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When putting an infant to bed:

• Make the nighttime routine consistent and pleasant.
• Give the last nighttime feeding shortly before putting the baby to bed. Never put the baby to bed with a bottle, as it can cause tooth decay. (See: Baby bottle tooth decay)
• Spend quiet time with your child by rocking, walking, or simple cuddling.
• Put the child in bed before he is deeply asleep. This will teach your child to go to sleep on his own.
• Your baby may cry when you lay him in his bed, because he fears being away from you. This is called separation anxiety. Simply go in, speak in a calm voice, and rub the baby's back or head. Do not remove the baby out of the bed. Once he has calmed down, leave the room. Your child will soon learn that you are simply in another room.
• If your baby awakens in the night for feeding, do not turn on the lights. Keep the room dark and quiet. Use night lights , if needed. Keep the feeding as brief and boring as possible. Do not entertain the baby. When the baby has been fed, burped and calmed, return him to bed. If you maintain this routine, your baby will become used to it and go to sleep on his own.
• Sleeping with a baby younger than 12 months of age may increase the risk of sudden infant death syndrome (SIDS).

When dealing with an older child:

• Make the nighttime routine pleasant and predictable.
• Keep activities such as taking a bath, brushing teeth, reading stories, saying prayers, and so forth in the same order every night.
• Before you turn out the light, ask if the child needs anything else.
• Establish a rule that the child cannot leave the bedroom.
• Ignore verbal requests after the child has gone to bed.
• If your child starts screaming, shut the door to his bedroom and say, "I'm sorry, but I have to shut your door. I will open it when you are quiet." If your child comes out of his room, avoid lecturing him. Using good eye contact, tell the child that you will open the door again when the child is in bed. If the child says he is in bed, open the door.
• If your child tries to climb into your bed at night, unless he is afraid, return him to his bed as soon as you discover his presence. Avoid lectures or sweet conversation. If your child simply cannot sleep, tell him he may read or look at books in his room, but he is not to disturb other people in the family.
• Praise your child for appropriate bedtime behavior.

Remember that bedtime habits can be disrupted by changes or stresses such as moving to a new home or gaining a new brother or sister. It may take time to reestablish previous bedtime practices.

Skin turgor is the skin's ability to change shape and return to normal (elasticity).

Doughy skin; Poor skin turgor; Good skin turgor; Decreased skin turgor

Skin turgor is a sign commonly used by health care workers to assess the degree of fluid loss or dehydration. Fluid loss can occur from common conditions, such as diarrhea or vomiting. Infants and young children with vomiting, diarrhea, and decreased or no fluid intake can rapidly lose a significant amount of fluid. Fever speeds up this process.

To determine skin turgor, the health care provider grasps the skin on the back of the hand, lower arm, or abdomen between two fingers so that it is tented up. The skin is held for a few seconds then released.

Skin with normal turgor snaps rapidly back to its normal position. Skin with decreased turgor remains elevated and returns slowly to its normal position.

Decreased skin turgor is a late sign in dehydration. It occurs with moderate to severe dehydration. Fluid loss of 5% of the body weight is considered mild dehydration, 10% is moderate, and 15% or more is severe dehydration.

Note: Edema (a buildup of fluid in the tissues that causes swelling) causes the skin to be extremely difficult to pinch up.

• Decreased fluid intake
• Dehydration
• Diarrhea
• Diabetes
• Extreme weight loss
• Heat stroke(excessive sweating without enough fluid intake)
• Vomiting

Connective tissue disorders, such as scleroderma and Ehlers-Danlos syndrome, can also affect the elasticity of the skin. This does not have to do with fluids, but is a change in the elastic properties of the skin tissue.

A quick check of skin turgor by pinching the skin over the back of the hand, on the abdomen, or over the front of the chest under the collarbone is a good way to check for dehydration at home.

Mild dehydration will cause the skin to be slightly slow in its return to normal. To rehydrate, drink more fluids -- particularly water.

If turgor is severe, indicating moderate or severe dehydration, see your health care provider immediately.

• Poor skin turgor occurs with vomiting, diarrhea, or fever.
• During a check of skin turgor the skin is very slow to return to normal, or the skin "tents" up. This can indicate dehydration that is severe enough to require immediate treatment.
• You have reduced skin turgor and are unable to increase your intake of fluids (for example, because of vomiting).

The health care provider will perform a physical exam and ask questions about your medical history, including:

• How long have you had symptoms?
• What other symptoms came before the change in skin turgor (vomiting, diarrhea, others)?
• What have you done to try to treat the condition?
  • Did it make it better?
  • Is it getting worse?
• What other symptoms do you have (such as dry lips, decreased urine output, and decreased tearing)?

Tests that may be performed:

• Blood chemistry(such as a chem-20)
• CBC
• Urinalysis

Intravenousfluids may be necessary for severe dehydration. You may need medications to treat other conditions that affect skin turgor and elasticity.

Greenbaum L. Deficit therapy. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 54.

Gorgas DL, Barry JD. Vital signs measurement. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 1.

Pilonidal dimple is a condition that can occur anywhere along the crease between the buttocks, which runs from the bone at the bottom of the spine (sacrum) to the anus.

Pilonidal dimple may appear as:

• A pilonidal abscess, in which the hair follicle becomes infected and pus collects in the fat tissue
• A pilonidal cyst, in which a cyst or hole forms if there has been an abscess for a long time
• A pilonidal sinus, in which a tract grows under the skin or deeper from the hair follicle
• A small pit or pore in the skin that contains dark spots or hair

Pilonidal abscess; Pilonidal sinus; Pilonidal cyst; Pilonidal disease

Symptoms may include:

• Pus may drain to a small pit in the skin
• Tenderness over the area after you are active or sit for a period of time
• Warm, tender, swollen area near the tailbone
• Fever (rare)

There may be no symptoms other than a small dent (pit) in the skin in the crease between the buttocks.

The cause of pilonidal disease is not clear. It is thought to be caused by hair growing into the skin in the crease between the buttocks.

This problem is more likely to occur in people who:

• Are obese
• Experienced trauma or irritation in the area
• Have excess body hair
• Sit for long periods of time
• Wear tight clothing

It may help to keep the area clean and dry and remove hair regularly to prevent infection.

Call your health care provider if you notice any of the following around the pilonidal cyst:

• Drainage of pus
• Redness
• Swelling
• Tenderness

You will be asked for your medical history and given a physical examination. Sometimes you may be asked for the following information:

• Has there been any change in the appearance of the pilonidal cyst?
• Has there been any drainage from the area?
• Do you have any other symptoms?

Rarely, a CT scan is done.

Pilonidal disease that causes no symptoms does not need to be treated.

A pilonidal abscess may be opened, drained, and packed with gauze. Antibiotics may be used if there is an infection spreading in the skin or you also have another, more severe illness.

Other surgeries that may be needed include:

• Removal (excision) of the diseased area
• Skin grafts
• Surgery to remove an abscess that returns

Stafford SJ, Klein MD. Pilonidal sinus and abscess. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 336.6.

Nelson H, Cima RR. Anus. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 51.

Humphries AF, Duncan JE. Evaluation and management of pilonidal disease. Surg Clin North Am. 2010;90:113-124.

Review Date: 11/07/2011

Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington, School of Medicine; Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Bellevue, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.