Anda di halaman 1dari 35

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 bulan Berat lahir rendah (BBLR) Malnutrisi Def. Vitamin A Gangguan imunitas selular Infeksi saluran nafas bawah Obat (antidiare, antibiotik)

FAKTOR RISIKO (2)


Anemia defisiensi besi Riwayat diare sebelumnya Pemberian susu hewan Umur, pendidikan dan pengalaman ibu Pola penyapihan

PENATALAKSANAAN DIARE

REDHIDRASI NURTISI OBAT JIKA DIPERLUKAN EDUKASI ORANG TUA

MASALAH

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

Antibiotic-associated diarrhea

Diarrhea patients ANTIBIOTIC


Non-diarrhea patients

Prolonged/Persistent diarrhea

Diarrhea

AAD in hospitalized children

KENAPA TERJADI

ORANG TUA MINTA OBAT DOKTER : KURANG PERCAYA DIRI ORT TIDAK MENGOBATI DIARE PROMOSI OBAT

PENENTUAN DERAJAT DEHIDRASI

Penilaian
Lihat: Kead. Umum Mata

A
Baik, sadar Normal

B
* Gelisah,

C
* Lesu,

rewel

lunglai, tak sadar

Cekung

Sangat cekung & kering

Air mata
Mulut dan lidah Rasa haus Periksa Turgor kulit Hasil pemeriksaan

Ada
Basah Minum biasa tidak haus Kembali cepat Tanpa dehidrasi

Tidak ada
Kering * Haus, ingin minum banyak
* Kembali lambat

Tidak ada
Sangat kering * Malas minum atau tidak bisa minum
* Kembali sgt

lambat

D. Ringan/sedang
1 tanda * (+) 1 atau lebih tanda lain

Dehidrasi berat
1 tanda * (+) 1 atau lebih tanda lain

Terapi

Rencana terapi A

Rencana terapi B

Rencana terapi C

PLAN TREATMENT A

Tanpa dehidrasi Muntah (-) pemberian makan sesuai umur malabsorpsi (-) tidak ada diet spesifik complex carbohydrate, fruit, vegetables ORS ?

PLAN TREATMENT B

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


or
Umur Total ORS < 1 tahun 300 ml 1-5 tahun 600 ml > 5 tahun 1200 ml dewasa 2400 ml

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

PLAN TREATMENT C

Dehidrasi Berat, IVFD Age Ist treatment 30 ml/BW in Infant < 12 months 1 hour Child > 12 months - 1 hours

2nd treatment 70 ml/BW in 5 hour 2 - 3 hours

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

ANTIBIOTIKA

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

EFEK SAMPING ANTIMIKROBA


1. PERUB. FLORA USUS 2. OVERGROWTH: - MONILIA - ENTEROCOCCUS - ANAEROB - PSEUDOMONAS 3. KERUSAKAN MUKOSA USUS 4. IRITASI 5. PSEUDOMEMBRANOUS ENTEROCOLITIS 6. BLOOD DYSCRASIA 7. MUNTAH

Therapi

Terbaru

Beberapa penelitian telah dilakukan dalam terapi diare adsorbant, mucoprotector, antisecretory, probiotic

PROBIOTIK

Kuman baik: efek positif thd kesehatan Bifidobacteri dan Lactobacillus Bermanfaat dalam tatalaksana diare akut, diare nosokomial, diare karena antibiotik

Protective Properties of Bifidobacteria


Inhibition of pathogens

Activation of the immune system

Lowering pH in environment Synthesis of digestive enzymes

Synthesis of vitamins

> 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)

Probiotics intervention to modulate immune response


Produce antibiotic molecules

Probiotics
Strengthen host defenses

Competitive binding on intestinal mucosa

Enhance secretory antibody

Tighten mucosal barrier

Balance T helper cells response

Produce volatile fatty acids and modify bile acids

PROBIOTIC AGENTS

Lactobacillus GG Lactobacillus acidophilus Bifidobacterium bifidum Enterococcus faecium Bifidobacterium longum Lactobacillus plantarum Streptococcus thermophilus Saccharomyces boulardii

