Paediatrica Indonesiana

VOLUME 51 May  NUMBER 3

Original Article

Epidemiology of Rotavirus diarrhea in children under

five: A hospital-based surveillance in Jakarta
Muzal Kadim1, Yati Soenarto2, Badriul Hegar1, Agus Firmansyah1

R
Abstract otavirus is the leading cause of acute
Background Rotavirus is still a major cause of acute diarrhea diarrhea in children across the world with
in children around the world, both in developed and developing DURXQG  GHDWKV SHU \HDU GXH WR
FRXQWULHV:+26XUYHLOODQFHIURPWRVKRZHGWKDWLQ diarrhea in children less than five years old.
children under five years of age treated for acute diarrhea, on average
RIFDVHVZHUHFDXVHGE\URWDYLUXV$SUHYLRXVVWXG\LQ,QGRQHVLD
Children in Asian and African countries account for
showed that the incidence of rotavirus diarrhea in children ranged RIWKHVHGHDWKV1-3 :+2VXUYHLOODQFHIURP
IURP  RI GLDUUKHD FDVHV +RZHYHU WKHUH KDYH EHHQ IHZ  UHYHDOHG WKDW  RI WUHDWHG DFXWH GLDUUKHD
studies identifying the genotypes of rotavirus strains in Indonesia. cases worldwide in children less than five years
This information is indispensable for manufacturing vaccines.
old were caused by rotavirus. The highest number
Objective To examine the epidemiology of rotavirus diarrhea,
including genotypes and clinical characteristics, in children under
RI URWDYLUXV VWUDLQV UHSRUWHG ZHUH * * * *
ILYH\HDUVZKRZHUHKRVSLWDOL]HGLQ-DNDUWD DQG*JHQRW\SHV36HYHUDOHSLGHPLRORJLFDOVWXGLHV
Methods This study was a prospective surveillance conducted of rotavirus diarrhea in Asia (Malaysia, Vietnam,
at Cipto Mangunkusumo Hospital, Jakarta from January to Thailand, Hong Kong, Taiwan, Korea, India, Middle
'HFHPEHU  LQYHVWLJDWLQJ KRVSLWDOL]HG FKLOGUHQ XQGHU ILYH (DVW $IULFD /DWLQ $PHULFD %UD]LO DQG (XURSH
years of age who suffered from acute diarrhea.
showed that rotavirus diarrhea remains a health
Results Ninety-nine patients joined the study. The incidence of
URWDYLUXVLQIHFWLRQLQWKLVVWXG\ZDV7KH\RXQJHVWZDV problem with negatively impacting health costs, time
months of age and the oldest 54 months of age, with an average age wasted and quality of life, due to the high morbidity
RIPRQWKV$VPXFKDVRIURWDYLUXVGLDUUKHDZDVIRXQG and mortality rates.4-17
LQVXEMHFWVDJHGPRQWKVZLWKDSHDNDJHRIPRQWKV Improved hygiene and sanitation can drastically
Nutritional status, degree of dehydration, bloating, fever, blood
in stool, and mucus in the feces were not significantly different
lower the incidence of diarrhea caused by non-
between rotavirus and non-rotavirus diarrhea. Vomiting tended to rotavirus agents, whereas rotavirus diarrhea is
be more frequently experienced by children with rotavirus diarrhea only slightly influenced by hygiene and sanitation
WKDQWKRVHZLWKQRQURWDYLUXVYV7KHUHZDVQRFOHDU
seasonal pattern for rotavirus diarrhea. Most G genotypes in this
VWXG\ZHUH***DQGWKHPDMRULW\RI
)URPWKH'HSDUWPHQWRI&KLOG+HDOWK8QLYHUVLW\RI,QGRQHVLD0HGLFDO
3JHQRW\SHVZHUH33DQG3
6FKRRO&LSWR0DQJXQNXVXPR+RVSLWDO-DNDUWD)URPWKH'HSDUWPHQW
Conclusions7KHLQFLGHQFHRIURWDYLUXVGLDUUKHDLQKRVSLWDOL]HG RI &KLOG +HDOWK *DGMDK 0DGD 8QLYHUVLW\ 0HGLFDO 6FKRRO 6DUGMLWR
FKLOGUHQ XQGHU ILYH \HDUV RI DJH LQ -DNDUWD ZDV  ZLWK D +RVSLWDO<RJ\DNDUWD
SUHGRPLQDQFHRI**DQG*JHQRW\SHV[Paediatr Indones.
2011;51:138-43]. Reprint request to 0X]DO .DGLP 0' *DVWURKHSDWRORJ\ 'LYLVLRQ
'HSDUWPHQWRI&KLOG+HDOWK8QLYHUVLW\RI,QGRQHVLD0HGLFDO6FKRRO
Keywords: epidemiology, incidence, acute &LSWR 0DQJXQNXVXPR +RVSLWDO -O 6DOHPED 1R -DNDUWD  7HO
diarrhea, rotavirus, children, Jakarta (PDLOPX]DON#\DKRRFRP

