Gastrooesepageal Refluks (GER) atau Sering Muntah Pada Anak, Karena Pengaruh Alergi atau Hipersensitif Makanan

Gastrooesepageal Refluks atau Sering Muntah Pada Anak

Karena Pengaruh Alergi atau Hipersensitif Makanan 

 

Latar Belakang

• Audi, laki-laki usia 2 tahun sejak lahir hingga sekarang , sering mengalami muntah, meski dengan pertambahan usia berangsur berkurang. Setelah usia 9-12 bulan mulai timbul gangguan mengunyah dan menelan sehingga hanya mau minum susu dan makan harus diblender. Selain itu Audi mudah sekali terserang demam, batuk dan pilek. Selain mengalami gangguan tidur malam, dia juga mengalami keterlambatan bicara atau bila bicara tidak jelas dan gangguan perkembangan motorik kasar dan gangguan keseimbangan (usia 6-8 bulan tidak duduk dan merangkak, jalan terlambat, dan setelah bisa berjalan jalan sering terjatuh atau goyang) .  Setelah itu dokter mengadviskan untuk dilakukan penanganan alergi dan hipersensitifitas makanan dengan menghindari sementara beberapa makanan yang diduga penyebab alergi makanan ternyata tidak dalam waktu lama keluhan muntah membaik,  daya tahan tubuhnya semakin  dan beberapa keluhan lainnya  yang menyertai membaik.

Amati Gangguan Gastroesophageal Refluks dan Sering muntah  pada anak anda 

• Pada usia bayi di bawah 6 bulan sering muntah dan gumoh. Setelah usia 6 bulan hingga 2 tahun berkurang. Pada kasus tertentu membaik setelah usia 5 – 7 tahun
• Muntah atau mual timbul saat berlari, menangis, batuk, memasukkan tangan ke mulut, tercium bau tajam  (bau tidak enak, bau amis  atau terlalu wangi)

Gangguan lain yang sering Menyertai

• Gangguan mengunyah menelan :  Tidak menyukai variasi banyak makanan, tidak mau makan nasi hanya minum susu. Sering pilih-pilih makanan. Makanan yang disukai adalah makanan yang gampang dikunyah seperti telor, mi, krupuk, biskuit, brokoli, wortel. tetapi makanan yang berserat seperti daging sapi, sayur, atau nasi lebih tidak disukai.
• Sebagian Besar kasus anak berat badannya lebih atau kegemukan sebagian kecil lainnya sebaliknya sulit naik berat badan
• Gangguan Motorik kasar dan keseimbangan
• Gangguan sensoris :  sensitif terhadap suara (frekuensi tinggi) , cahaya (mudah silau), perabaan telapak kaki dan tangan sensitif  (jalan jinjit, flat foot, mudah geli, mudah jijik, tidak suka memegang bulu, boneka dan bianatang berbulu)
• Daya tahan menurun sering sakit demam, batuk, pilek setiap bulan bahkan sebulan 2 kali (normal sakit seharusnya 2-3 bulan sekali)
• Emosi tinggi, keras kepala (sering membantah) dan gangguan konsentrasi

Amati Tanda dan gejala gangguan saluran cerna yang lain karena alergi dan hipersensitif makanan (Gastrointestinal Hipersensitivity)

(Gejala Gangguan Fungsi saluran cerna yang ada selama ini sering dianggap normal)

• Pada Bayi  : GASTROOESEPHAGEAL REFLUKS ATAU GER, Sering MUNTAH/gumoh, kembung,“cegukan”, buang angin keras dan sering, sering rewel gelisah (kolik) terutama malam hari, BAB > 3 kali perhari, BAB tidak tiap hari. Feses warna hijau,hitam dan berbau.  Sering “ngeden & beresiko Hernia Umbilikalis (pusar), Scrotalis, inguinalis. Air liur berlebihan. Lidah/mulut sering timbul putih, bibir kering
• Pada anak yang lebih besar :

