The clock says 4 a.m. Your 5-year-old is crying and has kept you up most of the night. You're worried. He has a slight fever, seems congested, and is breathing too rapidly. He looks so weak and little. You feel helpless.

Should you go to the Emergency Department or wait a few hours and call your pediatrician's office?

Parents always want to do what's best for their child. This means learning the warning signs beforehand of what makes for an urgent situation.

"In general, one should err on the side of going when deciding whether to go to the ED," says Kelly Ross, MD, pediatrician at St. Louis Children's Hospital and director of pediatric hospitalist medicine at Missouri Baptist Medical Center. "At the same time, if you don't need to be at the ED, and if your child is able to wait to see your pediatrician, you can save time and money.

"When in doubt, the best approach is to call your pediatrician. A large part of your pediatrician's role is to guide you in your decisions."

How a Parent Can Help
If you decide your child needs emergency care, Dr. Ross has four suggestions to make the visit a little easier.

• Know your child's medical history, immunizations, medications and allergies
• Bring a favorite stuffed animal, blanket or book, to help comfort your child
• If possible, have another adult stay home with siblings
• Do not allow the child to eat or drink anything on the way to the ED; treatment may require sedation, which necessitates an empty stomach for four hours; if your child eats en route, the clock starts from the last bite or drink

When to go to the ED
Warning signs that tell us it's time to head straight to the ED include:

• Head or neck injuries, especially with loss of consciousness or vomiting
• Severe cuts; profuse bleeding
• Fever -- if under 1-year-old and above 100 degrees; if older than one, a fever alone is rarely a reason to go to the ED
• Breathing issues -- if your child is working too hard to breathe, wheezing, choking, or turning blue around the lips; a child who is short of breath uses the stomach and neck muscles to get a deeper breath
• Dehydration -- if your child has been vomiting, or is too ill to drink fluids (try to re-hydrate the child at home with slow sips of liquid rather than a full glass, which could trigger vomiting
• Behavior changes -- if you notice significant changes, or if your child is lethargic and less alert; crying babies who seem more uncomfortable when being held, or who cannot be consoled for greater than an hour, warrant an emergency visit
• Severe burns (chemical or electrical)
• Possible poisoning -- ingestion of medicines, dangerous chemicals or hazardous substances (call Poison Control, (314) 772-5200)
• Severe animal or insect bites -- especially if the skin is broken or the child is having an allergic reaction
• Convulsions
• Signs of shock, including cold, clammy, pale skin and a weak or rapid pulse
• Extreme headache with vomiting or stiff neck
• Instinct -- if you just know something is wrong and you are afraid to wait to see your pediatrician, then the ED may be the right choice; if you need help in getting your child there, or if your child needs immediate medical attention, call 911.

Choosing a Pediatric ED
An Emergency department that specializes in children is best. St. Louis Children's Hospital recently opened a pediatric ED at Missouri Baptist, staffed by Washington University pediatricians, and pediatric nurses.

"Pediatric emergency rooms understand the disease processes of children and the differences in treatment," says Dr. Ross, "so when possible, it's best to take a child to a pediatric ED."

"In addition, pediatric emergency rooms focus on making the experience less traumatic. One way to accomplish this is decreasing painful procedures. Nitrous oxide, commonly known as laughing gas is available at our pediatric ED as a sedation, which means no-pain sedation for children who need it," says Dr. Ross.

"If your child should need a pediatric specialist, we have the ability to transport them directly to St. Louis Children's Hospital -- one of the best in the nation."

Don't Leave Home Without It
Most schools and camps require a child's medical information. Be sure to provide as much detail as possible with your contact information and preferred hospital.

If you're leaving your child with a babysitter, or your child is going out-of-town without you, provide the temporary caregivers with two items:

• A notarized "permission to treat" form
• A written medical history of immunizations, medications and allergies

"Most parents don't realize that if their child is hurt when traveling, treatment cannot be initiated until the parents have been contacted, or except in a dire emergency, without a notarized "permission to treat" form," says Dr. Ross. "We work hard to take the stress out of your visit to our emergency room.
Being prepared is one of the best things a parent can do."

Dr. Kelly Ross is a board-certified pediatrician and director of pediatric hospitalist medicine at Missouri Baptist Medical Center. She is on staff at Missouri Baptist Medical Center and St. Louis Children's Hospital. She received her medical degree from the University of Missouri School of Medicine in Columbia, and completed her internship and residency at Duke University Hospital.