General Information:
Phone triage, not emergency services.
You are deciding whether the parents should call 911, bring the child to the emergency department
immediately, or schedule a clinic appointment first thing the next day.
If you do not send them to a provider immediately, you should also give some advice regarding home
treatments, expected course of the illness, and red flags to watch for that would warrant a return call or
trip to the ED.
Remember, you can always have them call back later to check the child’s progress.
Remember, the moms and dads calling are concerned parents with sick child at home (either in reality
or in their perception). They were worried enough to call. In the end, we’d rather have parents call too
often, than not call when there is a critical issue.
You are basing advice on what they tell you. You cannot see or examine the child yourself.
Document the pertinent aspects of the call in EPIC as a communication tool for your colleagues in clinic.
If you don’t know what to do, call your back-up clinic attending (not the hospitalists).
If you are concerned about the patient, send them in to the ED to be evaluated.
Ask questions; it gives you time to think.
Do not prescribe medications over the phone. Although if a clinic prescribed medicine needs modification
such as change tablets to suspension, wrong dose, then that can be changed.
Break things down in easy-to-understand language for the parents
Ask name, age, brief past medical history (i.e., any major medical problems), medications, what have
parents tried so far for every patient
Check in EPIC to make sure they are our clinic patients only, If their PCP is a doctor not working in our
clinic then ask them to call their answering service. But before that just make sure that the child is ok and
not in any crisis.
Our patient is anybody who is followed at South campus, 3OPC or Dr. Wahl.
In case it is from Casa De Los Ninos then ask the operator to connect them to the on call attending.
If it is regarding a medicine prescribed by the inpatient resident then ask the operator to connect to the on
call hospitalist
Always document, If it wasn’t documented it did not happen.
Take notes so that when you document it say the next day, you don’t forget the important things,
especially if it was a middle of the night call.
Constipation
Questions
Name? Age?
What do stools look like?
How often does the child stool? When was the
last stool?
Timing / duration: when did this episode start? Is
this a long-term problem? Has the child had this
problem before?
What other symptoms is the child experiencing?
Does the child have any soiling (encopresis)?
What have you tried so far?
PMH? Meds? Diet?
Hard, dry, rabbit pellets = constipation
Normal stool timing: 3 times daily to every 2-3
days. Varies.
If chronic: schedule outpatient appointment
Straining (>10 min), pain, large stool, streaks of
blood in stool.
If encopresis is present: schedule outpatient
appointment (severe, chronic constipation; rule
out Hirschprung, cystic fibrosis)
Antihistamines, opioids, tricyclic antidepressants
Red flags: go to Emergency Department or have child seen in clinic
Vomiting
impaction / obstruction
>4-5 days duration for older children; infants can impaction / obstruction
stool every 4-5 days if soft
Severe rectal pain
Prolapse, fissure, abscess, surgical abdominal
process
Dehydrated newborn
Adequate breastfeeding (Q3-4h, >10 min)
Wet diapers (1 diaper for ea. day of life until age 6
days)
Advice
Education about constipation v. normal stooling behavior.
Normal stool habits in babies: straining, grunting, turning red in the face. Explain that these behaviors are
normal; it is difficult to poop when all you eat is milk and you’re lying flat on your back.
Constipating foods: dairy, cereal, bread, rice, banana
If <1 year old:
sorbitol-containing juice (prune > pear, white grape > apple (no citrus <1y)
One oz per age in months (up to 6) BID. Can mix in formula.
Glycerin suppository: rarely needed
If >1 year old:
Diet: raw fruit and vegetables at least TID. Figs, prunes, dates, raisins, peaches, pears, apricots,
apples, beans, peas, cauliflower, broccoli, cabbage.
Bran (can buy bran and mix ½ - 1 teaspoon in food), popcorn
Increase fluid intake
Decrease milk and dairy
Miralax (polyethlylene glycol) 0.8 g/kg (children >18 mo). If child really needs Miralax, he should
be seen in clinic.
Behavior: sit on toilet for 10 min after a meal
Take advantage of gastrocolic reflex; make sure feet touch the floor.
Avoid laxatives and cathartics. Do not recommend enemas over the phone.
Cough
Questions
Name? Age?
How long has child been coughing?
How bad is the cough? Is it getting better or
worse?
