CASE PRESENTATION

ACUTE DIARRHEA WITH MILD-MODERATE

DEHYDRATION

Ivan Kurniadi
0906644852

Supervisor:
dr. Pramita Gayatri Dwipoerwantoro, SpA(K)

CHILD AND ADOLESCENT HEALTH MODULE

DEPARTEMENT OF PEDIATRICS
FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA
SEPTEMBER 2014

CHAPTER I
CASE ILLUSTRATION

1. Patient Identity
Name

: Ch. AP

Gender

: Male

Address

: Kp. Teriti RT 01/04, Sepatan Village

Age
Caretaker
Nationality
Alloanamnesis
Date of Admission
Date of Examination

: 9 months
: Mother
: Indonesia
: Mother
: 22 September 2014
: 22 September 2014 8.30 pm

2. Chief Complaint
Diarrhea since 3 days before hospital admission
3. History of Present Illness
The patient came with a chief complaint of diarrhea since 3 days before hospital admission.
The mother said the diarrhea becomes more frequent each day. In the first day, the diarrhea
was 4 times and at the admission day the mother said the frequency was 10 times. She
could not determine the amount of feces in each diarrhea and only described it as 'one
sprout and that's it'. The mother said the stool is yellowish in color, watery, and mucus was
sometimes found in it and it was not foul-smelling. There was no blood in the stool. The
stomach was also complained to be bloating. The mother said after the diarrhea started, the
child is thirsty most of the time and drinks eagerly. The child also becomes more irritable
and restless. The urination was said to be normal. The child vomited in the first day of the
diarrhea but it was only once and did not continue.
Besides the diarrhea, the patient also had fever starting from 1 day before hospital
admission which reached 380C. He went to the clinic and got anti fever drug but the fever
subsided only for a while. There were no epistaxis, gum bleeding, seizure, or rashes.

4. History of Past Illness

Lung infection at the age of 4 months and was hospitalized.
5. History of Family Disease
There were no similar symptoms found in the family members.
6. Socioeconomic History

The child lives with his parents. The mother claimed to wash the milk bottle using brush
and soap and soak it in boiling water afterwards. The family drink bottled mineral water
and said to prepare the food cleanly.
7. History of Pregnancy
The mother had a routine monthly control to the midwife and there were no diseases in the
pregnancy period.
8. History of Delivery
The child was born aterm in the hospital. He was not blue, yellow, or pale and he
immediately cried.
9. History of Nutrition
Breastmilk was only given until the age of 4 months. Currently, he is fed with formula milk
and steamed rice.
10. History of Development
The child has been able to roll over, sit, and is starting to learn how to stand up.
11. History of Immunization
Complete except for measles
12. Physical Examination
22 September 2014
Pediatric Assessment Triangle
Apperance
Tone
: eutonic, active movement
Interactibility
: opens his eyes all the time
Consolability : could be calmed by his mother
Look
: looks actively in every direction
Speech
: cries
Breathing
: No difficulty in breathing
Circulation
: Warm extremities, no cyanosis
Primary Survey
Consciousness
General condition
Vital Signs
Heart rate
Respiratory Rate
Temperature
Anthropometry
Body weight
Body length
Nutritional Status
Weight-for-age
Length-for-age

Compos mentis
Moderately-ill
122x/ minute, regular, adequate filling, equal on all extremities
30x/minute, regular, no involvement of additional muscles
38C (axilla)
8 kg
71 cm
-1 SD
Between 0 and -1 SD
3

Weight-for-height
Head
Eye
Nose
Mouth
Ear
Neck
Lung

Between 0 and -1 SD
Normocephal, sunken fontannel, no petechiae
Sclera not icteric, conjunctiva not anemic, no sunken eyes
No septum deviation, no secrete
Dry mucosa, not hyperemic, no Koplik spots, T1/T1
No deformities, no secrete
No lymph node enlargement
Symmetrical both on static and dynamic condition, no
involvement of additional muscles

Heart
Abdomen
Genitalia
Extremities
Skin

S1-S2 normal, no murmur, no gallop

Bloated, hypertimpanic percussion, bowel sound 6x/minute, no
organomegaly or mass palpated
Erythema natum was found
Warm, CRT <2s, no edema
Good turgor, no petechiae, no rashes

13. Diagnosis
Acute diarrhea with mild-moderate dehydration ec viral infection DD/ bacterial

infection
Fever ec viral infection

14. Management Plan (ER and Ward)

IVFD RL 175 ml/kgBW/day, 14 dpm, observe every 3 hours

Paracetamol drop 0.6 ml
Cefotaxime 350 mg IV
Zinc 1x10 mg
Electrolyte and peripheral blood examination
Stool examination

