General Approach to Peds

Assessment Triangle: 

Appearance (Alert, Anxious), Work of Breathing (tachypnea, retractions), Circulation (normal perfusion)

APAP dose in kiddies <100 kg add a 0 to weight in pounds for the dose

Infared ear temp is no good (INFRARED EAR THERMOMETRY COMPARED WITH RECTAL THERMOMETRY IN CHILDREN: A SYSTEMATIC REVIEW
Craig, J.V., et al, Lancet 360:603 August 24, 2002)

 

Normal Resp Rates

NGT Depth

(Annals Em 39:3)

Heliox improves moderate to severe RSV (Pediatrics 2002:109)

Head injury can cause hypotension in peds patients (AM J Surg 184, p.555, 2002)

Resuscitation

Age/4 +4=tube size, 3 x size=depth

Shock

I-up to 15%

II-15-30% will have tachycardia, increased RR, but will maintain urine output

III-30-40% compensated but decreased UO, may have mental status changes

IV->40% decreased BP

Ophthalmologic Emergencies

conjunctivitis in newborns if >48 hrs after birth=gonorrhea, chlamydia, strep, staph or herpes.  If patient was in hospital, also consider pseudomonas

Pre/Orbital Cellulitis

Test EOM, should be pain free in preorbital.  Vision must be normal.  Can differentiate with CT with axial and coronal thin cuts.

ABD X-RAY

Bones

Stones

Mass

Gas

Consent

If an emergency, always treat.

All states allow minors to consent to diagnosis and treatment for STDs or drug abuse without parenteral consent  Most states also allow minors to consent for pregnancy related care.

Emancipated minor definitions vary by state

Hypertension

Hyperthyroid

Y

Pheochromocytoma

Eats too much (obesity)

Renal Disease

Thrombosis of renal arteries

Endocrine (CAH or Hyperaldosteronism)

Neurologic

Stenosis of renal artery or coarctation of aorta

Ingestion of toxin

OB (eclampsia)

Neuroblastoma

Dental Emergencies

Full bevy of primary teeth by age 2

Secondary teeth are often heralded by the 1^st molars (6 yr molars)

Eruption cysts-blue black, sometimes blood filled cyst over new tooth, bengin.

Teething can cause fever.

Ellis Class

I-only enamel

II-through enamel and dentin, will see yellow dentin in enamel

III-to pulp of tooth, will see bleeding

IV-involve the root, need x-ray to dx

Treat class I with filing, II and III should be covered with dental foil or commercial coating and sent to see a dentist within 24 hours (12 hours for <12 y/o)

Luxation Injuries

Intrusion-tooth impacted into alveolar socket

Extrusion-vertically dislodged from the socket

Lingual Luxation-displacement of the tooth towards the tongue

Labial Luxation-towards the lips

Lateral Luxation-occurs within the plane of the tooth.

Avulsion is a tooth knocked completely out of the socket.  Put in mouth of parent or child, or hanks solution, or milk or saline.  Never reimplant a avulsed primary tooth as ankylosis, a bony fusing of tooth to the ridge may occur

Permanent tooth luxations need immediate treatment.

ENT Emergencies

ask child which finger he picks his nose with

Retropharyngeal Abscess

uncommon after five years old

can track to mediastinum or carotid or jugular vein

Peritonsillar Abscess

quinsy, abscess pushes uvula to other side of mouth.  red, bulging soft palette.

The Crying Infant:

A Checklist to Consider

The crying infant represents a challenge to the emergency physician

to evaluate a disruptive, noncommunicative patient in obvious

distress.  In addition to more serious etiologies, many common minor

illnesses need to be excluded by a careful history and physical

exam. 

Areas to consider in the PE:

Vitals/Fever

Tachypnea

Fundi Retinal hemorrhages

Cornea Fluroscein dye for corneal abrasion

Inspect for foreign body

Ears Otitis

Foreign body

Abdomen/Rectal Inspect for anal fissure

Test stool for blood (e.g. intussusception)

Genitalia Inguinal hernia

Hair tourniquet

Digits Hair tourniquet

Urine Tox screen for cocaine metabolites

UTIs

CAN URINE CLARITY EXCLUDE THE DIAGNOSIS OF URINARY TRACT INFECTION?