How is the child breathing?
What does the cough sound like?
Does the child have a fever? Runny nose /
congestion?
Is the child coughing up blood?
PMH? Meds?
What have you tried? How is it working?
If >3 days, schedule appointment in 24h.
If chronic or recurrent, especially at night,
schedule appointment. May be uncontrolled
asthma.
Respiratory distress: call 911: retractions,
cyanosis, struggling, grunting, inability to speak,
head bobbing, belly breathing, decreased
alertness
--Pertussis: whoop (>1 year old), coughing
paroxysms (<1 year old)
--“Barky” or “brassy” in croup. Advise cool mist
humidifier, cold air, steam from shower, allowing
position of comfort. 911 or ED if respiratory
distress, drooling, or stridor at rest
If yes: ED immediately
Most common cause is vessel in throat or tonsils
Allergies, asthma, exposure to TB
Advice
Most common diagnosis: viral upper respiratory infection (common cold).
DDX: asthma, bronchiolitis, pneumonia, croup, pertussis, foreign body aspiration, post-nasal drip, allergic
rhinitis
No cough medicine in patients <6 years old (associated with increased risk of death). No benefit of
mucolytics, antihistamines, or decongestants.
Warm fluids (tea with lemon and honey if >1 year old), humidity (steam from shower, cool mist humidifier).
Scrupulous hand hygiene to reduce spread.
Child can continue to drink milk or formula. If post-tussive emesis occurs, continue feeding.
If respiratory distress develops, seek medical attention immediately.
Vomiting
Poison Control: 222-1222
Differentiate from spitting up (effortless regurgitation, relatively small volume) and post-tussive emesis
Questions
Name? Age?
How many times has the child vomited today?
When did it start?
Any blood or bile (bright green)?
Does it occur after coughing?
Does vomiting wake the child from sleep or only
occur in the morning?
Decreased number of wet diapers or
decreased urine output? Unable to keep fluids
down? Lips dry?
Does the child have diarrhea? How many times?
Is there blood? Is there mucus?
Sick contacts? Recent travel?
PMH? Meds?
Red flags
Ingestion
Head injury in last 3 days (subdural hematoma
with increased intracranial pressure)
Altered mental status
Recent abdominal trauma
Abdominal pain not relieved by vomiting
Decreased urine output, vomiting >24h
especially without diarrhea, frequent watery
diarrhea
Blood: ulcer, esophagitis, Mallory-Weiss tear,
varies, although usually from the tonsils or
stomach
Bile: biliary obstruction
Go to ED
Post-tussive emesis
Possible increase intracranial pressure.
Vomiting during the middle of the night is not
associated with increased ICP in most cases,
however wakening in early am (just before
sunrise) is.
Dehydration (go to ED).
Clear vomit 3-4 times +/- frequent watery
diarrhea: risk of dehydration, go to ED
Meds associated with vomiting: erythromycin iron.
Ingestion/overdose: go to ED
Call 911 if altered mental status
If altered mental status: call 911
If vomiting only: go to ED
Meningitis, encephalitis, increased ICP
Duodenal hematoma causing obstruction
Appendicitis, ileus, intussusception
Risk of dehydration
Advice
Rule out causes that require immediate attention. Most likely cause is viral gastroenteritis.
Oral rehydration: basically, roughly calculate maintenance fluid requirement and give orally.
Almost all children will tolerate frequent sips of clear fluids. Do not give ad lib or large amounts at once
(will exacerbate vomiting).
No anti-emetics (vomiting can be protective).
Serious or life-threatening causes of vomiting to keep in the back of your worried mind:
Pyloric stenosis (2 months to 2 years, projectile)
Intussusception
Obstruction
Appendicitis
Abdominal injury with duodenal hematoma
Increased intracranial pressure
Toxicity
Alcohol
Inborn error of metabolism
Fever
Fever = temp >100.4 F or >38 C. Hypothermia = temp < 96.8 or <36 (emergency in infants)
Your job: rule out serious disease, then counsel on rational fever management.
Parental assessment of fever (child “feels warm”) is 84% sensitive and 76% specific (Graneto 1996 Ped
Emerg Care 12(3):183-184).
