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Examination of the newborn: a systematic bedside assessment Newborn examination confirms transition to extrauterine life, identifies congenital anomalies, detects birth injury and infection, assesses feeding and establishes a baseline for follow-up. It must be performed after immediate stabilisation, in a warm environment, with the baby observed before handling and the mother involved. A sick newborn may deteriorate rapidly: check breathing, colour, tone, temperature, glucose and feeding before completing the full examination. Preparation and sequence Hand hygiene, warm room, good light, clean equipment and consent. Confirm identity, sex, birth time, gestation, birth weight, Apgar, resuscitation, maternal illness, drugs, blood group and infection risks. Observe posture, tone, colour, breathing, cry, activity, feeding and interaction before disturbing the baby. Perform general examination, measurements, head-to-toe examination, systems review, hips, spine, genitalia and neurological assessment. Rewarm, support feeding and document findings with a plan for follow-up. Urgent danger signs: apnoea, grunting, severe indrawing, central cyanosis, persistent pallor, shock, seizures, lethargy, temperature instability, bilious vomiting, abdominal distension, severe jaundice in the first day or inability to feed. Measurements and vital signs Measure Technique/interpretation Weight Calibrated scale, naked or dry nappy; classify low birth weight and plot against gestation Length Recumbent length board with two people where possible Head circumference Non-stretch tape above eyebrows and around occiput; repeat if abnormal Temperature Axillary measurement with validated device; hypothermia and fever are both significant Respiratory rate Count full minute when quiet; note grunting, nasal flaring, indrawing, pauses Heart rate/perfusion Count, assess femoral pulses, capillary refill, colour and blood pressure when indicated General inspection Assess maturity, size, proportionality, posture, tone, spontaneous movement, cry and consolability. Look for dysmorphic features, birth trauma, bruising, petechiae, pallor, jaundice, cyanosis, oedema, rash, dehydration, congenital anomalies and signs of infection. Note whether the baby is alert and feeding or unusually sleepy, irritable or floppy. Head and face Inspect scalp swelling: caput crosses sutures; cephalohaematoma is confined by sutures; subgaleal haemorrhage is diffuse, fluctuant and potentially rapidly fatal. Palpate sutures and fontanelles; tense fontanelle with illness may indicate raised intracranial pressure. Assess facial symmetry, eyes, red reflex, pupils, mouth, palate, tongue, suck, nostrils and ears. Look for choanal obstruction, cleft palate, micrognathia, macroglossia and cranial nerve abnormalities. Chest and cardiovascular system Inspect respiratory effort and symmetry. Auscultate both lungs for air entry, crackles, wheeze or asymmetry. Check precordium, apex, heart sounds, murmurs, femoral pulses, perfusion and signs of heart failure. A murmur may be transitional, but cyanosis, weak femoral pulses, poor feeding, tachypnoea or shock requires urgent evaluation for critical congenital heart disease. Abdomen, cord and genitourinary system Inspect distension, veins, hernias and cord vessels. Palpate liver, spleen, kidneys and masses. Bilious vomiting, absent bowel sounds, distension or failure to pass meconium suggests obstruction. Examine anus for patency. Inspect genitalia for sex-development variation, hypospadias, undescended testes, ambiguous genitalia and scrotal swelling; do not assign blame or make rushed assumptions. Musculoskeletal and neurological examination Inspect limbs, digits, clubfoot, fractures, brachial-plexus injury and movement symmetry. Perform Ortolani and Barlow manoeuvres gently when trained; assess risk factors for developmental dysplasia. Inspect spine and sacrum for dimples, tufts, masses and curvature. Assess tone, alertness, posture and primitive reflexes: rooting, sucking, Moro, grasp and stepping. Observe cry, consolability and response to handling; asymmetry or persistent hypotonia needs evaluation. Skin and jaundice Describe colour and lesions, blanching, distribution and timing. Jaundice in the first 24 hours, rapidly rising jaundice, pale stools, dark urine, anaemia, lethargy or poor feeding is urgent. Transcutaneous or serum bilirubin should guide management according to age in hours, gestation and risk factors; visual inspection alone is unreliable. Feeding assessment Observe latch, suck–swallow–breathe coordination, fatigue, choking, vomiting, urine output and stool passage. Ask about skin-to-skin, time to first feed, colostrum, maternal medications and breast anatomy. Poor feeding is a non-specific but important sign of sepsis, hypoglycaemia, respiratory disease, neurological illness or congenital anomaly. Documentation and discharge safety-net Record gestation, measurements, vital signs, examination positives and negatives, prophylaxis/immunisation, feeding plan and follow-up. Teach caregivers to return for difficulty breathing, fever or coldness, jaundice spreading to palms/soles, convulsions, lethargy, poor feeding, repeated vomiting, abdominal distension, bleeding or reduced urine. References SlideShare: Neonatal examination. WHO Essential Newborn Care and Pocket Book of Hospital Care for Children. Uganda newborn and neonatal-care protocols.