15. Supporting Examination

Laboratory Results

Examination
22/09/2014
Hematology
Complete Blood Count
Hb
12.3 g/dl
Ht
35%
Eritrosit
4.30.10^6/ul
Leukosit
10,500
Trombosit
261,000
Electrolye
Sodium
144 mmol/L
Potassium
4.52 mmol/L
Chloride
113 mmol/L
Feces Examination
Macroscopic
Color
Consistency
Mucus
Blood
Microscopic
Leukocyte
Erythrocyte
Amoeba coli
Amoeba hystolitica
Worm eggs
-

23/09/2014

24/09/2014

Yellow
Loose
Negative
Negative

Yellow
Loose
Negative
Negative

Negative
Negative
Negative
Negative
Negative

Negative
Negative
Negative
Negative
Negative

16. Prognosis
Quo ad vitam
:
bonam
Quo

ad

functionam
: bonam
Quo

ad

sanationam :

bonam

CHAPTER II
LITERATURE REVIEW
I. Definition and Epidemiology
Diarrhea is defined as the passage of three or more loose or liquid stools per day (or more
frequent passage than is normal for an individual). Thus, frequent passing of formed stool or
passing loose or pasty stool by breastfed babies are not classified as diarrhea. 1 Diarrheal
disease accounts for 760,000 death all over the world and is the second leading cause of death
in children under five years old. Diarrhea may cause the body to lack of fluid and electrolytes
essential for living. Most deaths occurring from diarrhea are caused by dehydration and fluid
loss and children with HIV or are malnourished are at a higher risk of life-threatening
diarrhea.
Based on the duration, diarrhea is classified into 3 types:
acute diarrhea, that lasts less than 7 days and it may be watery (includes cholera) or
bloody (dysentry)
prolonged diarrhea, that lasts 7-14 days
persistent diarrhea, that lasts for more than 14 days
Chronic diarrhea, on the other hand, is a diarrhea that lasts for more than 14 days and is not
only due to infection (unlike persistent diarrhea).
II. Transmission and Risk Factors
Generally, diarrhea is transmitted via fecal-oral pathway, which is through foods or drinks
infected with enteropathogen or direct hand contact with diarrhea patients, contact with
objects infected with the patients' feces or indirectly with flies (4F: finger, flies, food, fluid).
Risk factors:
Not giving exclusive breastfeeding
Absence of clean water supply
Lack of toilets
Unhygienic food storage and processing
Immunodeficiency
Malnutrition
Decrease of gastric pH
Decrease of intestinal motility
Suffering measles in the last 4 weeks
Genetic factor
1. Age
Most cases happen in the first 2 years of life and the highest incidence happens in 6-11
months of age when complementary food was given. This trend shows that diarrhea is
caused by the combination of the decrease of antibody from the mother, lack of the child's
own immunity, introduction of foods that may be contaminated by fecal bacteria, or direct
contact with human or animal feces when the child first crawls.
2. Asymptomatic infection
6

Most intestinal infections are asymptomatic, especially above the age of 2 years old due to
the already established immune system. People with asymptomatic infection paly a major
role in spreading the infection, especially if they do not practice good hygiene.
3. Seasonal Factor
In tropical countries, diarrhea caused by rotavirus can happen along the year while
bacterial infections tend to increase in rainy season. In subtropical countries, diarrhea due
to bacterial infection happens more often in summer while viral-related diarrhea happens
in winter.
III. Etiology and Pathogenesis
Two basic types of acute diarrhea due to infection are non inflammatory and inflammatory.
Enteropathogen leads to non-inflammatory diarrhea through bacterial enterotoxin production,
destruction of vili surface due to virus, parasitic attachment, and attachment and/or
translocation bacteria. on the other hand, inflammatory diarrhea is usually caused by bacteria
that invades intestine directly or produces cytotoxin.
Some causes of acute diarrhea in humans are:
1. Bacteria
2. Virus
3. Parasite
Pathogenesis of viral diarrhea
The virus selectively infects and destroys the tip of villi of the small intestine. This leads to
malabsorption of the small intestine. The villi will then be substituted with immature cuboid
enterocytes. The villi will be atrophied and will be unable to absorb fluid and food well.
Following that, the unabsorbed liquid will increase the osmotic colloid pressure, causing
hyperperistaltic movement of the intestine which leads to the evacuation of the food and
liquid through anus, manifesting as osmotic diarrhea due to incomplete water and nutrient
absorption.
Villi enterocytes of the small intestine are differentiated cells that functions in digestive
process such as hydrolysis of disaccharides and absorption functions such as water and
electrolyte transport through glucose and amino acid cotransporter. On the other hand, crypt
enterocytes are undifferentiated cells which do not have hydrophillic enzymes and are water
and electrolyte secretors. Thus, the destruction of the intestinal villi will lead to imbalanced
fluid absorption and secretion ratio and malabsorption of complex carbohydrates, most
importantly lactose.
Consequently, those unabsorbed solutes will retain water and cause the intraluminal water
volume to increase. In addition, the unabsorbed lactose will then pass to the large intestine,
where it is fermented by colonic bacteria, resulting in production of excessive gas.
Pathogenesis of Bacterial Diarrhea
The pathogenesis of diarrhea caused by salmonella, shigella, or E.coli are similar to that of
7

