DIARE AKUT PADA ANAKDIARE AKUT PADA ANAK

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

PERJALANAN KLINIK DIAREPERJALANAN KLINIK DIARE

85 % sembuh dalam waktu < 1 minggu85 % sembuh dalam waktu < 1 minggu

10 % sembuh dalam waktu 7-14 hari10 % sembuh dalam waktu 7-14 hari

5 % melanjut > 14 hari.5 % melanjut > 14 hari.

FAKTOR RISIKO (1)FAKTOR RISIKO (1)

Umur < 12 bulanUmur < 12 bulan Berat lahir rendah (BBLR)Berat lahir rendah (BBLR) MalnutrisiMalnutrisi Def. Vitamin ADef. Vitamin A Gangguan imunitas selularGangguan imunitas selular Infeksi saluran nafas bawahInfeksi saluran nafas bawah Obat (antidiare, antibiotik)Obat (antidiare, antibiotik)

FAKTOR RISIKO (2)FAKTOR RISIKO (2)

Anemia defisiensi besiAnemia defisiensi besi Riwayat diare sebelumnyaRiwayat diare sebelumnya Pemberian susu hewanPemberian susu hewan Umur, pendidikan dan pengalaman ibuUmur, pendidikan dan pengalaman ibu Pola penyapihanPola penyapihan

PENATALAKSANAAN DIAREPENATALAKSANAAN DIARE

REDHIDRASIREDHIDRASI NURTISINURTISI OBAT JIKA DIPERLUKANOBAT JIKA DIPERLUKAN EDUKASI ORANG TUAEDUKASI ORANG TUA

MASALAHMASALAH

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

Diarrheapatients

Non-diarrheapatients

Prolonged/Persistentdiarrhea

Diarrhea

ANTIBIOTIC

Antibiotic-associateddiarrhea

AAD in hospitalized children

KENAPA TERJADIKENAPA TERJADI

ORANG TUA MINTA OBATORANG TUA MINTA OBAT DOKTER : KURANG PERCAYA DIRIDOKTER : KURANG PERCAYA DIRI ORT TIDAK MENGOBATI DIAREORT TIDAK MENGOBATI DIARE PROMOSI OBATPROMOSI OBAT

PENENTUAN DERAJAT PENENTUAN DERAJAT DEHIDRASIDEHIDRASI

Lihat: Kead. Umum

Mata

Air mata

Mulut dan lidah

Rasa haus

Periksa Turgor kulit

Hasil pemeriksaan

Terapi

Baik, sadar

Normal

Ada

Basah

Minum biasa tidak haus

Kembali cepat

Tanpa dehidrasi

Rencana terapi A

* Gelisah, rewel

Cekung

Tidak ada

Kering

* Haus, ingin minum banyak

* Kembali lambat

D. Ringan/sedang

1 tanda * (+) 1 atau lebih tanda lain

Rencana terapi B

* Lesu, lunglai, tak sadar

Sangat cekung & kering

Tidak ada

Sangat kering

* Malas minum atau tidak bisa minum

* Kembali sgt lambat

Dehidrasi berat

1 tanda * (+) 1 atau lebih tanda lain

Rencana terapi C

Penilaian A B C

PLAN TREATMENT APLAN TREATMENT A

• Tanpa dehidrasi • Muntah (-) pemberian makan sesuai umur• malabsorpsi (-) tidak ada diet spesifik

• complex carbohydrate, fruit, vegetables• ORS ?

• Tanpa dehidrasi • Muntah (-) pemberian makan sesuai umur• malabsorpsi (-) tidak ada diet spesifik

• complex carbohydrate, fruit, vegetables• ORS ?

PLAN TREATMENT BPLAN TREATMENT B

Dehidrasi Ringan-sedangDehidrasi Ringan-sedang ORS (the first 3 hours) ORS (the first 3 hours) 75 ml x body weight75 ml x body weight

oror

Reevaluate after 3-4 hours Reevaluate after 3-4 hours plan th/ A, B, or C plan th/ A, B, or C

