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"Should I Call the Doctor?"

Waking up from a deep sleep at 2 a.m., Laura Liotta immediately recognized her baby's "something's wrong" cry. Nicholas, 4 months old, felt hot when she picked him up. The thermometer confirmed a fever of 101° Fahrenheit  -- too high for a low-grade fever from teething, she thought.

She wasn't sure how much acetaminophen to give him to bring it down and make him feel better. For kids under age 2, the label just said, "Consult physician." But in the middle of the night?

Exactly.

She dialed the pediatrician's office  -- one of the six doctors was always on call. Within ten minutes, one rang back and asked whether Nicholas was vomiting (no), seemed to have a painful or stiff neck (no), or was lethargic (yes, but no more than normal for the middle of the night). He reassured her that it didn't sound like an emergency, told her how much pain reliever Nicholas could have, based on his weight, and urged her to make an appointment in the morning. (It turned out her baby had an ear infection.)

"That quick conversation gave me the information I needed to help Nicholas feel better, and the peace of mind I needed to get back to sleep," says Liotta. She wound up calling again several more times during his first year, often after midnight. "I never sensed the slightest irritation from the doctors. In fact, one told me it's the parents who don't call who worry him," she says.

24/7 doctors
Before we became parents, few of us thought we'd ever need to be able to turn to a doctor day or night. Fortunately, our kids' doctors know we do, and good ones consider that part of their job.

On a typical night, a pediatrician will get four to eight calls from anxious moms or dads. While some could have waited until morning, studies show that parents are actually pretty good at figuring out when something needs after-hours medical attention. "Ask yourself, 'Am I so worried that I'm ready to go to the emergency room if the doctor directs me there?' If the answer is yes, I want them to call me no matter what the hour," says Encinitas, California, pediatrician Christine Wood, M.D. She also expects routine calls but appreciates parents who ask such questions during office hours instead.

New ways to communicate
An increasing number of doctors also use the Internet to interact with parents. Dr. Wood's website, for instance, offers guidelines so parents can figure out which symptoms need tending right away and which can wait until morning. Over the past five years, 8,000 pediatricians and 10,000 family physicians have started to use websites and secure e-mail provided by Medem, a service launched in 1999 by the American Academy of Pediatrics and other leading medical associations. "You shouldn't use them during an emergency," says Nancy Dickey, M.D., editor-in-chief of Medem. "But e-mail for such routine ailments as a low-grade fever or congestion can often save a parent from taking a day off from work to bring her child in to the doctor." (One caveat: Avoid any website that offers to answer specific medical questions for a fee.)

E-mail, of course, is too slow when you have to determine whether to see a doctor right away. So no matter what your child's age, you need to know which symptoms are nothing to worry about  -- and which mean "Call now."

The First Year

Birth to 3 months
For little babies, fever presents a special red flag. In newborns, even minor infections can spread rapidly and sometimes lead to a potentially life-threatening infection of the blood (sepsis) or the fluid surrounding the spinal cord and brain (meningitis). Pick up the phone if a baby under 3 months has any of the following:

? A rectal temperature over 100.4°F

? Repeated forceful vomiting (more than normal "spitting up" after eating)

? A significant change in stools  -- much more watery than usual

? A burn or sunburn that's more than slightly red or covers more than 10 percent of the body

? Abnormal, inconsolable crying

3 months to 1 year
As babies mature, pediatricians become less concerned about fever than about behavior that suggests serious illness. Thus, an older baby with a low-grade fever who won't eat or play worries a doctor more than one with a higher fever who perks up after acetaminophen. With this in mind, call at once if any of these occur:

? A rectal temperature higher than 104°F or an oral temperature over 103°F

? Repeated vomiting or persistent diarrhea plus signs of dehydration (sunken eyes, dry mouth, scant urine, no tears when crying)

? Abnormal, inconsolable crying

? Lethargy (won't wake or respond as usual)

? A burn, including sunburn, that's more than slightly red or covers more than 10 percent of your child's body

1 Year and Up

Though not common, certain conditions, such as appendicitis, occur more often after infancy. Dial the doctor if your child:

? Seems to have severe belly pain  -- and cries more when you press her stomach, especially on the right side (a sign of possible appendicitis). Another sign: The abdomen will feel more rigid than usual.

