DIARRHEA

D E PA R T M E N T O F C H I L D H E A LT H
U N I V E R S I TA S PA D 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 TA L B A N D U N G
2016
 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 shown
that, in addition to rotavirus vaccination
and breastfeeding, diarrhea prevention
focused on safe water and improved
hygiene and sanitation is not only
possible
Today, only 39 per cent of children with
Diarrhea kills 2,195 children every day diarrhoea in developing countries receive
more than AIDS, malaria, and measles the recommended treatment, and limited
combined
trend data suggest that there has been
little progress since 2000
 DEFINITION OF DIARRHEA

Passage of unusually loose or watery stools usually at least three

times in a 24 hour period

However it is the consistency of the stools rather than the number

that is most important.

Frequent passing of formed stools is not diarrhea. Babies fed only

breastmilk often pass loose, "pasty" stools; this also is not diarrhea.

Mothers usually know when their children have diarrhoea and may
provide useful working definitions in local situations
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 CLASSIFICATION OF DIARRHEA

Diarrhea Duration Mechanism

1. Acute diarrhea ( < 14 days )
2. Persistent diarrhea ( 14 days )
1. Secretory diarrhea
2. Invasive diarrhea
- Dysenteriform
- Non Dysenteriform
3. Osmotic diarrhea

Diarrhea with severe malnutrition (marasmus or kwashiorkor):

the main dangers are severe systemic infection, dehydration, heart
failure and vitamin and mineral deficiency.
 ETIOLOGY

INFECTION

CARBOHYDRATE MALABSORPTION

ALERGY

FOOD POISONING

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

S flexneri

S. dysenteriae Campilobacter
 Amuba
E coli

Salmonella
SECRETORY DIARRHEA

Occur due to active enzyme adenil

cyclase, which would convert
adenosine triphosphate (ATP) cyclic
adenosinemonophosphate (cAMP).

Accumulation of intracellular cAMP

causes active secretion of water,
chloride ion, sodium, potassium, and
bicarbonate into the intestinal lumen.

Adenil cyclase is activated by a toxin

produced by microorganisms:
Vibrio cholerae, Enterotoxigenic
Eschericia colli (ETEC), Shigella,
Clostridium, Salmonella, and
Campylobacter
SECRETORY DIARRHEA
 INVASIVE DIARRHEA

The existence of the invasion of microorganisms

into the intestinal mucosa damage to the
intestinal mucosa. Invasive diarrhea caused by
viruses, bacteria, or parasites.
There invasive diarrhea in 2 forms, namely:
Diarrhea non dysentriform form of diarrhea is not
2.
1 bloody, usually caused by rotavirus

Diarrhea dysentriform form of bloody diarrhea is

usually caused by the bacterium Shigella,
2 Salmonella, and EIEC.
INVASIVE DIARRHEA
 OSMOTIC DIARRHEA

Caused by high osmotic pressure inside

intestinal lumen draw fluid from the intracellular into the
intestinal lumen cause watery diarrhea.
Osmotic diarrhea is most often caused by carbohydrate
malabsorption.
Lactose is fermented by the enzyme lactase would
absorbed in the small intestine.
In case this disakaridase enzyme deficiency, the
accumulation of lactose in the intestinal lumen will cause
the high osmotic pressure, causing diarrhea.
DEPARTMENT OF HEALTH IMPLEMENTED 5 PILLARS
OF THE MANAGEMENT OF DIARRHEA:

Rehydration using the new ORS

Zinc given for 10 consecutive days

Breast milk and other foods are

allowed to continue

Selective Antibiotics

Advice or counseling to parents

Sumber: Subagyo B. 2010.12 dan Basics III

 ASSESSMENT OF THE CHILD WITH DIARRHEA

A child with diarrhea should be assessed for

dehydration
bloody diarrhea, persistent diarrhea
malnutrition and serious non-intestinal infections
so that an appropriate treatment plan can be
implemented.
 HISTORY

Ask the mother or other caretaker about:

duration of diarrhea;
presence of blood in the stool;
number of watery stools per day;
number of episodes of vomiting; swollen;
diaper rash
presence of fever, cough, or other important
problems (eq.convulsions, recent measles);
pre-illness feeding practices;
type and amount of fluids (including breast
milk) and food taken during the illness;
Last mixiy, weight before..
drugs or other remedies taken;
immunization history.
 PHYSICAL EXAMINATION

First, check for signs and symptoms of

dehydration.

