7. SIMPULAN dan SARAN
7.2. Saran
1. Penelitian lain diperlukan dengan jumlah subjek lebih besar untuk menilai hubungan faktor risiko defisiensi zinc dengan diare melanjut
2. Pada diare akut perlu dicermati riwayat diare sebelumnya, guna mencegah diare akut menjadi diare melanjut.
3. Diperlukan penelitian lain dengan menyingkirkan faktor bias dan menyertakan riwayat asupan makanan serta pemeriksaan kadar zinc tidak hanya pada serum juga pada feses.
1. Diarrhea: Why children are still dying and what can be done. Diunduh dari:http://whqlibdoc.who.int/publications/2009/9789241598415_eng.pdf. Diakses 8 Februari 2013.
2. Report on Result of National Basic Health Research (RISKESDAS 2007).
Diunduh dari:
http://203.90.70.117/searo/Indonesia/LinkFiles/Health__Information_and_evi dence_for_policy_Riskesdas_2007.pdf. Diakses 8 Februari 2013.
3. Ricci KA, Girosi F, Tarr PI, LimYW, Mason C, Miller M, dkk. Reducing stunting among children: the potential contribution of diagnostics. Nature. 2006;444:29–38.
4. Moore SR. Update on prolonged and persistent diarrhea in children. Curr Opin Gastroenterol. 2011:27;19–23.
5. Walker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA. Childhood pneumonia and diarrhoea 1: Global burden of childhood pneumonia and diarrhea. Diunduh dari:http://press.thelancet.com/DPSeries1.pdf. Diakses tanggal 1 Spetember 2013.
6. Profil Data Kesehatan Indonesia Tahun 2010. Diunduh dari:http://www.depkes.go.id/downloads/profil_data_kesehatan_indonesia_tah un_2011.pdfs. Diakses tanggal 7 September 2013.
7. Farthing M, Lindberg G, Dite P, Khalif I, Salazar-Lindo E, Ramakrishna BS, dkk. World gastroenterology organisation practice guideline: acute diarrhea.
March 2008. Diunduh
dari:http://www.worldgastroenterology.org/assets/downloads/en/pdf/guideline s/01_acute_diarrhea.pdf. Diakses 13 Maret 2013.
8. Guarino A, De Marco G. Persistent diarrhea. Dalam: Walker WA, Goulet O, Kleinman RE, Sherman PM, Shneider BL, Sanderson IR, penyunting. Pediatric gastrointestinal disease. Edisi ke-4. Hamilton, Ontario: BC Decker; 2004. h.180-93.
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9. Moore SR, Lima NL, Soares AM, Oria RB, Pinkerton RC, Barrett LJ, dkk. Prolonged episodes of acute diarrhea reduce growth and increase risk of persistent diarrhea in children. Gastroenterology. 2010;139:1156-64.
10. Bhutta ZA, Nelson EA, Lee WS, Tarr PI, Zablah R, Phua KB, dkk. Recent advances and evidences gaps in persistent diarrhea. J Pediatr Gastroenterol Nutr. 2008;47:260-5.
11. Bern C. Diarrhoeal disease. Global epidemiology of infectious disease. Diunduh dari: http://whqlibdoc.who.int/publications/2004/9241592303.pdf. Diakses 26 April 2012.
12. World Health Organization. The treatment of diarrhoea. A manual for physicians and other senior health workers. Diunduh dari:
http://whqlibdoc.who.int/hq/2003/WHO_FCH_CAH_03.7.pdf. Diakses
tanggal 2 Juli 2013.
13. Caulfield LE, Black RE. Zinc deficiency. Diunduh dari:
www.who.int/publications/cra/chapters/volume1/0257-0280pdf. Diakses
tanggal 24 Juni 2013.
14. Walker CLF, Black RE. Functional indicators for assessing zinc deficiency. Food Nutr Bull. 2007;3:S454-79.
15. Walker CLF, Ezzati M, Black RE. Global and regional child mortality and burden of disease attributable to zinc deficiency. Eur J Clin Nutr. 2009:63;591-7.
16. International Zinc Nutrition Consultative Group (IZincG), Hotz C, Brown KH, penyunting. Assessment of the risk of zinc deficiency in population and options for itscontrol [Technical Document]. Food Nutr Bull. 2004;25:94– 204.