Bulloch, B., et al, Pediatrics 106(5, Part 1): November 2000

METHODS: This study, from the Children's Hospital Medical Center in Cincinnati, examined the utility of urine clarity as an indicator of urinary tract infection (UTI) in a convenience sample of 159 previously healthy patients aged 4 weeks to 19 years for whom urine cultures were ordered during emergency department evaluation. An aliquot of urine was placed in a red-topped blood tube and held 1cm from a white background containing text printed in an 11-point black font. Ability to read the text through the urine sample, under fluorescent lighting, with the same clarity as through a tube containing water was considered consistent with clear urine and, consequently, absence of a UTI. Samples were tested by two independent observers.

RESULTS: Urine cultures were positive in 18% of the patients, while just under one-third of the specimens were judged to be cloudy. The sensitivity and specificity of urine clarity for UTI were 90% and 82 respectively, and the positive and negative likelihood ratios (LRs were 5.1 and 0.1. The sensitivity and specificity of other urine screening tests were 83% and 95%, respectively, for dipstick testing for leukocyte esterase, 28% and 98% for urinary nitrites 86% and 79% for pyuria (defined as at least 5 WBC/HPF) on urine microscopy, and 93% and 40% for microscopy positive for bacteria UTI was confirmed by culture in three patients with clear urine

CONCLUSIONS: Although the presence of clear urine on visual inspection does not definitively exclude UTI, it appears to be a rapid, inexpensive and relatively reliable bedside screening test I/Q R 4/4 - J 3/4

Top Ten Peds Issues

1. Fever

0-28 Days c a fever >38

Listeria, enterococcus, Group-B Strep, Staph

CBC, Blood Cx, Urine, Spinal Tap, Admit

Start Antibiotics:

Ampicillin to hit listeria and enterococcus

Cefotaxime for everything else

28-90 Days c a fever >38

Sepsis W/U

Rochester Criteria (Peds 94; 390-396, 1994)

<60 days

Temp >38

Term infant, no perinatal abx, no disease, not in hospital longer than mom, well appearing s source

WBC not <5 nor >15

Ab Bands <1500

UA <10 WBC per HPF

Stool (if sx) <5 WBC per field

Can send home if no high risk criteria

Sensitivity 92%, Spec 50%, NPV 98.9%

Boston (J Peds 120, 22-27, 1992)

28-89 days

>38

No immunizations in past 48 hours, no antibiotics in past 48 hours, not dehydrated, well appearing, no signs of infection.

CSF <10 wbcs/cc

UA <10WBC/hpf

Chest film:  no infiltrate

WBC <20000

Spec 94.6%, no sensitivity or NPV????

90 Days to 36 Months c >39 (102.2)

Occult Bacteremia (3-5%)

Urine:  Boys <6 months old if circed

                        <1 yr old if uncirced

            Girls  <2 yrs old

(Pediatrics 1993;92(1):1-12)

1 Rochester Ceftriaxone, send home, with follow-up

36 months-death

>105.8, even then, if they look good do nothing

2. Resp Disease

Asthma, Bronchiolitis, Croup, Pneumonia

To get a good exhalation, squeeze an infants chest between your hands

3. Trauma

Head Trauma

Get CT:

Falls >4 feet if <1 y/o

Falls >10 feet if >1 y/o

LOC

Change in Mental Status persistent to ED

Focal Neurological Signs

Anisocoria

Persistent Vomiting-> 5 episodes or an episode >6 hrs post-injury

Headache

Irritability or behavior change

Seizure-(three types contact seizure, immediate, early, late)

<3 months of age

+- Scan

>2 episodes vomiting

Hematoma > 2cm

Suspect Child Abuse

LOC < 1min

Scalp Hematomas

Subgaleal

Caput

Cephalohematoma

Skull Fxs

Diastatic separation of sutures, most commonly lamdoid

Linear-get CT

Depressed-get CT and admit

Basilar-Get CT scan

Infants can have skull fractures even in falls less than 3 feet.  The parietal bone is the most often fractured with the linear type being the most common.  (Annals 37:1, 2001)  15-30% of linear skull fractures will have underlying injury.  If there is a tear through the dura underlying the skull fracture, a growing skull fracture can result

Bleeds

Subdural-most common 8-10%, 75% venous

Epidural-2-3%, 75% middle meningeal

Abdominal Trauma

Extremity Trauma

Salter Classification

Plastic Fractures

Buckle or Torus

Greenstick

Bowing or Bending

Toddler Fractures

hairline fractures of distal third of tibia.  May not show up on x-ray.  Hold knee and twist ankle in opposite direction, may need bone scan

Abrasion, Fx, Lacs

4. Rash

Contact Dermatitis

Allergic Dermatitis

Miliaria (heat rash)

Milia (sebaceous gland occlusion)

Transient Neonatal Pustular Milanosis-present at birth

Erythema Toxicum-not born c it, 1^st day of life, looks like flea bites, disappears by 1 week

Varicella

Usually seen in the winter and the spring in 1-14 y/o.