Recommend Diamond Children’s ED (especially babies)
Acetaminophen 15 mg/kg Q4-6h
Ibuprofen 10 mg/kg Q6-8h
No aspirin (Reye syndrome)
160 mg/5ml
100 mg/5ml
Questions
Age?
Most recent temp? Highest temp? How did
you measure?
How long has the child had a fever?
Has the child had recent immunizations?
Does she have other symptoms?
How is the child acting (both when she has
the fever and when the fever goes down)?
Sick contacts? Travel? PMH? Meds?
What have you tried? Does it work?
Red Flags
Limp, lethargic, unresponsive, inconsolable,
irritable, bulging fontanel, stiff neck
Purple, non-blanching spots on skin
Age <2 mo
Temperature >105 F (40.6 C)
Duration >5 days
Drooling
Seizures
Dysuria, foul odor to urine, cloudy urine
Persistent fever despite antipyretics
<2 months: ED.
>105 F (>40.6 C): ED
>3 days in an infant: schedule appointment with PCP.
>5 days: Evaluate for Kawasaki disease
Usually low-grade fever. High fever after
immunizations is reportable. High fever and toxic
appearance: must think of other causes.
--Limp, asymmetric movements, pain with movement
of a joint: septic arthritis
--Vomiting and diarrhea: acute gastroenteritis
--URI symptoms
Lethargic / toxic: go to ED
Most children feel/act better when fever abates
--Congenital heart disease: risk of subacute
bacterial endocarditis
--Immunocompromised patient (transplant
patients, sickle cell disease, malignancy, HIV): Direct
admit (call attending).
Make sure parents are using correct doses of
antipyretics
Meningitis, sepsis, encephalitis: DO NOT MISS
Rocky Mountain spotted fever (most common on
the reservations; also associated with headache,
chills, myalgia), meningococcemia
Kawasaki disease
Epiglottitis (rare), retropharyngeal abscess
Urinary tract infection
More likely to be bacterial infection
Advice
Most common cause: viral URI. Fever is often first symptom.
Reassurance: Fever itself will not hurt child unless >107 F (41.7 C) – 108 F (42.2 C). (Think about going
outside in the summer in Tucson—it can be 105 outside and your brain does not melt.)
Fever is the body’s immune response to fight infection.
How the child looks is more important than the value of the temperature (exception: <2 months old).
Fevers will not continue to increase without treatment.
Comfort measures: Cool fluids, minimal clothing, light blanket if chills/shivering, sponging
Respiratory distress and congestion
Questions
Name? Age?
Describe the child’s breathing?
Fast or slow?
What is the child doing?
What sounds is the child making?
How bad is it?
When did this problem start? Is it intermittent or
constant?
Does the child have URI symptoms? Cough? If he
is an infant, does he get better when his nose is
suctioned?
PMH? Meds? Cardiac history?
Have parents been giving albuterol?
Does the child have asthma?
How often is she taking albuterol?
How does the child look after a treatment?
How far do you live from the hospital?
Is it Friday and the patient can tolerate Q4?
Red Flags
Apnea
Shallow, slow, weak
--Struggling for each breath
--Grunting
--Inability to speak or cry
--Severe retractions
--Head Bobbing
--Belly breathing
--Tachypnea: go to ED
--Shallow, slow, weak: may be impending apnea
(sepsis, toxic ingestion, increased ICP, DKA)
--Playing v. just lying there (depressed mental
status)
Wheezing, stridor (stridor at rest, stridor during
both inspiration and expiration: go to ED)
Clues for bronchiolitis: winter, age 0-2 years,
congestion, cough, fever.
Can still have severe distress requiring medical
attention.
Asthma, recurrent respiratory distress
Heart failure if history of cardiac lesions
If <Q4: go to ED
If Q2 and in distress: call 911
If minimal improvement: Call 911
Rx prednisone 1 mg/kg/day, call attending
--Initiate CPR, call 911
--Apnea may recur. Call 911 if
apneic episode resolved.
Impending apnea
Stridor
Go to ED if stridor at rest or if
stridor occurs during inspiration
and expiration
Child on home O2
Increase O2 concentration and
go to ED
Chest pain
RSV, pertussis, Chlamydia
pneumonia
sepsis, toxic ingestion,
increased ICP, DKA
Foreign body, croup, epiglottitis
(rare, ask about drooling),
anaphylaxis (ask about
exposure, rash, angioedema),
croup
Pneumothorax, pulmonary
embolism
Advice
Rule out more serious causes and determine that child has mild distress.
