Size and Shape

Children are distinct from adults in a variety of physical, physiologic, and psychological ways. The most obvious difference is size. During development, children may grow from the average 7-lb (3.18-kg) baby to a 140-lb (63.5-kg) adolescent, a 20-fold difference. Accordingly, medications and fluids must be calculated on an individual basis, based on the weight of the child. Table 99-1 lists average weights for age.

TABLE 99-1 Average Weight for Age

From U.S. Centers for Disease Control and Prevention National Center for Health Statistics (http://www.cdc.gov/nchs/).

This variation in size also influences a child’s risk of developing serious complications from envenomations. Many snakes, spiders, scorpions, and poisonous marine animals deliver the same dose of venom regardless of the size of the victim. Children often experience greater toxicity because of the increased dose of venom per kilogram of weight.

Children are not only smaller than adults, they also have a larger surface-area-to-mass ratio. For example, a 7-lb (3.18-kg) infant has 2.5 times more body surface area per unit weight than a 140-lb (63.5-kg) adult. Not only is the surface area of the young child’s body larger, the head, which is the part of the body most often left exposed, also takes up a larger proportion of the body (Figure 99-1). As a result, children experience greater exposure to environmental factors, such as cold, heat, and solar radiation. They are also more likely to suffer toxic effects from topical agents, such as medications.

FIGURE 99-1 Body proportions.

Musculoskeletal System

The musculoskeletal system in children differs from that in adults in several important ways. A child nearly doubles in height between birth and 2 years, and again between 2 and 18 years. In some respects, this rapid growth makes a child’s bones much more forgiving. Because of the active osteogenic potential of the periosteum, nonunion or permanent angulation deformities at the metaphysis are unusual in children. For the same reason, fractures in the pediatric population heal quite rapidly. For example, a fractured femur typically heals in 3 weeks in a newborn, compared with 20 weeks in a 20-year-old. The strong, pliable periosteum also allows for greenstick and buckle fractures, which are not seen in the adult population. These fractures with their intact periosteum are quite stable, with little swelling or crepitus. If nondisplaced, they are often incorrectly dismissed as sprains.

Another key difference between the musculoskeletal systems of children and adults is that children have an open growth plate, or physis, at the ends of long bones. The physis connects the metaphysis to the epiphysis and consists of soft cartilaginous cells that have the consistency of rubber and act as shock absorbers (Figure 99-2). They protect the joint surfaces from suffering the grossly comminuted fractures seen in adults. However, because the growth plate is more vulnerable to injury than are the strong ligaments or capsular tissues that attach to the epiphysis, a true sprain in a child is rare. Any significant juxta-articular tenderness in a child should be assumed to be a growth plate injury and immobilized accordingly. Such an injury is most common at the ankle (lateral malleolus), knee (distal femur), and wrist (distal radius). Physeal fractures have been classified into five Salter–Harris groups (see Figure 99-2). Salter–Harris I and II fractures generally heal without complications. Salter–Harris III and IV fractures often require open reduction of displaced fractures to realign the joint and growth plates and to permit normal growth. A Salter–Harris V fracture has a poor prognosis; impaction and crushing of some or all of the growth plate may result in a bony bridge that inhibits further growth or causes unequal, angulated growth. Consequently, any significant injury, especially if it involves the growth plate, requires full evaluation in a medical facility.

FIGURE 99-2 Salter–Harris classification of physeal fractures (I to V).

Cardiovascular and Respiratory Systems

Basic physiologic parameters change greatly during the transitions from infancy to childhood to adulthood. Recognizing these differences is important to avoid unnecessary and potentially harmful interventions in healthy children, and to intervene aggressively when abnormal vital signs are truly present. For example, a blood pressure of 70/35 mm Hg, pulse rate of 160 beats/min, and respiratory rate of 50 breaths/min are considered ominous vital signs for an adult. However, these vital signs are normal in a 2-month-old infant. Although blood pressure readings may not be available in a wilderness setting, it is possible to assess the general appearance, work of breathing, respiratory rate, pulse, and peripheral circulation of an ill child. These observations can accurately predict how sick a child is. In general, infants and children have higher respiratory and heart rates and lower blood pressure than do adults. The normal values for various age groups are presented in Table 99-2. It is important to note that children can often maintain normal blood pressure in the face of significant fluid or blood losses. Once blood pressure drops, however, children can deteriorate very rapidly. Therefore, prompt and aggressive fluid resuscitation is essential when other signs of dehydration or volume loss (e.g., tachycardia, increased capillary refill time, cool extremities) are present.