1. Mudah MUNTAH bila menangis, berlari atau makan banyak. MUAL pagi hari.
2. Sering Buang Air Besar (BAB)  3 kali/hari atau lebih, sulit BAB sering ngeden kesakitan saat BAB (obstipasi). Kotoran bulat kecil hitam seperti kotoran kambing, keras, warna hitam, hijau dan bau tajam. sering buang angin, berak di celana. Sering KEMBUNG, sering buang angin dan bau tajam. Sering NYERI PERUT, tidur malam nungging (biasanya karena perut tidak nyaman)
3. Nyeri gigi, gigi berwarna kuning kecoklatan, gigi rusak, gusi mudah bengkak/berdarah. Bibir kering dan mudah berdarah, sering SARIAWAN, lidah putih & berpulau, mulut berbau, air liur berlebihan.

MANIFESTASI KLINIS YANG SERING MENYERTAI ALERGI DAN HIPERSENSITIFITAS MAKANAN PADA BAYI :

• KULIT : sering timbul bintik kemerahan terutama di pipi, telinga dan daerah yang tertutup popok. Kerak di daerah rambut. Timbul bekas hitam seperti tergigit nyamuk. Kotoran telinga berlebihan & berbau. Bekas suntikan BCG bengkak dan bernanah. Timbul bisul.
• SALURAN NAPAS : Napas grok-grok, kadang disertai batuk ringan. Sesak pada bayi baru lahir disertai kelenjar thimus membesar (TRDN/TTNB)
• HIDUNG : Bersin, hidung berbunyi, kotoran hidung banyak, kepala sering miring ke salah satu sisi karena salah satu sisi hidung buntu, sehingga beresiko ”KEPALA PEYANG”.
• MATA : Mata berair atau timbul kotoran mata (belekan) salah satu sisi.
• KELENJAR : Pembesaran kelenjar di leher dan kepala belakang bawah.
• PEMBULUH DARAH :  telapak tangan dan kaki seperti pucat, sering terba dingin
• GANGGUAN HORMONAL : keputihan/keluar darah dari vagina, timbul bintil merah bernanah, pembesaran payudara, rambut rontok.
• PERSARAFAN : Mudah kaget bila ada suara keras. Saat menangis : tangan, kaki dan bibir sering gemetar atau napas tertahan/berhenti sesaat (breath holding spells)
• PROBLEM MINUM ASI : minum berlebihan, berat berlebihan krn bayi sering menangis dianggap haus (haus palsu : sering menangis belum tentu karena haus atau bukan karena ASI kurang.). Sering menggigit puting sehingga luka. Minum ASI sering tersedak, karena hidung buntu & napas dengan mulut. Minum ASI lebih sebentar pada satu sisi,`karena satu sisi hidung buntu, jangka panjang bisa berakibat payudara besar sebelah.

 

MANIFESTASI KLINIS YANG SERING MENYERTAI ALERGI DAN HIPERSENSITIFITAS MAKANAN PADA ANAK

• SALURAN NAPAS DAN HIDUNG : Batuk / pilek lama (>2 minggu), ASMA, bersin, hidung buntu, terutama malam dan pagi hari. MIMISAN, suara serak, SINUSITIS, sering menarik napas dalam.
• KULIT : Kulit timbul BISUL, kemerahan, bercak putih dan bekas hitam seperti tergigit nyamuk. Warna putih pada kulit seperti ”panu”. Sering menggosok mata, hidung, telinga, sering menarik atau memegang alat kelamin karena gatal. Kotoran telinga berlebihan, sedikit berbau, sakit telinga bila ditekan (otitis eksterna).
• SALURAN CERNA : Mudah MUNTAH bila menangis, berlari atau makan banyak. MUAL pagi hari. Sering Buang Air Besar (BAB)  3 kali/hari atau lebih, sulit BAB (obstipasi), kotoran bulat kecil hitam seperti kotoran kambing, keras, sering buang angin, berak di celana. Sering KEMBUNG, sering buang angin dan bau tajam. Sering NYERI PERUT.
• GIGI DAN MULUT : Nyeri gigi, gigi berwarna kuning kecoklatan, gigi rusak, gusi mudah bengkak/berdarah. Bibir kering dan mudah berdarah, sering SARIAWAN, lidah putih & berpulau, mulut berbau, air liur berlebihan.
• PEMBULUH DARAH Vaskulitis (pembuluh darah kecil pecah) : sering LEBAM KEBIRUAN pada tulang kering kaki atau pipi atas seperti bekas terbentur. Berdebar-debar, mudah pingsan, tekanan darah rendah.
• OTOT DAN TULANG : nyeri kaki atau kadang  tangan, sering minta dipijat terutama saat malam hari. Kadang nyeri dada
• SALURAN KENCING : Sering minta kencing, BED WETTING (semalam  ngompol 2-3 kali)
• MATA : Mata gatal, timbul bintil di kelopak mata (hordeolum). Kulit hitam di area bawah kelopak mata. memakai kaca mata (silindris) sejak usia 6-12 tahun.
• HORMONAL : rambut berlebihan di kaki atau tangan, keputihan, gangguan pertumbuhan tinggi badan.
• Kepala,telapak kaki/tangan sering teraba hangat. Berkeringat berlebihan meski dingin (malam/ac). Keringat  berbau.
• FATIQUE :  mudah lelah, sering minta gendong