Most common cause is viral upper respiratory infection.
Suction nose after applying few drops on normal saline (Little Noses brand or generic), humidifier.
Diarrhea / dehydration
Questions
How many stools has the child had today?
What do the stools look like?
Blood or mucus?
How long has diarrhea been present?
Vomiting?
Is the child taking fluids normally?
Is the child dehydrated?
--Decreased urine output?
--Not making tears when she cries?
--Dry lips/mouth?
--General ill appearance?
Abdominal pain?
Other household members with similar
symptoms?
PMH? Meds? Recent travel? New foods?
Red flags
Severe watery diarrhea
Limp, weak, unresponsive, cool/pale skin
<1 mo old with blood, mucus, foul odor
Fever
Best indicator of severity is frequency.
>8 in last 8 h: go to ED
Mild: loose, mushy bowel movements.
Severe: copious and watery.
Blood or mucus: Shigella, Salmonella,
Campylobacter, E. coli (STEC), intussusception
>2 weeks: schedule outpatient appointment
(Giardia, subacute bacterial gastroenteritis,
malabsorption, milk-protein allergy)
If vomiting, treat as vomiting (not diarrhea)
--Alert, happy, playful child is not dehydrated
--No UOP >6h (<1 year old), >12h (>1 year old):
go to ED
Usually gas, but consider appendicitis,
intussusception
Consider infectious etiology
ED or 911
Possible hypovolemic shock, call 911
ED (rule out NEC, sepsis)
ED or clinic (Rule out bacterial enterocolitis)
If it is difficult to differentiate between stool and urine, have parents place cotton ball near urethral
opening, check and call back later.
Advice: viral gastroenteritis or colitis, well hydrated or mildly dehydrated
DO: Offer unlimited fluids (note that this is different from the management of vomiting).
DO: Offer starchy foods
DO: give probiotics
DON’T: rest the gut (risk of dehydration) or give liquids only
DON’T: give juice, water (<4-6 months old), diluted or concentrated formula
DON’T: give Imodium (loperamide): slows the gut, does not allow egress of stool, risk of toxic megacolon
with shigellosis.
Children younger than 1 year:
--Formula-fed: Regular diet, full-strength formula
--Breast-fed: continue breast-feeding at more frequent intervals.
--Oral glucose-electrolyte solution (i.e. Pedialyte). Transition back to formula over 24h.
Children older than 1 year:
--Offer unlimited fluids. Give water and starchy foods. Offer yogurt (active culture, restores healthful
bacteria to gut).
Expected course: about 1 week despite treatment. Come to clinic if longer.
Scrupulous hand hygiene
Call back or go to clinic/ED if signs of dehydration, no improvement in 48h
Head injury
Questions
Name?
Age?
What happened?
--What height did he fall from
--What surface did he land on?
--What part of the head did he hit?
When did it happen?
Does the child have loss of consciousness?
What did the child do immediately afterwards?
How is the child acting now?
Is there any injury to the scalp?
Is the child vomiting?
< 6 months: have child evaluated (difficult to
assess neurologic status over phone)
High speed (i.e. motor vehicle collision)
Fall from > twice child’s height
Stairway
Great force (baseball bat)
Suspicious mechanism (not consistent with age)
Loss of consciousness, brief confusion,
amnesia: concussion. Go to ED.
Crying >30 min: have the child evaluated
See Red Flags below
Laceration: large with profuse bleeding (may
require sutures)
Hematoma >2 inches (5 cm) (increased risk of
TBI or fracture)
>3 times: go to ED
Red flags: the following behaviors indicate risk of traumatic brain injury
Loss of consciousness
Confusion, abnormal behavior
Slurred speech
Difficulty awakening
Changes in vision
Changes in gait (unsteadiness)
Weakness of upper extremities
Neck pain (Rule out spinal injury)
Advice
Wash laceration with soap and water. Apply wrapped ice or ice pack.
Rest. Allow patient to sleep but check on him periodically (about every 2 hours). Make sure he can
walk/talk normally.
Close observation for 48 hours. Awaken twice at night and make sure he can walk and talk.
Consider sleeping in same room to monitor respirations.