Look for these signs:

General condition: is the child alert; restless or
irritable; lethargic or unconscious?
Are the eyes normal or sunken?
When water or ORS solution is offered to drink, is
it taken normally or refused, taken eagerly, or is
the child unable to drink owing to lethargy or
coma?

Feel the child to assess:

Skin turgor. When the skin over the abdomen is
pinched and released, does it flatten immediately,
slowly, or
very slowly (more than 2 seconds)?
 PHYSICAL EXAMINATION

Then, check for signs of other important problems.

Look for these signs:

Does the child's stool contain red blood?
Is the child malnourished? Remove all upper body clothing to observe
the shoulders, arms, buttocks and thighs, for evidence of marked
muscle wasting (marasmus). Look also for oedema of the feet; if this is
present with muscle wasting, the child is severely malnourished. If
possible, assess the child's weight-for-age, using a
growth chart , or weight-for-length. Alternatively, measure the mid-arm
circumference
Is the child coughing? If so, count the respiratory rate to determine
whether breathing is abnormally rapid and look for chest indrawing.

Take the child's temperature:

Fever may be caused by severe dehydration, or by a non-intestinal
infection such as malaria or pneumonia.
PHYSICAL EXAMINATION DEHIDRATION
 DEHYDRATION
THE DEGREE OF DEHYDRATION IS GRADED ACCORDING TO SIGNS AND
SYMPTOMS THAT REFLECT THE AMOUNT OF FLUID LOST:
In early stages As dehydration increases
there are no signs signs and symptoms develop.
or symptoms. Initially these include:
- Thirst
- restless or irritable behaviour
- decreased skin turgor
- sunken eyes
- and sunken fontanelle
(in infants).
In severe dehydration
these effects become more
pronounced and the patient
may develop evidence of
hypovolaemic shock
including:
- Diminished consciousness
- lack of urine output
- cool moist extremities
- a rapid and feeble pulse
(the radial pulse may be
undetectable)
- low or undetectable blood
pressure
- peripheral cyanosis.
Death follows soon if
rehydration is not started
quickly.
 ASSESSMENT OF DIARRHEA PATIENTS
FOR DEHYDRATION

EVALUATION A B C

CONDITION Well, alert Restless, irritable * Lethargic or unconscious *

EYES Normal Sunken Sunken

TEAR Positive Negative Negative

ORAL MUCOSAL AND Moist Dry Very dry

TONGUE
THIRST Drinks normally, not thirsty Thirsty, drinks eagerly * Drinks poorly, or not able to
drink *
SKIN PINCH Goes back quickly Goes back slowly * Goes back very slowly *

EXAMINATION RESULTS NO DEHYDRATION SOME DEHYDRATION SEVERE DEHYDRATION

If 1* with 1 or more signs If 1* with 1 or more signs
in B in C
TREATMENT PLAN A PLAN B PLAN C

FLUID DEFICIT < 5% of body wt or < 50 5-10% of body wt or 50-100 > 10% of body wt or > 100
ml/kg body wt ml/kg of body wt ml/kg of body wt
 MANAGEMENT OF ACUTE DIARRHEA
(WITHOUT BLOOD)

The objectives of treatment are to:

Prevent dehydration
Treat dehydration when present
Prevent malnutrition
Reduce duration and severity of diarrhea and occurence of
future episodes by giving supplemental zinc
 Many diarrhea deaths are caused by dehydration.
Dehydration from acute diarrhoea of any aetiology and at any age,
except when it is severe, can be safely and effectively treated by Oral
Rehydration Salts (ORS)

ORS solution is absorbed in the small intestine even during copious

diarrhea, thus replacing the water and electrolytes lost in the faeces.

