DIARRHEA IN

CHILDREN
dr. Woro Indri Padmosiwi SpA
Child Health Department
Prof. Dr. W. Z. Johannes Hospital, Kupang-NTT
Epidemiology
 1.2 million - 530 000
Breast feeding
Hand hygiene
Clean water
Enviromental hygiene
Zinc
Immunization

United Nations Children's Fund (UNICEF)

 Diarrhea in worldwide

Mortality 530 000

Inpatient 2.4 milions

Outpatient 24 millions

Morbidity 114 millions

Outbreak diarrhea in Indonesia

2008 69 districts
8133 cases
239 death

24 districts
2009
5756 cases
100 death

33 districts
2010 4204 cases
73 death
 Cause of death in Indonesia

0-11 months % 12-59 months %

n = 173 n = 103
1 Diarrhea 15 Diarrhea 17.2
2 Pneumonia 12.7 Pneumonia 13.2
3 Meningitis 4.5 Tetanus 1.5
4 Congenital 5.7 Meningitis 5.1
5 Tetanus 1.7 Congenital 4.9

Basic health surveillance 2007

 Diarrhea situation in Indonesia 2013

Incidence for all age population is 350/1000 population

and
670/ 1000 children < 5 years old

Basic health surveillance 2013

 Diarrhea in Indonesia 2003-2014

Diarrhea cases in Indonesia

1200
996.7
1000
Diarrhea morbidity

800

600
423 411
374
400
214
200

0
2003 2006 2010 2012 2014
year
per a thousand population
 Diarrhea episode in children
3
2.6
Diarrheal episode

2.5

1.5 1.3 1.3 1.28

1
1

0.5

0
2003 2006 2010 2012 2014
Year
diarrheal episode in children <5 years old

Diarrhea, Gastrointestinal Infection, and Hepatitis Morbidity Survey,

Ministry of Health of Indonesia
Stool Characteristics in children under 5 years old
in Indonesia 2014

Percenta
ge

common diarrhea

bloody stool
rice water stool

mucus in stool

specific smell in stool

unknown

Diarrhea, Gastrointestinal Infection, and Hepatitis Morbidity Survey,

Ministry of Health of Indonesia
Rapid Survey 2015
Sub Dit Diarrhea
Incidence of diarrhea
Cause of diarrhea
Alarm sign
Prevention of diarrhea
Zinc
Active oral rehidration
 Diarrhea cases in Indonesia in 2016
NO PROVINCE TOTAL DIARRHEA CASES

1 ACEH 21,004
3 WEST SUMATERA 36,322
4 RIAU 18,970
5 RIAU ISLANDS 24,310
6 JAMBI 66,207
7 SOUTH SUMATERA 43,116
8 BENGKULU 17,080
9 LAMPUNG 104,486
10 DKI JAKARTA 18,344
11 WEST JAVA 553,063
12 CENTRAL JAVA 100,001
13 DI YOGYAKARTA 8,424
14 EAST JAVA 414,887
16 CENTRAL KALIMANTAN 25,577
17 SOUTH KALIMANTAN 23,725
Diarrhea, Gastrointestinal Infection, and Hepatitis Morbidity Survey, Ministry of Health of Indonesia

Diarrhea, Gastrointestinal Infection, and Hepatitis Morbidity Survey,

Ministry of Health of Indonesia
Diarrhea cases in Indonesia in 2016
NO PROVINCE TOTAL DIARRHEA CASES

18 EAST KALIMANTAN 73,721

19 NORTH KALIMANTAN 6,337
21 CENTRAL SULAWESI 48,401
22 SOUTH SULAWESI 171,690
23 SOUTH EAST SULAWESI 33,463
24 WEST SULAWESI 25,552
25 BALI 28,548
26 WEST NUSA TENGGARA 83,966
27 EAST NUSA TENGGARA 66,341
28 MALUKU 15,377
30 PAPUA 35,109
32 BANTEN 164,679
34 BANGKA BELITUNG 29,731
TOTAL 2,222,109

Diarrhea, Gastrointestinal Infection, and Hepatitis Morbidity Survey,

Ministry of Health of Indonesia
 Diarrhea cases in Indonesia in 2016
> 50 000 cases

South
Banten Sulawesi
164,679 171,690
Central Java
Lampung 100,001
104,486

East Nusa
West Java Tenggara
East Java
553,063 66,341
414,887 West Nusa
Tenggara
88,966

Diarrhea, Gastrointestinal Infection, and Hepatitis Morbidity Survey,

Ministry of Health of Indonesia
Pathophysiology
 Daily water exchanges
Duodenum Ileum Colon
Jejunum 2 liters Rectum
5.5 liters 1.3 liters

Stool
5ml/kg
Food and (children)
fluid
Intake
2 liters 200 ml
(adults)
7 liters
Endogenous secretions: intestinal,
pancreatic, salivary, biliary and
gastric juices
 Normal state
Villus Tip
Absorption

Crypt
Secretion
Diarrhea (infectious)

Destruction of enterocytes
EIEC, rotavirus, shigella

Defective absorption

Hypersecretion

Vibrio cholerae,
rotavirus, ETEC, shigella
 Lactose
intolerance
 Lactose intolerance

Lactase deficiency
Bacterial fermentation
Wattery diarrhea, gasses,
acid smell, abdominal
distension, flatus, anal
erytema
Stool pH and glucose
Osmotic Secretoric
diarrhea diarrhea
 Nutrien

Not absorbed

Bacterial fermentation
Osmotic diarrhea
Organic acid

Osmotic gradient increase

Diarrhea
 Microrganism

Toxin

Secretoric diarrhea c-AMP, c-GMP stimulation

Increase secretion of water/electrolyte

Diarrhea
Zuckerman et al, eds. Principles and Practice of Clinical Virology. 2nd ed. London: John Wiley & Sons; 1990
Zuckerman et al, eds. Principles and Practice of Clinical Virology. 2nd ed. London: John Wiley & Sons; 1990
 Osmotic Secretoric

Osmotic Secretoric
Stool volume < 200 ml/day > 200 ml/day
Fasting Diarrhea (-) Diarrhea (+)
Na+ < 70 mEq/l > 70 mEq/l
Stool glucose (+) (-)
Stool pH <5 >6
Assessment
and
Management
Diarrhea in children

85 % improved < 7 days

10 % improved 7-14 days

(prolonged)

5 % persistent > 14 days

(persistent)
 How long
> 14 days ?

Cause of diarrhea
Bloody diarrhea ?

Degree of dehydration
Degree of dehydration

WHO-CDC
 WHO

Some Dehydration Severe Dehydration

Restless, Irritable Lethargic or unconscious

Sunken Eyes Sunken Eyes

Drinks eagerly, Thirsty Not able to drink or drinking poorly

Skin Pinch goes back slowly Skin Pinch goes back very slowly

OR NO DEHYDRATION
 Five pillars

1. Rehydration
2. Nutrition
3. Zinc
4. Selective antibiotics
5. Education
 Plan of Treatment

No Dehydration PLAN-A

Some Dehydration PLAN-B

Severe Dehydration PLAN-C

 PLAN A

4 Rules of Home Treatment

Give extra fuid
Coninue feeding
When to return (advice to mother)
Give oral Zinc
 PLAN B

In PHC
Give 75 ml/kg of ORS in first 4 hours
If the child wants more, give more
After 4 hours
Re-assess and classify degree of
dehydration
 PLAN C

Start IV Fluid immediately

Give 100 ml/kg of Ringers Lactate

Age 30ml/kg 70 ml/kg

Under 12 months 1 hour 5 hours

12 months and older hour 2 hours

Thankyou