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When Should Your Child Go to the Hospital?

The doorbell rang around 10 p.m., announcing the arrival of my brother's family for a weekend visit. But they greeted us with "Where's a hospital?" Their 18-month-old had screamed in apparent pain for most of the five-hour drive, so they bolted to the ER. There, distracted by the commotion, the baby cheered right up. A doctor diagnosed a garden-variety ear infection, and the parents chastised themselves for jumping the gun.

I kept this incident in mind when my own daughter, at about the same age, woke up wailing and breathing hard. I calmed her easily, chalked up her symptoms to a virus, and waited until morning to see a doctor. Our pediatrician checked her oxygen level and quickly administered inhaled medicine to open her tight airways. As he briefed me on wheezing, noisy breathing that indicates a struggle for air, he said sternly, "Next time, don't wait -- we don't want her turning blue." I was mortified that I'd failed to recognize something serious.

Children ages 4 and younger account for about 10 percent of the 115 million emergency room visits a year. The most common reasons: respiratory illness and fever, followed by injuries and vomiting/diarrhea.

Most new parents eventually face the scary question "Should we go the ER?" And often, in hindsight, they regret their decision, forgetting they did what seemed wisest at the time. "People go to the emergency room for a reason: something exceeded their threshold for concern," says Joseph Luria, MD, emergency department medical director at Cincinnati Children's Hospital Medical Center. Meanwhile, other parents may talk themselves down from worry when their child really does need attention -- fast. So how do you discern a real or impending emergency from a case better handled at home or at your pediatrician's office? Here, guidance from emergency room experts.

Sometimes the need to call 911 is only too clear: a child is unconscious, blue, or badly injured. Other urgent situations aren't so obvious. "It helps to consider potential emergencies the same way doctors and nurses do, with ABCD," advises Milwaukee pediatrician Marc Gorelick, MD, a member of the American Academy of Pediatrics' committee on emergency medicine.

  • Airway: If the passage to the lungs is blocked -- for example, your child is choking -- have someone call 911 while you try to clear the airway. If you're alone, attend to your child first. To be prepared for such situations, take a course in CPR.
  • Breathing: Noisy, high-pitched, and rapid wheezing or grunting indicates a child is struggling for air, usually during a respiratory infection or an asthma attack. "You'll see the chest sucking in and the belly moving," says ER physician Joan Bothner, MD, chief medical officer at the Children's Hospital of Denver. It's just as hard -- if not harder -- to exhale as it is to inhale, which means your child's condition will deteriorate fast. Get emergency aid for a baby taking in more than 60 to 70 breaths per minute, a 1-year-old taking in 40 or more, or an older child taking in 30 or more (the normal rate slows with age).
  • Circulation: This applies not only to blood loss from trauma but also to dehydration from vomiting or diarrhea, which prevents blood from properly nourishing the body. Signs that your child needs intravenous fluids include decreased urination (fewer than two soaked diapers a day), a sunken soft spot on the head, a sticky mouth, tearless crying, sunken eyes with dark circles underneath, listlessness, paleness, and clammy skin.
  • Disability: Get immediate help for a child who's unconscious or having a seizure that involves going limp or stiffening and jerking, with eyes rolling back or staring. About 5 percent of young children are prone to febrile seizures. This frightening response to fever is almost always harmless, but a child's first seizure should be treated as an emergency to rule out a more serious problem. For subsequent episodes, there's no need to call 911 unless it lasts longer than the typical 5 minutes (but always report it to a doctor ASAP).

Most kids' illnesses, including ear infections, high fevers, and even all-nighters of vomiting or diarrhea, aren't emergencies, as long as the ABCDs don't apply. Much as you want an immediate diagnosis, it's best to avoid the ER if you can. The visit will likely be more stressful, more expensive, and much longer than a regular one: a patient's average time in an ER is four hours. Plus, doctors see patients in order of severity, not arrival, so if you rush in with a howling but alert child whose ear hurts, prepare for a wait.

Convenience and cost aren't the sole reasons to avoid the ER. Ultimately, a child who's not in danger is best off waiting to see his regular doctor, who is familiar with his medical history. Until you can get an appointment, offer acetaminophen or ibuprofen to relieve pain or reduce fever. Even repeated gastrointestinal bouts are usually far more distressing than dangerous; however, as soon as your child can keep liquids down, offer frequent sips of water, diluted juice, or a rehydration solution such as Pedialyte.