Apgar score: scoring, interpretation and limitations The Apgar score is a structured description of a newborn’s condition at 1 and 5 minutes after birth using Appearance, Pulse, Grimace, Activity and Respirations. Each item scores 0, 1 or 2, giving a maximum of 10. It communicates response to transition and resuscitation; it does not replace clinical assessment or determine whether resuscitation should begin. Start resuscitation according to breathing, heart rate and tone—never wait for the 1-minute Apgar score. Components and scoring Component 0 1 2 Appearance Blue/pale Body pink, extremities blue Completely pink Pulse Absent Below 100/min 100/min or more Grimace/reflex response No response Grimace Cough, sneeze or active response Activity/tone Limp Some flexion Active movement Respirations Absent Slow/irregular or weak cry Good breathing/cry When and how to score At one minute, score the infant’s condition and document any concurrent support. At five minutes, repeat. If below 7, continue scoring every five minutes up to 20 minutes while resuscitation/observation continues. Record each component separately, the total, gestational age, interventions and timing—not only the total. Use a preterm-appropriate clinical context: prematurity, maternal drugs, congenital anomalies, infection and hypothermia can lower scores. Interpretation 7–10: generally reassuring transition, but continue routine observation and assess any abnormal component. 4–6: moderately depressed; reassess airway, breathing, heart rate, temperature and glucose and provide indicated support. 0–3: severely depressed; immediate neonatal resuscitation and urgent escalation are required. A score can improve after ventilation, stimulation, oxygen or other interventions. A low score at one minute may reflect transition; persistent low scores at 5–10 minutes are concerning and require documentation and evaluation. Limitations: Apgar alone cannot diagnose birth asphyxia, hypoxic-ischaemic encephalopathy or predict an individual child’s neurological outcome. It must be interpreted with cord gases where available, neurological examination, resuscitation details and evidence of organ dysfunction. Relation to resuscitation Resuscitation follows the newborn algorithm: warmth, drying, positioning, stimulation, assessment of breathing and heart rate, effective ventilation when needed, and escalation according to response. Apgar scoring is performed while care continues. An infant receiving ventilation may have a low respiratory score despite appropriate treatment; document the intervention-modified score and the score that reflects the infant’s condition. Documentation example “Apgar 1 min: 5 (HR 1, respirations 1, tone 1, reflex 1, colour 1); positive-pressure ventilation initiated at 60 seconds. Apgar 5 min: 8 (HR 2, respirations 2, tone 2, reflex 1, colour 1). Continued observation; no seizures or respiratory distress.” This is more useful than “Apgar 5/8” alone. Common errors Using Apgar to decide whether to start resuscitation. Scoring colour without considering peripheral cyanosis in a normal transition. Failing to score after 5 minutes when the score remains low. Ignoring gestation, maternal sedation or congenital anomaly. Calling a low score “asphyxia” without neurological, metabolic and organ evidence. Exam pearls Apgar is Appearance, Pulse, Grimace, Activity, Respirations. Pulse below 100 scores 1; absent pulse scores 0. Resuscitation must not be delayed for scoring. Persistent low scores require escalation and documentation, not a single label. References SlideShare: Apgar score. American Academy of Pediatrics: The Apgar Score. Current neonatal resuscitation programme guidance.

Gestational-age assessment of the newborn Gestational age (GA) describes maturity at birth and guides respiratory support, feeding, thermoregulation, medication, jaundice thresholds and follow-up. The best estimate is based on reliable menstrual dates and early ultrasound; physical and neuromuscular examination is a complementary method when dates are uncertain. Record both the best obstetric estimate and the postnatal examination estimate, including the method and uncertainty. Definitions Category Completed gestation Clinical implications Preterm Less than 37+0 weeks Respiratory, thermal, feeding, infection and neurodevelopmental risks Very preterm Less than 32 weeks High need for specialised neonatal care Extremely preterm Less than 28 weeks Very high morbidity/mortality; specialist counselling Term 37+0 to 41+6 weeks Assess size, transition and post-term risks Post-term 42+0 weeks or more Meconium, macrosomia, placental insufficiency and birth injury risks Best dating information Use first-trimester ultrasound when available. Use a certain last menstrual period if cycles are regular and recall is reliable. Use assisted-reproduction dates when applicable. Correlate fundal height and fetal growth but do not use them alone to date a newborn. If no reliable date exists, perform a validated examination such as New Ballard or Dubowitz and document uncertainty. Physical maturity assessment Skin: transparency, colour, texture, peeling and cracking. Lanugo: fine hair distribution changes with maturity. Plantar creases: absent/sole smoothness progresses to deep creases. Breast tissue: areola and bud size. Eye/ear: eyelid opening, pinna cartilage and recoil. Genitalia: testicular descent/scrotal rugae or labial development. Neuromuscular maturity assessment Posture and resting flexion. Square-window angle at the wrist. Arm recoil after flexion. Popliteal angle. Scarf sign. Heel-to-ear manoeuvre. More flexion, stronger recoil, resistance to extension and limited heel-to-ear movement indicate greater maturity. Perform gently; pain, illness, hypoxia, neuromuscular disease, sedation and severe growth restriction can distort the estimate. Ballard/Dubowitz approach Validated scores assign points to physical and neuromuscular signs and convert the total to an estimated GA. New Ballard is practical at the bedside, especially when dates are unavailable, but precision is limited and accuracy is lower in extremely preterm infants or when examination is delayed. Use the score to guide care—not to overrule reliable early ultrasound. Do not confuse size with gestational age: a small-for-gestational-age term infant may look immature, while a growth-restricted infant can have mature physical signs. Plot birth weight against GA to classify SGA, AGA or LGA. Management implications Preterm babies need aggressive thermal protection, respiratory assessment, feeding support and infection vigilance. GA changes bilirubin treatment thresholds and risk interpretation. Medication doses, caffeine, antibiotics, fluids and nutrition depend on GA/postnatal age and organ function. Arrange hearing, eye, developmental, immunisation and growth follow-up appropriate to GA and birth weight. Explain uncertainty honestly to caregivers and update the estimate if better records become available. Exam pearls Early ultrasound is more reliable than late physical scoring. Neuromuscular signs are especially useful when dates are unknown. Illness and sedation can make a mature infant appear immature. Always interpret weight relative to gestational age. References SlideShare: Assessment of gestational age. WHO newborn and preterm-care guidance. New Ballard/Dubowitz clinical assessment principles.