Continued feeding or early resumptionContinued feeding or early resumption

UmurUmur < 1 tahun< 1 tahun 1-5 tahun1-5 tahun > 5 tahun> 5 tahun dewasadewasa

Total ORSTotal ORS 300 ml300 ml 600 ml600 ml 1200 ml1200 ml 2400 ml2400 ml

PLAN TREATMENT CPLAN TREATMENT C

Dehidrasi Berat, IVFDDehidrasi Berat, IVFD

Reevaluate every 1-2 jamReevaluate every 1-2 jam ORSORS After 6 hours (infants) or 4 hours (child) After 6 hours (infants) or 4 hours (child) reevaluate reevaluate

plan treatment A,B,C plan treatment A,B,C

AgeAge IIstst treatment treatment

30 ml/BW in30 ml/BW in

22nd nd treatmenttreatment

70 ml/BW in70 ml/BW in

Infant < 12 monthsInfant < 12 months 1 hour1 hour 5 hour5 hour

Child > 12 monthsChild > 12 months ½ - 1 hours ½ - 1 hours 2 ½ - 3 hours2 ½ - 3 hours

ANTIBIOTIKAANTIBIOTIKA

• Pemberian yang kurang tepat memperlambat kesembuhan Gangguan keseimbangan intestinal microflora

• antibiotic associated colitis• prolong the carier state (Salmonela)

• Pemberian yang kurang tepat memperlambat kesembuhan Gangguan keseimbangan intestinal microflora

• antibiotic associated colitis• prolong the carier state (Salmonela)

EFEK SAMPING ANTIMIKROBA

1. PERUB. FLORA USUS2. OVERGROWTH:

- MONILIA- ENTEROCOCCUS- ANAEROB- PSEUDOMONAS

3. KERUSAKAN MUKOSA USUS4. IRITASI5. PSEUDOMEMBRANOUS ENTEROCOLITIS6. BLOOD DYSCRASIA7. MUNTAH

• Therapi Terbaru

• Beberapa penelitian telah dilakukan dalam terapi diare

• adsorbant, mucoprotector, antisecretory, probiotic

PROBIOTIKPROBIOTIK

Kuman baik: efek positif thd Kuman baik: efek positif thd kesehatankesehatan

BifidobacteriBifidobacteri dan dan LactobacillusLactobacillus Bermanfaat dalam tatalaksana diare Bermanfaat dalam tatalaksana diare

akut, diare nosokomial, diare karena akut, diare nosokomial, diare karena antibiotikantibiotik

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

> > Induction of oral tolerance towards dietary allergens Induction of oral tolerance towards dietary allergens (Hanson & Telemo, 1997)(Hanson & Telemo, 1997)

Protective Properties of Protective Properties of BifidobacteriaBifidobacteria

Activation of Activation of the immune the immune

system system

Synthesis of Synthesis of vitaminsvitamins

Inhibition of pathogensInhibition of pathogens

Lowering Lowering pH in environmentpH in environment

Synthesis of Synthesis of digestive enzymesdigestive enzymes

Probiotics

Produce antibioticmolecules

Competitive bindingon intestinal mucosa

Produce volatile fatty acidsand modify bile acids

Strengthen hostStrengthen hostdefensesdefenses

EnhanceEnhancesecretorysecretoryantibodyantibody

TightenTightenmucosalmucosalbarrierbarrier

Balance TBalance Thelper cellshelper cellsresponseresponse

Probiotics intervention to Probiotics intervention to modulatemodulate

immune response immune response

PROBIOTIC AGENTSPROBIOTIC AGENTS

Lactobacillus GGLactobacillus GG Lactobacillus acidophilusLactobacillus acidophilus Bifidobacterium bifidumBifidobacterium bifidum Enterococcus faeciumEnterococcus faecium Bifidobacterium longumBifidobacterium longum Lactobacillus plantarumLactobacillus plantarum Streptococcus thermophilusStreptococcus thermophilus Saccharomyces boulardiiSaccharomyces boulardii

RCT of probiotic for treatment of RCT of probiotic for treatment of acute diarrheaacute diarrhea

PROBIOTIC AUTHORS N DAY TREATMENT GROUP CONTROL GROUP

L rhamnosus Isolauri, 1991Raza, 1995Pant, 1996

Shornikova, 1997Guandalini, 2000

714026

123287

52255

1.4 days31% (at day 2)

1.9 days2.7 days2.4 days

2.4 days75% (at day 2)

3.3 days3.7 days3.0 days

L reuteri Shornikova, 1997Shornikova, 1997

6640

55

1.5 days26% (at day 2)

2.5 days81% (at day 2)

S boulardii Cetina-Sauri, 1989 130 4 15% (at day 2) 60% (at day 2)

Treatment of Acute Diarrhea Treatment of Acute Diarrhea META-ANALYSISMETA-ANALYSIS

Lactobacillus therapy for acute infectious diarrhea Lactobacillus therapy for acute infectious diarrhea in childrenin children

9 studies (out of 26 studies published from 1966 to 9 studies (out of 26 studies published from 1966 to 2000)2000)

