The study examined how well caregivers are aware of severe respiratory symptoms in children in China's Hubei province. 2,702 pairs of caregivers and children from outpatient clinics, emergency departments and hospital wards took part in the research. Only 22.9% of caregivers achieved adequate awareness of the 12 respiratory red flags, with symptom recognition varying widely – cyanosis was recognized by 71.0% and strong chest contractions by 68.4%, but very low oxygen saturation by only 36.6% and apnea by 40.7%. Conversely, most caregivers (65.0%) demonstrated appropriate emergency activation intentions and a high tendency to contact emergency services during serious scenarios (86–89%). College education was the strongest predictor of adequate awareness, with caregivers with high health literacy having adequate awareness 29.8% of the time compared to 15.1% of those with low literacy. The study concludes that despite the appropriate intentions of emergency activation, there is a critical gap between knowledge and behavior, and therefore targeted educational interventions are needed.