What is the first action when a child presents with dry, cracked lips and anorexia?

First Action: Review the Last 24-Hour Intake and Output (Option C)

When a child presents with dry, cracked lips and anorexia, the first action should be to review the last 24-hour intake and output to establish baseline hydration status and guide subsequent assessment and intervention. 1

Rationale for This Approach

The combination of dry, cracked lips and anorexia in a child suggests potential dehydration, but the severity is unclear from these symptoms alone. Before proceeding with physical examination or interventions, establishing a quantitative baseline of fluid intake and output provides critical information to:

• Determine the degree of fluid deficit by calculating the difference between intake and expected output 1
• Guide the urgency and type of subsequent assessment (whether immediate IV access is needed versus oral rehydration) 1
• Establish whether ongoing losses are present that will need replacement in addition to rehydration 1

Why Not the Other Options First?

Skin Turgor Assessment (Option A) - Second Priority

While assessing skin turgor and dehydration signs is important, this physical examination should follow intake/output review because:

• Physical signs alone can be misleading - dry lips can occur from environmental factors or lip-licking behavior without significant dehydration 2
• The CDC defines dehydration severity (mild 3-5%, moderate 6-9%, severe ≥10% fluid deficit) based on clinical signs, but intake/output data provides more objective information to guide this assessment 3
• Skin turgor specifically indicates moderate dehydration (6-9% deficit) with skin tenting, but you need baseline data to interpret this finding appropriately 3

Oxygen Saturation and Behavior (Option B) - Least Relevant

This option is the least appropriate initial action because:

• Oxygen saturation is not typically affected by the dehydration levels suggested by dry lips and anorexia alone 1
• Behavioral changes (lethargy, irritability) indicate severe dehydration (≥10% deficit), which would be accompanied by more dramatic signs than just dry lips 3
• This assessment becomes relevant only if severe dehydration or shock is suspected after initial evaluation 1

Algorithmic Approach After Intake/Output Review

If Intake/Output Suggests Mild Dehydration:

• Assess for 3-5% fluid deficit signs: increased thirst, slightly dry mucous membranes 3
• Initiate oral rehydration with 50 mL/kg ORS over 2-4 hours 1
• Replace ongoing losses with 60-120 mL (if <10 kg) or 120-240 mL (if >10 kg) for each diarrheal stool or vomiting episode 1

If Intake/Output Suggests Moderate Dehydration:

• Assess for 6-9% fluid deficit signs: loss of skin turgor, skin tenting, dry mucous membranes 3
• Administer 100 mL/kg ORS over 2-4 hours 1
• For infants unable to drink adequately, consider IV isotonic crystalloid at 20 mL/kg boluses 1

If Intake/Output Suggests Severe Dehydration:

• Look for ≥10% fluid deficit signs: severe lethargy, prolonged skin tenting, decreased capillary refill 3
• Immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline 3
• Transition to oral rehydration once stabilized 1

Critical Considerations for Anorexia

The presence of anorexia requires specific attention:

• In acute illness context, anorexia with dehydration suggests gastroenteritis or infection requiring fluid replacement and monitoring 4
• If chronic or with concerning weight loss, screen for eating disorders, especially in adolescents, as mortality rates are significantly elevated with comorbid anorexia nervosa and medical complications 4
• Dry, cracked lips can be a dermatologic manifestation of chronic malnutrition in eating disorders, not just acute dehydration 5

Common Pitfalls to Avoid

• Do not use "clear liquids" instead of ORS - they cause osmotic diarrhea and electrolyte imbalance 3
• Do not delay assessment waiting for laboratory values when clinical assessment and intake/output history can guide immediate management 1
• Do not assume environmental causes for dry lips without ruling out dehydration, especially when paired with anorexia 2
• For vomiting children, start with very small volumes (5 mL) of ORS and gradually increase as tolerated 1