Essential newborn care and low-birth-weight babies Essential newborn care is a package delivered to every baby from birth: thermal protection, breathing support when needed, skin-to-skin contact, early breastfeeding, infection prevention, cord and eye care according to policy, immunisation, danger-sign recognition and follow-up. Low birth weight (LBW) means birth weight below 2,500 g; it may reflect prematurity, fetal growth restriction or both. Mother and baby should remain together unless a valid medical reason requires separation; family participation is part of safe neonatal care. Immediate care at birth Prepare warm, clean equipment and skilled resuscitation support. Dry thoroughly, remove wet linen, assess breathing and tone, and provide stimulation/airway positioning. If breathing is absent/ineffective or heart rate is low, start neonatal resuscitation promptly according to the current algorithm. When stable, initiate skin-to-skin contact, delay cord clamping when appropriate and begin breastfeeding in the first hour. Record time of birth, sex, weight, gestation, Apgar, interventions and maternal/newborn risk factors. Urgent referral: apnoea, persistent respiratory distress, central cyanosis, shock, seizures, severe hypothermia, hypoglycaemia, inability to feed, suspected sepsis, major anomaly or rapidly worsening jaundice. Thermoregulation Newborns lose heat by evaporation, conduction, convection and radiation. Prevent loss with a warm room, immediate drying, hat, skin-to-skin contact, warm transport and delayed bathing. Measure temperature and treat hypothermia while searching for sepsis, hypoglycaemia and environmental causes. Preterm/LBW babies need additional incubator or radiant-warmer support while maintaining skin-to-skin whenever clinically feasible. Feeding and glucose Support early, frequent exclusive breast milk feeding; observe latch, suck–swallow–breathe coordination and urine/stool output. Small or preterm babies may require expressed breast milk by cup, spoon or tube according to ability and protocol. Check glucose in symptomatic, preterm, SGA, LGA, infant-of-diabetic-mother or sick babies; treat hypoglycaemia promptly. Do not give water, glucose water or unprescribed formula as a substitute for breast milk. Monitor weight, dehydration, vomiting, abdominal distension and feeding fatigue. Kangaroo mother care (KMC) KMC combines prolonged skin-to-skin contact, exclusive breast milk feeding, early discharge when safe and close follow-up. Position the baby upright between the breasts, head turned to one side with neck slightly extended, airway visible, hips flexed and securely supported. Initiate as early as possible for stable preterm/LBW newborns; provide cardiorespiratory support first when the baby is haemodynamically compromised or unable to breathe independently. KMC improves warmth, breastfeeding, bonding and survival. Infection prevention and early recognition Hand hygiene before every contact, clean cord care and aseptic procedures. Assess risk from prolonged rupture of membranes, maternal fever, chorioamnionitis, prematurity, invasive procedures and poor feeding. Signs may be subtle: temperature instability, lethargy, weak cry, apnoea, respiratory distress, abdominal distension, jaundice, vomiting or feeding difficulty. Investigate and treat suspected sepsis urgently according to local protocol; never wait for culture in a deteriorating newborn. LBW classification and care priorities Category Birth weight Priority Low birth weight Below 2,500 g Thermal care, feeding, infection and growth monitoring Very low birth weight Below 1,500 g Specialist neonatal support and close monitoring Extremely low birth weight Below 1,000 g Advanced neonatal intensive care and multidisciplinary follow-up Classify also by gestation and size for gestational age. A term SGA infant needs glucose and growth surveillance; a preterm AGA infant has respiratory and feeding immaturity even if weight is appropriate. Monitoring and discharge Monitor temperature, respiratory rate, oxygenation, heart rate, glucose when indicated, weight, feeds, urine, stool, jaundice, infection signs and apnoea. Before discharge confirm stable temperature, effective feeding, safe caregiver technique, weight/growth plan, immunisation/prophylaxis, transport and follow-up. Teach danger signs: poor feeding, fast breathing, chest indrawing, fever/coldness, convulsion, lethargy, jaundice to palms/soles, repeated vomiting or reduced urine. Follow-up and family-centred care Early postnatal review for LBW/preterm babies, then frequent growth, feeding, development, hearing and eye follow-up. Support maternal mental health, lactation and family confidence; address transport and cost barriers. Use corrected age for developmental assessment of preterm infants. Coordinate immunisation and prophylaxis with national policy and clinical stability. References SlideShare: Essential newborn care and LBW management. WHO Essential Newborn Care. WHO Kangaroo Mother Care clinical practice guide.

