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D E P A R T M E N T O F C H I L D H E A L T H

U N I V E R S I T A S P AD J A D J A R A N

H A S A N S A D I K I N H O S P I T A L B A N D U N G

2 0 1 6

DIARRHEA

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Diarrheal diseases account for 1 in 9 child

deaths worldwide, making diarrhea the

second leading cause of death among

children under the age of 5.

Despite these sobering statistics, strides

made over the last 20 years have shownthat, in addition to rotavirus vaccination

and breastfeeding, diarrhea prevention

focused on safe water and improved

hygiene and sanitation is not only possible

oday, only !9 per cent of children withdiarrhoea in developing countries receive

the recommended treatment, and limited

trend data suggest that there has been

little progress since 2000

Diarrhea kills 2,195 children every daymore than AIDS, malaria, and measlescombined

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DEFINITION OF DIARRHEA

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A

T

H

W

A

Y

S

T

O

D

I

A

R

R

H

E

A

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CLASSIFICATION OF DIARRHEA

Diarrhea Dra!i"# Me$ha#i%&

1' A$!e (iarrhea ) * 1+ (a,% - 1' Se$re!"r, (iarrhea

2' Per%i%!e#! (iarrhea ) . 1+ (a,% - 2' I#/a%i/e (iarrhea

D,%e#!eri"r& N"# D,%e#!eri"r&

' O%&"!i$ (iarrhea

Diarrhea 3i!h %e/ere &a4#!ri!i"# )&ara%&% "r 53a%hi"r5"r-

!he &ai# (a#7er% are %e/ere %,%!e&i$ i#e$!i"#8 (eh,(ra!i"#8 hear!ai4re a#( /i!a&i# a#( &i#era4 (ei$ie#$,'

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ETIOLOG9

INFECARBOH9DRATE MALABSORPTIONALERGFOOD POISONING

Sumber: Burkhart DM.1999.2 Arvola.1999.9 Ladinsky M. 2000.10

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S flexneri

S. dysenteriae Camilobacter

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! coli

Salmonella

Am"ba

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SECRETOR9 DIARRHEA

"ccur due to active en#yme adenil

cyclase, which would convert

adenosine triphosphate $%&'cyclic

adenosinemonophosphate $c%(&'.

%ccumulation of intracellular c%(&

causes active secretion of water,

chloride ion, sodium, potassium, and

bicarbonate into the intestinal lumen.

%denil cyclase is activated by a to)inproduced by microorganisms*

+ibrio cholerae, nteroto)igenic

schericia colli $-', higella,

-lostridium, almonella, and

-ampylobacter

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SECRETOR9 DIARRHEA

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INVASIVE DIARRHEA

he e)istence of the invasion of microorganisms

into the intestinal mucosadamage to the

intestinal mucosa. /nvasive diarrhea caused by

viruses, bacteria, or parasites.

here invasive diarrhea in 2 forms, namely*

2.1

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INVASIVE DIARRHEA

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OSMOTIC DIARRHEA

-aused by high osmotic pressure inside

intestinal lumen draw fluid from the intracellular into the

intestinal lumencause watery diarrhea.

"smotic diarrhea is most often caused by carbohydrate

malabsorption.actose is fermented by the en#yme lactase would

absorbed in the small intestine.

/n case this disakaridase en#yme deficiency, the

accumulation of lactose in the intestinal lumen will causethe high osmotic pressure, causing diarrhea.

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DEPARTMENT OF HEALTH IMPLEMENTED : PILLARS OF THE MANAGEMENT OF DIARRHEA

Reh,(ra!i"# %i#7 !he #e3 ORS

Sumber: Subagyo B. 2010.12dan Basis !!!

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ASSESSMENT OF THE CHILD ;ITH DIARRHEA

% child with diarrhea should be assessed for

dehydration

bloody diarrhea, persistent diarrhea

malnutrition and serious nonintestinal infections

so that an appropriate treatment plan can beimplemented.

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HISTOR9

< A%5 !he &"!her "r "!her $are!a5er a="!

duration of diarrheapresence of blood in the stoolnumber of watery stools per day

number of episodes of vomiting swollen diaper rashpresence of fever, cough, or other important

problems $e3.convulsions, recent measles'preillness feeding practicestype and amount of fluids $including breast milk' and

food taken during the illnessast mi)iy, weight before..drugs or other remedies takenimmuni#ation history.