Reassurance than lumps, scrapes, and lacerations are common.
PECARN study looked at prediction rule for clinically-important TBI’s after head injury.
Younger than 2 years: normal mental status, no scalp hematoma except frontal, no loss of consciousness
or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and
acting normally according to the parents
Negative predictive value of 100%, sensitivity of 100%.
Older than 2 years: normal mental status, no loss of consciousness, no vomiting, non-severe injury
mechanism, no signs of basilar skull fracture, and no severe headache
Negative predictive value 99.95%, sensitivity 96.8%
(Kupperman et al. Identification of children at very low risk of clinically-important brain injuries after head
trauma: a prospective cohort study. Lancet 2009; 374: 1160–70)
Epidural hematoma: injury to side of head (middle meningeal artery), lucid interval. More common in
teens.
Subdural hematoma: venous. 10x more common than epidural. Gradual neuro changes.
Basilar skull fracture: CSF leak, raccoon eyes, Battle signs (posterior auricular eccymosis)
Rashes
Rule out anaphylaxis
Questions
Name? Age? Local, widespread, or associated with medications?
Purple, blood-colored, non-blanching;
What does it look like?
ask about other signs of bleeding (gums,
stool, nose, urine)
Bright red, tender, possible streaks
Like a burn, very tender, sloughing
<1 month old with blisters or pimples
Crusty, yellow
Hives
Anaphylaxis?
History of anaphylaxis?
URI symtoms?
Location?
Number/size of spots?
When did it start?
Medications?
Pruritis?
Round with central clearing
Hives
respiratory
distress
Vomiting
dysphagia
diarrhea
lip swelling
abdominal pain
slurred speech
URI symptoms
Hands, feet, mouth
Flexural surfaces (older), extensor
surfaces and face (younger)
Diaper
Feet
Contact distribution (clothes, socks,
jewelry; difficult to assess over phone)
petechiae/purpura, risk of
meningococcemia, sepsis,
bleeding disorder: ED or 911
Cellulitis: ED
Staphylococcal scalded skin
syndrome: ED
HSV: ED
erythema toxicum (benign)
Impetigo: go to clinic
ED; ask other symptoms (see
below)
Tinea, Lyme (rare in AZ)
911
Viral exanthem
Hand foot mouth disease
Eczema, usually chronic
Athlete’s foot
Exposure history, bites, burn, sting
See below
Local: most common cause is contact with irritant.
What have you tried?
Avoid irritants, soap and detergents with fragrance/dye. Avoid scratching. Apply cold compress, calamine
lotion, OTC hydrocortisone 1% cream/ointment (caution around face/eyes).
Usually resolves in 2-3 days.
Widespread: usually viral exanthem. Rule out serious causes (above).
If pruritic: apply cool compress or bath then calamine lotion. Avoid scratching. Can try antihistamine.
Usually self-resolves in 48 hours.
Associated with medications: clarify timing of med administration, when med was started, when
symptoms started.
Rule out anaphylaxis, endotoxin reaction from GNR’s after antibiotic.
If rash in 2h after giving med: risk anaphylaxis. Stop med. Ask about respiratory distress, dysphagia,
slurred speech, vomiting, diarrhea, lip swelling. If present, call 911.
If hives, itching, or any systemic symptoms: stop med and see PCP (may need to change med).
See physician immediately: Petechiae, Fever >3 days with rash, angioedema
Call 911: anaphylaxis symptoms develop (Hives with respiratory distress, vomiting, dysphagia, diarrhea,
lip swelling, abdominal pain, slurred speech)
Eye discharge
If chemical exposure or foreign body: flush, flush, flush, then go to the ED
Lukewarm water, hold eye open
Red eye without pus: allergic, chemical, foreign body, viral, uveitis, cellulitis, corneal ulcer, keratitis
Questions
Name?
Age?
One eye? Both eyes?
Discharge? Color? Amount? What is it like?
When did it start?
Eyelids red or swollen?
Are there changes in vision?
Is there pain with eye movement?
Is there photophobia?
Are there associated URI symptoms or recent
illness?
Does the child wear contact lenses?
