• by Dr. Y K Amdekar
• August 2015

When to rush your child to a hospital

Here's a test to find out how much you know about the seriousness of a child’s illness.

Which of these behaviors in a child who’s ill indicates an emergency?

• A.   Refusing to eat.
• B.   High fever.
• C.   Incessant crying.
• D.   Severe cough.

What's the correct answer? Read on.

Is refusing to eat an emergency?

Diseasecomes with no appetite. There are exceptions, but, there is no disease where you have a large appetite. When there is no disease and, yet, your child has no appetite, what can be the cause? Most commonly, it means his stomach is full. Children don’t eat because they’re not hungry.

Is high fever an emergency?

You can get trivial illnesses, too, with high fever: we all get high fever with a simple flu. At times, ‘no fever’ too can be an emergency. Fever, by itself, tells us nothing much.

High fever may not be an emergency. Sometimes it may be, sometimes not. We must, therefore, look at other signs before we say fever is emergency or ‘no fever’ is an emergency.

Is severe cough an emergency?

Some coughs may be an emergency, but not all. We have to study specific aspects of the cough and determine which cough is an emergency.

Is incessant crying an emergency?

Incessant crying means you are not able to manage the child's crying. You have tried everything: pick him up, take him out, offer him something: but he refuses to budge and continues to cry. Generally, your measures to console a child don’t fail if the cause is trivial. Even though he cries, he eventually comes around. When he doesn’t come around, that is incessant crying.

Incessant crying is a sign of an emergency. It is usually something serious. This message is important because it may never occur to most parents that incessant crying may be an emergency.

What is it that the doctor needs to find out?

The four signs of emergency

Regardless of cause of illness, observe your child for four signs of emergency:

1.   Change in normal behavior.
2.   Urine not passed for several hours.
3.   Fast breathing, skin rash, intolerable pain or crying.
4.   Unexpected new symptoms in a standard illness.

Change in behavior is an emergency.

Dr. Amdekar: Change in behavior is what we want you to sense. Be especially alert to notice any form of incessant behavior. What is an incessant behavior? It’s a sudden change of behavior that you cannot explain.

For example:

1.   A child never used to cry so unstoppably before—he always cried but would come around. This is something unusual, something that never   happened before: An unexplained change in behavior.
2.   A child is drowsy. Generally, drowsiness in children is unusual: Change in behavior.
3.   A child is talking irrelevantly. You ask a child his name, and he says something irrelevant. That means his brain is not clear and conscious. I  recall a child whose mother was standing in front of him. When I asked him, “Where is your mummy?”,he’s looking around, confused. He is  able to see; is probably alert. But his brain doesn’t think: Change in behavior.

Every mother knows her child’s normal behavior: When a mother tells me, “Sir, don’t worry, he always cries” then I know that’s no change in behavior. But if the mother says, “Sir, he never cries, and I don’t know why he’s crying unstoppably today”… I know it’s a change in behavior.

Any time you find a change in your child’s behavior: Somebody may be suddenly aggressive, and hit somebody—“Oh, he never did this before”: then there is something going wrong. Most of us grown-ups, at times, do change our behavior, but we come around quickly. But your child acts in innocence. Therefore a change in his behavior is an emergency.

In a high fever, a bad cough, a bad diarrhea, a mother would know: “Oh! He was never so different, but today I feel he’s something different.” That feeling of the mother is an emergency. Rush to the doctor, andlet the doctor take care of it.

Dr. Chokhani: Be it lethargy or irritability (which will show up in the child as crying), or drowsiness—all of these signs indicate an emergency.

With fever, the commonest complaint seen in children, you need to judge change in behavior at the trough of fever. At the height of fever, when the fever is, say 103, any of us can be irritable because we are not feeling comfortable. But after giving fever-reducing medicine to the child, the fever relatively drops. At that time, we expect the child to bounce back to his usual playful self. When this does not happen and, at the trough (the bottom) of fever, the child is still irritable, drowsy or lethargic, it could be an emergency and he needs urgent attention.

Not passing urine for several hours (if it is unusual of your child) is an emergency.

Dr. Amdekar: How do you check whether the child has passed urine sufficiently? There’s no magic figure: “So many times in so many hours.” It will depend on the child’s age or even the weather. Still, you can judge whether he has passed urine sufficiently or not by comparing his urine output with his routine frequency of passing urine. If he has not passed urine for a long time, that could be a sign of an emergency.

Fast breathing, skin rash, intolerable pain or crying.

Dr. Amdekar: Look at the breathing rate of the child. Fast breathing or rapid breathing may be an emergency.

Next, skin rashes. Skin rashes are a mixed group. Some rashes are dangerous, and some, harmless. It will depend on the type of rash, and the timing of fever and rash (if rash accompanies fever). "Fever started today and rash started today” is a different situation from “Fever started on this day, and rash came five days later”. There are many aspects to consider but, in general, a skin rash needs to be brought to the doctor’s attention.

Lastly, pay attention to incessant crying. Because an older child can speak, he can complain of intolerable pain. But a younger child will not be able to point out pain. Therefore, his complaint will manifest as crying.

Unexpected new symptoms in a standard illness (example: fast breathing in diarrhea).

Watch out for an unexpected new symptom in a standard illness. Imagine a child has seasonal cough, cold, fever: You know that cough, cold and fever are three things that go hand in hand. But, if this child suddenly changes behavior – becomes drowsy or irritable – you did not expect cough, cold and fever to end up in that. Or, suddenly, the child has a distended tummy. You didn’t expect that to happen with a cough, cold, fever. If something like these happen out of the blue, then you must get worried.

Another situation is, a child has vomiting and loose motions, and suddenly, like the switch of a button, his motions stop: now that cannot normally happen. No illness gets better like the switch of a button. If you see these sudden, unexpected things, they could be signs of an emergency.

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Two questions that help you determine an emergency.

Dr. Amdekar: Why does a child get into an emergency or a serious situation? Because his organs are not getting their supply of oxygen that is required for them to survive—that is the bottom line. Nature has failed to develop a model of human beingor, for that matter, an animal, who can store oxygen. Every minute you need oxygen; every organ must get oxygen. How do you get that oxygen? Through blood.

How does a mother or father at home know that every organ of the child is getting enough oxygen or enough blood? If the brain is functioning all right, it means the brain is getting enough oxygen. And how do you know the brain is functioning all right? If the child’s behavior is all right. How do you know if the kidneys are getting enough oxygen or blood? If the urine output is all right.

Brain and kidney. These are two organs you can sit at home and monitor. If these two organs are all right, the child is all right. Many other organs have an inherent capacity or ability to survive some delay in blood circulation. If the brain and kidneys are normal, then it is most likely that your child has no emergency. How easy it is for parents to know this?

When I get a phone call and hear a parent say, “My child has high fever”, my first question is, “How is he behaving? Has he passed urine all right?” If the answer is “Yes”, I say, “Don’t worry. Give him some paracetamol. Let him be.” If he has diarrhea, I ask the same question. If he has a cough, same question. If he’s got injured, same question. Keep these two questions in mind.