 

GANGGUAN PERILAKU YANG SERING MENYERTAI PENDERITA ALERGI DAN HIPERSENSITIFITAS MAKANAN PADA ANAK

• SUSUNAN SARAF PUSAT : sakit kepala, MIGRAIN, TICS (gerakan mata sering berkedip), , KEJANG NONSPESIFIK (kejang tanpa demam & EEG normal).
• GERAKAN MOTORIK BERLEBIHAN Mata bayi sering melihat ke atas. Tangan dan kaki bergerak terus tidak bisa dibedong/diselimuti. Senang posisi berdiri bila digendong, sering minta turun atau sering menggerakkan kepala ke belakang, membentur benturkan kepala. Sering bergulung-gulung di kasur, menjatuhkan badan di kasur (“smackdown”}. ”Tomboy” pada anak perempuan : main bola, memanjat dll.
• AGRESIF MENINGKAT sering memukul kepala sendiri, orang lain. Sering menggigit, menjilat, mencubit, menjambak (spt “gemes”)
• GANGGUAN KONSENTRASI: cepat bosan sesuatu aktifitas kecuali menonton televisi,main game, baca komik, belajar. Mengerjakan sesuatu  tidak bisa lama, tidak teliti, sering kehilangan barang, tidak mau antri, pelupa, suka “bengong”, TAPI ANAK TAMPAK CERDAS
• EMOSI TINGGI (mudah marah, sering berteriak /mengamuk/tantrum), keras kepala, negatifisme
• GANGGUAN KESEIMBANGAN KOORDINASI DAN MOTORIK : Terlambat bolak-balik, duduk, merangkak dan berjalan. Jalan terburu-buru, mudah terjatuh/ menabrak, duduk leter ”W”. 
• GANGGUAN SENSORIS : sensitif terhadap suara (frekuensi tinggi) , cahaya (mudah silau), perabaan telapak kaki dan tangan sensitif  (jalan jinjit, flat foot, mudah geli, mudah jijik, tidak suka memegang bulu, boneka dan bianatang berbulu)
• GANGGUAN ORAL MOTOR : TERLAMBAT BICARA, bicara terburu-buru, cadel, gagap. GANGGUAN MENELAN DAN MENGUNYAH, tidak bisa  makan makanan berserat (daging sapi, sayur, nasi) Disertai keterlambatan pertumbuhan gigi.
• IMPULSIF : banyak bicara,tertawa berlebihan, sering memotong pembicaraan orang lain
• AUTIS dan ADHD (Alergi dan hipersensititas makanan bukan penyebab Autis atau ADHD tetapi hanya memperberat gejalanya)

