Is My Child Sick Enough for the ER?

It’s 11PM, and the cough com­ing from your child’s room does­n’t sound the way it did at bed­time. Now it’s deep­er and barki­er. You’re stand­ing in the hall­way doing math you nev­er want­ed to learn: is this a wait-until-morn­ing thing or a get-in-the-car thing?

What makes that call eas­i­er is that you don’t have to fig­ure out which ill­ness your child has. Croup, res­pi­ra­to­ry syn­cy­tial virus (RSV), the flu, and a hand­ful of oth­er infec­tions all start out look­ing remark­ably sim­i­lar, and sort­ing them apart is your care team’s job, not yours.

Your job is to watch four things: breath­ing, hydra­tion, alert­ness, and how fast things are chang­ing. Those four will tell you whether to call the pedi­a­tri­cian in the morn­ing, head to Imme­di­ate Care today, or go straight to the ER.

Start with how hard your child is work­ing to breathe

A cough can sound fright­en­ing and still be fine. Sound isn’t the sig­nal. Effort is. Watch your child’s chest and face for a minute, ide­al­ly while they’re calm, and look for:

• Breath­ing much faster than usual
• Skin pulling in between or below the ribs with each breath
• Nos­trils flar­ing open
• Grunt­ing, or vis­i­bly struggling
• Trou­ble talk­ing, cry­ing, eat­ing, or drink­ing because breath­ing is tak­ing all their energy
• Blue, gray, or unusu­al­ly pale lips or skin
• Paus­es in breathing

Call 911 or go to the near­est emer­gency room for severe breath­ing dif­fi­cul­ty, blue or gray col­or­ing, paus­es in breath­ing, or a child who can’t speak, cry, or drink because they’re work­ing too hard to breathe. Don’t wait to see if it settles.

Check flu­ids and alertness

Kids who are sick tend to drink less, which can be for mul­ti­ple dif­fer­ent rea­sons depend­ing on what is wrong. Fever burns through flu­ids. Vom­it­ing and diar­rhea emp­ty the tank. A stuffy nose or fast breath­ing makes drink­ing uncomfortable.

Signs your child is run­ning low:

• Few­er wet dia­pers or trips to the bathroom
• Dry mouth or cracked lips
• No tears when crying
• Can’t keep flu­ids down
• Unusu­al weak­ness or sleepiness

That last one deserves a caveat, because extra sleep is nor­mal when a child is sick and it wor­ries par­ents more than it should. The con­cern isn’t sleep­ing more. It’s a child who’s very hard to wake, seems con­fused, goes limp, or just isn’t respond­ing the way they nor­mal­ly do. That needs emer­gency evaluation.

For symp­toms that wor­ry you but aren’t life-threat­en­ing, sched­ule a vis­it with a Duly pedi­a­tri­cian. Your child’s pedi­a­tri­cian knows their his­to­ry, their past ill­ness­es, and how they usu­al­ly behave. >

Croup: the cough you’ll rec­og­nize by sound

Croup swells the upper air­way and pro­duces a cough most par­ents describe the same way, like a seal bark­ing. You may also hear a hoarse voice and a high-pitched sound when your child breathes in, called stri­dor. It tends to show up or get loud­er at night, which is part of why it feels so alarming.

In many cas­es, chil­dren with croup can be watched at home. That’s usu­al­ly the case when your child:

• Breathes com­fort­ably at rest
• Has nor­mal color
• Stays alert and responsive
• Can drink fluids
• Only makes noisy breath­ing sounds while cry­ing or upset

Call your pedi­a­tri­cian or seek same-day care when the barky cough is get­ting worse, your child is drink­ing less, or you hon­est­ly can’t tell whether what you’re hear­ing is stri­dor, wheez­ing, or plain con­ges­tion. Not being sure is a rea­son to ask, not a rea­son to wait.

Sched­ule an appoint­ment with your Duly pediatrician. >

Go to the ER when stri­dor hap­pens while your child is calm and still, breath­ing looks like work, your child is drool­ing or can’t swal­low, or their col­or or alert­ness shifts. Most chil­dren with croup recov­er with sup­port­ive care, but real breath­ing dif­fi­cul­ty needs to be seen right away.

RSV: watch breath­ing and feeding

RSV usu­al­ly opens qui­et­ly. Con­ges­tion, a run­ny nose, cough­ing, sneez­ing, less inter­est in eat­ing. Symp­toms often arrive in stages instead of all at once, which is why day three can look noth­ing like day one. In very young infants, the first sign might be irri­tabil­i­ty, less activ­i­ty, or breath­ing that seems off before any­thing else.

Feed­ing is where it often shows up in babies. Suck­ing, swal­low­ing, and breath­ing have to hap­pen in a rhythm, and con­ges­tion or fast breath­ing breaks that rhythm. 

Call your Duly pedi­a­tri­cian when your baby is feed­ing less, mak­ing few­er wet dia­pers, or devel­op­ing a cough or wheeze that’s get­ting worse. >

Some chil­dren need a low­er thresh­old for call­ing. Infants younger than 6 months, babies born pre­ma­ture­ly, and chil­dren with cer­tain heart, lung, immune, or neu­ro­mus­cu­lar con­di­tions face high­er risk of severe ill­ness, so reach out ear­ly rather than wait­ing it out.

