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REFERAT

DIARRHEA IN CHILDREN
ANDHIKA HADI WIRAWAN 1102010020
Faculty of Medicine Yarsi
Pediatric Department

Rumah Sakit Bhayangkara tk.I R.S. Sukanto-Jakarta

Periode: 16 March 2015 23 May 2015

INTRODUCTION
DIARRHEA
The diarrhea word came from the Diarola
from Yunaani which means flowing through.
Indonesia :
About 30% bed in hospital filled by baby and
chlidren with diarrhea
In primary healthcare, diarrhea on the second
place in top 10 disease with most population

Generally, diarrhea divided into 3:


1. Based on etiology
2. Based on mechanism (Absorbtion and
Secretion)
3. Based on duration
1.
2.
3.

Acute (< 14 days)


Chronic (>14 days,etiology : non-infection)
Persistent (>14 days, etiology : infection)

ACUTE DIARRHEA

Definition

Decrease in the consistency of stools (loose or


liquid) and/or an increase in the frequency of
evacuations (typically >3 times in 24 hours), with
or without fever or vomiting;. Acute diarrhea
typically lasts <7 days and not >14 days.
In baby who still breastfeeding, with defecation
more than 3-4 times per day, is not called
diarrhea, but still physiologic as long as babys
weight still increasing.

EPIDEMIOLOGY
Leading Cause:
Viral

: Rotavirus
Bacteria : Campylobacter and Salmonella (depending
which country)
Indonesia :
Leading cause of death in chlidren < 5 years old
Based on Risdeskas 2007 :
Number 1 leading cause of death in baby (42 %, more than
pneumonia : 24%)
Number 1 leading cause of death in 1-4 years old (25,2%,
more than pneumonia : 15,5%)

TRANSMISSION AND RISK FACTOR


1. Age
2. Asimptomatik Infection
3. Seasonal
4. Epidemic and Pandemic

ETIOLOGY
Baktery :
Aeromonas
Bacillus cereus
Campylobacter jejuni
Clostiridium perfringens
Clostiridium defficile
Escherichia coli
Plesiomonas shigeloides
Salmonella
Shigella
Staphylococcus aureus
Vibrio cholera
Vibrio parahaemolyticus
Yersinia enterocolitica

Virus :
Astovirus
Calcivirus (Norovirus, Sapovirus)
Enteric adenovirus
Coronavirus
Rotavirus
Norwalk virus
Herpes simplex virus*
Cytomegalovirus*

Parasite :
Balantidium coli
Blastocystis homonis
Cryptosporidium parvum
Entamoeba histolytica
Giardia lamblia
Isospora belli
Strongyloides stercoralis
Trichuris trichuria

MECHANISM

Osmotic diarrhea
Secretoric diarrhea
General malabsorbtion
Peristaltic disorder
Immunology related

OSMOTIC DIARRHEA

The material which cannot be absorbed , causing


intraluminal material in the proximal part of
small intestine become hipertonis and causes
hiperosmolarity .
The difference between osmotic pressure from the
lumen of the intestines and blood and in a
segment of the intestines. Then on the jejunum
that is permeable , water will flow toward the
lumen of jejunum so there will a lot of water
accumulate in the intestineslumen

PERISTALTIC DISORDER

Motility rarely are the main cause of


malabsorption, but change in the motility have
an effect to absorption.Either an increase or a
decrease in motility, both can cause diarrhea.
The decline in motility can lead to overgrowth
bacteria which cause diarrhea.

GENERAL MALABSORBTION
Atrophy villi.
Certain
microorganisms
causes
nutrient
malabsorbtion by changing pyhysiology of brush
border without change in anatomy
The
complete carbohydrate maldigestion, and
trigliserid caused by insufficient pancreas ecsocrin
that causes significant malabsorbtion and osmotic
diarrhea

IMMUNOLOGY RELATED
Reaction to an allergen immunity which resulted
in the release of various cytokines that can lead
to tissue damage the intestinal mucosa
Damage can be in the form of atrophy of
intestines villi thus causing malabsorption

SECRETORIC DIARRHEA

Hiperplasia kripta
The theoretical existence of hyperplasia due to any
disease, kripta can cause intestinal secretion and
diarrhea. This disease generally caused villus
atrophy.

Luminal secretagogues
2 ingredients :
1.Enterotoxin of bacteria
2.Chemicals (Laxative)

ENTEROTOXIN

Toxin works by increasing the concentration of


cGMP or cAMP, intrasel Ca that would activate
protein kinase. Activation of protein kinase
membrane protein phosphorylation will cause
resulting in changes in ion channels, will cause
Cl-in kripta out.
On the other hand occurs increase of sodium
pump and sodium goes into the lumen of the
intestine along with Cl-.

CHEMICALS (LAXATIVE)

Laxative ingredient can cause varying effects on


the activity of the NaK-ATPase. Some of them
trigger elevation levels of intracellular cAMP,
improving intestinal permeability and partly
cause damage mucous cell.
Some drugs causes intestinal secretion.
Malabsorption diseases such as resection of
ileum and Crohn's disease can cause
abnormalities like secretions cause an increase in
the concentration of bile salts, fats.

