s diare pada anak diarrhea in children badriul hegar pediatric gastroenterology, department of child...
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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