TABLE 99-2 Age-Specific Resting Heart Rate and Respiratory Rate*

* Mean rate, ± 2 SD.

Thermoregulation

Because environmental extremes are often encountered when traveling in wilderness areas, it is important to recognize that thermoregulation is less efficient in children than in adults. A number of physiologic and morphologic differences make children more susceptible than adults to heat illness. During exercise, children generate more metabolic heat per unit mass than do adults. Children also have lower cardiac output at a given metabolic rate, resulting in lower capacity to convey heat from the body core to the periphery. Because they have a larger surface area–to-mass ratio, children also gain heat more rapidly from the environment than do adults when ambient temperature exceeds skin temperature. In hot environments, cooling from conduction, convection, and radiation ceases to be effective, leaving evaporation (sweating) as the only effective means of heat dissipation. Unfortunately, children have a lower capacity for evaporative cooling, presumably because of decreased sweat volume, regional differences in sweat patterns, and a higher sweat point (the rectal temperature when sweating starts).⁴² Finally, children acclimatize to hot environments at a slower rate than do adults.

Children are also at greater risk for hypothermia. Their larger surface area–to-mass ratio causes them to cool more rapidly than adults in cold environments. Children also have less subcutaneous fat and, therefore, less body insulation. Infants, in particular, have an inefficient shivering mechanism. This makes them particularly vulnerable to cold environments because shivering is the primary means of generating extra heat when humans are cold.⁴ In general, humans are poorly adapted for cold environments and must rely on adaptive behavioral responses, such as seeking shelter and dressing appropriately, to maintain body heat. Infants and young children are not capable of these responses and must rely on caregivers to provide shelter and appropriate clothing.

Immunology and Infections

Children experience a greater number of infections than do adults. The average 1-year-old suffers six to eight infections per year, whereas the average adult has only three to four infections per year. Infections in children also tend to be more severe. The younger the child, the more likely it is that a given infection represents a first exposure to a pathogen. A first-exposure infection is more likely to cause fever and produce severe symptoms than reexposure, in which the infection is attenuated by antibodies produced from the first exposure. Young children are also less likely to have cross-reacting antibodies from previous infections with antigenically related organisms. When present, cross-reacting antibodies serve to attenuate the immunologic response to an infection, thereby mitigating symptom severity.

Many common respiratory or viral infections tend to produce more severe symptoms in children because of anatomic differences. The pediatric bronchioles, eustachian tubes, and larynx are narrower and, therefore, more easily obstructed by edema and mucus. This obstruction worsens symptoms, prolongs clearance of infection, and increases risk for secondary infection. Pertussis (whooping cough) is a classic example of the difference in severity of infection between children and adults. Nearly 20% of infants with pertussis have severe complications, such as apnea, pneumonia, seizures, or encephalopathy. In contrast, adult pertussis, although a common cause of chronic cough, is generally indistinguishable from a common cold.

Trauma

Blunt trauma is the leading cause of morbidity and mortality in children ages 1 to 18 years. Closed head injuries are responsible for 80% of pediatric trauma deaths.⁴⁴ Although pedestrian and motor vehicle accidents are the source of many of these injuries, falls and drowning are close behind. Children differ from adults in their susceptibility to injuries from blunt trauma, and the injuries themselves differ. By nature of their smaller size, children’s airways are more prone to obstruction, particularly by their relatively large tongues. Their rib cages are more pliable and hence provide less protection to the lungs and mediastinum. Similarly, the abdominal musculature in children is underdeveloped relative to adults, leaving the intra-abdominal organs more vulnerable to injury. Pelvic fractures are uncommon in children; when they do occur, they rarely result in life-threatening bleeding or genitourinary injury.

The cranium of younger children is softer and hence less protective of the underlying brain. Fortunately, open fontanelles in infants provide a limited pressure buffer for children with intracranial hemorrhage or swelling. The relatively large head size, loose ligaments, poor cervical muscular support, and underdeveloped facets result in a different pattern of cervical spine injuries in children than is seen in adults. Although cervical spine injuries in children are uncommon, when they occur, they tend to be higher in the cervical spine and may involve injuries not visible with conventional radiography or computed tomographic (CT) scanning—thus the acronym SCIWORA, for spinal cord injury without radiographic abnormality. The term SCIWORA is somewhat of a misnomer, however, for although these injuries are not visible on radiograph or CT scan, they can be visualized with magnetic resonance imaging.