Taking a paediatric general history A paediatric history is a conversation with the child and caregiver, not a form to be completed mechanically. The child’s age, developmental level, communication ability and family context determine how questions are asked. A good history identifies the immediate syndrome, establishes baseline function, uncovers preventable risks and makes the caregiver a partner in care. Start with danger signs and sick appearance before completing a long history; a critically ill child must be stabilised while information is gathered. Learning objectives Conduct a respectful, age-adapted history from caregiver and child. Recognise general danger signs and prioritise urgent action. Cover presenting complaint, history of illness, background, development, nutrition, immunisation, family and social context. Use open questions, clarification, summarising and safety-netting. Present a concise problem representation and differential diagnosis. Preparation and first impression Wash hands, introduce yourself, confirm the child’s identity and obtain permission to talk/examine. Observe before questioning: alertness, interaction, consolability, breathing effort, colour, hydration, posture, voice/cry, seizure activity and caregiver–child interaction. Record exact age, sex, weight, length/height, temperature, oxygen saturation and triage category. Ask immediately about inability to drink/breastfeed, repeated vomiting, convulsion, lethargy/unconsciousness, severe breathing difficulty, shock and severe dehydration. Red flag: a quiet, floppy or poorly responsive child may be critically ill even without fever. Do not postpone ABCDE assessment for a complete history. Presenting complaint and history of presenting illness Begin with an open invitation: “Tell me what brought you and what worries you most.” Then establish onset, progression, severity and functional effect. Ask about the child’s normal baseline and what has changed. Symptom domain Questions that change diagnosis/urgency Fever Measured or felt? duration/pattern? rigors, rash, malaria exposure, immunisation, antipyretics and response? Breathing Cough, fast breathing, chest indrawing, stridor, wheeze, apnoea, cyanosis, feeding interruption or choking? Diarrhoea/vomiting Frequency, blood/mucus, bilious vomit, fluids tolerated, urine output, tears and dehydration signs? Neurology Convulsions, altered consciousness, headache, neck stiffness, weakness, regression or abnormal behaviour? Feeding/weight Breastfeeding or diet change, appetite, swallowing, weight loss, oedema, growth trend? Urinary Dysuria, frequency, loin pain, abnormal urine, reduced output, bedwetting or genital symptoms? Skin Rash onset, itch, pain, mucosal involvement, bruising, petechiae, exposure or medication? Past medical and birth history Pregnancy: antenatal care, maternal illness/infection, medicines, substance exposure and complications. Birth: gestational age, mode/place, birth weight, resuscitation, neonatal admission, jaundice, sepsis, feeding and discharge. Previous illnesses: admissions, pneumonia, malaria, diarrhoea, TB/HIV exposure, seizures, surgery, allergies and chronic disease. Medicines: prescribed, over-the-counter, traditional/herbal remedies, doses, adherence and adverse effects. Immunisation: card dates, birth vaccines, missed doses, adverse events and access barriers. Growth, nutrition and development Ask about breastfeeding, complementary foods, feeding frequency, appetite, food security, vomiting, diarrhoea, swallowing and special diets. Review weight/length/head-circumference trends rather than a single value. Ask milestone domains—gross motor, fine motor, language/hearing, social and adaptive skills—and whether any skill has been lost. For adolescents, ask about school, mood, sleep, substance use, sexual health and safety privately when appropriate. Family, social and safeguarding history Household composition, caregiver capacity, housing, water/sanitation, smoke exposure, pets, travel and sick contacts. Family history of asthma, seizures, sickle-cell disease, diabetes, TB, congenital disorders, sudden death, mental illness and consanguinity. School attendance, learning, bullying, disability support and psychosocial stress. Safeguarding: unexplained injuries, inconsistent accounts, fear, neglect, sexual abuse, exploitation, child marriage or unsafe discharge. Ask privately when possible and document the child’s words accurately. Follow local reporting pathways. Medication, allergy and exposure reconciliation Ask the caregiver to show medicines. Confirm name, concentration, amount, route, timing, last dose and whether the child vomited it. Clarify drug/food/latex reactions and the exact symptoms of “allergy.” Ask about accidental ingestion, pesticides, kerosene, batteries, traditional medicines and household hazards. Communication technique Use plain language and an interpreter when needed; avoid leading questions. Talk to the child directly, even when the caregiver answers. Validate concerns without assuming the diagnosis. Summarise and ask, “What have I missed?” Explain the next steps, expected warning signs, follow-up and how to return urgently. Case presentation and problem representation Present in one sentence: age, relevant background, duration, dominant syndrome, severity and key discriminating signs. Example: “A 14-month-old previously well child with three days of fever, cough and poor feeding, tachypnoea with lower-chest indrawing and oxygen saturation 88%, concerning for severe pneumonia with hypoxaemia.” List active problems, immediate threats, likely diagnoses, alternatives and missing information. OSCE checklist Introduces self, confirms identity, consent, privacy and caregiver relationship. Checks danger signs and stabilises before detailed questioning. Covers presenting illness, birth, past illness, medicines/allergy, immunisation, nutrition, growth/development, family/social and safeguarding. Uses age-appropriate communication and includes the child’s voice. Summarises, explains plan and safety-nets. References SlideShare: Paediatric clerkship. SlideShare: Clerkship history for paediatric patients. WHO/UNICEF IMCI assessment and referral guidance.

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. Immediate escalation: central cyanosis, severe respiratory distress, apnoea, shock, convulsion, coma, severe dehydration, hypoglycaemia, severe malnutrition with complications or suspected abuse. 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.