1-3 week incubation period, infectious 2 days before and 5 days after rash
1.  Skin Superinfection
2.  Pneumonia
3.  Hepatitis
4.  Pancreatitis
5.  Encephalitis
 

One of the few rashes present in the scalp, meningococcemia should not be in the scalp.  Kids with varicella before 1 year may have a second outbreak and are higher risk of shingles.  Usually leukopenia.  May see subclinical hepatitis.

Complications of varicella: death (data prior to 1995)—approximately 100 per year, 84% immunocompetent patients; typically due to encephalitis or Reye’s syndrome; bacterial superinfection—most common complication; may present with adenitis; most often due to Staphylococcus aureus or Streptococcus pyogenes; necrotizing fasciitis rare sequela; herpes zoster— 9% of children with shingles had varicella in first year; central nervous system (CNS) dysfunction—acute cerebellar ataxia most common neurologic complication; elevated protein in cerebrospinal fluid (CSF); admit to hospital for 1 to 2 days of observation; resolves spontaneously; encephalitis and cerebritis also reported (viral antigen in CSF); varicella pneumonia—admit child and treat with acyclovir; Reye’s syndrome—rare since vaccines available; hemorrhagic complications—very rare; patient cannot terminate viremia; unable to make interferon; changes in T cell subsets; 70% mortality; hemorrhage in all organs; thrombocytopenia rash looks like purpura fulminans (Audiodigest)

Motrin can give necrotizing fasciitis, aspirin can give Reye, use Tylenol and benadryl.  In 1st trimester, ¼ of fetuses will get limb deformations,  2nd trimester is no problem, 3rd trimester 5 days prior and 2 days post delivery can get Varicella encephalitis

Erythema Multiforme Minor and Major

Measles (Rubeola)

Seen in 0-20 y/o, usually in winter/spring.  Prodrome of high fever and URI sx.  Erythematous macules and papules which become confluent and turn coppery-colored.  Begins in hairline and moves down the body.  Koplik spots, conjunctivitis, photophobia, cough, and pneumonia

German Measles (Rubella)

5-25 y/o, usually in spring.  Prodrome is mild URI sx.  Maculopapular rash which becomes pinpoint.  Begins on face and migrates to the trunk.  Tender retroauricular, posterior cervical, and occipital lymphadenopathy.

Erythema Infectiosum (Fifth Disease)

From parvo B-19, 3-12 y/o or nonimmune adults.  Seen in winter/spring. Prodrome of fever and malaise.  Macular erythema on face, followed by erythematous macular eruption, then lacy erythema.  Rash progresses from face to extremities.  Associated with aplastic crisis, hydrops fetalis, popular-purpuric socks syndrome.

Exanthem Subitum (Sixth Disease, Roseola)

0-3 y/o, usually in Spring or Fall.  Prodrome of high fever for 3-5 days.  Rash of erythematous to pink macules and papules arranged in rosettes on trunk, neck, and proximal extremities.  Rash appears as fever resolves.

Scabies

Scarlet Fever

                   Disease                          Day of Fever which Rash Develops

Very           Varicella                        1^st day of Fever, rash develops

Sick            Scarlet Fever                2^nd

Pts              Small Pox                      3^rd

Must          Measles                         4^th

Take           Typhus                          5^th

Double       Dengue                          6^th

Eggs           Enteric Fever                7th

Jill M. Baren, MD, FACEP, FAAP

Maculopapular Eruption

V. References:

1. Edwards L. Dermatology in Emergency Care. Churchill Livingstone Inc., New York. 1997.

2. Fleisher GR and Ludwig S (eds.) Textbook of Pediatric Emergency Medicine, fourth edition. Lippincott Williams and Wilkins, Philadelphia. 2000.

3. Feigin RD and Cherry JD (eds.) Pediatric Infectious Diseases, third edition. W.B. Saunders Company, Philadelphia. 1992.