First 2 Years

Equipment

Because infants and young children are not capable of extended hikes, they are typically transported in carriers. Most front carriers work well from infancy until an age when babies can sit fairly well, typically 6 to 9 months (Figure 99-3). It is important that a front carrier extend up high enough in the back to completely support a young baby’s head. Once a child is sitting well, back carriers are better (Figure 99-4). Back carriers function on the same principle as framed backpacks, redistributing the weight off the shoulders and onto the hips. Many back carriers are able to stand alone and can double as a highchair. Children must be strapped into back carriers, because it is easy for a child to be catapulted out of a carrier if the adult bends over or falls.

FIGURE 99-3 Infants in front carriers.

(Courtesy Judith R. Klein, MD.)

FIGURE 99-4 Toddlers in back carriers.

(Courtesy Judith R. Klein, MD.)

Sleeping bags are available for infants and toddlers. However, in a warm climate, a blanket can suffice, and, in a colder environment, an insulated snowsuit is often adequate. Avoid placing diaper-clad infants into a sleeping bag with an adult; accidents or a leaky diaper can create very unpleasant sleeping conditions. Children, including young infants, also need their own sleeping pads. Such pads protect them from hard, rough ground under the tent and insulate them from the cold ground.

Shoes for young children should protect their feet and allow for full range of movement. The best shoes for toddlers are lightweight and flexible. They need shoes that stay on well, because children can flip their shoes off while in a carrier. Velcro-strapped shoes stay on well and are easy to put on and take off. Because children often lose shoes, an extra pair should be included.

2 to 4 Years

Safety

Unfortunately, 2- to 4-year-olds are notorious for exploring their environment by either wandering off or by trying to become a backcountry gourmet. Young children must be watched closely and cautioned to keep wild mushrooms, plants, berries, and other inedible or toxic items out of their mouths. Children should be kept within sight at all times, as their desire to explore often defies good judgment and exceeds their physical abilities. Although attacks are rare, mountain lions may view small children as easy prey and can strike quickly. Parents should, therefore, discourage their children from wandering ahead unaccompanied. Toddlers should also be encouraged to step only where they can see (i.e., on top of logs rather than over them) to avoid any unsuspecting reptile or large insect.

When selecting campsites, dangerous features, such as steep drop-offs and fast, deep water, should be avoided. Children should be dressed in brightly colored clothing, so they are more easily located if they become lost (Figure 99-5). As children get older, they may carry a whistle to call for help when they are lost. The standard distress signal is three blows to indicate “I’m lost” or “I need help”; the response is two blows to indicate “help is coming.” Parents should teach children to stay put once they discover they are lost and wait to let help come to them. If children panic and start running when they realize they are lost, they increase the chance not only of getting injured but also of traveling farther from the family. The concept of “hug a tree” will be described later in the chapter.

FIGURE 99-5 Appropriate wilderness wear: brightly colored clothing and whistle.

(Courtesy Judith R. Klein, MD.)

School Age (5 Years and Up)

Dehydration

Children are at greater risk of dehydration than are adults. Because the surface area–to-mass ratio of a child is greater than that of an adolescent or adult, insensible fluid losses through the skin account for a larger percentage of total fluid losses as the size of the child decreases. In addition, the sodium concentration of children’s sweat is generally less than that of adults, leading to a greater relative free water loss. Infants are unable to report thirst, an important marker of fluid deficit, thereby increasing their risk of dehydration. Even once they become verbal, children are often preoccupied and fail to report or meet their need for fluids, even when water is freely available.

Hypothermia

Children cool more rapidly than do adults because they have a relatively large surface area and often lack the knowledge and judgment to initiate behaviors that maintain warmth in a cold environment (see Chapter 5). In addition, they have a more difficult time, physiologically, maintaining body temperature in cold climates, predominantly because they do not shiver as effectively.⁴ As a result, parents participating in cold weather recreation with children should be able to recognize, treat, and preferably prevent hypothermia and frostbite.