Reduction in diarrhea duration of 0.7 days (95% CI: Reduction in diarrhea duration of 0.7 days (95% CI: 0.3-1.2 days)0.3-1.2 days)

Reduction in diarrhea frequency of 1.6 stools on Reduction in diarrhea frequency of 1.6 stools on day 2 of treatment (95% CI: 0.7-2.6 fewer stools)day 2 of treatment (95% CI: 0.7-2.6 fewer stools)

Conclusion: Lactobacillus is safe and effective as a Conclusion: Lactobacillus is safe and effective as a treatment for children with acute infectious treatment for children with acute infectious diarrheadiarrhea

Van Niel at al, Pediatrics 2002;109:1-13Van Niel at al, Pediatrics 2002;109:1-13

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

adultsadults

Outcomes: diarrhea lasting >3 days and duration Outcomes: diarrhea lasting >3 days and duration of diarrheaof diarrhea

23 studies: n=1917, 76% children23 studies: n=1917, 76% children Lactobacillus (21 studies), Saccharomyces Lactobacillus (21 studies), Saccharomyces

boulardi (2 studies)boulardi (2 studies) Patients who receives probiotic were less likely to Patients who receives probiotic were less likely to

have diarrhea lasting >3 dayshave diarrhea lasting >3 days Mean duration of diarrhea was reduced by 30 Mean duration of diarrhea was reduced by 30

hourshours

Allen et al, 2004Allen et al, 2004

Prevention of infantile Prevention of infantile diarrheadiarrhea

RCTRCT

55 infants aged 5-24 months hospitalized 55 infants aged 5-24 months hospitalized for non-GI diseasesfor non-GI diseases

Formula : Bifidobacteria vs controlFormula : Bifidobacteria vs control Observe for 7 monthsObserve for 7 months Diarrhea episode decreased (7% vs 31%)Diarrhea episode decreased (7% vs 31%) Rotavirus infection decreased (10% vs Rotavirus infection decreased (10% vs

39%)39%)Saavedra et al, 1994

Prevention of nosocomial Prevention of nosocomial diarrhea in infants: diarrhea in infants: RCTRCT

ND is a major problem in pediatric hospital ND is a major problem in pediatric hospital worldwideworldwide

81 children aged 1-36 months hospitalized for 81 children aged 1-36 months hospitalized for reason other than diarrheareason other than diarrhea

RCT: LGG (n=45) vs placebo (n=36)RCT: LGG (n=45) vs placebo (n=36) LGG 6x10LGG 6x1099 cfu twice daily cfu twice daily LGG reduced the risk of nosocomial diarrhea in LGG reduced the risk of nosocomial diarrhea in

comparison with placebo (6.7% vs 33.3%)comparison with placebo (6.7% vs 33.3%) LGG significantly reduced the risk of rotavirus LGG significantly reduced the risk of rotavirus

gastroenteritis (2.2% vs 17.7%)gastroenteritis (2.2% vs 17.7%)

Szajewska et al, 2001Szajewska et al, 2001

C. Difficile diarrheaC. Difficile diarrhea

Antibiotic associated diarrheaAntibiotic associated diarrhea Metronidazole / vancomicynMetronidazole / vancomicyn RelapseRelapse Treatment with Treatment with Lactobacillus caseiLactobacillus casei Bacteria-produced substance inhibit Bacteria-produced substance inhibit in vitroin vitro the the

growth of enteropatogens, including growth of enteropatogens, including C. difficileC. difficile Prevent relapse of Prevent relapse of C difficilleC difficille diarrhea diarrhea

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

SUPLEMENTASI SENGSUPLEMENTASI SENG

Komponen >300 enzim dan dibutuhkan Komponen >300 enzim dan dibutuhkan untuk sintesis DNA, protein dan mitosisuntuk sintesis DNA, protein dan mitosis

Prevalensi defisiensi Zn: 44-60%Prevalensi defisiensi Zn: 44-60% Angka kejadian diare 47% lebih tinggi Angka kejadian diare 47% lebih tinggi

pada anak dengan defisiensi Znpada anak dengan defisiensi Zn Metaanalisis: secara bermakna Metaanalisis: secara bermakna

menurunkan angka kejadian diare akut, menurunkan angka kejadian diare akut, disentri, diare persisten, pneumoniadisentri, diare persisten, pneumonia