4. Barkin RM (ed.). Pediatric Emergency Medicine Concepts and Clinical Practice, second edition. Mosby, St. Louis, 1997.

5. Nelson WE (ed.). Textbook of Pediatrics, 15^th edition. W.B. Saunders Company, 1996.

6. Habif, TP (ed.) Clincal Dermatology A Color Guide to Diagnosis and Therapy, third edition. Mosby, ST. Louis, 1996.

5.  Vomiting and Diarrhea

Treat Diarrhea if salmonella <3 months old or bacteremic and <1 y/o or or asplenic

Always treat Shigella or campylobacter

Can Rx E. Coli, but not if O157:H7 as it will make HUS worse

6.  Pregnancy

7.  Eye and Ear

To examine the relucatant child's eye, roll them open with Q-Tips

Conjunctivitis

Corneal Abrasion

Foreign Body

Eye Trauma-don’t patch, sub-conjunctival hemorrhage 360°, abnormal pupil shape

Nasal Lacrimal Duct Stenosis

Glaucoma->12mm pupil diameter, >20 on tonometry, 1 eye bigger, epiphora, photophobia, blephorospasm

Otitis Media

(everything above the clavicles is Pneumo, H. Flu or B. Catarrhalis)

to look in the ears of an infant, put them in a prone position.

<6 months old, give full course of antibiotics

6 months-2 years with certain dx of AOM, give antibiotics

6 months-2 years with uncertain diagnosis, give antibiotics if severe illness otherwise observe, return in 72 hours

>2 years treat only with certain diagnosis and severe illness.

Have patient return in 72 hours if no improvement (Br Med J 322:336, 2001)

ANTIBIOTIC TREATMENT IN ACUTE OTITIS MEDIA PROMOTES SUPERINFECTION WITH RESISTANT STREPTOCOCCUS PNEUMONIAE CARRIED BEFORE INITIATION OF TREATMENT (Dagan, R., et al, J Infect Dis 183(6):880, March 15 2001 )

Otitis Externa

coricosporin

Foreign Body

Laceration

Perfed Tympanic Membrane-corticosporin or floxin

Labrynthitis

Endolymphatic Fistula

8.  Urogenital

Boys

Posthitis-inflammation of foreskin, soak in water, poor hygiene

Belanitis-inflammation of glans only.  Give bactrim, can be STD

Phimosis-can’t retract foreskin, send for circumcision

Paraphimosis-can’t reduce foreskin, must treat

Testicular Torsion-Prehn’s sign:  if when you raise testicle, it feels better then it is not torsion.  Loss of cremasteric reflex is the best test.  Affected testicle will be higher.  Reduce like opening a book

Torsion of Appendix Testes-blue dot sign, only 1 point of the testicle is painful;

Inguinoscrotal hernia/hydrocele

Variocele-bag of worms in scrotum, if it disappears when supine, no big deal

Orchitis/Epididymitis-can be from chlamydia

Girls

Vaginitis-can be chemical, Vag discharge is estrogen dependant so normal at less than 1 month from mom or after menarche.  Infectious would be strep A or STDs (Chlamydia, candidiasis, gardinella, trichinosis)

Foreign Body

UTI

9.  Surgical Emergencies

Get fingerstick, UA, Icon (if appropriate age and sex). drop the diaper to examine testicles, and look in the throat to avoid missing diagnoses.  If patient is a virgin female, can assess adnexa by bimanual rectal exam.

Malrotation with volvulus (One to Two Weeks)

Surgical emergency

Any infant with bilious vomiting, especially  in 1^st week of life

double bubble sign on upright x-ray.  Absence of ligament of treitz.  Bloody stool.

Pyloric Stenosis (One to Two Months)

projectile bilious vomiting from 2-6 months

firstborn males.

Examine with the infant on their back, flex their hips 90° to relax abd.  May palpate the olive by gently starting palpation with rocking motion below the liver, usually found on the right, just below the Xiphoid.  Ultrasound is the test of choice.  Will get hypochloremic, hypokalemic metabolic alkalosis.  Must correct pH and electrolytes before the OR.

Intusseseption (One to Two Years)

Classic triad:  colicky intermittent abd pain, vomiting,  guiac + stools

usually will have lead point such as peyer’s patches, polyps, or meckel’s

May have RUQ mass as ileocecal junction is the most common location

Neuro symptoms are associated with this disease and can include weakness, lethargy, and seizures.

Air enema or obstructive series as first test.  Can also be seen on UTS.

