University of Warmia and Mazury in OlsztynFaculty of Medical Sciences

Department od Clinical Pediatrics

▸ Although some of the principles of examining children are similar to adult examination, there are important differences in both outline and detail.

▸ Children are not just small adults, and the pattern of disease, the approach to the examination and content of the examination are quite different in children.

▸ To complicate things further, the examination changes as children develop and get older.

▸ Eventually it is similar to examination in adults

The aims and objectives are:

▸ H = history

▸ E = examination

▸ L = logical deduction

▸ P = plan of management

▸ Obtaining the child’s cooperations: ◦ Make friends with the child ◦ Be confident but gentle ◦ Avoid dominating the child◦ Short mock examination, e.g. Auscultating a teddy or

the mother’s hand, may allay a young child’s fears◦ When first examining a young child, start at a non-

threatening area, such as hand or knee◦ Explain what you are about to do and what you want

him to do, in language he can understand◦ A smiling, talking doctor appears less threatening but

this should not be overdone as it can interfere with one’s relationship with the parents ◦ Leave unpleasant procedures until last

▸ Adapting to the child’s age: ◦ Adapt the examination to the child’s age◦ Babies in the few month are best examined on an

examination couch with a parent next to them◦ A toddler is best initially examined on his mother’s lap

or occasionally over a parent’s shoulder. Parents are helpful in facilitating the examination if guided as to what to do◦ Pre-school children may initially be examined whilst

they are playing◦ Older children and teenagers are often concerned

about privacy. Teenage girls should normally be examined in the presence of their mother, nurse or suitable chaperone. Be aware of cultural sensitivities in different ethnic groups

Warm smile

Warm hands

▸ Warm stethoscope

▸ Initial observations: Careful observation is usually the key to success in examining children. Look before touching the child. Inspection will provide information on: Severity of illness Is the child ill-appearing?

Growth and nutrition State of activity- increased/ decreased

Behaviour and social responsiveness Way of movement and crying

Level of hygiene and care

▸ Severity of illness:

◦ Airway and Breathing – respiration rate and effort, presence of stridor or wheeze, cyanosis◦ Circulation – heart rate, pulse volume,

peripheral temperature, capillary refill time◦ Disability - level of consciousness

▸ General state estimation◦ Good◦ Quite good◦ Intermediate◦ Quite poor◦ Poor◦ Agonal (terminal, extremely severe)

▸ The level of consciousness:

◦ Quantitative disorders presomnolence-child is apathetic but proper contact

is present somnolence- child is sleepy, difficult contact but still

present precoma-child may be aroused by strong stimuli coma- total loss of consciousness

◦ Qualitative disorders

▸ Measurements:-A variety of measurements can be recorded

and plotted to allow accurate assessment of growth and pubertal development

-As abnormal growth may be the first manifestation of chronic illness in children, always measure and plot growth on centile charts for:

▸ Head circumference routinely in those aged under 2 years▸ Length (under one year) or height.▸ Weight.▸ Plotting of serial measurements to establish pattern and

range of growth.▸ Use of appropriate growth charts.▸ Skin fold thickness where indicated.▸ Assess and plot pubertal development where indicated.

▸ Estimation of the body building and nutritional status

◦ Type of the body building- asthenic, athletic, pycnic

◦ Parameters of the growth- height/ weight

Obesity- >97 centile Eutreptic-+/- 10% of proper body weight Hypotreptic- poor nutritional status Atreptic- lack of >40% of proper body weight

▸ Estimation of psycho-motorical development

◦ Body posture and gross locomotion

◦ Visual-motor coordination

◦ Speech

◦ Social contacts, maturity, independence

▸ General appearance:

The face, head , neck and hands are examined. The general morphological appearance may suggest a chromosomal or dysmorphic syndrome. In infants, palpate the fontanelle and sutures.

