DIARE AKUT PADA ANAK

DEDDY S PUTRA SUB BAG GASTROHEPATOLOGI ANAK FK-UNRI/RSUD ARIFIN ACHMAD

PERJALANAN KLINIK DIARE

85 % sembuh dalam waktu < 1 minggu

10 % sembuh dalam waktu 7-14 hari

5 % melanjut > 14 hari.

FAKTOR RISIKO (1)Umur < 12 bulanBerat lahir rendah (BBLR)MalnutrisiDef. Vitamin AGangguan imunitas selularInfeksi saluran nafas bawahObat (antidiare, antibiotik)

FAKTOR RISIKO (2)

Anemia defisiensi besiRiwayat diare sebelumnyaPemberian susu hewanUmur, pendidikan dan pengalaman ibuPola penyapihan

MIKROBA PENYEBAB DIAREVIRUS Rotavirus

BAKTERI E. coli, Shigella, Campylobacter

PROTOZA Cryptosporidium

PATOFISIOLOGI

Diare Air Dehidrasi Kalium Hipokalemia Natrium Hiponatremia Bikarbonat Asidosis Nutrien Hipoglikemia

PENATALAKSANAAN DIAREREHIDRASI NUTRISIOBAT JIKA DIPERLUKANEDUKASI ORANG TUAZINC

MASALAHTERDAPAT KESENJANG APA YANG DIREKOMENDASIKAN DENGAN APA YANG DOKTER LAKUKAN (PRAKTEK)

DiarrheapatientsNon-diarrheapatientsProlonged/PersistentdiarrheaDiarrheaANTIBIOTICAntibiotic-associateddiarrheaAAD in hospitalized children

KENAPA TERJADIORANG TUA MINTA OBATDOKTER : KURANG PERCAYA DIRIORT TIDAK MENGOBATI DIAREPROMOSI OBAT

PENENTUAN DERAJAT DEHIDRASI

Lihat: Kead. Umum MataAir mataMulut dan lidahRasa haus

Periksa Turgor kulitHasil pemeriksaan

Terapi Baik, sadar Normal Ada Basah Minum biasa tidak haus

Kembali cepatTanpa dehidrasi

Rencana terapi A* Gelisah, rewel Cekung Tidak ada Kering * Haus, ingin minum banyak

* Kembali lambatD. Ringan/sedang1 tanda * (+) 1 atau lebih tanda lain Rencana terapi B* Lesu, lunglai, tak sadarSangat cekung & kering Tidak ada Sangat kering * Malas minum atau tidak bisa minum

* Kembali sgt lambatDehidrasi berat1 tanda * (+) 1 atau lebih tanda lainRencana terapi CPenilaian A BC

PLAN TREATMENT A Tanpa dehidrasi Muntah (-) pemberian makan sesuai umur malabsorpsi (-) tidak ada diet spesifik

complex carbohydrate, fruit, vegetables ORS ?

REHIDRASI ORALDiare tanpa dehidrasi sampai dehidrasi ringan-sedang.Oralit WHOCRO lain: larutan gula-garam, larutan garam-tajin, PedialyteSegera setelah diare terjadi

PENYEBAB GAGALNYA UROKeluaran tinja yang banyakMuntah terus menerusDehidrasi beratTidak mampu atau menolak minumMalabsorpsi glukosaPerut kembung dan ileusCara penyiapan dan pemberian oralit yang tidak benar

TAHAPAN UROTAHAPAN REHIDRASIMengganti kehilangan cairan dan elektrolit yang telah terjadi

TAHAP RUMATANMengganti cairan dan elektrolit akibat diare dan muntah yang masih berlangsung

INDIKASI REHIDRASI PARENTERALDehidrasi beratTidak dapat minum (lemah, sopor atau koma)Muntah hebatOliguri atau anuri berkepanjanganKomplikasi serius lain yang menghambat keberhasilan rehidrasi oral

PLAN TREATMENT B

Dehidrasi Ringan-sedangORS (the first 3 hours) 75 ml x body weightor

Reevaluate after 3-4 hours plan th/ A, B, or C Continued feeding or early resumption

Umur< 1 tahun1-5 tahun> 5 tahundewasaTotal ORS300 ml600 ml1200 ml2400 ml

Dehidrasi ringan sedangOral jika gagal dengan IV75 cc/kgbb/3jamSetelah anak dapat minum5ml/kgbb/jam10 ml/kgbb/setiap diare/muntah

PLAN TREATMENT C

Dehidrasi Berat, IVFD

Reevaluate every 1-2 jamORSAfter 6 hours (infants) or 4 hours (child) reevaluate plan treatment A,B,C

AgeIst treatment30 ml/BW in2nd treatment 70 ml/BW inInfant < 12 months1 hour5 hourChild > 12 months - 1 hours 2 - 3 hours