Appendicitis (Any Age)

can present with diarrhea.  Get CBC and UA

Compression graded UTS can be used, but CT is the better test.

In children less than 2 yrs old, symptoms may include cough, grunting, or walking with a limp. (Annals EM 36:39-51, 2000).  Diarrhea is present in up to 1/3 of children under 3 y/o with appendicitis (Am J Surg 173:80-82, 1997)

Ask the child how high they can jump, then let them show you to test rebound.

Can have white cells in urine, sometimes even bacteria (J Urol 129:1015, 1988 and Am J Surg 155(2), 1988)

Hernias

strangulated needs immediate op, incarcerated needs intervention.  Umbilical hernias are common, especially in African Americans.  Rarely become incarcerated.

Meckel’s

Rules of 2.  2% of population.  2 feet proximal to terminal ileum.  2% of people with meckel’s will have problems.  Usually has ectopic gastric mucosal.

DKA

Non-Accidental Trauma (NAT)

UTIs

infants with UTIs may have vomiting and diarrhea

Strep Pharyngitis

most common cause of abdominal pain in school age kids

Pneumonia

Testicular Torsion

10. Child Abuse/Psych Illness

Child Abuse

 FRACTURES MORE LIKELY TO BE ABUSIVE

· Metaphyseal-epiphyseal fractures (i.e., corner, bucket handle, and metaphyseal lucency)

· Rib fractures-especially posterior

· Fractures in different stages of healing

· Fractures inconsistent with history or developmental age of the child

· Avulsion fractures of the clavicle or acromion process

· Skull-multiple, depressed, bilateral, or across suture lines

· Pelvic and spinal fractures without a history of significant force

· Femur fractures in a child less than 1 year of age

· Fractures with delayed onset of seeking care

FRACTURES LESS LIKELY TO BE ABUSIVE

· Clavicle fractures

· Toddler's fracture of the tibia

· Supracondylar fractures of the humerus

· Fractures of the hands and feet

· Torus fractures of the long bones

· Pelvic or spinal fractures with a history of significant force
 

Tips on Examination

ask the child what his/her favorite food is, then ask if they would eat some now.

look for smurfs in the ears

have the child jump up and down to test for peritoneal pain.

have kids huff and puff and blow the house down to get good resp effort

or if kid is tiny, push in on their chest to get good exhalation

put baby on belly and elevate their head to stop crying, loud shush mimics sound of uterine arteries

Have child inhale during throat exam to prevent gagging

pant like a dog

Peanut Allergies

Unlike other food allergies, you do not grow out of this one.

Most common food allergy

Need 4 hour observation period secondary to severe recurrence after initial improvement.

Ibuprofen

(Pediatrics 2002; 109 e20)

can safely use motrin in peds asthmatics and more had exacerbation with APAP

Epistaxis

1/3 of children referred for recurrent epistaxis had a diagnosable coagulopathy.  Get CBC, PT/PTT, ristocetin cofactor activity.  Most common cause of coagulopathy is VWD. (J Pediatr Hematol Oncol 2002;24:47-49)

Lancet 360:603 August 24, 2002

BACKGROUND: Accurate temperature measurement is important for clinical decision- making, but can be difficult in children Infrared ear thermometers are currently being used by about two-third of pediatricians and family practice physicians, but their correlation with rectal temperature measurement has not been clearly established.

METHODS: The authors of this British study performed a systematic review of the literature to identify studies that compared rectal temperatures with temperatures measured by infrared ear thermometers. Their meta-analysis included 31 comparisons involving 4,441 children.

RESULTS: Using the rectal temperature as a reference standard, the pooled mean difference (rectal minus infrared ear thermometry) was 0.29C, with 95 confidence intervals that ranged between (-)0.74C to 1.32C. As such, for a measured rectal temperature of 38C temperatures measured by infrared ear thermometry could range between 37.04C and 39.2C. The 95% confidence intervals were wide in comparisons in which the ear device was used in various modes (e.g., rectal actual, core, oral or tympanic). There appeared to be no relationship between the child's age and differences between rectal and ear temperatures. There was insufficient information to determine the effects of otitis media on this parameter

CONCLUSIONS: In view of the wide range of the 95% confidence intervals in comparisons between rectal temperatures and those measured with infrared ear thermometry in children, the authors conclude that agreement between the two techniques is insufficient to rely upon infrared ear thermometry when precision in the measurement of body temperature is important.