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PH9SICAL E>AMINATION

4irst, check for signs and symptoms of dehydration.

< Look "r !he%e %i7#%

eneral condition* is the child alert restless or irritable

lethargic or unconscious6%re the eyes normal or sunken6

7hen water or "8 solution is offered to drink, is it

taken normally or refused, taken eagerly, or is the child

unable to drink owing to lethargy or coma6

< Feel !he $hi4( !" a%%e%%

kin turgor. 7hen the skin over the abdomen is

pinched and released, does it flatten immediately,

slowly, or

very slowly $more than 2 seconds'6

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PH9SICAL E>AMINATION

hen, check for signs of other important problems.

< L""5 "r !he%e %i7#%

Does the childs stool contain red blood6

/s the child malnourished6 8emove all upper body clothing to observe the shoulders,

arms, buttocks and thighs, for evidence of marked muscle wasting $marasmus'. ookalso for oedema of the feet if this is present with muscle wasting, the child is severely

malnourished. /f possible, assess the childs weightforage, using a

growth chart , or weightforlength. %lternatively, measure the midarm circumference

/s the child coughing6 /f so, count the respiratory rate to determine whether breathing

is abnormally rapid and look for chest indrawing.

< Ta5e !he $hi4(?% !e&@era!re

4ever may be caused by severe dehydration, or by a nonintestinal infection such as

malaria or pneumonia.

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PH9SICAL E>AMINATION DEHIDRATION

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DEH9DRATIONTHE DEGREE OF DEH9DRATION IS GRADED ACCORDING TO SIGNS ANDS9MPTOMS THAT REFLECT THE AMOUNT OF FLUID LOST

I# ear4, %!a7e% A% (eh,(ra!i"# i#$rea%e% I# %e/ere (eh,(ra!i"#

there are no signsor symptoms.

:

signs and symptoms develop./nitially these include*-hirst-restless or irritable behaviour-decreased skin turgor-sunken eyes-and sunken fontanelle

$in infants'.

these effects become morepronounced and the patientmay develop evidence ofhypovolaemic shockincluding*-Diminished consciousness-lack of urine output-cool moist e)tremities-a rapid and feeble pulse $the radial pulse may be undetectable'

-low or undetectable blood pressure-peripheral cyanosis.Death follows soon ifrehydration is not started3uickly.

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ASSESSMENT OF DIARRHEA PATIENTSFOR DEH9DRATION

EVALUATION A B C

CONDITION ;e448 a4er! Re%!4e%%8 irri!a=4e Le!har7i$ "r #$"#%$i"%

E9ES N"r&a4 S#5e# S#5e#

TEAR P"%i!i/e Ne7a!i/e Ne7a!i/e

ORAL MUCOSAL AND

TONGUE

M"i%! Dr, Ver, (r,

THIRST Dri#5% #"r&a44,8 #"! !hir%!, Thir%!,8 (ri#5% ea7er4, Dri#5% @""r4,8 "r #"! a=4e !"

(ri#5

SKIN PINCH G"e% =a$5 i$54, G"e% =a$5 %4"34, G"e% =a$5 /er, %4"34,

E>AMINATION RESULTS NO DEH9DRATION SOME DEH9DRATIONI 1 3i!h 1 "r &"re %i7#%

i# B

SEVERE DEH9DRATIONI 1 3i!h 1 "r &"re %i7#%

i# C

TREATMENT PLAN A PLAN B PLAN C

FLUID DEFICIT * : " ="(, 3! "r * :0

&457 ="(, 3!

:10 " ="(, 3! "r :0100

&457 " ="(, 3!

10 " ="(, 3! "r 100

&457 " ="(, 3!

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MANAGEMENT OF ACUTE DIARRHEA);ITHOUT BLOOD-

The "=e$!i/e% " !rea!&e#! are !"

&revent dehydration

reat dehydration when present &revent malnutrition

8educe duration and severity of diarrhea and occurence of

future episodes by giving supplemental #inc

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TREATMENT PLAN A

H"&e !hera@, !" @re/e#! (eh,(ra!i"# a#( &a4#!ri!i"#-hildren with no signs of dehydration need e)tra fluid and salt to

replace their losses of water and electolytes due to diarrhea.

