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REFERATDIARRHEA IN CHILDREN

ANDHIKA HADI WIRAWAN 1102010020Faculty of Medicine Yarsi

Pediatric DepartmentRumah 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 etiology2. Based on mechanism (Absorbtion and

Secretion)3. Based on duration

1. Acute (< 14 days)2. Chronic (>14 days,etiology : non-infection)3. Persistent (>14 days, etiology : infection)

ACUTE DIARRHEADefinition 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 baby’s weight still increasing.

EPIDEMIOLOGY Leading Cause:

Viral : Rotavirus Bacteria : Campylobacter and Salmonella

(depending which country)Indonesia :Leading cause of death in chlidren < 5 years oldBased 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 intestines lumen

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

Luminal secretagogues2 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

Body part examined

Point for symptomps0 1 2

General Condition

Healthy Restless, crying, apatis, sleepy

delirious, coma, shcok

Skin elasticity

Normal Slightly decreased

Extremely decreased

Eyes Normal Slightly sunken

Extremely sunken

Anterior fontsnelle

Normal Slightly sunken

Slightly sunken

Mouth Normal Dry Dry&CyanosisRadial

Pulse/mntStrong<

120Moderate(12

0-140)Weak> 140

Maurice king (1974) :0-2 = MILD 3-6 = MODERATE 7-12 = SEVERE

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 0 1 2

General

AppearanceNormal

Thirsty, restless

or lethargic but

irritable when

touched

Drowsy, limp, cold or sweaty

comatose

Eye Normal Slightly sunkenExtremely sunken

Mucous Membranes

(Tongue) Moist Sticky Dry

Tears Tears Decreased tears Absent tears

Gejala

klinik

Rotaviru

s

Shigella Salmonell

a

ETEC EIEC Kolera

Masa tunas 17-72 jam 24-48

jam

6-72 jam 6-72 jam 6-72 jam 48-72

jam

Panas + ++ ++ - ++ -

Mual

muntah

Sering Jarang Jarang + - Sering

Nyeri perut Tenesmus Tenesmu

s kramp

Tenesmus

kolik

- Tenesmu

s kramp

Kramp

Nyeri

kepala

- + + - - -

Lamanya

sakit

5-7 hari > 7 hari 3-7 hari 2-3 hari Variasi 3 hari

Sifat tinja

Volume Sedang Sedikit Sedikit Banyak Sedikit Banyak

Frekuensi 5-10x/hr >10x/hr Sering Sering Sering Terus

meneru

s

Konsistens

i

Cair Lembek Lembek Cair Lembek Cair

Darah - Sering Kadang - + -

Bau Langu + Busuk + Tidak Amis

khas

Warna Kuning

hijau

Merah-

hijau

Kehijauan Tak

berwarna

Merah-

hijau

Seperti

air

cucian

beras

Leukosit - + + - - -

Lain-lain Anorexia Kejang + Sepsis + Meteorismu

s

Infeksi

sistemik

+

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

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):

1. Rehydration with new oralit formula2. Give Zinc at least 10 days3. Continue breasfeeding and food4. Selective antibiotic5. 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 75Klorida 65Glucose, anhydrous 75Kalium 20Sitrat 10Total osmolarity 245

2.ZINCZinc dosage for children <6 months : 10mg (½ tablet) per day >6 months : 20 mg (1 tablet) per day

3. CONTINUE BREASTFEEDING AND FOOD

Based on children’s age with same menu during healthy, to prevent loss of body weight and change loss of nutrition

4. SELECTIVE ANTIBIOTICDont 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/kgFluid 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 oralitWorsening : 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 ½ hour : 30 cc/kg- Next 2 ½ hours : 70 cc/kg.

Reevaluate every hour. If there is no sign of improvement, I.V drops can be accelerated.After 6 hours, (baby) :reevaluateAfter 3 hours, (bigger children) : reevaluate

HOLIDAY-SEGAR METHOD TO CALCULATE MAINTENANCE FLUID

Child’s Weight

Baseline daily Fluid Requirement

1-10 kg 100 ml/kg10-20 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 properlyMake a habit of washing hand with soap

after defecate and before eatUse clean toilet for all family member

HOST Breastfeeding until 2 years Nutrition Immunisation

PROBIOTIC AND PREBIOTIC