Should I Stay or Should I Go?

When not to rush your baby to the ER (and when you must).

Deborah Blum was worried. Already she had soothed her screaming 6-month-old child, Marcus, back to bed — twice. At 3 a.m., when Marcus woke a third time, that was it. With dad, baby and diaper bag in tow, she sped off to the hospital. Within an hour, they had the diagnosis: an ear infection. More than 9 million sick babies and toddlers land in the emergency room each year. Like Marcus, a quarter of them have an ear infection (otitis media), making this the No. 1 ER diagnosis in kids under age 3. "We just couldn't tell what was wrong," says Blum, a writer in Madison, Wis. "He didn't even pull on his ear." And that's the problem. Babies rarely point to the source of pain. They just cry — and cry, and cry. In a panic, and especially at night, parents often decide the ER is their best option. But is it?

Emergency room risks Blum was lucky. Although her baby's condition was not life-threatening, she did get the help that she needed fairly quickly. But there are risks to going directly to an ER. One of them is that your baby could pick up another illness. "Hospitals are like the sewers of the city, with bacterial infections lurking around," says Bob Wiebe, M.D., director of pediatric emergency medicine at Children's Medical Center in Dallas. "And the younger the baby, the greater the risk from bacteria or viruses." Another problem is that even if your child is crying and uncomfortable, you may have to wait hours before a doctor can see you. What's more, pediatric care is not always available in every ER. To be smart, gather some information now about pediatric symptoms and local hospitals, so you know your options before that panicky middle-of-the-night situation arises. In some cases, there may actually be better choices than a trip to the ER.

What your doctor can do Some conditions may seem scary but are really not that serious. Your doctor can help you make that determination. So, short of an obviously life-threatening condition, to find out if your baby's condition really warrants the trip, call your pediatrician before heading off to the ER. (Some insurance companies require you to call your pediatrician first.) Many conditions are better handled by a visit to the doctor rather than to an ER. Here are five common ones.

Constipation Doctors may field more calls about diaper contents than anything else. Either a baby has too much, too little or the wrong kind. "Parents get concerned if a child hasn't had a stool in one day," says Susan Fuchs, M.D., a pediatric emergency physician at Children's Memorial Hospital in Chicago. "But as long as your baby's not crying or irritable, it's probably OK." Sometimes switching from breast milk to formula or from formula to solid food can jolt your baby's digestive system, causing constipation. Ask your doctor what to do.

Diarrhea Another diaper dilemma. Remember that babies often have soft, seedy stools — yellow if they're breastfed, green if bottle-fed. That's normal. If, however, the stool is watery or contains blood, call the doctor. Your baby may have a bacterial infection.

Vomiting Every baby spits up — some even make it a mealtime habit. This dribble of undigested food is usually nothing to fear. But if your baby spits up more than usual after several feedings or throws up with force (projectile vomiting), call your pediatrician to check it out.

Poor appetite One sign of a healthy baby is a healthy appetite. An infant who doesn't seem hungry for two or more feedings could be sick. On the other hand, a 2- or 3-week-old baby who consistently cries after eating may have colic. A doctor can usually tell the difference.

Incessant crying After the first few weeks, most parents begin picking up the nuances of baby talk. A whiny cry means fatigue; an angry wail is "Feed me!" If your baby cries inconsolably, first check her hands and feet — a stray hair may have knotted itself around a finger or toe. Also check your baby's diaper: Is a plastic tab rubbing, or a safety pin poking, sensitive skin? If not and if you can't think of a reason for your baby's cries, call your pediatrician or head to the ER.

Research hospitals now Find out which hospital your pediatrician is associated with; for insurance purposes, that may be the one you must go to. If you have a choice (many pediatricians are affiliated with more than one), remember that today — long before that scary crying bout — is the time to locate the best ER. Like doctors, no two hospitals are exactly alike. What's more, no national standards for emergency pediatric care exist. When it comes to pediatric care, an ER needs two things: training and equipment. Babies aren't little adults; from CPR to surgery, treatments for grown-ups and infants differ. You want an ER staff that knows how to treat the smallest patients. Large cities usually have children's hospitals with pediatric trauma centers and neonatal units. And in Los Angeles and Chicago, hospitals can apply to the local emergency medical services (EMS) authority for voluntary pediatric credentials. Approved hospitals post signs reading "Emergency Department Approved for Pediatrics (EDAP)" or "Pediatric Critical Care Center (PCCC)." Neighborhood urgent-care clinics may be convenient but should be avoided, according to Bob Wiebe. Many are not equipped to handle pediatric emergencies, and the quality of care can be inconsistent. If your baby truly needs to go to the ER, it's worth braving the risks of infection. But do take precautions. "Don't let other patients or their family members handle your baby," says Brad Schwartz, M.D., a partner in the California Emergency Physicians Medical Group in San Diego. "Don't let your child play on the floor, and try to stay away from anyone who's coughing or any child with an obvious rash. In fact, once you register, if the weather permits, you could wait outside."

Stand firm No matter which hospital you visit, expect to wait. Most ERs operate on a triage system, treating the sickest or most badly injured patients first. But there are limits. "The squeaky wheel gets the grease," Schwartz says. "If you're waiting too long, start bothering people."

Also, be prepared to stand firm. While it is common for doctors to discuss treatment with parents and get their approval, a physician may request procedures you don't want. Don Wallace, a New York novelist, found himself insisting to ER doctors that his infant son, Rory, did not need a spinal tap after an inconclusive blood test. Eventually, the doctor admitted that his staff had bungled Rory's blood results and said the tap was optional. "You must be able to make tough decisions," Wallace says. "Ultimately, you're the one in charge." And that's true whether you're talking in the ER or into the phone receiver.