? Is 4 years or older and complains of severe headache that doesn't resolve with the appropriate dose of acetaminophen or ibuprofen (a sign of possible meningitis)

At any age

Call if your child experiences any of these:

? Difficulty breathing (very noisy, rapid, labored)

? Difficulty swallowing (sometimes evidenced by excessive drooling)

? Change in color (paleness or blueness, especially in the face; a darker-skinned child will appear bluish around the lips, gums, and nail beds)

? Unusual and extreme lethargy (your child won't wake or respond as usual)

? Sudden limpness  -- a baby who becomes floppy or an older child who collapses

? Any fever accompanied by neck stiffness or pain

? A first, fever-related seizure  -- sudden stiffness, twitching, or lack of responsiveness  -- or a subsequent episode more severe or longer lasting

? Signs of dehydration (sunken eyes, dry mouth, scant urine, lack of tears)

? Blood in stool or urine

? Purplish or blood-red rash that doesn't fade when pressed (in rare instances, a sign of a serious blood disorder or bacterial infection)

? Severe abdominal pain along with vomiting and constipation (possible blocked intestine)

? A head bump followed by any of these: loss of consciousness, confusion, pupils of unequal size, difficulty in crawling or walking, unusual behavior or prolonged irritability, repeated vomiting, bloody or watery discharge from nose or ears

? A burn, or blistering sunburn, that covers more than 10 percent of the body and causes pain for more than a few hours. Also, any burn of any size that appears white or charred or resulted from contact with electricity

When you become a parent, you enter into a strange new world of pediatric health concerns  -- stuff you probably never thought about before. Paradoxically, the more you know about which symptoms signal danger and which don't, the more you can relax about the run-of-the-mill sniffles and boo-boos. But part of the job of your pediatrician is to help you figure out the difference. If you're not sure, call.

  Jessica Snyder Sachs is a contributing editor.

When to call 911

If your community lacks 911 service, have the emergency-response number posted prominently in your home.

Call immediately if:

? Your child stops breathing (her chest doesn't rise and fall, you can't feel or hear air moving out of her nose or mouth, her skin turns pale or blue  -- for a darker-skinned child, bluish around the lips, gums, and nail beds). If you're alone with your child, call 911 before beginning CPR.

? You can't detect a pulse. Call first, then begin CPR.

? Your child is bleeding and you can't stanch the flow.

? You suspect your child has swallowed poison, been exposed to a caustic or toxic chemical, or been bitten by a poisonous spider or snake. Call this number: 800-222-1222  -- it connects you to your local poison control center.

The Telephone Nurse

By 9 p.m., pediatric nurse Terri Weinzierl has fielded more than a dozen fevers; three asthma attacks; a bad fall; plus an assortment of plugged noses, inconsolably crying babies, and panicked moms and dads. She's reassured new parents that what they're seeing is normal, suggested home remedies, called five pediatricians, and sent four children to after-hours urgent-care centers and one directly to the ER. Weinzierl is halfway through her shift at Children's Healthcare of Atlanta's Call Center.

It's a growing trend for pediatricians to direct after-hours calls to such "triage centers." Instead of reaching an operator who then dials the on-call doc, you speak to a nurse who's trained to evaluate the level of medical attention a child needs, as well as provide advice on more routine matters.

You may have such a free service in your area. Over the past decade, the number of after-hours "telehealth" nurse centers in the United States has increased to between 800 and 1,000, assisting an estimated 150 million people, says Maureen Espensen, former director of Ask-a-Nurse, the country's largest network of such services. To find one near you, first ask your pediatrician. You can also call your insurer or the public relations department of your local hospital, or look in the phone book under "physician referral" or "nursing services."

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