Chandler Assessment of the Sick Child

My first registrar post in Australia was in a mixed ED with children. The most common question I statement I encountered was

I’m not sure if this child needs to come into Hospital

I use the CHANDLER assessment tool to highlight potential red flags for paediatric admission. If 2 of the major groups are seen, the child should be strongly considered for admission and Paediatric specialist involvement.


C – Colour

  • Pale- perhaps dehydrated
  • Blue- cyanosed, hypoxic, hypothermic
  • Red- Rash, Burn, infection
  • Pink- healthy

H – Hydration status

  • Moderate dehydration (4-6% loss)
  • Capillary refill time >2 secs
  • Mild decreased skin turgor

  • Severe dehydration(>7% loss)
  • Capillary refill time >3secs
  • Deep acidotic breathing
  • Signs of shock (Tachycardia, Hypotension, altered mental state)
  • Decreased skin turgor
  • Sunken eyes

A – Alert

  • GCS status
  • Is the patient awake, smiling and interacting.
  • With neonates are they looking around, interested in their surroundings- reaching out for things put in front of them or are they floppy and disinterested.
  • For older children are they tired and miserable looking or hard to rouse.
  • Is the child inconsolable

N – Nutritional Status

  • Fat reserves
  • Does the child have good nutritional reserve and appear to be on normal weight limits?
  • Are they very underweight? Consider serious medical/surgical illness; anorexia or even neglect in the home?
  • Is the child overweight? Consider weight related issues such as Diabetes.

D – Dysmorphia

  • *Important to remember associations of certain conditions with particular syndromes
  • Example – Congenital Heart Disease in children with Down’s Syndrome.
  • These children can get sick very quickly.
  • Children with syndromes also have an increased incidence of renal abnormalities and swallowing issues and at risk for aspiration

L – Limbs

  • Are all the limb moving – particularly important in neonates or young toddlers with obvious communication issues.
  • Take note of children not moving arms or legs, examining thoroughly for tenderness.
  • Caution in those also with a limp.
  • Problems may not be obviously in the knees or lower aspect of the leg but in the hip, or even in genitalia in boys.
  • Consider Non-accidental injury also in children <2yrs

E – External Supports

  • This can be noted on your first interaction with the child as parents or Ambulance bring them in.
  • Does the child require external supports such as:
    • Wheelchair or splint. Does the parent carry them (when they can easily walk)
    • Oxygen, nebulisers or IV fluids
    • Sedation or significant analgesia prior to arrival
    • Cooling aids (wet towels/ ice packs etc)

R- Respiratory Distress

  • Is the child’s breathing becoming compromised.
    • Increased Respiratory rate for age
    • Accessory Muscle use
    • Stridor
    • Posturing- tripod position
    • Sternal and Sub/intercostal recession
    • Tracheal Tug
    • Nasal Flaring and head bobbing

Additional Resources:

Emergency Medicine Physician, #FOAMed advocate and self confessed rugby tragic | @JohnnyIliff | LinkedIn

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