viral, only that bacterial infection invades the mucosa of the small intestine such that it could
cause systemic reaction. Shigella toxin may invade the central nervous system and causes
seizure. Diarrhea caused by salmonella and shigella toxin may present with blood, which is
called dysentery.
IV. Pathophysiology 2
1. Osmotic Diarrhea (absorption impairment)
Osmotic diarrhea is caused:
a. Consuming magnesium hydroxide
b. Lactase-deficiency
c. The presence of unabsorbed solutes that causes the intraluminal portion of the
proximal small intestine becomes hypertonic and hyperosmolar. As a result, in the
jejunum portion, which is more permeable, water will flow to the lumen, followed by
sodium (at the end, there is high volume of water with normal concentration of
sodium). Most of it will not be able to be absorbed back since solutes such as
magnesium, glucose, lactose, and maltose cannot be absorbed back to the less
permeable illeum and it exceeds the absorbing ability of the colon, which causes
diarrhea.
2. General Malabsorption
A characteristic picture that causes intestinal malabsorption is villi atrophy which may be
caused by the destruction as a result of viral or bacterial infection such as Salmonella,
Shigela, or Campylobacter infection. The villi impairment may also be caused by
inflammatory bowel disease caused by toxins or drugs. In addition, some microorganism
such as Giardia and E.coli causes nutrition malbabsorption by altering the brush border
membrane physiology. Maldigestion of protein, carbohydrate, and triglyceride caused by
pancreatic enzyme insufficiency also leads to significant malabsorption and causes
osmotic diarrhea.
3. Secretory Diarrhea (secretion impairment)
a. Crypt hyperplasia
Disease such as celiac disease causes crypt hyperplasia and hence increases the
secretion of water and electrolytes
b. Luminal secretagogue (secretion stimulant)
There are two substances which can stimulate the lumen secretion, which are bacterial
enterotoxin and chemicals such as laxatives, dihidroxy forms of bile salts, and long
chain fatty acid chains.
Bacterial enterotoxins work by increasing the concentration of intracellular cAMP,
cGMP, or Ca2+ which consequently will activate protein kinase. The activation of
protein kinase will cause protein membrane phosphorylation and hence causing Cl - in
crypts to come out. On the other hand, sodium pump activity also increases and sodium
8

will go into the intestinal lumen along with Cl-.

Laxative agents may lead to various effects on the activity of Na+/K+-ATPase pump.
Some of them are increasing the intracellular level of cAMP, increasing the intestinal
permeability, and damaging mucosa cells, increase the intestinal secretion.
4. Diarrhea due to Peristaltic Impairment
Hypoperistaltic condition may cause bacterial overgrowth and leads to diarrhea. Severe
motility failure may cause static of the intestine resulting in inflammation, bile salts
deconjugation, and malabsorption. Hyperperistaltic movement is rarely a cause of
diarrehea in children.
5. Inflammatory Diarrhea
Inflammation in the small intestine and colon may cause the loss of epithelial cells and
tight junction impairment causing water, electrolyte, mucus, protein, and often
erythrocytes and leukocytes to build up in the lumen. The enteral pathogen bacteria will
alter the structure and function of the tight junction, induce the secretion of fluid and
electrolytes, and activate inflammation cascade.
6. Immunology-related-diarrhea
Hypersensitivity reactions ocurring will release numerous numbers of mediators such as
cytokines, histamine, and also inflammatory reactions which can cause tissue disruption. It
will cause the mucosa surface area to decrease and stimulates the secretion of chloride,
followed by sodium and water.
V. Clinical Manifestation
Infection of the intestine may lead to both gastrointestinal symptoms, such as diarrhea,
abdominal cramp, and vomitting, and systemic symptoms, which depend on the etiology.
People with diarrhea will produce feces that contains considerably amount of water and ions
such as sodium, chloride, potassium, and bicarbonate. The water loss will also increase when
there is vomiting and fever. All of this loss may eventually lead to dehydration, metabolic
acidosis, and hypokalemia. Dehydration is very dangerous since it could cause hypovolemic
shock which may lead to death if not properly treated.
Fever commonly happens in patients affected with inflammatory diarrhea. More severe
abdominal pain and tenesmus that happen in the lower part of the abodmen and rectum show
the involvement of large intestine. Vomiting also commonly happens in non-inflammatory
diarrhea. Usually the patient does not have fever or only in subfebrile condition and has
watery diarrhea. This suggests the involvement of upper gastrointestinal tract.
Table 1-Characteristics of Different Types of Diarrhea