Hypothermia is defined as core body temperature below 35° C (95° F). At this temperature, the body no longer generates enough heat to maintain body functions. The condition is considered mild when the core temperature is 33° to 35° C (91° to 95° F); moderate at temperatures between 28° and 32° C (82° and 90° F), and severe when it is less than 28° C (82° F). The signs and symptoms of hypothermia are listed in Table 99-4, although these may be quite variable. The most important clue to significant hypothermia is altered mental status. An infant may become lethargic and difficult to arouse. An older child may be shivering, stumbling, or appear confused. These signs merit prompt treatment for hypothermia. Of note, the presence or absence of shivering is not a reliable marker of the severity of hypothermia. Physicians should also caution parents that hypothermia can develop at moderate ambient temperatures if adverse climatic conditions are compounded by illness, fatigue, dehydration, inadequate nutrition, or wet clothing.

TABLE 99-4 Signs and Symptoms of Hypothermia*

* Data from adult subjects.

Prevention

When preparing for cold weather activities, children should dress in layers to allow clothing to be added or subtracted as necessary (Figure 99-6). This avoids excessive perspiration while maintaining warmth. An inner, wicking layer should be followed by a middle, insulating layer and, finally, by an outer, protective layer.

FIGURE 99-6 Layering of clothing for cold environments.

(Courtesy Judith R. Klein, MD.)

Because children generally avail themselves of any opportunity to get wet, clothing that maintains low thermal conductance when moist is particularly important. Conductive heat loss may increase fivefold in wet clothing and up to 25-fold if the child is completely immersed in water. Traditional wool retains warmth when wet because of its unique ability to suspend water vapor within the fibers; however, it is heavier than synthetics and takes much longer to dry. Cotton has a high thermal conductance that increases greatly when wet and is, therefore, a poor choice for wilderness activities in cold weather. Synthetic materials (polypropylene, Capilene, Thermax, Coolmax) wick moisture away from the skin and dry quickly, making them ideal for an inner layer. Finely woven merino wool also provides these same advantages as a wicking layer. The middle, insulating layer may incorporate wool, polyester pile or fleece, down, or similar materials. Finally, windproof and water-resistant outer garments (e.g., Gore-Tex) decrease heat loss from convection and keep children dry. Hats and mittens are also essential; the uncovered head of a child dissipates up to 70% of total body heat production at an ambient temperature of 5° C (41° F).⁴

Frostbite

Localized cold injury can result in frostbite (see Chapter 8). Predisposing factors include wet skin, constricting garments that hinder blood circulation, fatigue, dehydration, contact with cold surfaces, and wind. If skin temperature drops below 10° C (50° F), cutaneous sensation is generally abolished and injury may go unnoticed. Skin cooled to −4° C (25° F) freezes.

Frostbite has traditionally been divided into degrees of injury, much like burns. Determination of depth of injury should occur 24 to 48 hours after rewarming; prior to this, frostbitten skin generally appears hard and feels numb. Skin with superficial frostbite is typically swollen, pink or erythematous, painful, somewhat warm, and often blistered. Sites with deep frostbite are cooler, not edematous, pale, anesthetic, and do not have blisters or bullae. In children, frostbite that extends into bone may affect the growth plate and result in skeletal deformities.⁴ Verbal children will frequently report cold hands and feet, but adults should be vigilant about checking the extremities and noses/ears of nonverbal children, particularly those poorly visible in back carriers. A mirror, frequently used, can assist in this regard. Reports of small children developing frostbite and hypothermia while being carried on the backs of adults engaged in outdoor winter pursuits are not infrequent.

Hyperthermia

Families participating in wilderness activities in hot climates must take special precautions to avoid heat illnesses (see Chapters 10 and 11). Children do not tolerate the demands of exercise in the heat as well as adults. They generate more heat per kilogram and are less able to disperse heat from the core to the periphery. Parents planning wilderness ventures with children in hot climates can follow some simple guidelines for avoiding heat illness. The most obvious entails reducing the duration and intensity of activities under conditions of high climatic heat stress. The likelihood of heat illness depends on relative humidity, wind velocity, and radiant heat, as well as standard dry-bulb thermometer temperature. Figure 99-7 gives a rough guide for activity levels based on temperature and relative humidity.

FIGURE 99-7 Activity levels based on temperature and relative humidity.

