PENGERTIAN DIARRHEA Diarrhoea is the passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual. WHO TERMINOLOGY Acute diarrhea lasts less than 7 - 14 days Chronic diarrhe: diarrhe that continues for more than four weeks. Am Fam Physician. 2005 May 1;71(9):1797. Diare berlanjut Persistent diarrhea Osmotic Diarrhea : electrolyte absorption is normal but water is held in the bowel lumen by some other osmotically active substance. AFP 2005 Secretory diarrhea : water is held within the bowel lumen by incompletely absorbed electrolytes. AFP 2005
DEFINITIONS Increase in daily stool weight above 200gm Increase in frequency, fluidity or amount Differentiate from incontinence and IBS Chronic lasts more than 2 - 3 weeks DEFINITIONS Diarrhea implies an increase in stool volume and diminished stool consistency. In children 2 y/o, diarrhea is defined as daily stools with a volume greater than 10 mL/kg. 2 y/o , diarrhea is defined as daily stools with a weight greater than 200 g. In practice, this typically means loose-to-watery stools passed 4 or more times per day. Individual stool patterns widely vary; for example, breastfed children may normally have 5-6 stools per day.
DISEASE BURDEN
DISEASE BURDEN Diarrhea still major child killer 2 million children die of diarrhea each year EPIDEMIOLOGY
WHO ORS Natrium 90 mmol/L; Cl 80 mmol/L, Glukose 111 mmol/L; Kalium 20 mmol/L; Cl 65 mmol/L ; citrate 10 mol/L and osmolarity of 311 /L. New WHO ORS Natrium 75 mmol/L; Cl 65 mmol/L, Glukose anhidrous 75 mmol/L, Kalium 20 mmol/L, Sitrat 10 mmol/L. Total osmolarity 245 mmol/L REPLACEMENT OF ONGOING FLUID LOSSES
1 mL of ORS should be administered for each gram of diarrheal stool. 10 mL/kg for each watery or loose stool passed, and 2 mL/kg of fluid should be administered for each episode of emesis. Excess fluid losses during maintenance therapy can be replaced with either low-sodium ORS (containing 40-60 mEq/L of sodium) or with ORS containing 75-90 mEq/L of sodium. When the latter type of fluid is used, an additional source of low-sodium fluid is recommended (e.g., breast milk, formula, or water). Recommendations for maintenance of dietary therapy depend on the age and dietary history of the patient.
ORS IN VOMITING In the child with vomiting, ORS should proceed with small, frequent volumes at first (e.g., 5 mL every minute). Administration via a spoon or syringe -- with close supervision -- helps guarantee a gradual progression in the amount taken. Often, simultaneous correction of dehydration lessens the frequency of vomiting.
ORS- LIMITATION
Bloody diarrhea Severe dehydration Intractable vomiting High stool output Monosaccharide malabsorption ORS Treatment with reduced osmolarity ORS solution was associated with a 33% reduction in the need for unscheduled iv therapy and had no apparent effect on stool output and illness
duration when compared with treatment with the standard WHO ORS
solution. Children with acute diarrhea, therefore, may benefit
from a reduced osmolarity ORS solution. The results of trials
that examine the efficacy and safety of reduced osmolarity ORS
solution in adult patients with cholera have to be taken into
consideration before consensus on composition of oral rehydration
formulation can be reached. PEDIATRICS Vol. 107 No. 4 April 2001, pp. 613- 618
COMPOSITION OF COMMERCIAL ORS 7 PRINCIPLES OF APPROPRIATE TREATMENT FOR CHILDREN WITH DIARRHEA AND DEHYDRATION FLUID IVF
DIET What is recommended ? - Continue breast feeding - Continue normal diet - Milk formula When to start feeding? AAP : starting an age-appropriate diet as soon as the patient is rehydrated. Pediatrics 1996;97:424-35. How frequent ? Accordingly DIET AAP : starting an age-appropriate diet as soon as the patient is rehydrated. Pediatrics 1996;97:424-35. DIETARY THERAPY- RECOMMENDATION
Continue BF For bottle-fed infants, full-strength, lactose-free, or lactose-reduced formulas should be administered immediately re unavailable, full- strength, lactose-containing formulas should be used under supervision to assure that carbohydrate malabsorption does not complicate the clinical course. Alternatively, diluted, lactose-containing formulas can be used for the initial infant feedings; however, the concentration of formula should be increased rapidly. Patients with true lactose intolerance will have exacerbation of diarrhea when a lactose-containing formula is introduced. The presence of low pH (less than 6.0) or reducing substances (greater than 0.5%) in the stool in the absence of clinical symptoms is not diagnostic of lactose intolerance; this diagnosis is indicated by more severe diarrhea upon introduction of lactose- containing foods. If lactose intolerance occurs, appropriate therapy includes temporary reduction or removal of lactose from the diet. Older children receiving semisolid or solid foods should continue to receive their usual diet during diarrhea. Recommended foods include starches, cereals, yogurt, fruits, and vegetables. Foods high in simple sugars and fats should be avoided.