<1 month with purulent discharge: gonorrhea
(first few days), Chlamydia (>5 days); ED or clinic
immediately
Parents will probably call any eye discharge “pus”,
ask specifically about qualities of discharge
If swollen shut, or entire lid is red, go to ED or
clinic immediately to rule out periorbital cellulitis
Difficult or impossible to assess in young children
Cellulitis, glaucoma, uveitis, severe conjunctivitis
Suggestive of viral conjunctivitis
Evaluate in clinic or ED, rule out Pseudomonas
Advice
Bring child to clinic if: parents have to wipe away discharge more frequently (multiple times per hour),
increasing redness, swelling of eyelids
Infant with clear discharge: may be dacrostenosis
Gently massage tear duct, wipe away discharge.
Significant increase in frequency or amount may indicate infection
Older child:
Allergic conjunctivitis:
Bilateral, watery discharge, other allergic symptoms
Over the counter artificial tears for symptom relief; cool compresses; avoid rubbing (as much as possible)
Viral conjunctivitis:
Highly contagious. Usually affects other eye in 24-48h. Gets worse over 3-5 days, may last 2 weeks.
Adenopathy, fever, pharyngitis, URI. Ocular manifestation of systemic infection. Spread
Injection; watery, stringy, mucoserous discharge (no true pus); burning, sandy, or gritty sensation.
Adenovirus.
No specific treatment. Self-limited. Can use non-antibiotic eye drops to wash eye for symptom relief,
remove virus from eye.
Bacterial conjunctivitis: (needs to be seen in clinic)
More common in children than in adults (may be because bacterial conjunctivitis is brought to medical
attention more frequently). Highly contagious.
Unilateral, purulent discharge, crusty, dried/matted, red/pink sclera, puffy eyelids
S. aureus (more common in adults), S. pneumoniae, H. influenzae, M. catarrhalis
Treatment is erythromycin ophthalmic ointment or polymyxin/trimethoprim drops; need to be seen in clinic
for prescription
Neonatal jaundice
Questions:
Age? Gestational age?
When did jaundice start?
Describe the jaundice: how much of the body is
involved? Are the eyes yellow?
How is the baby acting? Does the baby appear
sick? Is there a fever?
How did the baby do after birth? Any
complications during the nursery/post-natal
period?
What is the baby’s blood type? Mother’s blood
type?
Are there any bruises or lumps on the head?
Any siblings requiring phototherapy for jaundice?
Family history?
How is the baby feeding? How often? How
much?
How many wet diapers?
How many stools is the baby having?
>7 days with worsening jaundice (not physiologic)
Premature: needs to be evaluated (higher risk)
<24h of life
Face only: increase frequency of feeds.
Lower abdomen or legs: needs to be evaluated
If sick: go to ED, consider 911. (Sepsis workup)
ABO incompatibility (more common, Mom O,
baby A or B)
Rh incompatibility (Rh- mom, Rh+ baby)
Cephalohematoma
Risk factor
G6PD deficiency, hemoglobinopathies
Feed Q2-3h, not more than 4h apart at night, at
least 10 min (breastfeeding), baby appears
satisfied
Should have had a wet diaper within 6 h.
1 wet diaper for each day of life until day 6 (i.e. 1
diaper on day 1, 2 diapers on day 2, etc.)
Should have 3 stools/day. (This is variable; may
have fewer in breastfed infants before mom’s milk
comes in at day 4-5).
Consider having the parents take a picture and email it
Red flags: immediate evaluation
Not waking to feed
Lethargic
Decreased urine output
age <24h or >7 days
If baby appears sick: ED
If baby is not waking up at all: call 911.
Advice (once red flags have been ruled out)
Physiologic jaundice is normal in the majority of babies. Peaks day 4-5, dissipates over 1-2 weeks.
Increase frequency of feedings (Q1½-2½ hours). Continue breastfeeding. Can supplement with formula
after breastfeeding if baby appears hungry.
Do not let the baby sleep more than 4 hours at night before waking to feed.
Call back, take baby to clinic, or go to ED (night/weekend) if:
Jaundice worsens
Poor feeding or poor weight gain develop
Baby acts sick (ED)
References in case you are stuck
1.
2.
3.
4.
5.
6.
7.
Harriet –Lane- For medications and dosing. For normal ranges of BP, sugars, EKG changes. Etc
Yellow book
Uptodate
Redbook
Google search
Pediatric Telephone advice by Barton Schmitt.
On call Attending