INDIKASI PEMBERIAN ANTIBIOTIKTersangka Kolera (Tetrasiklin, Furazolidon)Tersangka Disentri (TMP-SMZ, ampisilin, asam nalidiksat)Terbukti Amebiasis (Metronidazol)Terbukti Giardiasis (Metronidazol)

ANTIBIOTIKA Pemberian yang kurang tepat memperlambat kesembuhan Gangguan keseimbangan intestinal microflora antibiotic associated colitis prolong the carier state (Salmonela)

EFEK SAMPING ANTIMIKROBA1. PERUB. FLORA USUS2. OVERGROWTH:- MONILIA- ENTEROCOCCUS- ANAEROB- PSEUDOMONAS3. KERUSAKAN MUKOSA USUS4. IRITASI5. PSEUDOMEMBRANOUS ENTEROCOLITIS6. BLOOD DYSCRASIA7. MUNTAH

UPAYA PENCEGAHAN DIAREPemberian ASIPerbaikan cara pemberian makanan pendamping ASIPenggunaan air bersih yang cukupCuci tanganPenggunaan jambanPembuangan tinja bayi/anak yang semestinyaImunisasi campak

Therapi Terbaru

Beberapa penelitian telah dilakukan dalam terapi diare

adsorbant, mucoprotector, antisecretory, probiotic

PROBIOTIKKuman baik: efek positif thd kesehatanBifidobacteri dan LactobacillusBermanfaat dalam tatalaksana diare akut, diare nosokomial, diare karena antibiotik

> Protection against enteral infections in a phase of insufficient immune response (Koletzko et al., 1998; Heine, 1998)

> Induction of oral tolerance towards dietary allergens (Hanson & Telemo, 1997)Protective Properties of BifidobacteriaActivation of the immune system Synthesis of vitaminsInhibition of pathogensLowering pH in environmentSynthesis of digestive enzymes

Probiotics Produce antibioticmoleculesCompetitive bindingon intestinal mucosaProduce volatile fatty acidsand modify bile acidsStrengthen hostdefensesEnhancesecretoryantibodyTightenmucosalbarrierBalance Thelper cellsresponseProbiotics intervention to modulate immune response

PROBIOTIC AGENTSLactobacillus GGLactobacillus acidophilusBifidobacterium bifidumEnterococcus faeciumBifidobacterium longumLactobacillus plantarumStreptococcus thermophilusSaccharomyces boulardii

RCT of probiotic for treatment of acute diarrhea

PROBIOTICAUTHORSNDAYTREATMENT GROUPCONTROL GROUPL rhamnosusIsolauri, 1991Raza, 1995Pant, 1996Shornikova, 1997Guandalini, 2000714026123287522551.4 days31% (at day 2)1.9 days2.7 days2.4 days2.4 days75% (at day 2)3.3 days3.7 days3.0 daysL reuteriShornikova, 1997Shornikova, 19976640551.5 days26% (at day 2)2.5 days81% (at day 2)S boulardiiCetina-Sauri, 1989130415% (at day 2)60% (at day 2)

Treatment of Acute Diarrhea META-ANALYSISLactobacillus therapy for acute infectious diarrhea in children9 studies (out of 26 studies published from 1966 to 2000)Reduction in diarrhea duration of 0.7 days (95% CI: 0.3-1.2 days)Reduction in diarrhea frequency of 1.6 stools on day 2 of treatment (95% CI: 0.7-2.6 fewer stools)Conclusion: Lactobacillus is safe and effective as a treatment for children with acute infectious diarrheaVan Niel at al, Pediatrics 2002;109:1-13

Meta-analysis: Probiotics reduced diarrhea lasting at 3 days in children and adults

Outcomes: diarrhea lasting >3 days and duration of diarrhea23 studies: n=1917, 76% childrenLactobacillus (21 studies), Saccharomyces boulardi (2 studies)Patients who receives probiotic were less likely to have diarrhea lasting >3 daysMean duration of diarrhea was reduced by 30 hoursAllen et al, 2004

Prevention of infantile diarrheaRCT

55 infants aged 5-24 months hospitalized for non-GI diseasesFormula : Bifidobacteria vs controlObserve for 7 monthsDiarrhea episode decreased (7% vs 31%)Rotavirus infection decreased (10% vs 39%)Saavedra et al, 1994

Prevention of nosocomial diarrhea in infants: RCTND is a major problem in pediatric hospital worldwide81 children aged 1-36 months hospitalized for reason other than diarrheaRCT: LGG (n=45) vs placebo (n=36)LGG 6x109 cfu twice dailyLGG reduced the risk of nosocomial diarrhea in comparison with placebo (6.7% vs 33.3%)LGG significantly reduced the risk of rotavirus gastroenteritis (2.2% vs 17.7%)Szajewska et al, 2001

