Original Article

Characteristics of Pediatric Patients with Diarrhea in

Indonesia: A Laboratory-based Report
Lia Amanda1, Karin Nadia Utami1, Andria Amanda Pulungan1, Diar Riyanti Rudiatmoko1, Fatima
Safira Alatas2
1
Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
2
Department of Child Health, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta,
Indonesia

Corresponding author:
Fatima Safira Alatas, MD, PhD
Abstract:
safiraalatas@gmail.com
Background: Diarrhea is still a common health problem in Indonesia, with high
morbidity and mortality rate. The severity of diarrhea is associated with age, nutritional
status, and cause of diarrhea. This study aims to describe the characteristics and
laboratory findings, particularly stool analysis, in pediatric patients with diarrhea.
Published: Methods: A retrospective study was conducted using data from patients aged 0 to 18
25 August 2022 with diarrhea who underwent stool analysis in Cipto Mangunkusumo Hospital
between 2012 and 2016.
DOI:
https://doi.org/10.58427/apg Results: The average age of children with diarrhea was 45 months, with most patients
hn.1.2.2022.8-15 (55,6%) being under two years old children. More than half of the patients were boys
(58.8%). Two-thirds of the patients (67%) presented with watery stool diarrhea. The
interpretation of stool analysis indicated that nearly half of the patients (48%)
experienced diarrhea due to bacterial infection, followed by fat malabsorption
(20.8%). Similar results were also seen in the stool analysis of children aged 0-24
Citation:
months, with the prevalence of bacterial infection (35.2%) and fat malabsorption
Amanda L, Utami KN,
Pulungan AA, and Alatas FS. (30.2%) being the most commonly identified etiology of diarrhea.
Characteristics of Pediatric Conclusion: In Indonesia, children under two and male gender were more frequently
Patients with Diarrhea in reported to experience diarrhea. The primary manifestation of pediatric diarrhea was
Indonesia: A laboratory-based
Report. Arch Pediatr Gastr watery stools, while the most common etiology was bacterial infections.
Hepatol Nutr. 2022(2):8-15
Keywords: diarrhea, stool analysis, pediatric patients

Introduction
The high morbidity and mortality rates of diarrhea remain a major concern in
developing countries, including Indonesia. Diarrhea is the recurrent passage of watery
stools that occurs at least three times in 24 hours. The disease is further classified as
acute diarrhea, which occurs for less than seven days; prolonged diarrhea, occurring
for 7-14 days; and persistent diarrhea that last for more than 14 days.1

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 The severity of diarrhea is associated with the age of the patient, nutritional status, and
the underlying cause of diarrhea.1 According to RISKESDAS 2013, infant is the main
age group that suffered from diarrhea. In addition, diarrhea in this particular age group
primarily occurred at the age of 12-23 months (7.6%), majorly in the male gender
(5.5%), and commonly in patients who lived in the countryside (6.2%). 2

A cross-sectional study conducted by Hendrawati et al. reported that more than 25%
of children with diarrhea also suffered from malabsorption syndrome, with the
prevalence of lactose and fat malabsorption were 11% and 51%, respectively.
Furthermore, this study found that 19% of 3480 stool specimens of pediatric patients
show signs of maldigestion. Food allergy may also lead to malabsorption. In addition,
previous study found that the prevalence of cow’s milk allergy in patients with diarrhea
in Indonesia was 3%.3,4

The purpose of this study was to identify the characteristics and laboratory findings
of pediatric patients based on their stool analysis profile treated in Cipto
Mangunkusumo Hospital.

Methods
This research was a retrospective, cross-sectional study conducted in Cipto
Mangunkusumo Hospital, Jakarta, Indonesia. Patients aged 0 to 18 years old who
suffered from diarrhea and underwent stool examination in the Laboratory of
Gastrohepatology Division, Department of Child Health, Cipto Mangunkusumo
Hospital were included in this study. Meanwhile, subjects with incomplete medical
records were excluded. Stool analysis and other supporting data were obtained from
the medical records documented in 2012 – 2016. Other supporting data include age,
gender, history of bacterial infection, fungal infection, food maldigestion,
carbohydrate maldigestion, protein maldigestion, lactose malabsorption, fat
malabsorption, and suspected cow milk allergy.