17. Scrimgeour AG, Lukaski HC. Zinc and diarrheal disease: current status and future perspectives. Curr Opin Clin Nutr Metab Care. 2008;11:711–7.
18. Wapnir RA. Zinc deficiency, malnutrition and gastrointestinal tract. J Nutr. 2000;130:1388S-92S.
19. Cuevas LE, Koyanagi A. Zinc and infection: a review. Ann Trop Paediatr. 2005;25:149-60.
20. Dhingra U, Hiremath G, Menon VP, Dhingra P, Sarkar A, Sazawal S. Zinc deficiency: descriptive epidemiology and morbidity among preschool children in peri-urban population in Delhi, India. J Health Popul Nutr. 2009;27:632-9. 21. Bitarakwate E, Mworozi E, Kekitiinwa A. Serum zinc status of children with
persistent diarrhea admitted to diarrhea management unit of Mulago hospital, Uganda. Afr Health Sci 2003;3:54–60.
22. Hoque KM, Sarker R, Guggino SE, Tse CM. A new insight into pathophysiological mechanisms of zinc in diarrhea. Ann NY Acad Sci. 2009;1165:279-84.
23. Lazzerini M, Ronfani L. Oral zinc for treating diarrhoea in children. Cochrane Database of Systematic Reviews 2013, Issue 1. Diunduh dari:
http://www.bibliotecacochrane.com/pdf/CD005436.pdf. Diakses tanggal 22 Juni 2013.
24. Bahl R, Bhandari N, Hambidge M, Bhan MK. Plasma zinc as predictor of diarrheal and respiratory morbidity in children in an urban slum setting. Am J Clin Nutr. 1998;68:414S-7S.
25. Bhutta ZA, Black RE, Brown KH, Gardner JM, Gore S, Hidayat A, dkk. Zinc investigators collaborative group. Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries: Pooled analysis of randomized controlled trials. J Pediatr. 1999;135:689-97.
26. Aggarwal R, Sentz J, Miller MA. Role of zinc administration in prevention of childhood diarrhea and respiratory illnesses: a meta-analysis. Pediatrics. 2007;119;1120-30.
27. Guandalini S. Acute diarrhea. Dalam: Walker WA, Goulet O, Kleinman RE, Sherman PM, Shneider BL, Sanderson IR, penyunting. Pediatric Gastrointestinal and Liver Disease. Edisi ke-4. Hamilton, Ontario: BC Decker; 2004. h.166-79.
28. Bhutta ZA, Ghishan F, Lindley K, Memon IA, Mittal S, Rhoads JM. Persistent and chronic diarrhea and malabsorption: working group report of the second world congress of pediatric gastroenterology, hepatology, and nutrition. J Pediatr Gastroenterol Nutr. 2004:39;711-6.
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29. Thapar N, Sanderson IR. Diarrhoea in children: an interface between developing and developed countries. Lancet 2004;363:641–53.
30. World Health Organization. Diarrhoeal disease control programme. Persistent diarrhea in children in developing countries: memorandum from a WHO meeting. Bull World Health Org. 1988:66;709-17.
31. Stanly MA, Sathiyasekaran BWC, Palani G. A population based study of acute diarrhoea among children under 5 years in a rural community in South India. Sri Ramachandra J Med. 2009;1:1-7.
32. Etiler N, Velipasaoglu S, Aktekin M. Risk factors for overall and persistent diarrhoea in infancy in Antalya, Turkey: a cohort study. Public Health. 2004;118:62-9.
33. Sodemann M, Jakobsen MS, Molbak M, Martins C, Aaby P. Episode-spesific risk factors for progression of acute diarrhoea to persistent diarrhoea in West African children. Trans R Soc Trop Med Hyg. 1999;93:65-8.
34. Carlos J, Haro A, Ramirez PC, Tostado HR, Chavez ER, Alicia Y, dkk. Changing trends in prevalence, morbidity, and lethality in persistent diarrhea of infancy during the last decade in Mexico. Arch Med Res. 2003;34:209-13. 35. Vernacchio L, Vezina RM, Mitchell A, Lesko SM, Plaut AG, Acheson DW.