MILK FORMULA Lactose free milk formula (AL 110, NL33, Bebelac FL, Olac) Low lactose milk formula ( SGM LLM) Normal formula MILK FORMULA soy-based, lactose-free
formulas can be safely used during the acute phase of diarrheal
illness in infants and that their use shortens the duration
of illness and decreases stool output in comparison with standard
therapy. AAP 1985 PROBIOTICS Probiotics inhibit growth of harmful bacteria and normalize
intestinal flora. Guarino A, et al. Curr Opin Gastroentrol. 2008; 25:1823. The most recent Cochrane review concluded
that probiotics appeared to be a moderately effective adjunctive
therapy in reducing the duration of infectious diarrhea. Allen SH, et al. Cochrane Database Syst Rev. 2009;1. Decrease duration of diarrhea and hospital stay (60.1 hours vs 86.3 hours, P=.003; 2.9 days vs 4.2 days,
P=.009) compare to placebo Chen CC, Kong MS, Lai MW, et al. Probiotics have clinical,
microbiologic, and immunologic efficacy in acute infectious
diarrhea. Pediatr Infect Dis J. 2010;29(2):135138; PROBIOTICS Probiotics exert their beneficial effects through various mechanisms, including lowering intestinal pH, decreasing colonization and invasion by pathogenic organisms, and modifying the host immune response. American Journal of Health-System Pharmacy. 2010;67(6):449-458 PROBIOTICS ESGPID (2008) recommended probiotics as an effective adjunct in the management
of diarrhea. Guarino A, et al. J Pediatr Gastroenterol Nutr. 2008;46:619621. Not yet approved by FDA Lactobacillus
is safe and effective as a treatment for children with acute
infectious diarrhea. AAP 2002 .
THE ROLE OF ZINC zinc supplementation results in clinically important reductions in the frequency, duration and severity of diarrhea morbidity . NEJM 1995; 333:839-844 PEDIATRICS 2007
AJCN 2000 International Journal of Epidemiology 2010
ZINC For infants and young children with acute diarrhea,
zinc supplementation results in clinically important reductions
in the duration and severity of diarrhea. NEJM 1995; 333:839-844 AJCN 2000 International Journal of Epidemiology 2010 39(Supplement 1):i63-i69 ANTIBIOTIC Indicated only in - Acute bloody diarrhea with gross stool - Cholera - shigella positive culture - Associated systemic culture - Severe malnutrition mmmmm ANTIBIOTICS- INDICATION Dysentery High fever watery diarrhea lasts for greater than 5 days (+) stool cultures, microscopy, or epidemic setting indicate an agent for which specific treatment is required. MMWR October 16, 1992 / 41(RR-16);001
ANTIBIOTIC OF CHOICE Rotavirus no anti viral treatment E coli sulfametoxazole-trimetoprim Salmonella thyposa ciprofloxacin, cephalosporin Shigella shigae Ampicillin , SMZ-TMP, Ceftriaxone Amoebic dysentri Metronidazole Campylobacter erythromycin, azithromycin, Yersinia First-line drugs include aminoglycosides and trimethoprim-sulfamethoxazole.