138Paediatr Indones, Vol. 51, No. 3, May 2011

 Muzal Kadim et al: Epidemiology of Rotavirus diarrhea in children under five: A hospital-based surveillance

improvements. Rotavirus is often referred as a QXWULWLRQEHWZHHQWRIRUQRUPDOQXWULWLRQDQG

democratic virus, because it can affect children in !IRURYHUZHLJKW
developing and developed countries with similar )HFDOVSHFLPHQVZHUHVWRUHGDW&WKHQVHQWWR
incidence. Through vaccination it is hoped that the Biofarma Laboratory, Bandung to test for rotavirus.
morbidity and mortality rates of diarrhea caused by 'HWHFWLRQRIURWDYLUXVDQWLJHQZDVSHUIRUPHGXVLQJ
rotavirus infection can be reduced in children. In WKHHQ]\PHLPPXQRDVVD\(,$3UHPLHUH5RWDFORQH
countries that have carried out a rotavirus vaccination DQG'DNRSDWWV'DNR,QWHUQDWLRQDOPHWKRG$WRWDO
program, decreases in the incidence of severe rotavirus RI  VWRRO VSHFLPHQV WHVWLQJ SRVLWLYH IRU URWDYLUXV
infection have been observed, although mild infection were sent to the microbiology laboratory at Gadjah
remains ongoing. Mada University to determine the genotype of the
3UHYLRXV VWXGLHV LQ ,QGRQHVLD VLQFH URWDYLUXV rotavirus strains.
ZDV IRXQG E\ %LVKRS LQ  KDYH GHVFULEHG WKH This study was approved by the Ethical
incidence of rotavirus infection as a cause of acute Committee of Research in Medical Health at Faculty
GLDUUKHD LQ FKLOGUHQ WR UDQJH IURP  of Medicine, University of Indonesia.
<HW RQO\ D VPDOO QXPEHU RI VWXGLHV LQ ,QGRQHVLD
identified the rotavirus strains responsible for
infection. This study is part of a multi-center Results
study involving six research facilities: Muhammad
+XVHLQ+RVSLWDO3DOHPEDQJ&LSWR0DQJXQNXVXPR %HWZHHQ-DQXDU\WR'HFHPEHUWKHUHZHUHDWRWDO
+RVSLWDO-DNDUWD+DVDQ6DGLNLQ+RVSLWDO%DQGXQJ RIFKLOGUHQOHVVWKDQILYH\HDUVROGKRVSLWDOL]HGIRU
6DUGMLWR +RVSLWDO <RJ\DNDUWD 6DQJODK +RVSLWDO DFXWHGLDUUKHDLQWKH'HSDUWPHQWRI&KLOG+HDOWK
'HQSDVDU DQG 0DWDUDP +RVSLWDO 1XVD 7HQJJDUD &LSWR 0DQJXQNXVXPR +RVSLWDO  6WRRO VSHFLPHQV
Barat. The purpose of this study was to investigate could not be collected for seven patients for various
the epidemiology, strains and clinical characteristics UHDVRQV VR WKDW OHIW  SDWLHQWV LQ RXU VWXG\ 7KH
of rotavirus infection in children under five with \RXQJHVW ZDV DJHG  PRQWKV DQG WKH ROGHVW 
acute diarrhea. months, with average age of 13.6 months. A total of
SDWLHQWVWHVWHGSRVLWLYHIRUURWDYLUXVDV
the cause of diarrhea. The majority of diarrhea cases
Methods ZHUH IRXQG LQ FKLOGUHQ DJHG  PRQWKV Figure
1) Rotavirus infections were similarly clustered in
This study was a prospective surveillance in Cipto FKLOGUHQDJHGPRQWKVZLWKDSHDNDJH
Mangunkusumo Hopital Jakarta conducted from RIPRQWKV
-DQXDU\WR'HFHPEHU:HLQFOXGHGDOOSDWLHQWV
with acute diarrhea aged less than five years old
ZKRZHUHKRVSLWDOL]HGDWWKHRQHGD\FDUH2'&
facility or pediatric ward of Cipto Mangunkusumo
Hospital. Acute diarrhea was defined as loose or
watery stools with a frequency of more than 3 times
LQKRXUVDQGODVWLQJIRUOHVVWKDQGD\V$IWHU
informed consent was obtained, history taking and
physical examination in the inpatient unit were
conducted to complete the data in the research form
which included age, sex, nutritional status, degree
of dehydration, clinical symptoms (fever, vomiting,
bloating, stool characteristics) and final diagnosis.
Nutritional status of patients was determined by
measuring weight to height ratios (weight/height) Figure 1. Age groups of patients < 5 years old with
DQG ZHUH FODVVLILHG E\ ]VFRUH  IRU  XQGHU acute diarrhea in Jakarta.