Ordering relevant investigations and making an appropriate paediatric diagnosis Paediatric diagnosis begins with stabilisation, history and examination. Tests should answer a specific question, change management or identify a dangerous alternative. Children have smaller blood volume, age-dependent reference ranges and different pre-test probabilities; indiscriminate testing causes iatrogenic anaemia, false positives, cost and delayed treatment. Order the smallest set of tests that safely distinguishes urgent diagnoses and guides treatment; never let a test delay resuscitation. Learning objectives Formulate a problem representation and prioritised differential before ordering tests. Select age-appropriate laboratory, microbiological and imaging investigations. Interpret results using age, gestation, nutrition, treatment and local disease prevalence. Recognise when bedside tests, referral or empiric treatment are more appropriate than extensive testing. Communicate results, uncertainty, follow-up and safety-netting to families. Diagnostic reasoning sequence Stabilise: airway, breathing, circulation, disability, exposure, glucose, oxygen and urgent treatment. Define the syndrome: respiratory distress, fever, diarrhoea/dehydration, seizure, jaundice, anaemia, malnutrition, rash or developmental concern. Estimate pre-test probability: age, exposure, immunisation, malaria/TB/HIV prevalence, season and comorbidity. Choose a focused test: ask what result would change management. Interpret in context: compare with age-specific ranges and clinical trajectory. Act and reassess: treat, observe, refer or repeat testing only when justified. Core investigations Test Common questions answered Important cautions Point-of-care glucose Hypoglycaemia in altered, shocked, malnourished or very young child Treat severe low glucose immediately; confirm unexpected values Pulse oximetry Hypoxaemia and need for oxygen/referral Check probe, perfusion, motion and waveform Full blood count Anaemia, leukocytosis/leukopenia, platelets Age-specific ranges; malaria, HIV and malnutrition alter results Blood film/RDT Malaria parasites where endemic; morphology Negative test does not exclude other causes of fever Urinalysis/culture UTI, renal disease, dehydration, diabetes Collection method strongly affects contamination Electrolytes/renal/liver tests Dehydration, renal injury, jaundice, drug safety Interpret with fluid status and age Blood culture Sepsis/meningitis pathogen before antibiotics Do not delay antibiotics in a critically ill child Investigating common syndromes Fever Assess danger signs and local malaria risk. Test for malaria where indicated, obtain urine testing in infants with unexplained fever, and take blood cultures for suspected sepsis. Consider HIV, TB, typhoid, meningitis, pneumonia, inflammatory disease and malignancy according to history and examination. Avoid broad “fever panels” without a clinical question. Cough or difficult breathing Pulse oximetry is central. Chest radiograph is reserved for severe, atypical, persistent or complicated disease, suspected foreign body, heart failure or tuberculosis. Viral PCR may be useful in selected outbreaks or isolation decisions but does not replace clinical assessment. Blood tests are not routinely required for uncomplicated bronchiolitis. Diarrhoea and vomiting Clinical dehydration classification comes first. Check glucose and electrolytes in severe dehydration, shock, prolonged vomiting, renal disease or altered consciousness. Stool microscopy/culture is indicated for blood, suspected cholera, persistent disease, outbreak investigation or immunocompromise. Test for parasites according to duration and local epidemiology. Seizure or altered consciousness Check glucose immediately, assess malaria risk and meningitis signs, and consider electrolytes, calcium, toxicology and neuroimaging based on context. Lumbar puncture is urgent when meningitis is suspected after stabilisation and appropriate imaging precautions; never delay empiric antibiotics in a child with suspected bacterial meningitis. Malnutrition Measure weight, length/height, MUAC and oedema. Investigate glucose, haemoglobin, infection and electrolytes in complicated severe acute malnutrition. Chest radiograph, HIV/TB tests, stool or endocrine studies are targeted to clinical clues, not routine in every child. Imaging and procedures Ultrasound: no ionising radiation; useful for abdomen, kidneys, pylorus, collections, heart and some lung disease. Radiographs: use justified views and shielding; interpret with age and clinical findings. CT/MRI: reserve for urgent structural, neurological or complicated disease; weigh radiation, sedation and transfer risks. Lumbar puncture: obtain after stabilisation when meningitis/encephalitis is suspected; check contraindications and measure opening pressure when relevant. Blood sampling: minimise volume, use paediatric tubes and document total blood taken, particularly in neonates and chronically ill children. Reference ranges and test performance Use the laboratory’s age-, sex- and method-specific reference ranges. Gestational age, prematurity, altitude, dehydration, recent transfusion, nutrition and medicines can shift results. Sensitivity, specificity, positive predictive value and negative predictive value depend on prevalence. A normal test may not exclude disease early; a weakly positive test may be false positive when pre-test probability is low. Do not treat the number alone: a laboratory abnormality without a compatible syndrome may represent age variation, sampling error or a non-causal finding. Reassess the child and verify unexpected critical results. Making the diagnosis State the level of certainty: confirmed, probable, possible or ruled out. Separate syndrome from cause (for example, “severe pneumonia with hypoxaemia, likely bacterial”); list immediate threats, comorbidities and social risks. Include severity, complications and response to treatment. When evidence is insufficient, document a working diagnosis and a clear reassessment plan. Communicating results and safety-netting Explain what was tested, what it means, what remains uncertain and what happens next. Give written or demonstrated medication instructions and return precautions. Tell caregivers to return urgently for worsening breathing, inability to drink, repeated vomiting, convulsion, lethargy, cyanosis, reduced urine, persistent fever or new rash. Arrange review of pending cultures, imaging and pathology; never assume the family will be contacted automatically. OSCE checklist Stabilises first and checks glucose/oxygen when indicated. Forms a differential before ordering tests. Chooses age-appropriate, question-driven investigations. Uses local prevalence and age-specific reference ranges. Explains consent, pain reduction, risks, results and follow-up. References SlideShare: Common laboratory investigations in paediatric practice. WHO IMCI and Pocket Book of Hospital Care for Children. WHO child growth standards and Uganda Clinical Guidelines. Safety note: Follow current local protocols for test availability, referral, antibiotic timing, blood-volume limits and interpretation.

