Table 1

Serious Signs and Symptoms of Children that Require Immediate Medical Referral

Symptom/Sign	Explanation/Implication
Neonate	Since the health status of a neonate can change rapidly, any signs of illness require immediate referral.
Lethargy	Absence of interaction, hypotonia and/or crying
High Respiratory Rate	Rapid or difficult respirations not related to activity; respiration rate >60 breaths/minute with rib recession
Blue Lips or Tongue	May indicate reduced blood oxygen level
Dehydration	Common sequel to diarrhea or vomiting. Dry mouth, sunken fontanelle, tenting skin, <4 wet nappies/diapers (60-90 mL/4-6 TBS). Urine should be pale and mild smelling.
Pain and Tenderness	Child screams when touched or being moved; avoids being held. Sudden onset of groin pain in a boy may be a sign of testicular torsion; episodic screaming in young children may be a sign of intussusception
Tender Abdomen	Inability to tolerate 2 cm abdominal impression; bloated or rigid abdomen
Inability to Walk	Refusal or inability to walk in child who previously was walking (or crawling); development of a limp requires attention
Bulging Fontanelle	Evident bulge and rigidity in anterior fontanelle in a quiet child in an upright position
Stiff or Rigid Neck	Refusal/inability to look toward their toes or at a toe placed on their chest may be an early sign of meningitis; very young infants may have meningitis with no obvious signs of neck stiffness
Petechiae	Purple or blood-red spots on the skin that do not blanch with pressure may be a sign of bloodstream infection. Exclude bruises that have an explanation
High Fever	Referral for consult: Neonates (<28days): ≥38 C (100F); 28-90 days >38 C with signs of toxicity or incessant crying; 91-36 months: >39 C (102.2F) and signs of toxicity [58].
Drooling	Sudden onset of drooling not associated with teething, especially when associated with difficult swallowing, may be a sign of epiglottal or pharyngeal infections