An improved ORS solution has been developed, called reduced (low)

osmolarity ORS solution, containing 75 mEq/l of sodium and 75
mmol/l of glucose (Old ORS: 90 mEq/L). reduces the incidence of
vomiting, stool volume, and need for supplemental IV fluid therapy

Zinc supplementation is a new addition to the diarrhoea treatment

strategy, decrease the duration and severity of diarrhoea and the
likelihood of future diarrhoea episodes in the 2-3 months following
supplementation, 10mg 6 mth, 20mg > 6 mth
 TREATMENT PLAN A:

Home therapy to prevent dehydration and malnutrition:

Children with no signs of dehydration need extra fluid and salt to
replace their losses of water and electolytes due to diarrhea.

Fluids to be given
ORS
Salted drinks eg. salted rice water or salted yoghurt drink
Vegetable or chicken soup with salt
Home based ORS: 3 gm of table salt and 18 gm of common sugar in
one liter of water.

Plain water should also be given.

Commercial carbonated beverages, fruit juices, sweetened tea, coffee,
medicinal tea should be avoided.
 TREATMENT PLAN A:

How much to give

Give as much fluid as the child wants until diarrhea stops
Children < 2 years of age : 50-100 ml of fluid
Children 2 years - 10 years : 100-200 ml
Older children and adults : As much as they want
What feeds to give?
The infant's usual diet should be continued during diarrhea
and increased afterwards. Breastfeeding should always be
continued.
ZInc supplement
(10-20 mg) every day for 10 to 14 days should be given.
 Continue to feed the child, to prevent malnutrition
In general, foods suitable for a child with diarrhea are the same as
those required by healthy children.

Take the child to a health worker if there are signs of

dehydration or other problems

The mother should take her child to a health worker if the

child:
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.
 TREATMENT PLAN B:

Oral rehydration therapy for children with some

dehydration:
ORS + Zinc supplementation

Amount of ORS to be given in 1st 4 hours

Age* < 4 mths 4-11 mths 12-23 2-4 years 5-15 years 15 years
mths or older
Weight < 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9 kg 30 kg or
more
ml 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

*Age should be used only if weight is not known.

 Oral rehydration therapy for
children with some dehydration:

Age < 1 years : 300 ml Jumlah oralit :

Age 1-5 years : 600 ml 75 ml/kgBB
Age > 5 years : 1200 ml dalam 3 jam
pertama
Adult : 2400 ml

Sumber: WHO.2005.7
 TREATMENT PLAN B:

Approximate amount of ORS required (in ml) can also be

calculated by multiplying the patient's weight in kg by 75 If
more ORS is required, give more.
Except for breast milk, food should not be given during the
initial 4 hour rehydration period.
However children continued on treatment Plan B longer
than 4 hours should be given some food every 3-4 hours as
in Plan A.
Begin to give supplemental zinc, as in Treatment Plan A, as
soon the child is able to eat following the initial four hour
rehydration period.
 TREATMENT PLAN B:

After 4 hours, reassess the child and decide what treatment

to be given next as per Grade of dehydration.
Children who continue to have some dehydration even
after 4 hours should receive ORS by nasogastric tube or
RL intravenously (75 ml/kg in 4 hours).
If abdominal distension then oral rehydration should be
withheld and only IV rehydration should be given.
 TREATMENT PLAN C:

For patients with severe dehydration

Preferred treatment is rapid intravenous rehydration. Give 100 ml/kg RL or

normal saline solution as follows:
Age First give 30 ml/kg n Then give 70 ml/kg in
Infants 1 hour * 5 hours
Older children 30 min * 2 hours
* Repeat once if pulses are weak or not detectable.
 TREATMENT PLAN C:

Reassess patient every 1-2 hours.

If hydration is not improving, give the IV drip more
rapidly.
After completion of IV fluids, reassess the patient and
choose the appropriate treatment Plan (A, B or C).
If IV therapy is not available, then ORS by nasogastric
tube or orally at 20 ml/kg/hour for 6 hours (total of
120/kg) should be given.
If abdomen becomes swollen or the child vomits
repeatedly, then ORS should be given more slowly.
PREVENTING DIARRHEA, SAVING LIVES

Safe water/adequate sanitation: Improved hygiene: Routine vaccination:

Treat water before use and Wash hands when appropriate. Provide rotavirus vaccine.
dispose of waste safely.