Bacterial infection was considered positive if the stool leucocyte count was higher than
+2 or 10-20 leucocytes per high magnification field. 3 Meanwhile, the diagnosis of
fungal infection was noted in samples with positive appearance of fungal. Food
maldigestion was indicated by the presence of meat or vegetable fibers in the stool,
while carbohydrate maldigestion was considered positive in the existence of amylum.3,5
The presence of the protein molecule indicated protein maldigestion. 5 Furthermore,
the diagnosis of lactose malabsorption was established in samples with fecal pH less
than 6, or if the fecal reducing substance results read as 0, trace (1/4% glucose), +
(1/2% glucose), ++ (3/4% glucose), +++ (1% glucose), and ++++ (2% glucose).6,7
Fat malabsorption was confirmed if the amount of fat exhibited positive 2 (++) in the
microscopic examination.3 Lastly, cow’s milk allergies were suspected in patients with

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 erythrocyte counts in stool > 5. The data collected were then quantified using SPSS
version 21.

All data, including other personal information provided and gathered, was kept
confidential. This research had received ethical permission no.
964/UN2.F1.D1/KBK/PDP.01/2016.

Result
Subjects Demographics
From 2012 until 2016, stool analysis was performed on 1031 pediatric patients with
diarrhea in Cipto Mangunkusumo Hospital. The age ranged between 0 to 18 years old,
with the average age of 45 months. Most of the patients were children under two years
old (55.6%). Furthermore, more than half of the patients (58.8%) were male.

Table 1. Characteristics of study subjects

Characteristics n (%)
Gender
Male 606 (58.8)
Female 423 (41)
Age
<24 months 573 (55.6)
24-59 months 191 (18.5)
>60 months 262 (25.4)

Consistency of the Stool

The stool analysis results demonstrated various stool characteristics such as
consistency, and laboratory findings. Among the 857 patients, 67% of the patients
presented with watery stool diarrhea.

Table 2. Consistency of stool analysis in this study

Consistency n (%)
Normal 155 (15)
Solid 11 (1.1)
Liquid 691 (67)

Laboratory Findings and Interpretation

Various laboratory examinations of the stool samples were performed to determine
the cause of diarrhea. Each etiology presented distinct characteristics, which were
mentioned in the methodology. One patient might have more than one significant
laboratory findings and hence was diagnosed with more than one causes of diarrhea.

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 Most of the samples demonstrated the presence of leucocytes, erythrocytes, and fat.
Positive results with a low number of these components in stool can be considered
normal. However, excessive amounts may indicate various conditions such as bacterial
infection, dysentery, or fat malabsorption.

Table 3. Stool analysis profile of the study subjects

Laboratory Findings* n (%)
Mucus 536 (52)
Blood 25 (2.4)
Leucocyte
+1 273 (26.5)
+2 395 (38.3)
+3 198 (19.2)
Erythrocyte
+1 471 (45.7)
+2 200 (19.4)
+3 82 (8.0)
Fat
+1 347 (33.7)
+2 188 (18.2)
+3 63 (6.1)
Amylum 129 (12.5)
Plant fibers 192 (18.6)
Muscle fibers 34 (3.3)
Occult blood 337 (32.7)
pH
6 or more 951 (92.2)
Less than 6 80 (7.8)
Glucose
0.25% 22 (2.1)
0.50% 36 (3.5)
0.75% 8 (0.8)
1% 16 (1.6)
2% 3 (0.3)
Parasites 6 (0.6)
Fungi 216 (21)
*One participant might present with more than 1 significant findings

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 The laboratory findings of each participant were then interpreted to determine the
etiology of diarrhea. The most common interpretation indicated that most patients
suffered from diarrhea caused by bacterial infection (48%).

Table 4. Interpretation of stool analysis profile in patients aged 0-18 years

Diagnosis* n (%)
Bacterial infection 503 (48.8)
Fungal infection 80 (7.8)
Carbohydrate maldigestion 130 (12.6)
Food maldigestion 187 (18.1)
Protein maldigestion 29 (2.8)
Fat malabsorption 214 (20.8)
Lactose malabsorption 76 (7.4)
Suspected cow’s milk allergy 45 (4.4)
Dysentery/Infective colitis 143 (13.4)
*One participant might have more than 1 interpretation

Table 5. Interpretation of stool analysis profile in patients aged 0-59 months

Diagnosis* n (%)
Bacterial infection 269 (35.2)
Fungal infection 49 (6.5)
Carbohydrate maldigestion 72 (9.5)
Food maldigestion 81 (10.7)
Protein maldigestion 9 (1.2)
Fat malabsorption 228 (30.2)
Lactose malabsorption 76 (10.1)
Suspected cow’s milk allergy 42 (5.6)
Dysentery/Infective colitis 94 (12.4)
*One participant might have more than 1 interpretation

