Emergency Red Flags: Identifying a Deteriorating Child During Telephone Triage

In telephone triage, the ability to identify a rapidly deteriorating child can be lifesaving. Health professionals need to quickly and accurately assess the severity of a child’s condition based on verbal descriptions provided by caregivers. This blog provides UK health professionals with essential guidelines for recognizing signs of rapid deterioration in children during telephone triage.

Understanding the Challenges of Telephone Triage

Telephone triage presents unique challenges due to the lack of visual and physical examination. Health professionals must rely on their clinical knowledge, experience, and effective communication to gather critical information. Prompt recognition of a rapidly deteriorating child is crucial to initiate immediate intervention and ensure timely access to emergency care.

Key Indicators of Rapid Deterioration

  1. Respiratory Distress

Signs to Identify:

Increased Respiratory Rate: Ask about the child’s breathing pattern. Is the child breathing faster than usual?

Laboured Breathing: Enquire if the child is using extra muscles to breathe (e.g., pulling in at the neck or ribs).

Noisy Breathing: Stridor, wheezing, or grunting sounds during breathing can indicate severe respiratory distress.

Cyanosis: Although difficult to assess over the phone, ask if the caregiver notices any bluish tint around the lips or extremities.

  1. Altered Consciousness

Signs to Identify:

Lethargy or Unresponsiveness: A child who is difficult to wake or shows little response to stimulation is a critical concern.

Irritability or Inconsolable Crying: Persistent crying that is unusual for the child or an inability to soothe the child can be an indication of severe distress.

Confusion or Disorientation: Ask if the child seems confused or does not recognize familiar people or objects.

  1. Circulatory Compromise

Signs to Identify:

Pale, Mottled, or Cold Skin: Inquire about the child’s skin colour and temperature. Pale, mottled, or unusually cold skin can indicate poor perfusion.

Capillary Refill Time: While this can be challenging to assess over the phone, ask the caregiver to press on the child’s fingernail or skin and note how quickly colour returns. Delayed capillary refill (more than 2 seconds) is concerning.

Weak or Rapid Pulse: Ask if the caregiver can feel the child’s pulse and describe its strength and rate. A very fast or very weak pulse can be a sign of circulatory failure.

  1. Severe Pain or Distress

Signs to Identify:

Persistent, Severe Pain: A child who is in constant severe pain, especially if it is not relieved by usual measures, needs urgent assessment.

High-Pitched, Persistent Crying: This can be an indicator of severe discomfort or neurological issues.

Effective Communication Techniques & Structured History Taking

Use a structured approach to gather comprehensive information:

Signs and symptoms



Past medical history

Last meal

Events leading to the current condition

Open-Ended Questions

Start with open-ended questions to allow caregivers to provide detailed descriptions:

“Can you describe what’s happening with your child right now?”

“How has your child been acting differently today?”

Focused Questions

Follow up with specific questions to home in on critical details:

“How fast is your child breathing?”

“Is your child’s skin colour normal, or does it look different?”

Reassurance and Clarity

Provide clear instructions and reassurance to the caregiver. Ensure they understand the importance of the symptoms described and the need for immediate action if necessary.

Actions and Recommendations

Immediate Referral

If any signs of rapid deterioration are identified, recommend that the caregiver immediately call emergency services (999) or go to the nearest A&E department.

Monitoring and Follow-Up

For less severe cases, provide clear instructions on what symptoms to monitor and advise on when to seek further help. Schedule a follow-up call if necessary to reassess the child’s condition.


Thoroughly document all information provided by the caregiver, including symptoms, advice given, and any actions taken. Accurate records are essential for continuity of care.


The ability to identify a rapidly deteriorating child during telephone triage requires a keen understanding of critical symptoms and effective communication skills. By focusing on key indicators of respiratory distress, altered consciousness, circulatory compromise, and severe pain, health professionals can make prompt and accurate assessments. This ensures that children receive the urgent care they need, potentially saving lives.

Further Reading and Resources

For more in-depth information and guidelines, visit the following articles on the Practitioner Development UK website:

A Brief Guide to Structuring a Paediatric Telephone Triage Call: Gain insights into effectively structuring your telephone triage calls to ensure comprehensive assessments. Read more.

The Traffic Light System: Identifying Children at Risk of Deterioration: Learn about the traffic light system to help identify and prioritize children at risk. Read more.

Signs Of Serious Illness in Children: Understand the critical signs that indicate serious illness in children to make informed decisions during triage. Read more.


British Medical Journal (BMJ), 2019. Paediatric Telephone Triage. Available at: https://www.bmj.com/content/paediatric-telephone-triage [Accessed 4 June 2024].

Royal College of Paediatrics and Child Health (RCPCH), 2020. Spotting the Sick Child. Available at: https://www.spottingthesickchild.com [Accessed 4 June 2024].


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