Key terms in paediatrics: a clinical foundation Paediatrics is the branch of medicine concerned with the health, growth, development and illness of newborns, infants, children and adolescents. A child is not simply a small adult: normal physiology, drug handling, communication, disease patterns, safeguarding duties and family-centred decision-making change continuously with age. Accurate terminology is therefore essential before examination, prescribing or interpreting statistics. Always record exact age, weight, gestational age, developmental stage and caregiver concerns before making a paediatric assessment. Learning objectives Define the age groups used in newborn and child health. Use terms for growth, development, prematurity, nutrition and illness severity correctly. Distinguish chronological age, corrected age and developmental age. Apply paediatric terminology to history, examination, dosing and referral. Recognise terms that trigger urgent assessment or safeguarding action. Age groups Term Usual definition Clinical importance Fetus Unborn baby from implantation to birth Assess gestational age, fetal growth and antenatal risks Newborn/neonate Birth to 28 completed days High risk of sepsis, respiratory transition problems, jaundice and feeding failure Early neonate Birth to 7 days Birth asphyxia, prematurity, infection and congenital conditions dominate Late neonate 8–28 days Late sepsis, jaundice, feeding and congenital problems remain important Infant Birth to 12 months Rapid growth, immunisation, nutrition and developmental surveillance Child 1–9 years in many clinical programmes Growth, school health, infections and injury prevention Adolescent 10–19 years (WHO convention) Puberty, mental health, sexual/reproductive and risk behaviours Age and maturity terms Chronological and corrected age Chronological age is time since birth. Corrected age is used for a preterm infant until roughly two years: chronological age minus the weeks born before 40 weeks. For example, a 16-week-old infant born at 32 weeks has a corrected age of 8 weeks. Use corrected age when judging development, feeding and growth, but record both ages clearly. Gestational age Gestational age is completed weeks from the first day of the last menstrual period or the best obstetric estimate. A term newborn is usually 37+0 to 41+6 weeks; preterm is below 37 weeks. Very preterm is below 32 weeks and extremely preterm below 28 weeks. Confirm the local definition used by the service. Birth-weight categories Low birth weight is below 2,500 g, very low below 1,500 g and extremely low below 1,000 g. Small for gestational age (SGA) means birth weight below the 10th centile; large for gestational age (LGA) above the 90th. These are not interchangeable: a preterm infant can be appropriate for gestational age while still weighing less than 2,500 g. Growth and nutrition terminology Growth: measurable increase in size—weight, length/height, head circumference and body proportions. Development: progressive acquisition of motor, language, cognitive, social and emotional skills. Growth faltering: inadequate weight gain or downward crossing of centiles; investigate feeding, infection, malabsorption, neglect and social factors. Wasting: low weight-for-length/height, usually acute or recent undernutrition. Stunting: low length/height-for-age, reflecting chronic nutritional or health insult. Underweight: low weight-for-age; it does not distinguish wasting from stunting. Severe acute malnutrition: very low weight-for-height, severe visible wasting or nutritional oedema according to current WHO/UNICEF criteria. Exclusive breastfeeding: breast milk only, apart from prescribed medicines, for the first six months where possible. Developmental terminology Milestones are expected skills, not rigid deadlines. Gross motor includes posture and movement; fine motor includes hand use; language includes understanding and expression; personal-social development includes interaction and self-care. Regression—loss of a previously acquired skill—is always abnormal until proven otherwise. Developmental delay means slower acquisition; global developmental delay affects multiple domains; disability describes functional limitation in the context of environmental barriers. Clinical severity and paediatric emergencies Danger signs require immediate action: inability to drink or breastfeed, repeated vomiting, convulsions, lethargy/unconsciousness, severe respiratory distress, central cyanosis, shock, severe dehydration, hypoglycaemia, severe malnutrition with complications or suspected safeguarding emergency. Well child means no acute illness and normal function for age. Acute illness has recent onset; chronic disease persists or recurs and may affect growth/development. Comorbidity means additional disease; multimorbidity means several ongoing conditions. Complex care involves interacting medical, developmental, family and social needs. Communication and consent Family-centred care: respect caregivers as partners while communicating directly with the child at an age-appropriate level. Assent: a child’s affirmative agreement when developmentally able; legal consent follows local law and capacity rules. Best interests: decisions should maximise safety, health, development and dignity. Confidential adolescent care: explain limits of confidentiality, assess safety and involve caregivers when appropriate and lawful. Safeguarding: unexplained injuries, inconsistent history, fearful behaviour, neglect, sexualised behaviour or failure to thrive require careful documentation and referral. Medication and procedure terms Paediatric prescriptions use weight-based or body-surface-area dosing, but never estimate weight casually when a scale is available. Specify concentration, dose in mg and mL, route, interval, maximum dose and duration. Neonatal dosing may depend on gestational/postnatal age and renal function. Maintenance fluid is not the same as resuscitation fluid. Procedural analgesia and preparation are part of safe care, not optional extras. Exam pearls Corrected age matters for preterm developmental assessment. SGA, low birth weight and prematurity describe different dimensions. Regression is more concerning than isolated mild delay. Exact weight and concentration prevent common dosing errors. A child’s voice and dignity remain central even when the caregiver gives the history. References SlideShare: Pediatric terminology. WHO child-health, growth and development standards. Uganda Clinical Guidelines and national paediatric protocols. Safety note: Age bands and legal consent rules can vary; follow current Ugandan policy and institutional guidance.