Characteristics of persistent diarrhea in a community-based cohort of young US children. J Pediatr Gastroenterol Nutr. 2006;43:52-8.
36. Trihatmodjo P, Simanjuntak CM, Firmansyah A, Suharyono. Etiologi mikrobiologi diare kronik pada anak balita di Jakarta. CDK. 1993;85:52-6. 37. Ghani L. Faktor-faktor risiko terjadinya diare persisten di Bagian Ilmu
Kesehatan Anak FKUI RSCM Jakarta 1990-1996 [Tesis]. Fakultas Kesehatan Masyarakat FKUI 1997.
38. Dwipoerwantoro PG, Khairina A, Fadiana G. Pathogens associated with non-HIV persistent diarrhea in children hospitalized in Cipto Mangunkusumo hospital, Jakarta, Indonesia: a 2-year retrospective study. Diunduh dari: http://www.kenes.com/wspid2011/abstracts/pdf/827.pdf. Diakses tanggal 8 Maret 2012.
39. Soenarto Y, Aman AT, Bakri A, Waluya H, Firmansyah A, Kadim M dkk. Burden of severe rotavirus diarrhea in Indonesia. J Infect Dis. 2009;200:S188-94.
40. Abba K, Sinfield R, Hart CA, Garner P. Pathogens associated with persistent diarrhoea in children in low and middle income countries: systematic review. BMC Infect Dis. 2009;9:88.
41. Karim ASMB, Akhter S, Rahman MDA, Nazir MFH. Risk factors of persistent diarrhea in children below five years of age. J Gastroenterol. 2001;20:59-61.
42. Umamaheswari, Biswal N, Adhisivam B, Parija SC, Srinivasan S. Persistent diarrhea: risk factors and outcome. Indian J Pediatr. 2010;77;885-8.
43. Patel AB, Ovung R, Badhoniya NB, Dibley MJ. Risk factors for predicting diarrheal duration and morbidity in children with acute diarrhea. Indian J Pediatr. 2012;79:472-7.
44. Direktorat Jenderal Pemberantasan Penyakit Menular dan Penyehatan Lingkungan Pemukiman. Buku ajar diare. Jakarta: Departemen Kesehatan Republik Indonesia; 1999.
45. Aldo A, Lima M, Guerrant L. Persistent diarrhea in children: epidemiology, risk factors, pathophysiology, nutritional impact, and management. Epid Rev. 1992;14:222-42.
46. Salgueiro MJ, Zubillaga M, Lysionek A, Sarabia MI, Care R, Paoli T dkk. Zinc as an essential micro nutrient: a review. Nutr Res. 2000; 20:737-55. 47. Salgueiro MJ, Zubillaga MB, Lysionek AE, Caro RA, Weill R, Boccio JR.
The role of zinc in the growth and development of children. Nutrition. 2002:18:510-9.
48. Duggan C, Gannon J, Walker WA. Protective nutrients and functional foods for the gastrointestinal tract. Am J Clin Nutr. 2002;75:789-808.
49. Akhtar S. Zinc status in South Asian populations—an update. J Health Popul Nutr. 2013;31:139-49.
50. Thurlow RA, Winichagoon P, Pongcharoen T, Gowachirapant S, Boonpraderm A, Manger MS dkk. Risk of zinc, iodine and other micronutrient
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defeiciencies among school children in North East Thailand. Eur J Clin Nutr. 2006;60:623-32.
51. Deghani SM, Katibeth P, Haghighat M, Moravej H, Asadi S. Prevalence of zinc deficiency in 3-18 years old children in Shiraz Iran. Iran Red Crescent Med J. 2011;13:4-8.
52. Atmarita. Nutrition problems in Indonesia. The article for an integrated International Seminar and Workshop on Lifestyle – Related Diseases Gajah Mada University, 19 – 20 March, 2005.
53. Dijkhuizen MA, Wieringa FT, West CE, Muherdiyantiningsih, Muhilal. Concurrent micronutrient deficiencies in lactating mothers and their infants in Indonesia. Am J Clin Nutr 2001;73:786–91.
54. Nriagu J. Zinc deficiency in human health. Diunduh dari:
http://www.extranet.elsevier.com/homepage_about/mrwd/nvrn/Zinc%20Defic
iency%20in%20Humans.pdf. Diakses 1 September 2013.
