Cheryl Martin (Host): This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

It can be difficult to tell if your infant or toddler is sick enough to require medical help. Here to discuss the warning signs to be aware of, is Emily Bianconi, a Pediatric Nurse Practitioner at Skagit Regional Health.

This is Be Well with Skagit Regional Health. I'm Cheryl Martin. Emily, delighted you are here. I have lots of questions on behalf of parents of young children.

Emily Bianconi, ARNP: I'm happy to be here.

Cheryl Martin (Host): So first, Emily, what are the most common signs that an infant is ill and needs to see a pediatrician?

Emily Bianconi, ARNP: So this can be really tricky, and I think I want to start just by saying if you're ever worried or have questions, parents should feel free to call their office and ask to speak with the triage nurse, or most offices have someone available on call after hours. Again, you call the office, there are instructions on that.

And then most insurances on the back of the card, there's a 24-hour nurse line that you can reach if you ever have questions about whether or not this is something to be worried about or something that needs to be seen. But a few things to keep in mind. If your infant is seeming more fussy than normal, if they're not feeding well, if there's a decrease in the number of wet diapers they're having, that can be concerning. Certainly, if they're having any problems breathing, and then if they're just generally not looking well, we'll sometimes describe them as looking puny, then follow your parent instinct and have them seen.

Cheryl Martin (Host): Hmm, good advice and I'm glad to know you mentioned they can call because a lot of times when we call doctor's offices it will say, you know, if this is a medical emergency just call or text 9-1-1.

Emily Bianconi, ARNP: Exactly. So if you thought it was an emergency, you would, but there usually is the option to say you'd like to talk to a nurse to get advice.

Cheryl Martin (Host): That's great. Now, at what point should parents call the doctor if their baby has a fever and are there specific temperature thresholds to be aware of?

Emily Bianconi, ARNP: These are great things to think about. And I think let's start with, how to take a temperature in kids and infants. There are different ways. There are the thermometers that go across the forehead. There are the ones that go in the ear. There are the ones that go in the mouth. At medical offices, we might choose to do a rectal temperature at certain times on infants, but that's not something we ever ask or expect parents to do.

With these different ways of taking temperatures, I just want to discourage parents from taking the ear temperature in infants because their ear canals are so small, that it doesn't actually get a very accurate temperature. And speaking of inaccurate temperatures, you can do a temperature under their armpit but just know that if you do that, it is pretty inaccurate as well.

Then in terms of knowing what a fever is, I think it's also important, and there's a lot of misunderstanding around this. A fever is 100.4 degrees Fahrenheit or higher is a fever. And so any infant under the age of three months who has a fever should be seen right away. And if the regular office, is closed, when you find out that your infant has a fever, that's a case where you would want to go into the urgent care or the emergency room for them.

Another concerning thing with fevers is if they have a fever all by itself without any other symptoms, no tummy upset, no cold symptoms, that's concerning because we don't know where the infection is coming from. And then a fever that lasts more than three days, so even if they have cold symptoms, if they have a fever that lasts more than three days, that's not typical, and they should be seen to get evaluated further.

I do often have people ask me about how high a fever can go and still be safe, and we don't really like to give upper thresholds. There are some kids who get really high fevers, but I would say if a fever is getting to 104 or 105, that makes me a little more concerned that there might be some bacterial infection going on, such as an ear infection, and so I would suggest that they be seen.

Cheryl Martin (Host): I know that being a new parent can be nerve-wracking, so how can parents differentiate between normal newborn behavior and symptoms that require a doctor's visit?

Emily Bianconi, ARNP: Yeah, so this really gets to the heart of some of the tricky stuff with parenting, right? And I think, you're in doubt, go ahead and come in. I much appreciate people coming in to get things evaluated when they are worried rather than anxiously trying to wait things out at home. And there are like you said, there's some things that are just going to be normal in infants.

So, babies when they're about two weeks old start to become more fussy. And that ramps up until they're about six weeks old, and then it's better by three to four months. So some things to know about that are it's usually pretty consistent. It's usually around the same time of the day. It is usually afternoon or evening. If you were sort of noticing some increased fussiness and it fits with those patterns, that might be something that you don't worry too much about.