F4i(% !" =e 7i/e#; "8; alted drinks eg. salted rice water or salted yoghurt drink

; +egetable or chicken soup with salt

;

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TREATMENT PLAN A

H"3 &$h !" 7i/e

; ive as much fluid as the child wants until diarrhea stops; -hildren ? 2 years of age * 50100 ml of fluid

; -hildren 2 years 10 years * 100200 ml

; "lder children and adults * %s much as they want;ha! ee(% !" 7i/e

he infants usual diet should be continued during diarrhea

and increased afterwards. @reastfeeding should always be

continued.I#$ %@@4e&e#!

$1020 mg' every day for 10 to 1A days should be given.

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C"#!i#e !" ee( !he $hi4(8 !" @re/e#! &a4#!ri!i"#/n general, foods suitable for a child with diarrhea are the same as

those re3uired by healthy children.

Ta5e !he $hi4( !" a hea4!h 3"r5er i !here are %i7#% "(eh,(ra!i"# "r "!her @r"=4e&%

The &"!her %h"4( !a5e her $hi4( !" a hea4!h 3"r5er i !he

$hi4( ; starts to pass many watery stools

; has repeated vomiting

; becomes very thirsty

; is eating or drinking poorly ; develops a fever

; has blood in the stool or

; the child does not get better in three days.

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TREATMENT PLAN B

A7e * + &!h% +11 &!h% 122&!h%

2+ ,ear% :1: ,ear% 1: ,ear%"r "4(er

;ei7h! * : 57 :' 57 10' 57 111:' 57 162' 57 0 57 "r

&"re

&4 200+00 +00600 60000 001200 12002200 2200+000

B%ge should be used only if weight is not known.

Ora4 reh,(ra!i"# !hera@, "r $hi4(re# 3i!h %"&e(eh,(ra!i"#"8 C inc supplementation

A&"#! " ORS !" =e 7i/e# i# 1%! + h"r%

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Age < 1 years : 300ml

Age 1-5 years : 600

ml Age > 5 years :

1200 ml

Adult : 2400

Ora4 reh,(ra!i"# !hera@, "r$hi4(re# 3i!h %"&e (eh,(ra!i"#

Jumlah

oralit :75

ml/kgdalam 3

!am"ertama

S"mber# $%&.2''5.(

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TREATMENT PLAN B

%ppro)imate amount of "8 re3uired $in ml' can also becalculated by multiplying the patients weight in kg by E5 /f

more "8 is re3uired, give more.

)cept for breast milk, food should not be given during the

initial A hour rehydration period.

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TREATMENT PLAN B

%fter A hours, reassess the child and decide what treatment

to be given ne)t as per rade of dehydration.

-hildren who continue to have some dehydration even afterA hours should receive "8 by nasogastric tube or 8

intravenously $E5 mlFkg in A hours'.

/f abdominal distension then oral rehydration should be

withheld and only /+ rehydration should be given.

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TREATMENT PLAN C

A7e Fir%! 7i/e 0 &457 # The# 7i/e 0 &457 i#/nfants 1 hour B 5 hours

"lder children !0 min B 2G hours

F"r @a!ie#!% 3i!h %e/ere (eh,(ra!i"#

&referred treatment is rapid intravenous rehydration. ive 100 mlFkg 8 or

normal saline solution as follows*

B 8epeat once if pulses are weak or not detectable.

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TREATMENT PLAN C

8eassess patient every 12 hours.

/f hydration is not improving, give the /+ drip more

rapidly.

%fter completion of /+ fluids, reassess the patient andchoose the appropriate treatment &lan $%, @ or -'.

/f /+ therapy is not available, then "8 by nasogastric

tube or orally at 20 mlFkgFhour for H hours $total of

120Fkg' should be given./f abdomen becomes swollen or the child vomits

repeatedly, then "8 should be given more slowly.

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PREVENTING DIARRHEA8 SAVING LIVES

R"!i#e /a$$i#a!i"#

&rovide rotavirus vaccine.

I&@r"/e( h,7ie#e

7ash hands when appropriate.

Sae 3a!era(ea!e %a#i!a!i"#

reat water before use anddispose of waste safely.

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