Performing a paediatric physical examination
Paediatric examination is a planned assessment adapted to age, fear, developmental ability and illness severity. Observe first, examine the least frightening parts before invasive manoeuvres, keep the child warm and involve the caregiver. A complete examination includes general condition, growth and nutrition, vital signs, system examination and a targeted search for danger signs.
Examine the child in the caregiver’s arms when possible; crying changes respiratory rate, heart rate, colour and lung findings.
Learning objectives
- Prepare a safe, child-friendly examination environment.
- Perform an age-appropriate ABCDE and general examination.
- Measure and interpret growth, vital signs, hydration and nutritional status.
- Complete cardiovascular, respiratory, abdominal, neurological and developmental examinations.
- Document positive and important negative findings and recognise urgent referral signs.
Preparation and sequence
- Hand hygiene, introduce yourself, confirm identity, consent and privacy.
- Have equipment ready: thermometer, paediatric cuff, pulse oximeter, scale, length board/stadiometer, measuring tape, penlight, otoscope, stethoscope, glucometer and reflex hammer.
- Observe from the doorway: posture, alertness, interaction, work of breathing, colour, hydration, nutrition and caregiver interaction.
- Examine while calm: hands/skin, face, chest and abdomen; leave ears, throat and painful areas until last unless urgent.
- Reassess vital signs after calming and after treatment if abnormal.
General examination and vital signs
| Measure | Technique | Interpretation cautions |
|---|---|---|
| Temperature | Use a validated site/device; record method | Fever thresholds vary by age; hypothermia is also dangerous in neonates |
| Respiratory rate | Count a full minute while calm; repeat if crying | Age-specific tachypnoea; observe retractions, grunting, stridor and apnoea |
| Heart rate | Count a full minute, assess pulses and perfusion | Crying/fever raise rate; bradycardia in a sick child is late danger |
| Blood pressure | Correct cuff width; arm at heart level | Interpret by age, sex and height centiles; hypotension is late shock |
| SpO₂ | Warm, well-perfused finger/toe; verify waveform | Motion, cold extremities, dyshemoglobins and probe position mislead |
| Glucose | Point-of-care test in altered, shocked, malnourished or very young child | Treat severe hypoglycaemia immediately while confirming when appropriate |
Growth and nutrition examination
- Weigh with minimal clothing and plot weight-for-age.
- Measure length recumbent below two years and standing height in older children; plot length/height-for-age.
- Measure head circumference in infants and young children.
- Assess weight-for-length/height, mid-upper-arm circumference and bilateral pitting oedema where malnutrition is suspected.
- Look for wasting, muscle loss, pallor, hair/skin changes, oral lesions, rickets, dehydration and micronutrient deficiency.
- Assess feeding ability, suck, swallow, aspiration, oral-motor coordination and caregiver–child interaction.
ABCDE assessment
Airway
Look for obstruction, drooling, stridor, muffled cry, facial trauma, foreign body and positioning. Maintain airway with age-appropriate manoeuvres and call for help early.
Breathing
Count rate, inspect chest movement, nasal flaring, grunting, indrawing, asymmetry and cyanosis. Auscultate for wheeze, crackles, reduced air entry and bronchial breathing. Assess speech/cry and fatigue.
Circulation
Assess mental state, pulse quality, capillary refill, skin temperature/colour, urine output and blood pressure. Look for dehydration, bleeding and signs of heart failure.
Disability
Use AVPU or paediatric GCS, check pupils, seizures, tone, posture and glucose. Compare with baseline and caregiver report.
Exposure
Expose only what is necessary while preserving warmth and dignity. Look for rash, petechiae, bruising, burns, oedema, jaundice, trauma, dehydration and safeguarding clues.
System examination
Respiratory
Inspect shape and symmetry, palpate expansion and tactile fremitus, percuss when useful and auscultate systematically anteriorly, laterally and posteriorly. In infants, nasal obstruction and transmitted upper-airway sounds are common mimics.
Cardiovascular
Check pulses in all limbs when indicated, precordial activity, apex position, heart sounds, murmurs, gallop rhythm, hepatomegaly, oedema and signs of poor perfusion. Describe murmurs by timing, location, radiation, intensity and effect of position.
Abdomen
Inspect distension, veins, scars and hernias. Auscultate, then palpate gently for tenderness, masses, liver, spleen and kidneys. Check ascites, genitalia and anus when clinically indicated and with consent.
Neurological
Assess alertness, interaction, speech, cranial nerves, tone, power, reflexes, coordination, gait and sensation according to age. Examine infants for fontanelle, head control, symmetry, primitive reflexes and developmental milestones.
Skin, lymph nodes and joints
Describe lesions by morphology and distribution. Examine nodes, joints, range of motion, warmth, swelling and tenderness. Non-blanching rash with fever is an emergency until proven otherwise.
Age-specific adaptations
- Newborn: temperature, breathing, colour, tone, feeding, cord, fontanelle, hips, reflexes, genitalia and congenital anomalies.
- Infant: examine on caregiver’s lap; observe feeding, attachment, head control, tone, fontanelle and growth.
- Toddler: use play, allow exploration and examine ears/throat last.
- School child: explain steps, offer choices, assess school and psychosocial function.
- Adolescent: ensure privacy, offer part of examination without caregiver and explain confidentiality limits.
Documentation and reassessment
Record appearance, vital signs with method, anthropometry and centiles, positive findings, relevant negatives, response to treatment and who was present. Document the child’s and caregiver’s words when safeguarding is relevant. A changing child needs repeated examination; a normal first assessment does not end observation when the trajectory is concerning.
OSCE checklist
- Hand hygiene, introduction, consent, privacy and appropriate draping.
- Initial observation and danger-sign screen.
- Accurate age-appropriate vital signs and growth measures.
- Complete general and system examination without causing avoidable distress.
- Summarise findings, state differential, plan investigations/referral and safety-net.
References
- SlideShare: Pediatric physical assessment.
- SlideShare: The paediatric history and physical examination.
- WHO IMCI and Pocket Book of Hospital Care for Children.