Pada diare: 20 mg Zn selama 10-14 hariPada diare: 20 mg Zn selama 10-14 hari

Zinc DefficiencyZinc Defficiency

In children < 5 yearsIn children < 5 years Increase the risk of incidence for Increase the risk of incidence for

diarrhea by 1.28 (95% CI 1.10-1.56)diarrhea by 1.28 (95% CI 1.10-1.56) Increase the risk of incidence for Increase the risk of incidence for

pneumonia by 1.52 (95% CI 1.20-1.89)pneumonia by 1.52 (95% CI 1.20-1.89) Increase the risk of incidence for Increase the risk of incidence for

malaria by 1.56 (95% CI 1.29-1.89)malaria by 1.56 (95% CI 1.29-1.89)Caulfield & Black, 2004Caulfield & Black, 2004

Zinc for the Treatment of Zinc for the Treatment of DiarrhoeaDiarrhoea

Research FindingsResearch Findings• 15% reduction in duration of acute 15% reduction in duration of acute

diarrhoeadiarrhoea• 24% reduction in duration of persistent 24% reduction in duration of persistent

diarrhoeadiarrhoea• 42% reduction in treatment failure or death 42% reduction in treatment failure or death

in persistent diarrhoeain persistent diarrhoea

Zinc Investigators’ Collaborative Group.Zinc Investigators’ Collaborative Group. AJCN 2000. AJCN 2000.

Additional Preventive Additional Preventive Aspects of Zinc TreatmentAspects of Zinc Treatment

• Zinc supplementation for 10-14 days has Zinc supplementation for 10-14 days has longer term effects on childhood illnesses in longer term effects on childhood illnesses in the 2-3 months after treatmentthe 2-3 months after treatment

• 34% reduction in prevalence of diarrhoea34% reduction in prevalence of diarrhoea

• 26% reduction in incidence of pneumonia 26% reduction in incidence of pneumonia

Zinc Investigators’ Collaborative Group. Pediatrics. 1999.Zinc Investigators’ Collaborative Group. Pediatrics. 1999.

WHO/UNICEF Joint WHO/UNICEF Joint StatementStatement

WHO and UNICEF therefore recommend WHO and UNICEF therefore recommend daily 20 mg zinc supplements for 10–14 daily 20 mg zinc supplements for 10–14 days for children with acute diarrhea, days for children with acute diarrhea, and 10 mg per day for infants under six and 10 mg per day for infants under six months old, to curtail the severity of months old, to curtail the severity of the episode and prevent further the episode and prevent further occurrences in the ensuing 2-3 months.occurrences in the ensuing 2-3 months.

May, 2004May, 2004

VAKSIN ROTAVIRUSVAKSIN ROTAVIRUS Rotavirus sebagai penyebab utama Rotavirus sebagai penyebab utama

diare pada anak di duniadiare pada anak di dunia Infeksi alamiah rotavirus: infeksi Infeksi alamiah rotavirus: infeksi

primer menimbulkan gejala klinis primer menimbulkan gejala klinis berat, selanjutnya lebih ringan dan berat, selanjutnya lebih ringan dan asimptomatisasimptomatis

Vaksin rotavirus oralVaksin rotavirus oral Masih mahalMasih mahal

Pencegahan

9 Pilar tatalaksana diare 9 Pilar tatalaksana diare dehidrasi ringan sedang pada dehidrasi ringan sedang pada

anak anak Menggunakan CROMenggunakan CRO Cairan hipotonikCairan hipotonik Rehidrasi oral cepat (3-4jam)Rehidrasi oral cepat (3-4jam) Realimentasi cepat dengan makanan normalRealimentasi cepat dengan makanan normal Tidak dibenarkan memeberikan susu formula khususTidak dibenarkan memeberikan susu formula khusus Tidakdibenarkam memberikan susu yang diencerkanTidakdibenarkam memberikan susu yang diencerkan ASI diteruskanASI diteruskan Suplemen dengan CRO (rumatan)Suplemen dengan CRO (rumatan) Anti diare tidak diperlukanAnti diare tidak diperlukan

Kelompok Ahli Gastroenterologi duniaKelompok Ahli Gastroenterologi dunia

KESIMPULANKESIMPULAN

Utamakan rehidrasi oral sejak diniUtamakan rehidrasi oral sejak dini Rujuk kasus berat ke RS untuk TRPRujuk kasus berat ke RS untuk TRP Dukungan nutrisi untuk mencegah Dukungan nutrisi untuk mencegah

malnutrisimalnutrisi Penggunaan antibioitik secara rasionalPenggunaan antibioitik secara rasional Suplementasi ZnSuplementasi Zn ProbiotikProbiotik Edukasi pada orangtuaEdukasi pada orangtua

TERIMA KASIH