Toxicology

One Tsp or One Tablet can kill a kid:

1. Chloroquine

2. Hydroxychloroquine

3. Imipramine

4. Theophylline

5. Thioridazine

6. Quinine

7. Chlorpromazine

8. Desipramine

9. Camphor

10. Methylsalicylate

11. 3 Tabs of Codeine

12. 5 Tabs of Lomotil

13. 5 Tabs of Benadryl

INFANT COLIC: EMPIRICAL EVIDENCE OF THE ABSENCE OF AN ASSOCIATION WITH SOURCE OF EARLY INFANT NUTRITION

Clifford, T.J., et al, Arch Ped Adol Med 156:1123, November 2002

BACKGROUND: It has been estimated that from 5% to 40% of infants develop colic, generally between the second and sixth weeks of life. Infantile colic can be the source of significant parental stress, possibly leading to abusive behavior. Some studies have implicated early infant nutrition as playing a role in the development of colic, but methodologic shortcomings limit the confidence with which these conclusions can be accepted.

METHODS This study, from the University of Western Ontario, examined relationships between early infant feeding (exclusively or partially breast-fed or exclusively formula-fed) and the development of colic during the first six weeks of life. The study included 856 mother-infant pairs. In addition to nutritional source, information was collected regarding maternal anxiety postnatal depression and social support. A diagnosis of colic was based on prospectively completed diary charts and/or retrospectively completed questionnaires.

RESULTS: Colic developed in 23% of exclusively breast-fed infants, 21% of exclusively formula-fed infants, and 29% of breast-fed infants with formula supplementation. On multivariate analysis that adjusted for confounders, there was no apparent relationship between infant nutrition and the development of colic. Development of colic appeared to be possibly related to factors such as the mother's employment status two months before delivery, maternal anxiety marital status and use of alcohol.

CONCLUSIONS: In this study the development of infantile colic was not related to the source of early infant nutrition.

Lymphadenopathy

Must first know patterns of drainage:

Anterior Cervical=mouth, pharynx, upper respiratory tract

Occipital and Posterior Cervical=scalp

-

Duration of Viral Illnesses

CLINICAL COURSE OF ACUTE INFECTION OF THE UPPER RESPIRATORY TRACT IN CHILDREN: COHORT STUDY

(Br Med J 327:1088, November 8, 2003)

Clinicians should advise caregivers that more than half of children with an acute viral infection of the upper respiratory tract will be unwell for at least one week, and about one-fourth will be unwell for approximately two weeks. More realistic predictions regarding the course of the illness might promote greater confidence in caregivers and reduce unnecessary repeat visits.

IS THIS CHILD DEHYDRATED?
Click here to hear the Reviewer's comments via MP3.
Steiner, M.J., et al, JAMA 291(22):2746, June 9, 2004


BACKGROUND: Several organizations have developed treatment guidelines for pediatric dehydration that are dependent upon clinical classification of dehydration as mild, moderate or severe, but under- or overestimation of the degree of dehydration is common.

METHODS: The authors, from the University of North Carolina at Chapel Hill, conducted a systematic review of 13 studies (1,246 patients) of the utility of the history, physical exam and laboratory testing for the assessment of dehydration in children aged one month to five years.

RESULTS: None of the studies fulfilled criteria for high methodologic quality. Parental reporting of symptoms was not found to be useful. Of eleven clinical findings, the three most useful predictors of 5% dehydration were prolonged capillary refill time (positive likelihood ratio [LR] 4.1), abnormal skin turgor (LR 2.5) and abnormal respiratory pattern (LR 2.0). Low positive LRs and/or wide 95% confidence intervals limited the predictive ability of other clinical findings (sunken eyes, dry mucous membranes, cool extremities, weak pulse, absence of tears, increased heart rate, sunken fontanelle and poor overall appearance). Diagnostic accuracy appears to be improved by the use of combinations of clinical findings or clinical scales. The ability of clinical signs to predict the degree of dehydration is problematic, and agreement between examiners is only fair to moderate. BUN or bicarbonate levels should not be considered definitive evidence of dehydration and are most useful when markedly abnormal, although a normal bicarbonate level reduces the likelihood of dehydration.

CONCLUSIONS: These findings highlight the pitfalls of relying on clinical evaluation for the assessment of dehydration in children. The authors favor the WHO approach which advocates use of the physical examination to classify dehydration as "none," "some" or "severe" as a guide to clinical management. 45 references (dewaltd@med.unc.edu)
 

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