▸ Skin

◦ Colour

◦ Temperature

◦ Characteristics: rough/smooth, dry/wet, elasticity, flexibility

◦ Anomalies of blood vessels

◦ Pathological rash- papules, purpura, scars, bruises

▸ Subcutaneous tissue

◦ Thickness: poor, moderate, excessive

Check under the scapula,on the posterior part of armon abdomen

Oedema

▸ Lymph nodes

◦ Size

◦ Consistence: soft, tough, cohesive, splashing

◦ Tenderness, pain

◦ Fixed or movable

◦ Skin over lymph nodes- normal, reddish, hot, ulcerous

▸ Bones and joints

◦ Skull shape, symmetry, fontanelle

◦ Chest-types of chest, symptoms of vit D deficiency

◦ Vertebral column

◦ Symmetry of hips

◦ Upper and lower limbs

◦ Joints- flexibility (passive, active) pain symmetry

▸ Detailed examination

◦ Head and neck

◦ Chest

◦ Abdomen

◦ Genito-urinary tract

◦ Neurological assessment

▸ Head and neck ◦ Observe the size and the shape of the skull

◦ Amount, colour and consistency of the hair

◦ Fontanelles- size, tension (increased/decreased) , bulging

◦ Sutures

◦ Cranial bones- craniotabes

▸ Ears

▸ Face- Eyes- position, palpebral fisure, oedema

Squint, colouring of the conjunctival mucousiris

Nose- check for nasal passage Mouth- lips colour, state of the mucosa, teeth

(primary/secoundary dentition), palate, tongue- size, tonsils

Neck-

▸ Respiratory system:◦ Cyanosis ( central cyanosis is best observed on the

tongue)

◦ Clubbing of the fingers and/ or toes (chronic lung disease e.g. cystic fibrosis, congenital heart disease, occasionally in inflammatory bowel disease or cirrhosis)

◦ Tachypnoe (rate of respiration is age-dependent) Age Normal Tachypnoe

Neonate 30-50 >60breaths/min

Infants 20-30 >50Young children 20-30 >40Older children 15-20 >30

▸ Respiratory system:◦ Dyspnoe ( laboured breathing. Increased work of

breathing)* nasal flaring* expiratory grunting * use of accessory muscles* retraction of the chest wall (from use of suprasternal,

intercostal and subcostal muscles)* difficulty speaking, or feeding

- Chest shape- Hyperexpansion or barrel shape (asthma)- Pectus excavatum (hollow chest) or pectus carinatum (pigeon

chest)- Harrison’s sulcus (from diaphragmatic tug) poorly controlled

asthma- Asymmtery of chest movements

▸ Respiratory system:◦ Palpation – chest expansion – this is 3-5cm in school-age

children. Measure maximal chest expansion with tape measure.

Palpable rhonchi or local tenderness crepitant sensation of subcutaneous emphysema

◦ Percussion Needs to be done gently, comparing like with like, using

middle fingers Seldom informative in infants Localised dullnes –collapse, consolidation,fluid

▸ Respiratory system:◦ Auscultation

Note quality and symmetry of breath sounds and any added sounds

Harsh breath sounds from upper airways are readily transmitted to the upper chest in infants

Hoarse voice – abnormality of vocal cord Stridor – harsh, low-pitched, mainly inspiratory sound from

upper airways obstruction Breath sounds – normal are vesicular; bronchial breathing is

higher --pitched and the lengths of inspiration and expiration are equal

Wheeze – high-pitched, expiratory sound from distal airway obstruction

Crackles – discontinuous ‘moist’ sounds from the opening of bronchioles

▸ Cardiovascular system: Cyanosis Clubbing of fingers or toes Pulse - rate

- rythm (sinus arrhythmia)- volume (small – circulatory insufficiency,

aortic stenosis increased in high-output states)

- collapsing (in PDA, aortic regurgitation)

Inspection:* respiratory distress* precordial bulge – caused by cardiac enlargement* operative scars – mostly sternotomy or left lateral thoracotomy

▸ Cardiovascular system:PalpationThrill= palpable murmurApex (4th-5th intercostal space, mid-clavicular line)

Not palpable in some normal infants, plump children or dextrocardia

Heave from left ventricular hypertrophy

PercussionCardiac border percussion is rarely helpful in children

▸ Cardiovascular system:AuscultationListen for heart sounds and murmurs

Heart sounds Splitting of second sound is usually easily heard and is

normal Fixed splitting of second heart sound in atrial septal

defects Third heart sound in mitrial area is normal in young

children

Murmurs Timing – systolic/diastolic/continuous Duration – mid-systolic (ejection)/ pansystolic Loudness

▸ Cardiovascular system:

Murmurs Timing – systolic/diastolic/continuous Duration – mid-systolic (ejection)/ pansystolic Site of maximal intensity –

mitral/pulmonary/aortic/tricuspidareas

Radiation: To neck in aortic stenosis To back in coarctation of the aorta or pulmonary

stenosis Loudness – systolic murmurs graded:

1-2 soft, difficult to hear3 easily audible, no thrill4-6 loud with thrill

▸ Cardiovascular system:

Features of heart failure in infants: Poor feeding/ failure to thrive Sweating Tachypnoe Tachycardia Gallop rhythm Cardiomegaly Hepatomegaly

▸ Cardiovascular system:

Normal resting pulse rate in children:

Age Beats/ min<1 110-1602-5 95-1405-12 80-120>12 60-100

▸ Cardiovascular system:

Check femoral pulses !