Sun Damage

Hazards of overexposure to sunlight include sunburn, photoaging, skin cancer, and phototoxic and photoallergic reactions (see Chapter 14). Climatic changes such as global warming and ozone degradation have increased these hazards.⁵⁴ Preventing ultraviolet damage to skin should begin in childhood, as 50% to 80% of a person’s lifetime sun exposure occurs before 21 years of age.^25,48 Adolescence is the period when children are most at risk. In one study, 83% of children 12 to 18 years old reported at least one sunburn per summer; 36% reported three or more sunburns per summer.²⁵ Recent evidence suggests that the risk of developing malignant melanoma increases significantly with the number of sunburns in childhood.¹⁹ This risk is even higher if a child is light-skinned with a propensity to burn rather than tan. Tolerance to sun exposure is determined by the amount of melanin in skin and ability of skin to produce melanin in response to sunlight. In general, children have lower melanin levels and thinner skin than do adults and are, therefore, at greater risk of sun damage.

The ultraviolet wavelengths UVA and UVB are principally responsible for the harmful effects of solar radiation. UVB is primarily responsible for suntan and sunburn and also promotes development of skin cancer and skin aging. UVB increases 4% for every 1000-foot (300-m) gain in elevation above sea level. Therefore, a backpacker at 10,000 feet (3050 m) will have a 40% increase in UVB exposure. UVA, which is 10 to 100 times more abundant than UVB, is only 0.001 as potent at inducing sunburn. It is also less affected than is UVB by changes in season or solar zenith angle. UVA is primarily responsible for photosensitivity reactions and solar urticaria. It also contributes to skin cancer and skin aging. A number of drugs often used in adolescence, such as tetracycline, vitamin A derivatives (Retin-A, Accutane), and nonsteroidal antiinflammatory drugs (NSAIDs), increase the risk of photosensitivity reactions and the need for UVA protection. Consequently, it is important to use sunscreens that protect against both UVA and UVB.

The harmful effects of ultraviolet radiation from the sun can be reduced if parents are educated regarding the dangers of sun exposure and encouraged to use sun-protective clothing and sunscreens early in their children’s lives. One study demonstrated 60% reduction in childhood sunburns with good parental role-modeling and sunscreen vigilance.⁴⁸ Regular use of sunscreen with sun protection factor (SPF) of at least 15 for the first 18 years of life reduces a person’s lifetime risk of developing nonmelanoma skin cancer by 78%.²⁷

Prevention

The most effective means of preventing sun damage is use of protective clothing and avoidance of excessive sun exposure. Midday hours, particularly around highly reflective surfaces (e.g., water, sand, snow), at high altitude and at the equator are the most dangerous in terms of quantity of ultraviolet exposure. Shady areas should be used for activities during these times. Hats with wide brims and neck drapes help to protect the face and neck from sun exposure (Figure 99-8). Clothing made from tightly woven fabrics is more protective than is clothing made from loosely woven fabric. For example, loosely woven fabrics, such as those used in most T-shirts, have an SPF of only 5. Most clothing loses more of its sun protective effect when wet. Several manufacturers are marketing high-SPF (25 to 50) protective clothing (http://www.coolibar.com; http://www.sunprotectiveclothing.com). This specialized clothing is cool and lightweight, dries quickly, and can maintain its full SPF capabilities when wet (Figure 99-8). Caution is advised on overcast days, because 80% of the sun’s rays still reach the earth even when the sun is not visible.²⁷ In addition, because clouds filter out heat from infrared rays, children feel more comfortable and tend to stay out longer, therefore increasing their overall UV exposure.

FIGURE 99-8 Child with appropriate sun wear: protective clothing, wide-brimmed hat, and sunglasses.

(Courtesy Judith R. Klein, MD.)

Proper eye protection is often overlooked in infants and young children. Excessive ultraviolet light, particularly during snow and water activities, can result in ultraviolet keratitis (see Chapter 28) with even brief exposures. Properly fitting sunglasses that transmit less than 10% of ultraviolet rays should be part of a child’s outdoor activity armamentarium (Figure 99-8). Side shields and polarizing lenses are particularly important in snow conditions.

