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 ½ - 1 hours 2 ½ - 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 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