Between the black-and-white of a clear emergency or obvious illness, there are still shades of gray -- especially during the night, when fatigue can heighten frustration and fear. Never hesitate to call your child's doctor for guidance.

Before you dial, prepare to give as many details as possible: symptoms and when they started, including frequency of vomiting or diarrhea; temperature and how you took it; amounts and timing of meds; and changes in sleeping, feeding, and waste excretions. "Go to your child's bedroom to make the call so you're prepared to answer when the doctor says, 'Tell me this,'" Dr. Bothner says.

Don't worry about disturbing the doctor; many offices have after-hours programs staffed by nurses whose job is to help parents decide what to do. At a regular visit, find out how questions are handled when the office is closed and if your doctor prefers a particular hospital. "If your child has a complex medical history, such as a heart problem, ask your doctor for a letter describing it, and keep it with your car keys or on the refrigerator under a magnet," Dr. Bothner advises.

If you end up going to the ER, take that letter, along with bottles of any drugs your child is taking, a well-stocked diaper bag, and change for pay phones -- cell phones may not work in ERs.

During a baby's first 6 to 12 weeks, almost anything out of the ordinary qualifies as a possible emergency, including symptoms considered minor in older children, such as a fever of 100.5 degrees F. or higher, difficulty feeding, or a bump or bruise on the head. The reasons: The immature immune system doesn't fight infection well, so a minor illness can quickly become major; a not-yet-established sleep-wake schedule makes it hard to determine the reason for inconsolable crying; and the developing brain is more vulnerable. "Also, conditions such as heart or gastrointestinal problems not identified right after delivery might become evident now," says Kathy Shaw, MD, director of emergency medical services at The Children's Hospital of Philadelphia.

Doctors stress that, despite general guidelines, parents should trust their instincts when they believe a child needs medical care fast. "Some parents worry about abusing the ER because the situation turns out to be less serious than they thought," Dr. Gorelick says. "But I'm happy to figure out that a kid's not seriously sick. For example, croup causes a barking cough in the middle of the night, and it's appropriate for a parent to rush in with a child who's having trouble breathing. Cold night air relieves this, so some kids are better by the time they get to the ER -- but that doesn't mean they shouldn't have come."

1. A child who vomits through the nose has a serious gastrointestinal problem.
False.
The passage from the nose goes into the throat, so this vomiting is normal. A true emergency: A baby has green vomit, which signals an abdominal obstruction that may require surgery.

2. Your sick child has a blotchy rash on his tummy -- but that's no reason for extra worry.
True.
Red bumps and blotches are common, from easily recognizable problems such as diaper rash to more mysterious breakouts that often accompany a mild viral illness. One important exception: flat red pinpoints or purplish spots. "If the rash doesn't go away when you press on it -- most will turn white for a second or two -- and your child has a fever, it could signal a serious illness such as meningitis, which demands immediate attention," says Dr. Shaw.

3. Your toddler fell on her head and acts fine -- but that egg-size lump needs a CAT scan.
False.
A big bump alone isn't cause for panic. If she hasn't vomited or acted dizzy or disoriented within four hours of her fall, she should be okay. It's also a common misconception that a child shouldn't sleep after bumping her head. Don't force a tired child to skip a nap, but do rouse her within two hours of going to sleep to make sure she's fine.

4. Avoid giving your child a pain reliever before going to the ER -- it could mask symptoms and delay diagnosis.
False.
"Knowing how a child reacts to medication helps us decide what to do; otherwise we have to wait and see how the child responds to the medication she receives at the hospital," says Dr. Gorelick. Newborns are an exception: In infants under 3 months, it's important to document the severity of an actual fever. Once a doctor has seen the baby, medicine is fine.

5. Spiking a fever higher than 104 degrees F. won't cause brain damage.
True.
"Fever is the body's way of fighting infection, and harmful effects are very rare," says Dr. Luria. The brain is unscathed, except in the unlikely situation of a prolonged temp above 107.6 degrees F. (such as with untreated heatstroke). An untreated illness-related fever rarely tops 105 degrees F.


Copyright © 2008. Used with permission from the May 2008 issue of American Baby magazine.

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