In coarctation of the aorta:- decreased volume or may be impalpable in infants- Brachiofemoral delay in older children

Heart disease is more common in children with other congenital abnormalities or syndromes

▸ Abdomen:

Abdominal examination is performed in three major clinical settings:

Routine examination An ‘acute abdomen’ Abdominal distension/ mass

Associated signs:- the eyes for signs of jaundice and anemia- The tongue for coating and colour- The fingers for clubbing

▸ Abdomen:

Abdominal examination includes: observation auscultation percussion palpation

Abdomen is divided into right upper, right lower quadrant left upper, left lower quadrant

▸ Abdomen:ObservationThe abdomen is protuberant in normal toddlers and

young children. The abdominal wall muscels must be relaxed for palpation

Generalised abdominal distension is most often explained by the five ‘F’s:

Fat Fluid Faeces (constipation) Flatus (malabsorption, intestinal obstruction) Fetus (not to be forgotten after puberty)

Occasionally it is caused by a grossly enlarged liver and/or spleen or muscle hypotonia

▸ Abdomen:

The abdomen is protuberant in normal toddlers and young children. The abdominal wall muscels must be relaxed for palpation

Generalised abdominal distension is most often explained by the five ‘F’s:

Fat Fluid Faeces (constipation) Flatus (malabsorption, intestinal obstruction) Fetus (not to be forgotten after puberty)

Occasionally it is caused by a grossly enlarged liver and/or spleen or muscle hypotonia

▸ Abdomen:

Causes of localised abdominal distension are: Upper abdomen- gastric dilatation from pyloric

stenosis, hepato/ splenomegaly Lower abdomen – distended bladder, masses

Other signs: Dilated veins, abdominal striae Operative scars Peristalsis – from pyloric stenosis, intestinal obstruction

▸ Abdomen:

Auscultation

perform before percussion or paplation

Are the bowel sounds present? Are they frequent or sparse

quiet abdomen hyperactive bowel sounds

▸ Abdomen:

Percussion

Tympanitic (drum-like) sounds- over air filled structures

Dull sounds- over a solid structure or fluid

To determine the size of the liver or spleen

Assessment of the cause of abdominal distention (fluid or gas)

▸ Abdomen:

Palpation: Use warm hands, explain, relax the child and keep the

parent close at hand

Palpate in systemic fashion- liver, spleen, kidney’s, bladder, through four abdominal quadrants

Watch the child’s face for grimacing as you palpate. A young child may become more cooperative if you palpate first with his hand or by putting your hand on top of his

▸ Abdomen:

Palpation:

superficial deep

Begin in an area that is certain to be normal

▸ Abdomen:

Tenderness: Location – localised in appendicitis, hepatitis,

pyelonephritis, generalised in mesenteric adenitis, peritonitis

Guarding – often unimpressive on direct palpation in children. Pain on coughing, on moving about/walking/bumps during car journey suggests peritoneal irritation. Back bent on walking may be from psoas inflammation in appendicitis

▸ Abdomen:

In case of peritonitis check for:

Rovsing sign–pain in the right lower quadrant in response to left-sided palpation or percussion

Blumberg sign- after gradually pressure over the area of tenderness, sudden release produces pain

▸ Abdomen:

Deep palpation:

LiverSpleenKidneyUrinary BladderStool massesPregnency

▸ Abdomen:

Hepatomegaly: Palpate from right iliac fossa Locate edge with tips or side of finger Edge may be soft or firm Unable to get above it Moves with respiration Measure (in cm) extension below costal margin in mid-

clavicular lineLiver tenderness is likely to be due to inflammation from

hepatitis

▸ Abdomen:

Hepatomegaly: Infection (congenital infections, mononucleosis,

hepatitis, malaria, parasitic infection) Heamatological (sickle cell anaemia, thalassaemia) Liver disease (chronic hepatitis, portal hypertension,

polycystic disease) Malignancy (leukemia, lymphoma, neuroblastoma,

Wilms’ tumor, hepatocellular carcinoma Metabolic (glycogen and lipid storage disorders,

mucopolysaccharidoses) Cardiovascular (heart failure) Apparent (chest hyperexpansion from bronchiolitis or

asthma)

▸ Abdomen:

Splenomegaly: Palpate from left iliac fossa Edge is ussually soft Unable to get above it Notch occassionally palpable if markedly enlarged Moves on respiration Measure size below costal marigin (in cm)

▸ Abdomen:

Splenomegaly:

Infection (congenital infections, mononucleosis, hepatitis, malaria, parasitic infection, infective endocarditis)

Heamatological (haemolityc anaemia) Malignancy (leukemia, lymphoma) Metabolic (glycogen and lipid storage disorders,

mucopolysaccharidoses) Other (portal hypertension)

▸ Neurological examination:

Signs of meningism:

Neck stiffness- flex the patient’s neck passively

Kernig’s sign- try to strighten the knee while keeping the patient’s hip flexed

Brudzinski’s sign- on flexing the head the tights and knees also flex

▸ Neurological examination:

Signs of tetany (hypocalcaemia):

Trousseau’s sign- blood pressure cuff is placed on the arm with the preassure raised above patient’s systolic preasure. The thumb becomes adducted, fingers are extended- main d’accoucheur

Chvostek’s sign-tapp over the facial cranial nerve under the ear- brisk muscular twitch occurs on the same side of the face

▸ Neurological examination:

Cranial Nerves

Motor system muscle tone- passive movements of the limbs-

hypotonia, hypertonia motor power- flexion or extension against resistance coordination

Sensory systemReflexes

▸ Newborn babiesThe assessment and examination of the

newborn and neonates (under 4 weeks) often require a specific and detailed series of checks, observations and measurements supplemented with detailed history from the parents. Babies are routinely checked and examined at birth and at between 6 and 8 weeks. This is covered in the separate article 

▸ Important aspects of the examination:◦ Ill babies can be assessed according to the baby check

system.◦ The examination is similar to that for newborn babies.◦ Progress with feeding should be discussed.

▸ Growth:◦ Weight, length and head circumference should be plotted.◦ Deviation from centiles should be discussed and followed

up.▸ Development:◦ Milestones should be briefly reviewed in all babies.

▸ General examination:◦ The parameters and methods are as for those outlined in

young and newborn babies .◦ Hips may be examined again.

▸ This age group is frequently seen by doctors.▸ From the age of about 3 months viral illnesses are very common.▸ It is a period of rapid growth and development.▸ Routine checks are no longer normally performed in this age group.▸ Assessment of growth and development is usually done opportunistically.▸ Growth: is very rapid (with a doubling on average of birth weight by 5 months).▸ Length and weight should be plotted and compared with previous readings.▸ It can be very difficult to obtain an accurate length in this age group.▸ Development: Parents will often present with children when there are concerns

over developmental progress.▸ It is a period of rapid developmental progress.▸ Developmental milestones should be reviewed opportunistically. For example:◦ Social smile should have appeared by 8 weeks.◦ Children should be sitting unsupported by 8 months.◦ Children should be babbling by 8 months.

▸ General examination:Rashes are common and may be due to viral infections, as well as skin conditions such as eczema.

▸ Doctors should be familiar with important rashes (such as the purpuric rashes of meningococcal septicaemia, idiopathic thrombocytopenic purpura and Henoch-Schönlein purpura).

▸ Cardiovascular examination:Cardiac output is regulated mostly by changes in heart rate (as with newborn and younger babies). Tachycardia is an important sign which needs explanation.

▸ Respiratory examination:This is frequently performed in this age group.▸ Observation is again very important.▸ It is important to distinguish wheeze from stridor.▸ Gastrointestinal examination:Observation is again important. For

example, with peritonitis, the child lies very still with flexed knees and shallow breaths.

▸ Inspect the anogenital area if appropriate. This is an increasingly difficult examination as children get older and requires sensitive handling.

▸ Warm hands and reassurance are needed to palpate the abdomen of an ill child.

▸ Neurological and developmental examination:Formal examination is very difficult. Improvisation is often required.