Paediatr Indones, Vol. 51, No. 3, May 2011 139

 Muzal Kadim et al: Epidemiology of Rotavirus diarrhea in children under five: A hospital-based surveillance

Table 1 shows the clinical characteristics Figure 2 shows the seasonal pattern of
associated with rotavirus infection including sex, age, rotavirus infection. The distribution suggested that
nutritional status, degree of dehydration, vomiting, rotavirus infection was present at all times in a year.
bloating, fever, and stool characteristics. Nevertheless, the highest number of cases mainly
occurred between January and June and decreased
Table 1. Clinical characteristics associated with rotavirus infection IURP-XO\WR'HFHPEHU
in children < 5 years old with acute diarrhea Forty stools specimens testing positive for
Rotavirus Rotavirus rotavirus were randomly taken for genotype
Clinical
Characteristic
Positive Negative P* examination. We found the G genotype distribution
N = 66 (%) N = 33 (%)
ZDV *   *   *  
Male sex 33 (50) 19 (57) 0.477
Age group 0.247 DQGXQW\SHDEOHZKLOH*DQG*ZHUH
0 5 months 11 (17) 8 (24) QRWIRXQG7KHPDMRULW\RI3JHQRW\SHVZHUH33
6 35 months 53 (80) 22 (67) DQG 3 ZKLFK DFFRXQWHG IRU   
36 59 months 2 (3) 3 (9)
Nutritional status 0.861
respectively.
weight/height (z-score)
Under(< -2) 15 (22.5) 8 (24)
Normal (-2 to 2) 50 (76) 24 (73)
Over (> 2) 1 (1.5) 1 (3)
Degree of dehydration 0.600
No dehydration 1 (1.5) 0 (0)
Mild-moderate 64 (97) 33 (100)
Severe 1 (1.5) 0
Vomiting 0.012
Yes 58 (88) 22 (67)
No 8 (12) 11 (33)
Bloating 0.095
Yes 41 26
No 25 7
Fever 0.674
Yes 8 (12) 5 (15)
No 58 (88) 28 (85)
Blood in stool 0.074
Yes 2 (3) 4 (12)
No 64 (97) 29 (88)
Mucus in stool 1.00
Yes 22 (33) 11 (33)
No 44 (67) 22 (67) Figure 3. Rotavirus genotype distribution in children
%JKUSWCTGVGUV2KUEQPUKFGTGFUKIPKECPV < 5 years old in Jakarta.

Figure 2. Seasonal pattern of Rotavirus diarrhea in children < 5 years old in Jakarta.

