results are often not available when making decisions regarding early clinical management Though not sensitive or specific, an elevated osmolar gap may be used as an early surrogate marker of toxic alcohol poisoning Additionally, serum methanol concentration can be estimated by the formula (osmolar gap × = methanol in mg/dL) A methanol concentration greater than 20 mg/dL is considered toxic There are three specific treatments for methanol intoxication: sodium bicarbonate, folic acid, and fomepizole (which has largely replaced ethanol) Sodium bicarbonate should be administered to correct metabolic acidosis: this improves physiologic functioning and may help prevent formate from reaching sensitive tissues Folate is provided because of its role in formic acid disposition within the tetrahydrofolate cycle Customary doses are mg/kg IV every hours Fomepizole, an alcohol dehydrogenase inhibitor, can prevent the metabolism of methanol to its toxic metabolites in cases where the methanol level exceeds 20 mg/dL If fomepizole is unavailable, ethanol, which has a higher affinity for alcohol dehydrogenase than methanol, may be provided to competitively block further production of toxic metabolites The loading dose of fomepizole is 15 mg/kg, which may be given IV or orally The maintenance dose is 10 mg/kg every 12 hours for four doses, then 15 mg/kg every 12 hours thereafter More frequent dosing is required during hemodialysis If fomepizole in unavailable, ethanol is administered with the goal of maintaining serum ethanol concentrations of at least 100 mg/dL Ethanol may be given by continuous IV infusion (600 mg/kg bolus followed by 110 mg/kg/hr) or by oral administration During dialysis, ethanol dosing may need to be doubled to maintain sufficient blood ethanol content to effectively block the metabolism of methanol IV ethanol is preferred but has the problems of lack of availability, hyperosmolarity (precluding its administration in small veins), and the need to administer large fluid volumes When the oral route is used, it must be remembered that proof designation of a beverage is twice the alcohol concentration expressed as a percentage (e.g., 80 proof equals 40% alcohol) Children must be closely monitored for the complications of ethanol administration, including mental status depression, hypoglycemia, and hypothermia Hemodialysis is recommended for children who demonstrate significant metabolic acidosis, end-organ injury (including coma or seizures), and/or acute kidney injury; this suggests the presence toxic metabolites amenable to extracorporeal removal When alcohol dehydrogenase is blocked, methanol has a very long time to elimination, primarily via exhalation; therefore, dialysis can