RCT of probiotic for treatment of acute diarrhea


PROBIOTIC L rhamnosus AUTHORS Isolauri, 1991 Raza, 1995 Pant, 1996 Shornikova, 1997 Guandalini, 2000 Shornikova, 1997 Shornikova, 1997 Cetina-Sauri, 1989 N 71 40 26 123 287 66 40 130 DAY 5 2 2 5 5 5 5 4 TREATMENT GROUP 1.4 days 31% (at day 2) 1.9 days 2.7 days 2.4 days 1.5 days 26% (at day 2) 15% (at day 2) CONTROL GROUP 2.4 days 75% (at day 2) 3.3 days 3.7 days 3.0 days 2.5 days 81% (at day 2) 60% (at day 2)

L reuteri

S boulardii

Treatment of Acute Diarrhea


META-ANALYSIS

Lactobacillus therapy for acute infectious diarrhea in children 9 studies (out of 26 studies published from 1966 to 2000) Reduction in diarrhea duration of 0.7 days (95% CI: 0.31.2 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 diarrhea
Van 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 diarrhea 23 studies: n=1917, 76% children Lactobacillus (21 studies), Saccharomyces boulardi (2 studies) Patients who receives probiotic were less likely to have diarrhea lasting >3 days Mean duration of diarrhea was reduced by 30 hours
Allen et al, 2004

Prevention of infantile diarrhea


RCT

55 infants aged 5-24 months hospitalized for non-GI diseases Formula : Bifidobacteria vs control Observe for 7 months Diarrhea episode decreased (7% vs 31%) Rotavirus infection decreased (10% vs 39%)
Saavedra et al, 1994

Prevention of nosocomial diarrhea in infants: RCT

ND is a major problem in pediatric hospital worldwide 81 children aged 1-36 months hospitalized for reason other than diarrhea RCT: LGG (n=45) vs placebo (n=36) LGG 6x109 cfu twice daily LGG 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 diarrhea

Antibiotic associated diarrhea Metronidazole / vancomicyn Relapse Treatment with Lactobacillus casei Bacteria-produced substance inhibit in vitro the growth of enteropatogens, including C. difficile Prevent relapse of C difficille diarrhea
Biller et al (1995), Bennet et al (1987), Silva et al (1987)

SUPLEMENTASI SENG

Komponen >300 enzim dan dibutuhkan untuk sintesis DNA, protein dan mitosis Prevalensi defisiensi Zn: 44-60% Angka kejadian diare 47% lebih tinggi pada anak dengan defisiensi Zn Metaanalisis: secara bermakna menurunkan angka kejadian diare akut, disentri, diare persisten, pneumonia Pada diare: 20 mg Zn selama 10-14 hari

Zinc Defficiency

In children < 5 years Increase 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 Diarrhoea Research Findings

15% reduction in duration of acute diarrhoea 24% reduction in duration of persistent diarrhoea 42% reduction in treatment failure or death in persistent diarrhoea

Zinc Investigators Collaborative Group. AJCN 2000.

Additional Preventive Aspects of Zinc Treatment

Zinc 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 Statement

WHO 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

Pencegahan

VAKSIN ROTAVIRUS

Rotavirus sebagai penyebab utama diare pada anak di dunia Infeksi alamiah rotavirus: infeksi primer menimbulkan gejala klinis berat, selanjutnya lebih ringan dan asimptomatis Vaksin rotavirus oral Masih mahal

9 Pilar tatalaksana diare dehidrasi ringan sedang pada anak

Menggunakan CRO Cairan hipotonik Rehidrasi oral cepat (3-4jam) Realimentasi cepat dengan makanan normal Tidak dibenarkan memeberikan susu formula khusus Tidakdibenarkam memberikan susu yang diencerkan ASI diteruskan Suplemen dengan CRO (rumatan) Anti diare tidak diperlukan
Kelompok Ahli Gastroenterologi dunia

KESIMPULAN

Utamakan rehidrasi oral sejak dini Rujuk kasus berat ke RS untuk TRP Dukungan nutrisi untuk mencegah malnutrisi Penggunaan antibioitik secara rasional Suplementasi Zn Probiotik Edukasi pada orangtua

TERIMA KASIH