140Paediatr Indones, Vol. 51, No. 3, May 2011

 Muzal Kadim et al: Epidemiology of Rotavirus diarrhea in children under five: A hospital-based surveillance

Discussion dehydration, abdominal bloating, fever, the presence

of blood and mucous in the stool were not significantly
7KH LQFLGHQFH RI URWDYLUXV GLDUUKHD  LQ WKLV different between rotavirus positive patients and
study was higher than that of other studies around rotavirus negative patients. This shows that the
WKHZRUOGDQDYHUDJHLQFLGHQFHRI4-17 Rotavirus fecal characteristics cannot be used to differentiate
remains a major cause of acute diarrhea in children URWDYLUXV DQG QRQURWDYLUXV LQIHFWLRQV 6RPHZKDW
and previous studies in Indonesia showed that the surprisingly, symptoms of bloating in this study did
incidence of rotavirus infection as a cause of acute not differ significantly between rotavirus and non-
GLDUUKHDLQFKLOGUHQUDQJHGIURP In rotavirus diarrhea, since generally the intestinal villi
FRPSDULVRQZLWKRWKHUUHVHDUFKFHQWHUVLQ3DOHPEDQJ damage in children with acute diarrhea caused by
%DQGXQJ<RJ\DNDUWD'HQSDVDUDQG0DWDUDPZLWK rotavirus is thought to commonly causes symptoms
LQFLGHQFHVRIURWDYLUXVLQIHFWLRQRI of secondary lactose intolerance due to reduced
 DQG UHVSHFWLYHO\ -DNDUWD  KDG WKH ODFWDVHHQ]\PH3DWLHQWVZLWKDFXWHGLDUUKHDFDXVHG
highest incidence. This result was slightly higher by rotavirus infection were more likely to experience
WKDQ D SUHYLRXV VWXG\  RI RXWSDWLHQWV LQ WKH vomiting compared to those with non-rotavirus
3HGLDWULF *DVWURHQWHURORJ\ RXWSDWLHQW FOLQLF &LSWR LQIHFWLRQYV3 +HQFHSDWLHQWV
Mangunkusumo Hospital.  3DWLHQWV ZLWK DFXWH with acute rotavirus diarrhea were more likely to be
diarrhea caused by rotavirus infection tended to have KRVSLWDOL]HG FRPSDUHG WR WKRVH ZLWK QRQURWDYLUXV
more severe clinical symptoms, so they were more diarrhea because of oral rehydration failure due to
OLNHO\WREHKRVSLWDOL]HGWKDQWKRVHZLWKQRQURWDYLUXV vomiting.
diarrhea. The seasonal pattern of rotavirus infection was
The predominant patient age group testing similar to that of other studies in several countries
SRVLWLYHIRUURWDYLUXVZDVPRQWKVVLPLODUWRPDQ\ in Asia with similar climates to Indonesia. This
other studies throughout the world.4-17 This can be finding differs from research in Turkey and some sub-
H[SODLQHGE\WKHIDFWWKDWDWWKHDJHRIPRQWKV tropical countries, which showed rotavirus diarrhea to
maternal antibodies have a protective effect, while at be more common in the winter season from November
!PRQWKVFKLOGUHQPD\KDYHGHYHORSHGQDWXUDO to February, and rarer in the summer.15-17
immunity due to recurrent rotavirus infections. The genotype of rotavirus strains found in the
7KHSHDNDJHRIPRQWKVLQWKLVVWXG\GLIIHUV :+2VXUYHLOODQFHLQZHUH***
somewhat to many other studies in Asia which showed *DQG*GLIIHULQJIURPWKHUHVXOWVRIRXUUHVHDUFK3
a peak of infection in the first year of life.4 The age Compared to other research centers, Jakarta had the
distribution of children with rotavirus infection in our KLJKHVW SURSRUWLRQ RI XQW\SHDEOH JHQRW\SHV 
study is consistent with a European study showing the IROORZHGE\<RJ\DNDUWD2IWKHVL[UHVHDUFK
peak of infection in the second year of life.15 FHQWHUVLQWKLVPXOWLFHQWHUHGVWXG\RQO\<RJ\DNDUWD
Table 1 shows that gender did not differ between had genotypes G3 and G4, while other research
patients with acute diarrhea testing rotavirus positive FHQWHUVKDGYDULRXVGLVWULEXWLRQVRI***DQG
DQGURWDYLUXVQHJDWLYH1XWULWLRQDOVWDWXV untypeable genotypes.:HIRXQGWKHPDMRULW\RI3
of patients was determined by measuring the weight genotype infections were strains commonly circulating
to height ratio (weight / height) and was classified by ZRUOGZLGHQDPHO\33DQG30L[HGLQIHFWLRQV
]VFRUHVIRUXQGHUQXWULWLRQEHWZHHQWR DQG XQW\SHDEOH VWUDLQV ERWK DFFRXQWHG IRU 
IRUQRUPDOQXWULWLRQDOVWDWXVDQG!IRURYHUZHLJKW Further development in genotype determination is
Nutritional status was not significantly different needed, particularly for untypeable genotypes. These
between patients testing rotavirus positive and those strains may prove to conform to a known genotype if
WHVWLQJ URWDYLUXV QHJDWLYH 3UHYLRXV UHVHDUFK KDV investigated further.
shown that malnutrition causes more severe disease In conclusion, the incidence of rotavirus diarrhea
symptoms, however, the risk of rotavirus infection did LQKRVSLWDOL]HGFKLOGUHQXQGHUDJHILYH\HDUVLQ-DNDUWD
not appear to be influenced by nutritional status. ZDV  7KH SUHGRPLQDQW * JHQRW\SHV ZHUH *
Other clinical characteristics including the degree of * DQG * DQG 3 JHQRW\SHV ZHUH 3 3 DQG 3