55. Schneider JM, Fujii ML, Lamp CL, Lonnerdal B, Zidenberg-cherr S. The prevalence of low serum zinc and copper levels and dietary habits associated with serum zinc and copper in 12 to 36 month old children from low income families at risk for iron deficiency. J Am Diet Assoc. 2007;107:1924-9.
56. Liu J, Ai Y, Hanlon A, Shi Z, Dickerman B, Compher C. Micronutrient deficiency and associated socio-demographic factors in Chinese children. World J Pediatr. 2011;7:217-23.
57. Strand TA. Adhikari RK. Chandyo RK, Sharma PR, Sommerfelt H. Predictors of plasma zinc concentration in children with acute diarrhea. Am J Clin Nutr. 2004;79:451-6.
58. Ugwuja EI, Nwosu KO, Ugwu NC, Okonji M. serum zinc and copper levels in malnourished pre-school age children in Jos, North central Nigeria. Pakistan J Nutr. 2007;6:349-54.
59. Khubchandani A, Sanghani H, Sidhu G, Sendhav S, Gandhi P, Solanki V. Serum copper and zinc level in preschool children with protein energy malnutrition. Int J Res Med. 2013;2:7-10.
60. Lowe NM, Fekete K, Decsi T. Methods of assessment of zinc status in humans: a systematic review. Am J Clin Nutr. 2009;89:2040S–51S.
61. Hotz C, Peerson JM, Brown KH. Suggested lower cutoffsof serum zinc concentrations for assessing zinc status: reanalysis of the second national health and nutrition examination survey data (1976–1980). Am J Clin Nutr. 2003;78:756–64.
62. Arsenault JE, Wuehler SE, Romana DL, Penny ME, Sempertegui F, Brown KH. The time of day and the interval since previous meal are associated with plasma zinc concentrations and affect estimated risk of zinc deficiency in young children in Peru and Ecuador. Eur J Clin Nutr. 2011;65:184–90.
63. Strand TA. Adhikari RK. Chandyo RK, Sharma PR, Sommerfelt H. Predictors of plasma zinc concentration in children with acute diarrhea. Am J Clin Nutr. 2004;79:451-6.
64. Khatun UHF, Malek MA, Black RE, Sarkar NR, Wahed MA, Fuchs G, Roy SK. A randomized controlled clinical trial of zinc, vitamin A or both in undernourished children with persistent diarrhea in Bangladesh. Acta Paediatr. 2001;90:376-80.
65. Roy SK, Tomkins AM, Ara G, Jolly SP, Khatun W, Chowdhury R, dkk. Impact of zinc deficiency on Vibrio cholera enterotoxin-stimulated water and electrolyte transport in animal model. J Health Popul Nutr. 2006;24:42-7. 66. Khalili B, Hart A, Mardani M, Khalili M, Mcardle F, Cuevas L.
Diarrhea-associated micronutrient deficiencies and risk of subsequent diarrhea in admitted children to Hajar hospital in Shahrekord, Iran. Iran J Clin Infect Dis 2007;2:121-8.
67. Patel AB, Mamtani M, Badhoniya N, Kulkarni H. What zinc supplementation does and does not achieve in diarrhea prevention: a systematic review and meta-analysis. BMC Infect Dis. 2011;11:122-39.
68. Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, Hidayat A, dkk. Zinc investigators collaborative group. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr. 2000;72:1516–22. 69. Lukacik M, Thomas RL, Aranda JV. A meta-analysis of the effects of oral
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70. Madiyono B, Moeslichan S, Sastroasmoro S, Budiman I, Purwanto SH. Perkiraan besar sampel. Dalam: Sastroasmoro S, Ismael S, penyunting. Dasar-dasar metodologi penelitian klinis. Edisi ke-4. Jakarta: Sagung Seto, 2011.h.348-82.
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79. Alloway BJ. Zinc in soils and crop nutrition. Edisi ke-2. Brussels and Paris: IZA and IFA; 2008.h.1-139.
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Lampiran 1. Formulir data penelitian Defisiensi Zinc sebagai Faktor Risiko Diare akut menjadi Diare Melanjut
Nama : ……… L / P No sampel:…..
Alamat : ………
Tanggal lahir : ……… Umur :………
Nama Ibu : ………. Umur ………tahun .
