When children are ill, often the first indicator is a change in behavior. Less energy, decreased eating or drinking, sleeping more or less than usual and crankiness are hallmark signs of illness. Often these changes are scary to parents because your child is just not herself. Most visits to the ER in the middle of the night are sparked by a child who is not sleeping and keeping the family up with him, a child who has been crying intermittently for hours or concern for a child who is just picking at her food. ("She hasn't eaten anything for two days!" and yet the child is running circles around the department.)

As a physician, I am very interested in these changes, but I am especially concerned about dangerous changes in behavior. Let me give you a few examples. A tired and sleepy child may be sick, but a lethargic and unarousable child is dangerously ill and needs to be seen in the Emergency Department right away. A child who is cranky but feels better and calms down when being held by his mother is not as worrisome as a baby who is crying and seems to be even more uncomfortable with being held. This may be a sign that she has pain that is worse with being squeezed or moved.

Many children eat less when they are ill and that is all right, especially if they have a fever, but a child who hasn't urinated all day because he hasn't been drinking may be dangerously dehydrated. A child who doesn't want to play or engage in her favorite activities may simply need rest and recuperation, but a child who is actually confused needs to be evaluated.

Remember, you know your child best. Watch for the more subtle cues that your child is not feeling like herself. These may prompt you to cancel a busy day, skip school, check her temperature and treat a fever (which often resolves the crankiness or lack of appetite) or schedule an appointment with her pediatrician. If there is a change that makes you worried enough to go to the ER, make sure you describe the episode to the doctors so they understand your perspective. A child that seemed confused or disoriented at home, for example, may not be obviously so to a stranger.

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