Go to the ER for severe chest retrac­tions, paus­es in breath­ing, blue or gray col­or­ing, inabil­i­ty to feed because of breath­ing trou­ble, severe dehy­dra­tion, or unusu­al dif­fi­cul­ty wak­ing. You can also read more about ear­ly RSV symp­toms and warn­ing signs in infants and young chil­dren.

Fever: the num­ber mat­ters less than you’d think

While par­ents should in fact watch the ther­mome­ter, for old­er babies and chil­dren, that num­ber is one data point among sev­er­al. What tells you more is how your child looks between dos­es: are they drink­ing, uri­nat­ing, breath­ing com­fort­ably, and perk­ing up as the fever comes down?

Call your pedi­a­tri­cian or seek same-day care when a fever:

• Runs sev­er­al days with­out improving
• Comes back after your child seemed to be past it
• Shows up along­side a wors­en­ing cough, ear pain, or sore throat
• Comes with less drink­ing or few­er wet diapers
• Affects a child with a chron­ic med­ical condition

Two excep­tions over­ride every­thing above. A baby younger than 3 months with a tem­per­a­ture of 100.4°F (38°C) or high­er needs prompt eval­u­a­tion, no mat­ter how well they seem. And fever at any age is an emer­gency when it comes with severe breath­ing trou­ble, a stiff neck, a seizure, con­fu­sion, dif­fi­cul­ty wak­ing, a pur­ple or bruise-like rash, or severe dehydration.

Pedi­a­tri­cian, Imme­di­ate Care, or ER?

Your pedi­a­tri­cian is the right call for non-emer­gency symp­toms, prob­lems that keep com­ing back, med­ica­tion ques­tions, and any ill­ness that isn’t improv­ing the way you expected.

Duly’s Imme­di­ate Care Cen­ter fits when your child needs to be seen today for some­thing that isn’t life-threat­en­ing, like:

• Cough or cold symp­toms that are get­ting worse
• Ear pain or sore throat
• Fever with breath­ing that looks normal
• Mild wheez­ing with­out real distress
• Vom­it­ing or diar­rhea with pos­si­ble mild dehydration
• A spread­ing rash with­out emer­gency warn­ing signs

For a same-day ill­ness that can’t wait for a rou­tine appoint­ment, find a near­by Duly Imme­di­ate Care Center. >

Choose the ER for any­thing poten­tial­ly life-threat­en­ing: severe breath­ing dif­fi­cul­ty, unre­spon­sive­ness, seizures, seri­ous aller­gic reac­tions, or a child who’s going down­hill fast.

What to have ready before you go

A few notes on your phone will make the vis­it eas­i­er for you and the provider. Jot down when symp­toms start­ed, what the ther­mome­ter has said and when, how much your child has had to drink, how many wet dia­pers or bath­room trips, and every med­ica­tion you’ve giv­en, includ­ing dos­es and times.

Video helps more than par­ents expect. Cough­ing, wheez­ing, and noisy breath­ing have a habit of dis­ap­pear­ing in the exam room, and 10 sec­onds of footage from 2 a.m. can show your child’s care team exact­ly what you were hear­ing at home.

Most of all, you don’t have to fig­ure this out alone. Dr. Tess Saib­ert, a pedi­a­tri­cian at Duly Health and Care, puts it this way:

“Any cold or res­pi­ra­to­ry ill­ness in your child can be scary! I hope par­ents can use this arti­cle to help guide where to go to ensure their child is healthy. If par­ents want more infor­ma­tion on these res­pi­ra­to­ry ill­ness­es and how they affect their child, I encour­age fam­i­lies to vis­it healthy​chil​dren​.org, which is a great evi­dence-based resource backed up by the Amer­i­can Acad­e­my of Pedi­atrics. Of course, the best place to ask ques­tions is your child’s pediatrician!”

When symp­toms are per­sis­tent, recur­ring, or just hard to read, con­nect with Duly Pedi­atrics for guid­ance and ongo­ing care. >

Fre­quent­ly Asked Questions

Can Imme­di­ate Care treat croup or RSV? In many cas­es, yes. Imme­di­ate Care can eval­u­ate chil­dren with res­pi­ra­to­ry symp­toms and deter­mine whether your child needs treat­ment there or a high­er lev­el of care. Avail­able ser­vices and age require­ments dif­fer by location.

Is a high fever always an emer­gency? Not always. In old­er chil­dren, breath­ing, hydra­tion, alert­ness, and what else is going on usu­al­ly mat­ter more than a sin­gle tem­per­a­ture read­ing. Fever in a baby younger than 3 months is the excep­tion and needs prompt evaluation.

Is it safe to let a sick child sleep? Yes. Rest is doing real work. Check in peri­od­i­cal­ly to make sure your child is breath­ing com­fort­ably and can be wok­en and respond normally.

What does labored breath­ing actu­al­ly look like? Rapid breath­ing, nos­trils flar­ing, grunt­ing, or skin pulling inward around the ribs. Severe dif­fi­cul­ty, paus­es in breath­ing, or blue or gray col­or­ing mean emer­gency care now.

Can a child be seri­ous­ly ill with­out a fever? Yes. RSV and oth­er ill­ness­es can change how a child breathes, feeds, or responds with­out ever push­ing the ther­mome­ter up. Look at your child, not just their temperature.

Sched­ule an appoint­ment with your Duly pedi­a­tri­cian today. >