Clinical

Rotavirus

Shigella

Salmonella

ETEC

EIEC

Cholera
9

Presentation
Incubation

17-72

24-46

period
Fever
Nausea and

hours
+
Often

hours
++
Rare

++
Often

vomiting
Abdominal

Tenesmus

Tenesmus

Tenesmus

pain
Cephalic pain
Duration of

5-7 days

cramp
+
>7 days

colic
+
3-7 days

sickness
Characteristic

Rotavirus

Shigella

of The Stool
Volume
Frequency
Consistency
Blood
Smell

Moderate
5-10x/day
Watery
-

Little
>10x/day
Loose
Often
+/-

6-72 hours

6-72 hours

6-72

48-72 hours

hours
++
-

Often

Tenesmus

Cramp

2-3 days

cramp
Varies

3 days

Salmonella

ETEC

EIEC

Cholera

Little
Often
Loose
Sometimes
Foul

Much
Often
Loose
+

Little
Often
Loose
+
None

Much
>>>
Loose
Foulcharacteristi

Color

Yellow-

Red-green

Greenish

Colorless

Red-green

c
Like rice

Leukocyte
Others

green
Anorexia

+
Seizure

+
Sepsis

Meteorismu

Systemic

+/-

infection

VI. Diagnosis
1. Anamnesis
The following aspects need to be asked: how long has the diarrhea last, frequency, volume,
consistency, color, smell, and the presence of mucus and/or blood. If there is vomiting,
explore about the volume and frequency. The urination frequency also needs to be
explored, especially in the last 6-8 hours. Foods and drinks consumed prior to the diarrhea
and whether there are accompanying symptoms such as cough, sneezing, otitis media, or
measles. In addition, any interventions or medications that the child has obtained also have
to be explored, such as the administration of ORS and any drugs consumed.
2. Physical examination
Examine the vital signs and any signs of dehydration. Deep and fast respiratory rate
indicates metabolic acidosis where decreased or absent bowel sound may suggest
hypokalemia.

10

Figure 1 - Signs of Dehydration

3. Laboratory Examination
In most cases, complete laboratory examination is not needed. In some cases such as
undetermined underlying cause or in patients with severe dehydration, examinations such
as complete blood count, electrolyte, BGA, blood glucose, antibiotic resistance, and urine
and feces culture might be considered.
Stool Examination
Macroscopic stool examination has to be done in all cases of diarrhea. Watery stool
without the presence of mucus is usually caused by viral enterotoxin protozoa, or extra GI
tract infection. Stool that contains blood or mucus can be caused by bacterial infection that
produces cytotoxin or enteroinvasive bacteria that causes mucosal inflammation such as E.
hystolytica, E. coli, and T. trichuria. The blood usually mixes with the stool except in E.
hystolytica in which the blood was seen on the surface of the stool and in EHEC infection
where blood streaks are seen. Foul-smelling stools are seen in Salmonella, Giardia,
Cryptosporidium, and Strongyloides infection.
Microscopic stool examination which shows the presence of leukocyte indicates the
presence of invasive pathogen or cytotoxin-producing pathogen such as Shigella,
Salmonella, C. jejuni, EIEC, and C. difficile. Parasitic infections do not usually produce a
considerable amount of leukocyte. In most cases, there is no indication to look for eggs of
11

parasites unless the person has a history of travelling to endemic area, negative stool
enteropathogen culture, diarrhea of more than 1 week, or in immunocompromised
patients.
VII. Therapy
Indonesian ministry of health publishes five pillars of diarrhea management which are:
1. Rehydration using new ORS
The new ORS contains less sodium compared the old one and hence reduces its osmolarity
and the risk of hypernatremia. Each pack of ORS is to be diluted in 100 ml of water and is
given to the child with the following condition:
a. Children < 2 years old: 50-100 ml of ORS for every diarrhea
b. Children > 2 years old : 100-200 ml of ORS for every diarrhea
Table 2 - Composition of The New ORS