Discussion
The relationship between diarrhea and nutrition has been discussed widely. Many
factors contributed in the effect of diarrhea towards nutritional status. Increased

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 nutrients loss, malabsorption, maldigestion, and the impact of inflammatory responses
are some of the factors involved in diarrhea with malnutrition. In this study, diarrhea
mainly occurred in children aged 0-24 months (55.6%). This result was similar to other
research in Indonesia, which stated that diarrhea mainly occurred in children aged less
than 24 months with the prevalence of 56.68%.8

This study demonstrated that the prevalence of diarrhea in children, especially boys,
was higher than in girls. It is similar to a study done in a hospital located in Yogyakarta,
Indonesia.9 Another study in Munimbili National hospital also revealed that 60% of
diarrhea patients were boys aged 7-12 months old.10

The characteristics of stool analysis varied among patients. The most prevalent
consistency among the samples in our study was liquid / watery stool (67%). Diarrhea
can cause malabsorption when the fluid volume in the colon is higher than the
absorption capacity. Damage in the intestine due to diarrhea decreases absorption and
increases secretion, generating the liquid consistency of the stool.1

Leukocytes in stools are produced as a response to the inflammatory process in the

mucosa of the colon. The presence of leukocytes in the feces indicates the existence
of invasive bacteria or bacteria-produced cytotoxin, which may cause tissue damage.
Furthermore, higher numbers of leukocytes increase the likelihood of invasive
pathogens infection. Fecal leukocyte stain was considered to have better accuracy and
diagnostic value in determining the etiology of diarrhea.11, 12 In our study, the number
of samples with leukocyte counts of +2 was higher than patients with leukocytes count
of +3, which accounted for 38.3% and 19.2% respectively.

The erythrocyte counts in our study were accounted for 19.4% (+2) and 8% (+3),
respectively. Although there was still no consensus in interpreting the erythrocytes
count in stool analysis, a study in Bangladesh had reported the benefit of direct
microscopical stool examination to quantify the leukocytes and erythrocytes in making
an early diagnosis of Shigella infection.13

Diarrhea is commonly related to motility dysfunction. Changes in motility can affect

absorption and lead to diarrhea. The reduction in motility promotes faster growth of
bacteria, as the pathogen can invade the intestine and disrupt the immunity of the
mucosal intestine, leading to the disruption of nutrient absorption.14

Based on the interpretation of stool analysis, bacterial infections were the most
frequently identified etiology of diarrhea in our study. It contradicts other findings,
which stated that viral infection was more likely to cause diarrhea in children. 15
However, our study did not perform any viral examination and stool culture.

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 Therefore, the presence of viral infection and the type of bacteria causing diarrhea
could not be determined.

Diarrhea can cause maldigestion and malabsorption, which decreases nutrient

absorption. The main types of maldigestion and malabsorption that frequently
occurred in this study were fat malabsorption (20.8%), food maldigestion (18.1%), and
carbohydrate maldigestion (12.6%). Despite the lack of information on the prevalence
of food maldigestion, a study by Hendrawati et al. stated that the prevalence of fat
malabsorption and carbohydrate maldigestion were 51% and 19%, respectively. These
findings were higher compared to our study.3 The lower prevalence in our study could
be caused by the absence of data in some medical records. In addition, Hendrawati et
al. found that the peak incidence of carbohydrate maldigestion occurred at the age of
12-59 months.3 Carbohydrate is a component of diet with the highest percentage of
consumption in children at this particular age (12-59 months old). Furthermore,
diarrhea caused by Enterotoxigenic E.coli (ETEC) was found to occur more
frequently in children aged 12-59 months old. Diarrhea caused by ETEC is classified
as secretory diarrhea, in which the increase in intestinal motility and decrease in transit
time were observed. This will cause rapid contact between digestive enzymes and
carbohydrates, leading to inadequate digestion of carbohydrates, which results in the
occurrence of carbohydrate maldigestion.16

Conclusion
Diarrhea in children mainly occurs before two years old, particularly in boys than girls.
Watery diarrhea was the most frequent type of diarrhea, and bacterial was found to be
the primary etiology.

Conflict of Interest
None declared.

Funding
This research was a self-funded study.

Acknowledgement
The authors would like to thank the medical record and laboratories staffs in Cipto
Mangunkusumo Hospital for their support and help during the study.

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