Hi Kathy!! In response to your questions, here's my 24 cents
1. If there's any suspicion that the child is not "otherwise
healthy". That is to say, any element of the history/exam suggesting
the case is not garden variety VD & D. For example, rota should make
90%+ of its sufferers have diarrhea within 48 hrs of unresolved
vomiting. Isolated emesis for 48h w/o improvement is atypical and
should raise the CNS pathology or metabolic red flag (DKA, etc). By
the way, salmonella and other bacterial pathogens are more common
than we (or at least I used to) think.
2. see above. furthermore, if there is severe dehydration,
electrolytes may change your management. Base deficit can guide
reconstitution strategy, etc.
3. tough question. I haven't landed on this one but my general
approach is that if the child has returned to the pre-dry baseline,
has no holes in his follow-up, and had a typical presentation, I
would discharge and follow up. This is one of the many ideal
candidates for the 23h obs venue.
Great questions, I wish there were good data to base some of these
ideas on. I must say that as I percolated through my training, less
and less of these kids were admitted. Has it been because managed
care has improved the follow-up care or having our admission
practices scrutinized more in a MC environ has caused us to be less
conservative but just as careful, both, neither???
Michael L. Forbes, MD
Clinical Director, Pediatric Critical Care Unit
Allegheny University Hospitals, Allegheny General
Pittsburgh, PA 15212-4772
PS. Any snow down there?....
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