Component
Sodium
Chloride
Anyhydrous glucose
Potassium
Citrate
Total osmolarity

Mmol/liter
75
65
75
20
10
245

If, however, the child suffers from mild-moderate dehydration or severe dehydration,
different approach as shown by WHO guideline is used:

12

Table 3 - WHO Guideline for Mild-moderate Dehydration

If, however, there is profuse vomiting or the child does not want to drink, 70 ml/kgBW IV
fluid can be administered in the first 5 hours (>12 months children) or 2.5 hours (>12
years). Once the child is willing to drink, give 5 ml/kgBW/hour ORS.

13

Table 4 - WHO Guideline for Mild-moderate Dehydration

The vital signs of the patient should be assessed every 15-30 minutes and once the child is
willing to drink, give 5 ml/kgBW/hour ORS to the child.
2. Zinc for 10 consecutive days
The administration of zinc in diarrhea is useful in increasing water and electrolyte
absorption by the small intestine, increasing the rate of the villi regeneration, increasing
the number of apical brush border, and increasing immune system that functions in
clearing pathogen away from the intestine.
Dose of zinc:
a. < 6 months

: 10 mg (1/2 tablet) per day

14

b. > 6 months

: 20 mg (1 tablet) per day

3. Continuation of breastfeeding and food

Food and breastmilk should be continued to give to prevent weight loss and as a
replacement for the lost nutrition. Foods that are low in fiber and high in potassium, such
as banana and fruit juice, are best to give. An increase of appetite indicates that the patient
has started to recover.
4. Selective antibiotic and Drug
Antibiotic is only given if it is indicated, for example in bloody diarrhea or cholera.
Irrational antibiotic administration will instead prolongs the recovery phase since it
disturbs the normal flora of the intestine.
Table 5 - Several Antibiotics Used in Diarrhea

Etiology
Cholera

Shigella

Choice of Antibiotic
Tetracycline

Alternative
Erythromycin

12.5 mg/kgBW

12.5 mg/kgBW

4x/day for 3 days

Ciprofloxacin

4x/day for 3 days

Pivmexcillinam

15 mg/kgBW

20 mg/kgBW

2x/day for 3 days

4x/day for 5 days

Ceftriaxone
50-100 mg/kgBW
1x/day for 2-5 days

Amoebiasis

Metronidazole
10 mg/kgBW

Giardiasis

3x/day for 5 days

Metronidazole
5 mg/kgBW
3x/day for 5 days

Drugs such as antiemetic, steroid, antimotility, and cardiac stimulant are useless and have
shown many side effects and thus should not be given to any children.
Probiotics, on the other hand, affects the intestinal microflora by loweringtheintestinalpH,
theproductionofbactericidalsubstancessuchasorganicacids(lactic,acetic,butyric acid),
H2O2andbacteriocines,agglutinationofpathogenicmicroorganisms,adherencetothe
cellularsurfaceofthemucosa,andcompetitionforfermentablesubstratesorreceptors,
strengtheningthebarriereffectoftheintestinalmucosa,releaseofgutprotective
15

metabolites(arginine,glutamine,shortchainfattyacids,conjugatedlinoleicacids),binding
andmetabolismoftoxicmetabolites,immunologicmechanisms,andregulatingofthe
intestinalmotilityandmucusproduction.Vreseetal(2007)suggestedthatprobioticsare
beneficialintreatingacutediarrheacausedbyviralorbacterialinfectionsbypromoting
effectssuchasdecreasedfrequencyofinfections,shorteningthedurationofepisodesby1
1.5days,promotionofsystemicorlocalimmuneresponse,andanincreaseinthe
productionofrotavriussepcificantibodies.3However,itseffectivenessisoftenstrain
dependentandhencetheuseofprobioticsisnotroutinelyrecommended.4
5. Education
Educate the caregiver if there is fever, bloody stool, repeated diarrhea, decreased intake,
eager drinking, or have not shown any improvement in 3 days.
VIII. Prevention
1. Preventing the spread of the pathogen
a. Hygienic storage and processing of breastmilk and the consumed food
b. Adequate use of clean water
c. Washing hands after defecating and before having a meal
d. The use of hygienic toilet
e. Proper disposal of infants
2. Improving the immune system of the host
a. Giving breastmilk until at least 2 years
b. Increasing the nutritional content of the complementary food