CHRONIC AND PERSISTENT


DIARRHEA
Based on UKK Gastroenterologi Hepatologi
IDAI, there are 2 type of diarrhea ( >14 days):
1. Persistent (etiology : infection)
2. Chronic (etiology : non-infection)

DIAGNOSIS
Anamnesis
Duration, frequency, volume, consistency, colour,
smell, mucous? Blood?
+ vomitting : volume dan frequency.
Diuresis: normal, decrease, in last 6-8 hours.
Food and drink consumption during diarrhea
Sufferring other disease?(cough,influenza, otitis,
measles)
Medicine given
Immunization history

Maurice king (1974) :


0-2 = MILD 3-6 = MODERATE 7-12 = SEVERE
Body part

Point for symptomps


0

Healthy

Restless,

delirious, coma,

Condition

crying, apatis,

shcok

Skin

sleepy
Slightly

Extremely decreased

examined
General

Normal

decreased

elasticity
Eyes

Anterior

Normal

Slightly

Extremely sunken

Normal

sunken
Slightly

Slightly sunken

sunken

fontsnelle
Mouth

Normal

Dry

Dry&Cyanosis

Radial

Strong< 120

Moderate(120

Weak> 140

CDS for children (total score from 0 to 8)


A score of 0 represents no dehydration; a score of 1 to 4, some dehydration;
and a score of 5 to 8 moderate/severe dehydration.
0 1 2
Characteristics
General
Appearance

Normal

1
Thirsty, restless
or lethargic but
irritable when

2
Drowsy, limp, cold or sweaty
comatose

touched

Extremely sunken
Eye

Mucous Membranes
(Tongue)

Normal

Slightly sunken

Moist

Sticky

LABORATORY
Blood: complete blood, serum elektrolit, AGD,
glucose, culture and antibiotic sensitivity test
Urine: complete urine, culture and antibiotic
sensitivity test
Feses: macroscopic dan microscopic

TREATMENT

1.
2.
3.
4.
5.

DEPKES with IDAI, based on WHO : Strategy in


treatment of diarrhea is not only rehydration, but
also improving condition of bowel and stop
diarrhea. 5 main points for diarrhea treatment
(for children <5 years old in home or hospital):
Rehydration with new oralit formula
Give Zinc at least 10 days
Continue breasfeeding and food
Selective antibiotic
Give advice to parent

1.ORALIT
Give mother 2 sachet oralit
Mix 1 sachet oralit with 1 liter boiled water, for
24 hours stock.
Give oralit everytime children defecate:
Children <2 years old : give 50-100 ml after
defecate
Children 2 years old
: give 100-200 ml after
defecate
If in 24 hours still there is oralit left, dispose

New oralit (low osmolarity)

Mmol/liter

Natrium

75

Klorida

65

Glucose, anhydrous

75

Kalium

20

Sitrat

10

Total osmolarity

245

2.ZINC
Zinc dosage for children
<6 months
: 10mg ( tablet) per day
>6 months
: 20 mg (1 tablet) per day
3. CONTINUE BREASTFEEDING AND FOOD
Based on childrens age with same menu during
healthy, to prevent loss of body weight and change
loss of nutrition

4. SELECTIVE ANTIBIOTIC
Dont Give antibiotic unless there is an indication,
for example bloody diarrhea or cholera.
Selective antibiotic :
Cholera : Tetracycline 12.5 mg/ kg/ 24 hours or
Erytromycin 12.5 mg/kg. Four times per day,
given for three days
Shigella Dysentri : Ciprofloxacin 25mg/ kg /24
hours or Ceftriaxone 25mg/kg. Two times per
day.given for three days
Amoeba : Metronidazole 15 mg/ kg/ 24 jam, Three
times per day.given for five days

5. GIVE ADVICE TO PARENT OR NANNY:

Back to hospital immediateiy if : fever, bloody


stool, less eat and drink, very thirsty, diarrhea
more frequent, there is no sign of improvement in
3 days

MILD TO MODERATE DEHYDRATION


Oral Rehydration Therapy
Give oralit : first 3 hours 75 ml/kg
Fluid loss :
< 1 years old: 300 ml,
1-5 years old:600 ml,
5 tahun : 1200 ml
Adult :2400 ml
If oralit cant be give oral, use nasgogastric : 20
ml/kg/jam. After 3 hours, reevaluate.
Improvement : dehydration handled continue therapy
in home using oralit
Worsening : severe dehydration parenteral rehydration

SEVERE DEHYDRATION

PARENTERAL REHYDRATION THERAPY


Hospitalize
Best therapy is using parenteral, if still can drink
give oralit until infus is ready
After infus attached, keep giving oralit during
parenteral rehydration (+ 5 ml/kg/hours) if can drink
well 3-4 hours (baby). 1-2 hours (bigger child)
Use Ringer Laktat with dosage 100 ml/kg.
< 1 years old : First 1 hour : 30 cc/kg
Next 5 hours : 70 cc/kg
>1 years old : First hour : 30 cc/kg
Next 2 hours : 70 cc/kg.

Reevaluate every hour. If there is no sign of


improvement, I.V drops can be accelerated.
After 6 hours, (baby) :reevaluate
After 3 hours, (bigger children) : reevaluate

HOLIDAY-SEGAR METHOD TO CALCULATE MAINTENANCE FLUID

Childs

Baseline daily Fluid Requirement

Weight
1-10 kg

100 ml/kg

10-20 kg

1000 ml + 50 ml/kg for each kg >10 kg

>20 kg

1500 ml + 20 ml/kg for each kg > 20 kg

COMPLICATION
SEIZURE
ELECTROLIT IMBALANCE

HIPERNATREMI
HIPONATREMI
HIPERKALEMI
HIPOKALEMI

PREVENTION

AGENT
Breastfeeding

properly
Make a habit of washing hand with soap after
defecate and before eat
Use clean toilet for all family member

HOST
Breastfeeding until 2 years
Nutrition
Immunisation
PROBIOTIC AND PREBIOTIC