C. Difficile diarrheaAntibiotic associated diarrheaMetronidazole / vancomicynRelapseTreatment with Lactobacillus caseiBacteria-produced substance inhibit in vitro the growth of enteropatogens, including C. difficilePrevent relapse of C difficille diarrhea

Biller et al (1995), Bennet et al (1987), Silva et al (1987)

SUPLEMENTASI SENGKomponen >300 enzim dan dibutuhkan untuk sintesis DNA, protein dan mitosisPrevalensi defisiensi Zn: 44-60%Angka kejadian diare 47% lebih tinggi pada anak dengan defisiensi ZnMetaanalisis: secara bermakna menurunkan angka kejadian diare akut, disentri, diare persisten, pneumoniaPada diare: 20 mg Zn selama 10-14 hari

Zinc DefficiencyIn children < 5 yearsIncrease the risk of incidence for diarrhea by 1.28 (95% CI 1.10-1.56)Increase the risk of incidence for pneumonia by 1.52 (95% CI 1.20-1.89)Increase the risk of incidence for malaria by 1.56 (95% CI 1.29-1.89)Caulfield & Black, 2004

Zinc for the Treatment of DiarrhoeaResearch Findings15% reduction in duration of acute diarrhoea24% reduction in duration of persistent diarrhoea42% reduction in treatment failure or death in persistent diarrhoea

Zinc Investigators Collaborative Group. AJCN 2000.

Additional Preventive Aspects of Zinc TreatmentZinc supplementation for 10-14 days has longer term effects on childhood illnesses in the 2-3 months after treatment

34% reduction in prevalence of diarrhoea

26% reduction in incidence of pneumonia

Zinc Investigators Collaborative Group. Pediatrics. 1999.

WHO/UNICEF Joint StatementWHO and UNICEF therefore recommend daily 20 mg zinc supplements for 1014 days for children with acute diarrhea, and 10 mg per day for infants under six months old, to curtail the severity of the episode and prevent further occurrences in the ensuing 2-3 months.

May, 2004

VAKSIN ROTAVIRUSRotavirus sebagai penyebab utama diare pada anak di duniaInfeksi alamiah rotavirus: infeksi primer menimbulkan gejala klinis berat, selanjutnya lebih ringan dan asimptomatisVaksin rotavirus oralMasih mahal

Pencegahan

9 Pilar tatalaksana diare dehidrasi ringan sedang pada anak Menggunakan CROCairan hipotonikRehidrasi oral cepat (3-4jam)Realimentasi cepat dengan makanan normalTidak dibenarkan memeberikan susu formula khususTidakdibenarkam memberikan susu yang diencerkanASI diteruskanSuplemen dengan CRO (rumatan)Anti diare tidak diperlukan

Kelompok Ahli Gastroenterologi dunia

KESIMPULANUtamakan rehidrasi oral sejak diniRujuk kasus berat ke RS untuk TRPDukungan nutrisi untuk mencegah malnutrisiPenggunaan antibioitik secara rasionalSuplementasi ZnProbiotikEdukasi pada orangtua

TERIMA KASIH

*What is the relevance of a bifido-dominated flora in breast-fed infants? Several health-promoting and protective properties have been attributed to Bifidobacteria such as an activation of the immune system as described beforethe inhibition of pathogens by secretion of substances which are directly inhibitory towards several bacteria lowering the pH by production of strong acids such as acetate and lactic acid, leading to an antibacterial environmentproduction of digestive enzymes such as casein phosphatase and lysozymeand the production of vitamins, largely of the B-group;The entirety of these effects might protect infants from pathogenic micro-organisms in the intestine in a phase of insufficient immune response.It is also suggested that this promotes an induction of oral tolerance towards dietary antigens. For these reasons, it seems desirable to increase the numbers of Bifidobacteria also in the intestinal flora of formula-fed infants. References: Gibson GR, Roberfroid MB. J Nutr 1995;125:1401-1412.Koletzko B et al. Br J Nutr 1998, 80, Suppl. 1, S5-S45Heine W. Pd 1998, 4, 178-184Hanson L & Telemo E. Acta Paediatr 1997;86:916-918*All patients included in these studies received ORS. And Zinc supplementation was ALWAYS recommended in addition to ORS or home fluids.

Zinc supplementation has been shown to decrease the duration of diarrhoea by at least 15% in acute diarrhoea and 24% in persistent diarrhoea.

Zinc supplementation has also been shown to decrease treatment failure or death by 42%.

Treatment failure was defined as an increase in diarrhoea severity, the occurrence of dehydration, or diarrhoea continuing for 7 or more days (or 14 or more days).

*The preventive aspects of zinc supplementation are very important reasons to encourage and support widespread use of zinc supplementation for the treatment of diarrhoea.

In short-course trials where supplementation was given for 10-14 days and children were followed for 2-3 months following assessing the incidence and prevalence of illnesses, there was a significant decrease in the prevalence of diarrhoea (34%) and the incidence of pneumonia (26%).