Pendidikan : ..……….
Nama ayah : ……….… Pekerjaan : ………. Pendapatan Rp …………./bulan
ANAMNESIS
Diare sejak …….. hari Konsistensi: cair/ampas
Lendir +/- Demam +/-
Muntah +/-
Mendapat ORALIT di rumah +/- ASI dilanjutkan : YA/TIDAK
Pemakaian obat-obatan: antibiotik -/+
Mendapatkan zinc: YA/TIDAK, berapa hari:…………. Riwayat diare berulang; YA/TIDAK
PEMERIKSAAAN FISIS
BB ……… kg, TB ………. Cm Tanda dehidrasi +/-
Kembung +/- Eritema natum +/- Status gizi : (pilih)
• Obesitas • Gizi lebih • Gizi Baik • Gizi Kurang
• Gizi Buruk tipe Marasmik/kwashiorkor DIAGNOSIS
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Lampiran 2. Lembar penjelasan dan persetujuan orangtua Bapak/Ibu yang saya hormati,
Seperti yang diketahui Bapak/Ibu bahwa diare masih merupakan penyebab kesakitan dan kematian pada anak.Untuk itu Divisi Gastrohepatologi Departemen Ilmu Kesehatan Anak FKUI RSCM melakukan penelitian yang berjudul “Defisiensi zinc sebagai faktor risiko diare akut menjadi diare melanjut”.
Tujuan penelitian ini salah satunya adalah mengetahui kadar zinc darah pada anak dengan diare. Dengan mengetahui kadar zinc darah, maka dapat diketahui apakah kadarnya normal atau kurang. Bila ternyata kadar zinc kurang dari normal, akan kami edukasi tentang manfaat zinc dan asupan yang mengandung zinc yang cukup.
Bila putra/putri Bapak/Ibu berusia >1bulan-60 bulan, mengalami diare dan Bapak/Ibu setuju mengikuti penelitian ini, maka Kami akan melakukan pengambilan sampel darah. Sampel darah diambil sebanyak 3mL yang akan dilakukan oleh perawat dalam pengawasan dokter. Pemeriksaan ini tidak dipungut biaya. Namun, tindakan pengambilan darah ini selain menimbulkan nyeri dan risiko infeksi, masih mungkin dapat terjadi kegagalan dan risiko perdarahan. Untuk meminimalkan risiko infeksi, pengambilan darah dilakukan dengan prosedur a dan antiseptik. Bila terjadi perdarahan, tindakan akan kami hentikan dan kami lakukan penekanan serta pembalutan untuk menghentikan perdarahan.
Bapak dan Ibu bebas memutuskan keikutsertaan anak dalam penelitian ini. Bila membutuhkan penjelasan lebih lanjut, Bapak/Ibu dapat menghubungi dr.Dede Lia di nomor telepon 08121280535.
Formulir Persetujuan
Semua penjelasan sudah disampaikan dan semua pertanyaan sudah dijawab oleh dokter. Saya mengerti dan bila masih terdapat hal yang perlu dijelaskan, saya akan mendapat penjelasan dari dr.Dede Lia. Dengan menandatangani formulir ini saya setuju putra/putri saya ikut serta dalam penelitian ini.
Jakarta,
Tanda tangan orangtua/wali
Nama jelas
Tanda tangan saksi
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Lampiran 3. Kuesioner follow-up
Nama : ……… L / P
No sampel : ………..
Alamat : ………
Tanggal lahir/umur : ……… 1. Berapa kali frekuensi buang air besar pasien?
2. Bagaimana konsistensi fesesnya? (berdasarkan skala tinja Bristol)
Lampiran 4. Skala Tinja Bristol
Tipe Gambar Keterangan
Tipe 1 Keras, mirip kacang (sulit
dikeluarkan)
Tipe 2 Seperti sosis tetapi masih
menggumpal/kental
Tipe 3 Berbentuk sosis
permukaannya retak
Tipe 4 Mirip sosis atau ular, empuk
dan halus
Tipe 5 Seperti gumpalan, lembut,
tepinya jelas, namun mudah dikeluarkan
Tipe 6 Potongan-potongan halus,
tepinya kasar, lembek
Tipe 7 Sama sekali tak berbentuk,