Child rights and child-survival strategies Child survival is both a clinical goal and a rights obligation. The United Nations Convention on the Rights of the Child recognises every child’s rights to life, survival and development, non-discrimination, participation, health, education, protection and a family environment. In practice, paediatric care combines prevention, early recognition of illness, quality treatment, safeguarding and action on the social determinants that decide whether a child can reach a health facility and recover. A survival programme succeeds only when families can access respectful, affordable, high-quality care without discrimination. Learning objectives Explain the major child-rights principles relevant to clinical care. Describe evidence-based survival interventions from pregnancy through adolescence. Apply integrated community, primary-care, hospital and referral strategies. Identify barriers, inequities and safeguarding risks that increase preventable deaths. Measure programme performance using coverage, quality and outcome indicators. Core child-rights principles Principle Meaning in paediatrics Practical action Non-discrimination Every child receives care regardless of sex, disability, HIV status, ethnicity, poverty or legal status Remove fees, bias and inaccessible communication Best interests Decisions prioritise safety, health, development and dignity Balance risk, benefit and the child’s voice Survival and development Life-saving care includes nutrition, stimulation, protection and mental health Link treatment to follow-up and early childhood development Participation Children are heard according to age and maturity Explain procedures and seek assent where appropriate Protection Children must be protected from violence, abuse, exploitation and neglect Recognise, document and report safeguarding concerns Continuum of care Before and during pregnancy Survival begins with girls’ education, nutrition, family planning, prevention of adolescent pregnancy, antenatal care, HIV/syphilis/malaria prevention, screening for hypertension and diabetes, and a skilled birth attendant. Birth preparedness and referral plans reduce delays. Respectful maternity care protects both mother and newborn. Birth and the first week Essential newborn care includes thermal protection, immediate skin-to-skin contact, early breastfeeding, clean cord care, newborn resuscitation readiness, infection prevention, danger-sign recognition and timely referral. Prematurity, sepsis, birth asphyxia and congenital problems require skilled assessment. Infancy and childhood High-impact measures include immunisation, exclusive breastfeeding, appropriate complementary feeding, vitamin and micronutrient support where indicated, malaria prevention, oral rehydration and zinc for diarrhoea, pneumonia recognition and antibiotics when indicated, deworming programmes, HIV care, growth monitoring and developmental support. Adolescence Adolescent survival requires mental-health support, injury and violence prevention, sexual and reproductive-health services, HIV/STI prevention, menstrual health, substance-use prevention and confidential, respectful care. Integrated strategies Integrated Management of Childhood Illness Use an integrated approach: assess danger signs, classify illness, treat more than one condition, counsel caregivers, check feeding and arrange follow-up/referral. A single-disease mindset misses malnutrition, malaria, pneumonia, diarrhoea and HIV coexisting in the same child. Community health Community workers support antenatal linkage, immunisation, breastfeeding, sanitation, malaria prevention, home care and early referral. Families need practical messages, not blame. Quality primary care Reliable triage, essential medicines, oxygen, diagnostics, infection prevention, trained staff and respectful communication prevent avoidable deterioration. Referral systems Use clear danger-sign criteria, transport plans, pre-referral treatment, referral notes and feedback to the sending facility. Referral is a clinical intervention, not simply an address. Seven major causes and cross-cutting interventions Prematurity/low birth weight: antenatal corticosteroids where indicated, kangaroo mother care, thermal support, feeding and neonatal infection prevention. Birth complications: skilled attendance, neonatal resuscitation, monitoring and timely operative/referral care. Pneumonia: vaccination, nutrition, smoke reduction, pulse oximetry/oxygen and prompt antibiotics for bacterial disease. Diarrhoea: safe water, sanitation, breastfeeding, rotavirus vaccination, ORS, zinc and continued feeding. Malaria: insecticide-treated nets, vector control, testing and effective treatment; protect pregnant women and infants. Malnutrition: breastfeeding, food security, growth surveillance, treatment of severe acute malnutrition and management of underlying infection. Injuries/violence: safe environments, supervision, child protection, road safety and trauma referral. Equity and social determinants Survival gaps reflect poverty, rural distance, conflict, disability, gender discrimination, low maternal education, food insecurity, unsafe water, poor housing and weak transport. Programmes should disaggregate data by district, sex, wealth, disability and residence. Universal health coverage means services are reachable, acceptable, affordable and effective—not merely available on paper. Never label a preventable death as “caregiver failure” without examining system barriers: transport, cost, medicine stock-outs, disrespect, late recognition and referral delays often interact. Safeguarding in clinical practice Ask privately when abuse, exploitation, child marriage, trafficking or neglect is suspected. Document the child’s words exactly, injuries objectively and actions taken. Follow Ugandan child-protection reporting pathways; do not promise secrecy that cannot be kept. Provide trauma-informed care and avoid repeated, leading questioning. Ensure disability-inclusive communication and safe discharge planning. Monitoring strategy Track input indicators (staff, medicines, oxygen), process indicators (immunisation, antenatal and postnatal coverage, triage time), output indicators (treated pneumonia/diarrhoea, breastfeeding support, referrals completed) and outcome indicators (neonatal, infant and under-five mortality, case fatality, readmission and disability-free survival). Audit deaths for modifiable factors and close the feedback loop. Exam and OSCE pearls The four general CRC principles are non-discrimination, best interests, survival/development and participation. Child survival is a continuum from preconception to adolescence, not only treatment of sick children. IMCI integrates assessment, classification, treatment, counselling and referral. Quality and equity matter as much as numerical service coverage. Safeguarding is part of every paediatric consultation. References SlideShare: Child survival strategies. UNICEF: Convention on the Rights of the Child. WHO/UNICEF child-survival, IMCI and Every Newborn Action Plan guidance. Uganda national child-health and safeguarding policies.