Paediatr Indones, Vol. 51, No. 3, May 2011 141

 Muzal Kadim et al: Epidemiology of Rotavirus diarrhea in children under five: A hospital-based surveillance

Nutritional status, degree of dehydration, abdominal  .LP -6 .DQJ -2 &KR 6& -DQJ <T, 0LQ 6A, 3DUN 7H,
bloating and fever were not significantly different et al. Epidemiological profile of rotavirus infection in the
between rotavirus and non-rotavirus diarrhea cases. republic of Korea: results from prospective surveillance in
Vomiting tended to be more frequently experienced by WKH-HRQJHXEGLVWULFW-XO\WKURXJK-XQH-
children with rotavirus diarrhea, hence these patients ,QIHFW'LV66
UHTXLUHGKRVSLWDOL]DWLRQPRUHRIWHQWKDQSDWLHQWVZLWK  +VX935DKPDQ+:RQJIbrahim LH, <XVRII$F, Chan LG,
QRQURWDYLUXVGLDUUKHD6WRROFKDUDFWHULVWLFVZHUHQRW et al. Estimates of the burden of rotavirus disease in Malaysia.
a good determinant for distinguishing rotavirus and -,QIHFW'LV66
non-rotavirus diarrhea.  9DQ0DQ19DQ7UDQJ1/LHQ+33UDFK''7KDQK17+
7X39HWDO7KHHSLGHPLRORJ\DQGGLVHDVHEXUGHQRIURWDYLUXV
LQ9LHWQDPVHQWLQHOVXUYHLOODQFHDWKRVSLWDOV-,QIHFW'LV
Acknowledgements 
 -DLQ9'DV0%KDQ0.Glass RI, Gentsch JR. Great diversity of
:H WKDQN 3$7+ DQG %LRIDUPD IRU IXQGLQJ WKLV ZRUN $EGXO group A rotavirus strains and high incidence of mixed rotavirus
Wahab for data analysis, Abu Thalib Aman for determining LQIHFWLRQVLQ,QGLD-&OLQ0LFURELRO
genotypes of rotavirus strains, and the nurses and administrative  6DQWRV19RORWDR(06RDUHV&&Campos G6, 6DUGL6I,
staff for their assistance in this study. Hoshino <3UHGRPLQDQFHRI5RWDYLUXV*HQRW\SH*GXULQJ
WKHVHDVRQVDPRQJKRVSLWDOL]HGFKLOGUHQ
LQWKHFLW\RI6DOYDGRU%DKLD%UD]LOLPSOLFDWLRQVIRUIXWXUH
References YDFFLQHVWUDWHJLHV-&OLQ0LFURELRO
 ,QWXVRPD86RUQVULYLFKDL9-LUDSKRQJVD&9DUDYLWKD\D:
 3DUDVKDU8'+XPPHOPDQ(*%UHVVH-60LOOHU0$*ODVV Epidemiology, clinical presentations and burden of rotavirus
RI. Global illness and deaths caused by rotavirus disease in diarrhea in children under five seen at Ramathibodi Hospital,
FKLOGUHQ(PHUJ,QIHFW'LV 7KDLODQG-0HG$VVRF7KDL
 3DUDVKDU8'*LEVRQ&-%UHVHH-6*ODVV5,5RWDYLUXVDQG  6WDQGDHUW%+DUOLQ2'HVVHOEHUJHU87KHILQDQFLDOEXUGHQ
VHYHUHFKLOGKRRGGLDUUKHD(PHUJ,QIHFW'LV of rotavirus disease in four countries of the European Union.