Sunscreens

Sunscreens formulated with a variety of different agents to prevent UV damage to the skin include physical blocks, chemical blocks, and antioxidants. Physical blocks, such as zinc oxide and titanium dioxide, reflect ultraviolet light and do not penetrate the skin. Chemical blocks prevent ultraviolet light from entering skin, and are themselves absorbed into skin. Chemical blocks have ingredients that block UVB, UVA, or both. Agents that block UVB include PABA, cinnamates, salicylates, and anthranilates; those that block less potent UVA rays include avobenzone and the anthranilates. Benzophenones, oxybenzone, and the physical blocking agents protect against both UVA and UVB.²⁷ Antioxidants present in sunscreens include Vitamins C and E, resveratrol, and pomegranate. These agents help to repair skin damage. Sunscreens that combine protective ingredients with antioxidants are the most effective. The sun protection factor (SPF) is a measure of a sunscreen’s effectiveness. It is measured in terms of the minimal dose (in length of time) of UV radiation required to cause skin erythema. Sunscreens with SPF 30 or higher provide a superior degree of photoprotection and almost completely prevent cellular changes seen with sunburn.²⁷

Overall, there is little difference between child and adult sunscreens except for price. Parents should select sunscreens based on ingredients. Physical blocks are preferred for children because they are difficult to wash/rub off and do not degrade in the sun. Therefore, they do not need to be reapplied with as great frequency as do chemical sunscreens. Zinc oxide can be quite colorful, whereas titanium dioxide is colorless. Apply a thick coat of sunscreen at least half an hour before outdoor activity. Sunscreens must be applied in adequate quantity to provide the SPF indicated on the bottle.⁵¹ Select a sunscreen with an SPF of at least 15, but preferably greater than 30. Waterproof sunscreens are preferred if children are anywhere near water, because these products maintain efficacy for up to 80 minutes of water immersion. Sunscreens should be reapplied at least every 2 hours (or more frequently) during prolonged water immersion or excessive sweating. Cream and lotion sunscreens provide superior coverage to spray-on formulations because they can be applied evenly and in the quantities required to provide effective sun protection. Infants younger than age 6 months should be outfitted with hats and protective clothing and should placed in the shade. Sunscreens in this age group should be limited to small areas of skin only, because infant skin is thin and chemically sensitive.

Drowning

According to the Centers for Disease Control, drowning (see Chapter 75) is the number two cause of injury-related death in children, resulting in more than 900 fatalities in children under 14 in 2005.⁶⁶ Of all deaths among children age 1 to 4 years in 2005, 30% were the result of drowning.⁶⁶ Those most at risk are unsupervised toddlers and male teenagers, in particular, those with inadequate swimming skills and poor judgment. Morbidity and mortality result from asphyxiation, hypothermia, and/or trauma.

If a child is pulled from the water after a submersion event, cervical spine precautions should be maintained unless the event is witnessed and no trauma has occurred. All children who have experienced a period of near-drowning should be transported to a hospital for observation, particularly if they demonstrate any sign of distress. If the child is apneic or pulseless, CPR should be initiated immediately and the child transported to an emergency care facility as quickly as possible. All wet clothing should be removed and rewarming initiated. Prognostic assessments based on the initial appearance of the child should not be made in the field, particularly in the setting of cold water immersion. The exception would be in a remote wilderness area, where transport and evacuation times may be extremely long. Survival with good neurologic outcome has been documented in children with prolonged (>40 minutes) submersion in cold water. The emphasis in the field should be on rapid rescue and immediate CPR.

High-Altitude Illness

High-altitude illness (see Chapter 1) can be viewed as a continuum from acute mountain sickness (AMS) to life-threatening conditions such as high-altitude pulmonary edema (HAPE) and high-altitude cerebral edema (HACE). AMS usually develops within 24 hours of ascent. The incidence and severity of AMS depend on individual susceptibility, as well as rate of ascent and altitude attained. In one study, 37% of children who ascended rapidly to 3500 m (11,500 feet) developed AMS.⁶ Other studies have shown even higher incidences of AMS in children and have suggested that children are more susceptible to hypobaric hypoxia than are adults.⁴³

Bites and Stings

Bites and stings occur commonly in the pediatric age group. In 2008, the American Association of Poison Control Centers reported that more than 25,000, or roughly one-third, of reported bites and stings occurred in individuals under the age of 20 years.⁸ Remarkably, no fatalities were reported in this age group. This emphasizes the need for appropriate triage to determine which children require aggressive therapy so that potentially harmful field interventions can be avoided.

Dangerous interactions between children and surrounding fauna can be limited by judicious use of protective clothing, sturdy footwear, appropriate chemical barriers, and education. These principles apply to snakes, bees, wasps, yellow jackets, mosquitoes, and ticks.

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