DIARRHEA

D E P AR T M E N T O F C H I L D H E A LTH
U N I V E R S I TAS PAD 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 TAL B A N D U N G
2016

 Diarrheal diseases account for 1 in 9 child

Diarrhea kills 2,195 children every day

more than AIDS, malaria, and measles
combined

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
diarrhoea in developing countries receive
the recommended treatment, and limited
trend data suggest that there has been
little progress since 2000

DEFINITION OF DIARRHEA

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CLASSIFICATION OF DIARRHEA

Diarrhea Duration

Mechanism

1. Acute diarrhea ( < 14 days )

1. Secretory diarrhea

2. Persistent diarrhea ( 14 days )

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
CARBOHYDRATE
INFE
FOOD
ALERG
POISONINGMALABSORPTION

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

S flexneri

S. dysenteriae

Campilobacter

E coli

Amuba

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:
2.

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

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

or symptoms.

signs and symptoms develop.

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

CONDITION

Well, alert

Restless, irritable *

Lethargic or unconscious *

EYES

Normal

Sunken

Sunken

TEAR

Positive

Negative

Negative

ORAL MUCOSAL AND

TONGUE

Moist

Dry

Very dry

THIRST

Drinks normally, not thirsty Thirsty, drinks eagerly *

Drinks poorly, or not able to

drink *

SKIN PINCH

Goes back quickly

Goes back very slowly *

EXAMINATION RESULTS
TREATMENT
FLUID DEFICIT

NO DEHYDRATION

Goes back slowly *

SOME DEHYDRATION SEVERE DEHYDRATION

If 1* with 1 or more signs
in B

If 1* with 1 or more signs

in C

PLAN A

PLAN B

PLAN C

< 5% of body wt or < 50

ml/kg body wt

5-10% of body wt or 50-100

ml/kg of body wt

> 10% of body wt or > 100

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

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
mths

2-4 years

5-15 years

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

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

15 years
or older

2200-4000

Oral rehydration therapy for

children with some dehydration:

Age < 1 years : 300

ml
Age 1-5 years : 600
ml
Age > 5 years :
1200 ml
Adult

Sumber: WHO.2005.7

: 2400

Jumlah
oralit :
75
ml/kgBB
dalam 3
jam
pertama

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:

Treat water before use and
dispose of waste safely.

Improved hygiene:
Wash hands when appropriate.

Routine vaccination:
Provide rotavirus vaccine.

THANK YOU