 &HQWHUV IRU 'LVHDVH &RQWURO DQG 3UHYHQWLRQ &'& 3HGLDWU,QIHFW'LV-6XSSO66
5RWDYLUXV VXUYHLOODQFHZRUOGZLGH  00:5  %R]GD\L*'RJDQ1'DOJLF%%RVWDQFL,6DUL6%DWWDORJOX
0RUE0RUWDO:NO\5HS 12HWDO'LYHUVLW\RIKXPDQURWDYLUXV*DPRQJFKLOGUHQ
 %UHVHH-6+XPPHOPDQ(1HOVRQ$6*ODVV5,5RWDYLUXVLQ LQ7XUNH\-0HG9LURO
Asia: the value of surveillance for informing decisions about the  .KRXU\+2JLOYLH,(O.KRXU\$&'XDQ<*RHWJKHEHXU
LQWURGXFWLRQRIQHZYDFFLQHV-,QIHFW'LV66 MM. Burden of rotavirus gastroenteritis in the Middle Eastern
 1HOVRQ($67DP-6%UHVHH-63RRQ.H, Ng CH, Ip K6, DQG 1RUWK $IULFDQ SHGLDWULF SRSXODWLRQ %0& ,QIHFW 'LV
et al. Estimates of rotavirus disease burden in Hong Kong: 
KRVSLWDOEDVHGVXUYHLOODQFH-,QIHFW'LV66  +HJDU % .DGLP 0 3DVDULEX $ .DUDNWHULVWLN PLNUR
 0DVW7&&KHQ3</X.&+VX&0/LQ+&/LDR:& organisme saluran cerna pada anak dengan diare akut. Maj
et al. Epidemiology and economic burden of rotavirus .HGRNW,QGRQHV
gastroenteritis in hospitals and paediatric clinics in Taiwan,  +HJDU%(YDOXDVLSHQGHULWDGLDUH\DQJGLUDZDWGLEDQJVDO
9DFFLQH *DVWURHQWHURORJLDQDN56831&LSWR0DQJXQNXVXPR0DM
 0DOHN0$7HOHE1$EX(O\D]HHG55LGGOH066KHULI0( .HV0DV\,QGRQHV
6WHHOH$'HWDO7KHHSLGHPLRORJ\RIURWDYLUXVGLDUUKHDLQ  6RHQDUWR<6HERGR75LGKR5$OUDVMLG+5RKGH-(%XJJ
FRXQWULHVLQWKH(DVWHUQ0HGLWHUUDQHDQUHJLRQ-,QIHFW'LV HC, et al. Acute diarrhea and rotavirus infection in newborn
6XSSO6 EDELHVDQGFKLOGUHQLQ<RJ\DNDUWD,QGRQHVLDIURP-XQH
 0ZHQGD -0 1WRWR .0 $EHEH $ (QZHURQX/DU\HD & WR-XQH-&OLQ0LFURELRO
Amina I, Mchomvu J, et al. Burden and epidemiology of  %LVKRS5)8QLFRPE/)6RHQDUWR<6XZDUGML+5LVWDQWR
rotavirus diarrhea in selected African countries: preliminary Barnes GL. Rotavirus serotypes causing acute diarrhea in
results from the African rotavirus surveillance network. J KRVSLWDOL]HGFKLOGUHQLQ<RJ\DNDUWD,QGRQHVLDGXULQJ
,QIHFW'LV6XSSO66 $UFK9LURO

142Paediatr Indones, Vol. 51, No. 3, May 2011

 Muzal Kadim et al: Epidemiology of Rotavirus diarrhea in children under five: A hospital-based surveillance

 6RHQDUWR < $PDQ $7 %DNUL $ :DOX\D + )LUPDQV\DK  +XSSHUW]+,6DOPDQ1*LDTXLQWR&5LVNIDFWRUVIRUVHYHUH
A, Kadim M, et al. Burden of severe rotavirus diarrhea in URWDYLUXVJDVWURHQWHULWLV3HGLDWU,QIHFW'LV-6
,QGRQHVLD-,QIHFW'LV6XSSO6 6

Paediatr Indones, Vol. 51, No. 3, May 2011 143