KOMPLIKASI  SERING MENYERTAI ALERGI DAN HIPERSENSITIFITAS MAKANAN PADA ANAK

• Daya tahan menurun sering sakit demam, batuk, pilek setiap bulan bahkan sebulan 2 kali. (normal sakit seharusnya 2-3 bulan sekali)
• Karena sering sakit berakibat Tonsilitis kronis (AMANDEL MEMBESAR) hindari operasi amandel yang tidak perlu  atau mengalami Infeksi Telinga
• Waspadai dan hindari efek samping PEMAKAIAN OBAT TERLALU SERING. 
• Mudah mengalami INFEKSI SALURAN KENCING.  Kulit di sekitar kelamin sering kemerahan 
• SERING TERJADI OVERDIAGNOSIS TBC  (MINUM OBAT JANGKA PANJANG PADAHAL BELUM TENTU MENDERITA TBC / ”FLEK ”)  KARENA GEJALA ALERGI MIRIP PENYAKIT TBC. BATUK LAMA BUKAN GEJALA TBC PADA ANAK BILA DIAGNOSIS TBC MERAGUKAN SEBAIKNYA ”SECOND OPINION” DENGAN DOKTER LAINNYA  
• MAKAN BERLEBIHAN KEGEMUKAN atau OBESITAS
• INFEKSI JAMUR (HIPERSENSITIF CANDIDIASIS) di lidah, selangkangan, di leher, perut atau dada, KEPUTIHAN

 

Bila tanda dan gejala  Gastrooesepageal Refluks (GER) atau Sering Muntah pada anak tersebut terjadi pada anak anda dan disertai salah satu gangguan saluran cerna serta beberapa tanda, gejala atau komplikasi alergi dan hipersensitifitas makanan tersebut maka sangat mungkin Gastrooesepageal Refluks (GER) atau Sering Muntah pada anak disebabkan karena alergi atau hipersenitifitas makanan.

Penyebab lain yang memperberat  Gastrooesepageal Refluks (GER) atau Sering Muntah Pada Anak adalah saat anak terkena infeksi seperti demam, batuk, pilek, diare atau muntah dan infeksi lainnya 

  

Memastikan Diagnosis

• Diagnosis Gastrooesepageal Refluks (GER) atau Sering Muntah Pada Anak yang disebabkan  alergi atau hipersensitif makanan dibuat bukan dengan tes alergi tetapi berdasarkan diagnosis klinis, yaitu anamnesa (mengetahui riwayat penyakit penderita) dan pemeriksaan yang cermat tentang riwayat keluarga, riwayat pemberian makanan, tanda dan gejala alergi makanan sejak bayi dan dengan eliminasi dan provokasi.
• Untuk memastikan makanan penyebab alergi dan hipersensitifitas makanan harus menggunakan Provokasi makanan secara buta (Double Blind Placebo Control Food Chalenge = DBPCFC). DBPCFC adalah gold standard atau baku emas untuk mencari penyebab secara pasti alergi makanan. Cara DBPCFC tersebut sangat rumit dan membutuhkan waktu, tidak praktis dan biaya yang tidak sedikit.
• Beberapa pusat layanan alergi anak melakukan modifikasi terhadap cara itu. Children Allergy clinic Jakarta melakukan modifikasi dengan cara yang lebih sederhana, murah dan cukup efektif. Modifikasi DBPCFC tersebut dengan melakukan “Eliminasi Provokasi Makanan Terbuka Sederhana”. Bila setelah dilakukan eliminasi beberapa penyebab alergi makanan selama 3 minggu didapatkan perbaikan dalam gangguan muntah tersebut, maka dapat dipastikan penyebabnya adalah alergi makanan.
• Pemeriksaan standar yang dipakai oleh para ahli alergi untuk mengetahui penyebab alergi adalah dengan tes kulit. Tes kulit ini bisa terdari tes gores, tes tusuk atau tes suntik. PEMERIKSAAN INI HANYA MEMASTIKAN ADANYA ALERGI ATAU TIDAK, BUKAN UNTUK MEMASTIKAN PENYEBAB ALERGI. Pemeriksaan ini mempunyai sensitifitas yang cukup baik, tetapi sayangnya spesifitasnya rendah. Sehingga seringkali terdapat false negatif, artinya hasil negatif belum tentu bukan penyebab alergi. Karena hal inilah maka sebaiknya tidak membolehkan makan makanan penyebab alergi hanya berdasarkan tes kulit ini.  
• Dalam waktu terakhir ini sering dipakai alat diagnosis yang masih sangat kontroversial atau ”unproven diagnosis”. Terdapat berbagai pemeriksaan dan tes untuk mengetahui penyebab alergi dengan akurasi yang sangat bervariasi. Secara ilmiah pemeriksaan ini masih tidak terbukti baik sebagai alat diagnosis. Pada umumnya pemeriksaan tersebut mempunyai spesifitas dan sensitifitas yang sangat rendah. Bahkan beberapa organisasi profesi alergi dunia tidak merekomendasikan penggunaan alat tersebut. Yang menjadi perhatian oraganisasi profesi tersebut bukan hanya karena masalah mahalnya harga alat diagnostik tersebut tetapi ternyata juga sering menyesatkan penderita alergi yang sering memperberat permasalahan alergi yang ada
• Namun pemeriksaan ini masih banyak dipakai oleh praktisi kesehatan atau dokter. Di bidang kedokteran pemeriksaan tersebut belum terbukti secara klinis sebagai alat diagnosis karena sensitifitas dan spesifitasnya tidak terlalu baik. Beberapa pemeriksaan diagnosis yang kontroversial tersebut adalah Applied Kinesiology, VEGA Testing (Electrodermal Test, BIORESONANSI), Hair Analysis Testing in Allergy, Auriculo-cardiac reflex, Provocation-Neutralisation Tests, Nampudripad’s Allergy Elimination Technique (NAET), Beware of anecdotal and unsubstantiated allergy tests.

