properties

anxiolytic and anterograde amnestic. onset is usually within minutes

Indications

procedures such as suturing, removal of foreign body from nose etc.

Dose

oral / buccal 0.5 - 1.0 mg/kg.(max 15mg) intranasal 0.6mg/kg (max 10mg) - may have more rapid onset.

Draw up solution (5 mg/ml) in a 1 or 2 ml syringe. May be mixed with small volume of cordial to disguise acid taste.

Cautions

Observe the child in Emergency until fully alert (usually recover by 60 minutes) Midazolam will potentiate the effects of other sedative drugs eg. opiates. Midazolam should not be given to children with pre-existing respiratory insufficiency, or

neuromuscular problems such as myasthenia gravis.

Nitrous Oxide / Oxygen Mix (Entonox, Zeropain)

See Nitrous Oxide Guideline

Ketamine

See  Ketamine Guideline

3. Algoritma pada nyeri perut

Algorithm for evaluating acute abdominal pain in children.Adapted with permission from King BR. Acute abdominal pain. In: Hoekelman RA. Primary pediatric care. 3d ed. St. Louis: Mosby, 1997:188.

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Gizi Buruk Pada Balita 2. Penjaringan Balita Gizi Buruk di Wilayah Kerja Puskesmas3. Pelacakan Balita Gizi Buruk di Wilayah Kerja Puskesmas