ANTIBIOTICS - CONTRAINDICATION watery diarrhea and vomiting in a child less than 2 years of age most likely represent viral gastroenteritis and therefore do not require antimicrobial therapy. MMWR October 16, 1992 / 41(RR-16);001
ANTIBIOTICS Not routinely use self-limited nature of most cases, the cost of antibiotics, potential of antibiotic resistance Highly effective for Shigella, ETEC, and V. cholerae infections, and metronidazole is indicated for C. difficile colitis. Gastroenterol Clin North Am. 2001 Sep;30(3):817-36. ANTI VOMITUS Anti-emetic medications ondansetron, granisetron, tropisetron, dolasetron, ramosetron, promethazine, dimenhydrinate, metoclopramide, domperidone, droperidol, prochlorperazine, and trimethobenzamide. Ondansetron shows promise as a first-line anti- emetic, and judicious use of this agent might increase the success of ORT, minimize the need for intravenous therapy and hospitalization, and reduce healthcare costs. Paediatr Drugs. 2007;9(3):175-84. ANTI VOMITUS Cohrane study Review of 4 study Sample size 501 participants Result - one trial reported a higher proportion of patients without vomiting over 24 hours in the ondansetron and metoclopramide groups than placebo. - Oral ondansetron in one trial ensured cessation of emesis for 8/12 (67%) patients within the first 4 hours and 7/12 (58%) patients in the first 24 hr period - In one trial 14% of patients who received oral ondansetron vomited during oral rehydration compared to 35% to the placebo group - In a further trial intravenous rehydration was required in 21.6% (ondansetron group) versus 54.5% (placebo group) P< 0.001. Conclusion : SThe small number of included trials provided some limited evidence favouring the use of ondansetron and metoclopramide over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. Cochrane Database of Systematic Reviews 2009, Issue 2 ANTI MOTYLITIC Loperamide and lomotil usually used in adult Not recommended in children because - Prevent the excretion of infecting organism allowing more contact time in the intestine diarrhea more severe Arcangelo VP et al. Pharmacotherapeutics for advanced practice: a practical approach p.397
VITAMIN A No effect of oral vitamin A supplementation on serum vitamin A levels, duration of diarrhea, or weight gain during an acute diarrheal episode could be demonstrated in our study group of infants between 6 and 12 months of age who had no malnutrition. JPGN 2000 CLINICAL MANAGEMENT IN THE HOSPITAL
Inpatient care is indicated for children if caregivers cannot provide adequate care at home; substantial difficulties exist in administrating ORT, including intractable vomiting, ORS refusal, or inadequate ORS intake; concern exists for other possible illnesses complicating the clinical course; ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes; severe dehydration (>9% of body weight) exists; social or logistical concerns exist that might prevent return evaluation, if necessary, or such factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation. MMWR . November 21, 2003 / 52(RR16);1-16
PERSISTENT DIARRHEA Diare akut dengan atau tanpa disertai darah yg berlangsung lebih dari 14 hari Faktor resiko - Bayi < 4 bln - Tidak mendapat ASI - Malnutrisi berat - Diare akut dengan bakteri infasif - Tatalaksana diare akut yg tidak tepat
Klassifikasi Berdasarkan derajat dehidrasinya - Diare persisten ringan tanpa dehidrasi - Diare persisten berat dengan dehidrasi Tatalaksana - Rawat jalan - Cairan rehidrasi oral Treatment plan A lebih bijaksana bila kadar gulanya lebih rendah - Mikronutrisi dan vitamin
Suplemen multivitamin & mineral Asam folat 100g Zinc 20 mg Vitamin A Besi 20 mg Tembaga 2 mg Magnesium 160 mg Identifikasi infeksi pencernaan dan non pencernaan AB Nutrisi - ASI dilanjutkan - SF : rendah laktosa - Diet sesuai usia - Small and frequent diet
DIARE PERSISTEN BERAT Tatalaksana - Dehidrasi treatment plan B &C - Suplemen mineral dan multivitamin - Antibiotik oral untuk diare yg berdarah - Nutrisi : target kalori 110 kkal/kgBB/hari
Tatalaksana pengelolaan komplikasi - Hipoglikemia - Hiponatremia - Sepsis - Perforasi - Meg akolon toksik toksin Shigella - Kejang - Sindrom hemolitik Uremik trias anemia hemolitik, gagal ginjal akut dan trombositopenia - Malnutrisi Patogenesis - Infeksi berlanjut - Kerusakan mukosa usus - Defisiensi laktosa - Malnutrisi - Antibodi defisiensi - Motilitas usus kurang - Regenerasi sel mukosa usus lambat
MANAGEMENT OF CHRONIC DIARRHEA
MANAGEMENT OF PERSISTENT DIARRHEA
COMPLICATION
PROGNOSIS
PREVENTION Safe water and santitation LEGAL ASPECT