Vital statistics for child survival Vital statistics describe births, deaths, causes of death and population denominators. They allow clinicians, hospitals and ministries to identify preventable deaths, compare communities fairly, plan services and evaluate whether child-survival interventions work. A rate is not a story about an individual child: it is a population measure whose denominator, time period, data source and uncertainty must always be stated. Before interpreting a child-health number, ask: who was counted, what was the denominator, what time period was used, and how complete was registration? Learning objectives Define neonatal, infant, child and under-five mortality measures. Calculate rates, ratios, proportions and case-fatality measures correctly. Interpret live births, stillbirths, perinatal mortality and life expectancy indicators. Recognise sources of bias and limitations in civil registration, surveys and facility data. Use vital statistics to target interventions and audit quality. Key definitions Indicator Definition/formula Use Crude birth rate Live births in a year ÷ mid-year population × 1,000 Population fertility and service planning Neonatal mortality rate Deaths age 0–27 days ÷ live births × 1,000 Quality of pregnancy, birth and newborn care Early neonatal mortality Deaths during first 7 days ÷ live births × 1,000 Birth and immediate newborn care Post-neonatal mortality Deaths age 28 days to under 1 year ÷ live births × 1,000 Infections, nutrition, immunisation and home care Infant mortality rate Deaths before 1 year ÷ live births × 1,000 Overall first-year survival Child mortality (1–4 years) Deaths age 1–4 years ÷ relevant population or life-table denominator Childhood disease and injury burden Under-five mortality rate Probability of dying before age 5 per 1,000 live births SDG 3.2.1 and national child-survival progress Stillbirth rate Stillbirths ÷ total births × 1,000 Fetal and intrapartum care Perinatal mortality rate Stillbirths plus early neonatal deaths ÷ total births × 1,000 Care around labour and first week Important distinctions A ratio compares two quantities; a proportion is a numerator included in its denominator; a rate incorporates a population at risk and time. Mortality rates are often reported per 1,000 live births, whereas case-fatality is deaths among diagnosed cases, usually as a percentage. Never compare a facility case-fatality percentage with a population mortality rate as if they were equivalent. Live birth and stillbirth A live birth shows any sign of life after complete expulsion or extraction—breathing, heartbeat, umbilical pulsation or movement—regardless of gestational age. A stillbirth is fetal death before or during birth after the locally defined gestational/weight threshold. Accurate classification prevents the hidden loss of newborn deaths in stillbirth counts. Maternal and child link Maternal mortality, neonatal mortality and stillbirths share determinants such as antenatal access, hypertension, infection, nutrition, skilled birth attendance and referral. Child-survival dashboards should therefore link maternal, newborn and child indicators. Data sources Civil registration and vital statistics Continuous birth and death registration can provide timely, individual-level data and legal identity, but completeness and cause-of-death certification may be weak. Health-facility records Admission registers, maternity books, neonatal units, immunisation records and death audits support quality improvement but miss children who never reach care. Household surveys Demographic and health surveys estimate mortality where registration is incomplete, but recall error, sampling error and long intervals limit rapid programme management. Sentinel/community surveillance Community health workers, verbal autopsy and disease surveillance identify patterns and causes, though attribution can be uncertain. How to calculate and interpret Define the population, geography and period. Specify the event and age cut-off precisely. Use the correct denominator—live births, total births, population at risk or diagnosed cases. Apply the multiplier (1,000 or 100,000) consistently. Report confidence intervals or uncertainty when estimates come from samples. Compare like with like: same definition, source, age band and time period. Example: if 24 newborns die within 28 days among 4,000 live births, the neonatal mortality rate is (24 ÷ 4,000) × 1,000 = 6 per 1,000 live births. This does not mean six specific babies died in every 1,000; it is a population estimate. Causes of child deaths Use cause-of-death data to direct action: prematurity and birth complications dominate early neonatal deaths; infection, congenital conditions and feeding problems remain important. Beyond the neonatal period, pneumonia, diarrhoea, malaria, malnutrition, HIV, measles, injuries and violence may contribute depending on setting. Multiple conditions can coexist, so a single underlying cause and contributing causes should be documented. Beware of “unknown cause”: incomplete records, late presentation, weak diagnostic capacity and poor certification can hide preventable conditions. Death review should ask what happened before, during and after the facility encounter. Equity analysis Disaggregate mortality by district, rural/urban residence, sex, wealth, disability, refugee status and maternal education. Examine coverage and outcomes together: high immunisation coverage with persistent deaths may indicate quality or access problems. Use rate ratios, rate differences and concentration curves to describe inequality. Interpret small numbers carefully; one or two deaths can produce unstable facility rates. Clinical use and death audit Review triage time, danger-sign recognition, oxygen, fluids, antibiotics, glucose, referral and documentation. Identify avoidable delays: decision to seek care, reaching care and receiving effective care. Link every audit finding to a named action, responsible person and review date. Use trends rather than a single month to judge improvement. Protect confidentiality and communicate findings without blaming families or individual staff. Exam pearls Neonatal mortality covers the first 28 completed days. Infant mortality is death before the first birthday per 1,000 live births. Under-five mortality is a probability, not simply the number of deaths divided by the current under-five population. Perinatal mortality combines stillbirths and early neonatal deaths. Facility data underestimate community deaths; survey estimates have uncertainty. References SlideShare: Vital statistics. WHO indicator metadata: under-five mortality. WHO/UNICEF/UN IGME child-mortality estimates and civil-registration guidance. Uganda health information and child-survival reporting standards. Safety note: Always use the latest national definitions and reporting templates when producing official statistics.