16

CHAPTER III
DISCUSSION
The patient is a nine-month year old boy who came with a chief complaint of diarrhea since
three days before hospital admission which, according to the mother, was watery, sometimes
contained mucus with no blood found in it, and not foul-smelling. He also looked veryh
thirsty and drank eagerly. The diarrhea was also accompanied by fever of 38 0C that started
one day before the hospital admission and there were no epistaxis, gum bleeding, seizure, or
rashes. Physical examination showed the patient was restless and drank eagerly. There were
also sunken fontanel and the oral mucosa was dry. The skin turgor was still good and the
abdominal percussion was hypertympanic and the anus was erythematous.
The diagnosis of acute diarrhea with mild-moderate dehydration was established since
the child showed symptoms of acute diarrhea, which was diarrhea less than seven days, loose
stool consistency, and increased frequency of defecation of more than three times per day,
and mild-moderate dehydration, which are restlessness and eager drinking. The etiology of
the diarrhea was most probably viral infection since the diarrhea was watery and contains no
blood, although the mother reported at first there was mucus inside the stool. This was
confirmed by the stool examination which showed there was no leukocyte, blood, or mucus.
Besides the diarrhea, there was also fever examined in this patient. The fever pattern was
persistent and subsided only with drugs. There were also no other symptoms, such as
epistaxis, bleeding gum, rashes, nor seizure. Thus, the fever was more likely to be an
accompanying symptom of the viral infection.
The initial management done in this patient was IVFD RL 14 dpm to manage the
dehydration. However, according to the WHO guideline, the oral rehydration therapy using
ORS should first be attempted in mild-moderate dehydration and reserving intravenous
access in case of difficult intake or profuse vomiting, which did not occur in this patient since
he was still able to drink. Hence, an initial management of oral intake of 600 ml ORS in the
first 3 hours should first be attempted while observing for the dehydration signs and
symptoms. If profuse vomiting occurred or if the child does not want to drink, IVFD KaEn
3B can be done with the rate of 20 dpm.
Second, since the working diagnosis (which was eventually confirmed by the stool
examination) was not bacterial infection, antibiotic treatment should not have been initiated
in this case. Careful use of antibiotics is also in line with the guideline published by
Indonesian Ministry of Health, which is rational antibiotic use. The zinc given in this patient
was also inadeqaute since according to WHO, in children with age of more than 6 months,
17

the dose of the zinc is 20 mg. Paracetamol, on the other hand, was needed as it functioned as
an antipyretic to prevent any possible adverse events may be caused by fever such as seizure.
However, the dose given, which is 0.6 ml drop, was inadequate since it only consisted of 60
mg of paracetamol, whereas with the child's body weight, a dose of 80-120 mg was needed
for each administration. Thus, it would be better to prescribe 2 drops of paracetamol or
administer the paracetamol in the form of pulveres.
The supporting examinations done in this patient were complete blood count,
electrolyte examination, and stool examination. However, since there were no indications
such as bleeding or suspicion of hypokalemia or hyponatremia, both CBC and electrolyte
examinations were actually not a priority in this case. The stool examination, however, was
essential to know the definite etiology and rule out the possibility of bacterial infection.
The education given to the patient, however, was not thorough enough as the mother
was not informed that she was not explicitly told to continue to breastfeed the child. In
addition, the family was not informed to give foods that contain potassium such as banana or
fruit juice.

18

CHAPTER IV
REFERENCES

19

1
WHO.
Diarrhoeal
disease
[Internet].
2013
[cited
2014
Sept
25].
Available
from:
http://www.who.int/mediacentre/factsheets/fs330/en/
2 UKK Gastroenterologi Hepatologi IDAI. Buku ajar Gastroenterologi-Hepatologi Jilid 1. Badan Penerbit IDAI;
Jakarta: 2009.
3 de Vrese M, Marteau PR. Probiotics and Prebiotics: Effects on Diarrhea. The Journal of Nutrition. 2007 March 1,
2007;137(3):803S-11S.
4 American Family Physician. AAP reports on Use of Probiotics and Prebiotics in Children [Internet]. 2010 [cited 2014
Sept 28]. Available from: http://www.aafp.org/afp/2011/0401/p849.html