 PENATALAKSANAAN 

• Penanganan Gastrooesepageal Refluks (GER) atau Sering Muntah Pada Anak karena alergi dan hipersensitifitas makanan pada anak haruslah dilakukan secara benar, paripurna dan berkesinambungan. Pemberian obat terus menerus bukanlah jalan terbaik dalam penanganan gangguan tersebut tetapi yang paling ideal adalah menghindari penyebab yang bisa menimbulkan keluhan alergi tersebut.    
• Penghindaran makanan penyebab alergi pada anak harus dicermati secara benar, karena beresiko untuk terjadi gangguan gizi. Sehingga orang tua penderita harus diberitahu tentang makanan pengganti yang tak kalah kandungan gizinya dibandingklan dengan makanan penyebab alergi. Penghindaran terhadap susu sapi dapat diganti dengan susu soya, formula hidrolisat kasein atau hidrolisat whey., meskipun anak alergi terhadap susu sapi 30% diantaranya alergi terhadap susu soya. Sayur dapat dipakai sebagai pengganti buah. Tahu, tempe, daging sapi atau daging kambing dapat dipakai sebagai pengganti telur, ayam atau ikan. Pemberian makanan jadi atau di rumah makan harus dibiasakan mengetahui kandungan isi makanan atau membaca label makanan.  
• Obat-obatan simtomatis, anti histamine (AH1 dan AH2), ketotifen, ketotofen, kortikosteroid, serta inhibitor sintesaseprostaglandin hanya dapat mengurangi gejala sementara, tetapi umumnya mempunyai efisiensi rendah. Sedangkan penggunaan imunoterapi dan natrium kromogilat peroral masih menjadi kontroversi hingga sekarang.  

Obat

• Pengobatan Gastrooesepageal Refluks (GER) atau Sering Muntah Pada Anak karena alergi dan hipersensitifitas makanan yang baik adalah dengan menanggulangi penyebabnya. Bila gangguan sulit makan yang dialami disebabkan karena gangguan alergi dan hipersensitifitas makanan, penanganan terbaik adalah menunda atau menghindari makanan sebagai penyebab tersebut.    
• Konsumsi obat-obatan saluran cerna atau penahan muntah, terapi tradisional ataupun beberapa cara dan strategi untuk menangani Gastrooesepageal Refluks (GER) atau Sering Muntah pada anak tidak akan berhasil selama penyebab utama  alergi dan hipersensitifitas makanan tidak diperbaiki.

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