▸ Cranial nerves are examined by observation - for example, of behavioural and facial movements. Cranial nerve abnormalities in this age group include:◦ Bell's palsy.◦ Eighth cranial nerve impairment (sensorineural deafness).◦ Sixth cranial nerve deficit (convergent squint) with raised intracranial pressure.

▸ Important aspects of the examination:Toddlers are infants who are walking (usually over 1 year) but under 2 years of age.

▸ Again this group consults often.▸ Attendance is likely to be distributed between different settings (for

example, hospital, primary care, clinics, walk-in centres).▸ Good communication between these different agencies is important.▸ Growth and development is rapid.▸ Checks of growth and development will often have to be done

opportunistically.▸ Genu varus is physiological in this age group.▸ Growth:Growth decelerates from the end of the first year.▸ Head growth is rapid as the brain grows with myelination in cortical

areas.▸ Development:Important milestones should be identified. Briefly:◦ Hand dexterity improves along with visual acuity from palmar grasp to pincer grip in

the first year. By the second year a tower of six bricks can be constructed.◦ Speech develops from babbling to six or more words at 18 months and short

phrases during the second year.◦ Comprehension allows simple instructions to be followed by about a year.◦ Babies progress from crawling to cruising and then walking by about 1 year (before

18 months).

▸ General examination:It is usually best to examine babies on a parent's lap and establish relaxed rapport.

▸ Engage in play to facilitate the examination.▸ It may be necessary to be quite selective and examine

important or relevant systems first.▸ Leave more intrusive or unpleasant examinations

until the end (for example, throat examination).▸ Cardiovascular examination:Refer to normal values.▸ Identify innocent murmurs (often heard).▸ Respiratory examination:Observe and identify normal

rate, breathing sounds and pattern.▸ Gastrointestinal examination as above.Neurological

and developmental examination as above.

▸ Important aspects of the examination:This age group also frequently attends for medical care and advice.

▸ Illness and, increasingly, accidents will prompt attendance.▸ Again, rapport and confidence have to be established and maintained for

easier examination. Trust can be built for future examinations.▸ Genu valgus is physiological in this age group.▸ Growth:Growth is decelerating at this stage.▸ Centile charts should be used and checked.▸ Development:The most marked advances are in communication skills

and use of language.▸ A brief assessment of language skills should be made in all children.▸ General examination:Again, most often achieved on a parent's lap or

standing close to the parent.▸ Explain and commentate on procedures as they progress. Answer

questions - they are usually very inquisitive at this age.▸ Cardiovascular examination:Examination is easier in this age group.▸ Again, innocent murmurs are common.▸ Heart sounds are more easily identified with slower heart rates.

▸ Respiratory examination:Observation is again most important.▸ Peak flow measurement is not reliable until about age 5 years▸ Gastrointestinal examination:It is often best to examine kneeling

down alongside the patient.▸ Children may prefer palpation to be done with their hand

underneath the examiner's.▸ Hip and knee examination:Irritable hip and other hip conditions

can occur at this age and require assessment.▸ Normal genu varus (physiological in the toddler) and valgus

(physiological in the pre-school child) often require reassurance at this age.

▸ Neurological and developmental examination:This increasingly approaches what is possible in adults.

▸ Vision can be checked by shape or letter matching at 3 years of age.

▸ A circle will be copied by 3 years, a cross by 4 years, a square by 4.5 years and triangles by about 5 years.

▸ Important aspects of the examination:◦ This age group is examined less often by doctors.◦ Psychological factors begin to play more of a part in how

problems present.▸ Growth:◦ Growth will be steady leading up to the pubertal growth

spurt.◦ Concerns may begin to be expressed about growth and

development in relation to puberty.▸ Development:◦ Social and behavioural aspects of development become

more important.◦ Other aspects of development approach those of adults.

▸ Examination:◦ There are now few differences from adult examination.

▸ Important aspects of the examination:◦ Adolescents attend for medical advice infrequently.◦ Rapport and good communication may be difficult to

establish.◦ Psychological factors are likely to be very important.[4]

◦ Most adolescents are very self-conscious and this can impede adequate examination.◦ It is recommended to have a chaperone.◦ Confidentiality and consent become more important

issues.▸ Growth:◦ Puberty initiates a period of rapid growth.◦ Normal and abnormal puberty should be recognised.

▸ Examination:◦ Examination is very similar to that undertaken in adults.