But if it falls outside those patterns or you have concerns, with increased fussiness, then the infant should be seen. Certainly, infants can have irregular breathing patterns too. So they'll have things where they pause for a little bit and then maybe they breathe fast and then maybe they breathe a little bit slower, and it'll vary over the course of a minute. If you ever notice that your baby is having rapid breathing that lasts more than a minute, or certainly if there are long pauses in the breathing, then they should be seen. The other thing that infants will often do, and it can be hard to figure out if it's normal or abnormal, is little twitches of their body, or funny spasmodic movements.

And so, with these, again, I think, if you're ever worried it's happening again and again, they should be seen, but I would say if parents can get a video of it when it's happening, that's helpful to bring into the visit with you because it helps us to be able to see exactly what was happening so we can help distinguish if it's normal or abnormal.

The times when they need to be seen are if they are not feeding well or there is a decrease in wet diapers.

Cheryl Martin (Host): That is a great idea for them to videotape it. Very, very helpful. Now that we have that technology, so you mentioned fussiness, when should a parent be concerned about their infant crying and suspect it could be due to an illness?

Emily Bianconi, ARNP: So this is also sort of about knowing what your baby's normals are and if it's at a different time, so if they have a fussy time kind of in the afternoon or evening, but now they're having that same fussiness and it's not at their normal time, that's concerning. If they're crying a lot more for either longer or more frequently than they typically would, they're just not consolable like typical, or if the cry sounds different, then all of those are reasons to be seen. I would say, one of the things I usually encourage people to check when the baby seems like they're uncomfortable or crying seems different, is to check for something we call hair tourniquets.

So hair or even just the normal little fuzz in socks can get wrapped around their digits and it can cut off circulation. And it can be hard to see because it really can just be a single strand of hair wrapped around the finger. So looking really closely at fingers, toes, and for boys, checking the penis too, to make sure that there's no hair or anything like that that's cutting off circulation.

Cheryl Martin (Host): Now, what are the warning signs of dehydration in infants and when should parents seek medical help?

Emily Bianconi, ARNP: There are a few things that we typically think of with dehydration, but they are sort of late signs of dehydration. So I'm going to list a few, and if you ever notice these, I would say I'd go right into the emergency room because this means the baby's pretty dehydrated. This can be that the soft spot on the top of their head is sunken in. They do not have tears when they cry or it looks dry in their mouth. All of those means they are dehydrated. Earlier signs of dehydration are a decrease in the frequency of their wet diapers. So most babies have a wet diaper every two to three hours. So if you were noticing that is decreasing in frequency, would start to pay attention and try to get them maybe to feed a little more often or try to get them to feed more to rehydrate.

If they ever go more than six hours without having a wet diaper, then they should be seen either by their primary care or at an urgent care or emergency room.

Cheryl Martin (Host): What respiratory symptoms like coughing, wheezing or rapid breathing should warrant a call to the pediatrician's office?

Emily Bianconi, ARNP: I think any time there's rapid breathing or wheezing, then they should be seen right away. The exception is if your child's been diagnosed with some type of reactive airway disease and you have breathing treatments at home certainly you'd follow the advice that's been given by your provider, in terms of what to do and when to follow up. But either of those, I would get them seen right away. And again, you could call the office, but if it's trouble getting an appointment in a timely fashion, then go into the urgent care or emergency room, or even call or text 9-1-1 with those things. In terms of the cough, there are a lot of different kinds of coughs out there.

The thing that would worry me the most would be a croupy cough. So that's kind of a barky seal sound. It usually comes in the middle of the night and sometimes they will have what we call stridor when they inhale. So it sounds like a squeak when they're inhaling after their cough. And those things, I'd definitely call the after-hours nurse line if that's happening.

But again, you might need to get your infant seen if those things are happening. And just to let people know kind of the typical, course of a cough so that you could know if things aren't following is that most cough colds will kind of gradually get worse over the first three to four days.

It kind of ramps up the congestion and the cough. And then at that 3 to 4-day mark, it starts to get better, but the total duration of a cough can last about 2 weeks with a viral illness. So certainly if anything outside of that, they're not starting to get better after 3 or 4 days, or the cough is lasting longer than 2 weeks, then they should certainly be seen.

Cheryl Martin (Host): So, Emily, how long is too long for an infant to, let us say, have diarrhea or vomiting before calling the pediatrician?

Emily Bianconi, ARNP: Most stomach viruses will start with the vomiting and that can last from one to three days and then sometime during that first couple of days usually is when the diarrhea starts up and that can easily last a week for many of the viruses. And so deciding when to be seen really depends on whether or not they are able to stay hydrated.

That can be hard with the vomiting if they cannot keep anything down. It can be hard with the diarrhea too, just because they lose so much fluid through the diarrhea that even if they are not vomiting, it is sometimes hard for them to take in enough fluids. So again, pay attention to those wet diapers and if they are not having a wet diaper at least once every six hours, they should be seen.  Certainly, if there is blood in the vomit or the stool, then they should be seen.

Cheryl Martin (Host): Talk about skin changes like rashes, discoloration or swelling. Should those prompt a call to the doctor?

Emily Bianconi, ARNP: Oh gosh, yeah, skin things are so common and can be so tricky. There are some things like heat rash, and those things go away pretty quickly. So it looks like little red bumps. It is usually at the back of their neck or on their chest. Usually, it was at a time that was warmer or they had been pretty wrapped up.

In addition, you will notice the rash and the baby's otherwise acting fine and you wait a few hours or maybe give it 24 hours and it goes away. That is pretty common for a heat rash. Certainly, again, anything that you think, gosh, this just doesn't look right, then we should see it.

I know a lot of times parents call asking about rashes. It is hard without really looking at it and actually being able to touch the rash too helps us figure out what is going on. Certainly, any baby that has vesicles so what looks like little water blisters or any pustules, rashes that are spreading, and any rashes that are itchy or painful, we would want to see them in.

Cheryl Martin (Host): So, what should parents do if their infant is refusing to eat or seems to be losing weight?

Emily Bianconi, ARNP: If these things are happening, I would definitely be seen, because then we can check the weight, compare it to where they were last time, and confirm whether or not they're losing, or if maybe they're not gaining fast enough, because really, all the infants should consistently be gaining weight.

I will say that there is this time between four to six months of age where they just become so much more socially aware and so they will often start to get really distracted during their feeds because they are paying attention to all the other things going on in the house. And so if that is the case and the babies just aren't taking as big of feeds because they're so distracted during them, it might mean moving into a quiet dark room for their feeds for a little while. But in general, if they're not feeding well or there's concern about weight loss, let's see them.

Cheryl Martin (Host): They are learning distractions like adults, okay.

Emily Bianconi, ARNP: Yes.

Cheryl Martin (Host): Now are there specific symptoms or situations where parents should bypass the pediatrician and go directly to the nearest emergency room?

Emily Bianconi, ARNP: There are. I think about it a few different ways. One is to trust your parent instinct. If this seems scary or worrisome to you and you feel like this should be seen right away, there's no time to call and wait for a call back from the nurse or wait to see if there's an appointment, then go into the emergency room.

You could certainly, if you are unsure, always call like I said, the triage line either at the office or on the back of the insurance card to get guidance as to how long this could wait to be seen. But there are a few things that I would definitely just go to the emergency room for, and that would be injuries that you think are going to require stitches because most offices aren't doing stitches in the outpatient office.

Anything where it looks like they are having an allergic reaction with swelling around the mouth or cough or wheezing should go to the emergency room or actually, I would call or text 9-1-1 for that. And if there's something going on where the parent thinks for some reason this is going to need lab work or imaging like X-rays, and we'd want to get all of the results urgently; that's a better situation for the emergency room. But I do want to emphasize, that parents shouldn't be expected to know whether or not something needs labs or imaging. You can follow your instincts and say, I'm really worried about this. I want this figured out as quickly as possible. Then go into the emergency room.

Cheryl Martin (Host): Emily Bianconi, you have shared some great information for parents of young children with symptoms of a mild illness, and I'm hoping that parents will just share this podcast with other parents in their peer group because it's great information just to hold onto in case one of these issues come up. So thank you for sharing your expertise.

Emily Bianconi, ARNP: Thank you for having me. It was a pleasure to be on today.

Cheryl Martin (Host): To learn more, visit SkagitRegionalHealth.org. Now, if you found this podcast helpful, please share it on your social channels, and check out our entire podcast library for other topics of interest to you. This is Be Well with Skagit Regional Health. Thanks for listening.