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Age (completed months and years)
childgrowth/standards/weight_for_age/en/ © World Health Organization 2017. All rights reserved.
If required, use a chart to stage puberty (Fig. 15.19). Pubertal
staging has a wide normal range, with abnormalities apparent only
on follow-up. Delayed or precocious puberty is not uncommon.
Physical examination techniques
Children usually present with a symptom. Children with acute
symptoms often have physical signs such as wheeze, but
examination is normal in the majority of children with chronic
symptoms. Routine screening examination after infancy is
unhelpful, as many paediatric diseases only produce signs late
Similarities in examination between
The techniques used when examining children are the same as
those in adults, with some exceptions. Examining a child is a skill
that takes time to learn. The key skills involve being:
• Observant of the child during discussion or play, to identify
elements of the examination that are naturally displayed
and so can be partitioned from the formal examination
process, reducing the duration of what is often a stressful
• Opportunistic, to examine systems as the child presents
them. Chest and cardiac auscultation may be better earlier
in the examination in younger children before they become
• Adaptive to a child’s mood and playfulness. A skilled
practitioner can glean most examination findings from even
the most uncooperative child. Usually the history suggests
the diagnosis; the examination confirms it.
Differences in examination between
The appropriate approach varies with the child’s age.
All children at this age can be reluctant to be approached by
strangers, and particularly dislike being examined. Early on, let
children gradually become used to your presence and see that
your encounter with their parents is friendly. Carefully observe
the child’s general condition, colour, respiratory rate and effort,
and state of hydration while taking the history: that is, when
the child is not focused on your close attention. For the formal
examination, ask the parent to sit the child on their knees. Examine
the cardiorespiratory system and the abdomen with the young
child sitting upright on the parent’s knee. With patience, abdominal
examination can be done with the child lying supine on the bed
next to a parent or on the parent’s lap. Taking your stethoscope
from around your neck to use it can upset the child, so make
slow, non-threatening moves. If the child starts crying, chest
auscultation and abdominal palpation become very difficult; take
a pause. Ear, nose and throat examination often causes upset
and is best left till last; suggesting that ear examination will tickle
Some children in this age range have the confidence and maturity
to comply with some aspects of adult examination. They may
cooperate by holding up their T-shirts for chest examination
This stage of adolescence, when an individual becomes
physiologically capable of sexual reproduction, is a time of rapid
physical and emotional development. The age at the onset and
end of puberty varies greatly but is generally 10–14 years for girls
and 12–16 years for boys (Fig. 15.18). The average child grows
30 cm during puberty and gains 40–50% in weight.
8 1 9 1 0 12 14 16 18 2 1 13 15 17 19 0
8 1 9 1 0 12 14 16 18 2 1 13 15 17 19 0
Fig. 15.18 Timing of puberty in males and females.
The physical examination • 313
signs, they should ideally be reassessed in 1–2 hours if there
is a high level of parental or clinical anxiety that the signs are
out of keeping with a simple viral illness in a child of that age.
Use a stadiometer (Fig. 15.20).
and turning round; if so, comment warmly on this cooperation
and provide positive feedback on helpful behaviour. Children’s
social skills regress when they are unwell and some are very
The child may comply with a full adult-style examination. Although
children under 11 years are often not able to express themselves
well, those over 5 years are able to understand and comply with
requests such as finger-to-nose pointing, heel-to-toe walking, and
being asked to ‘sit forward’ and ‘take a deep breath in and hold it’.
There are many non-specific signs that are common to a range
of conditions from a simple cold to meningitis. These include
a runny nose, fever, lethargy, vomiting, blanching rash and
irritability. However, some signs are serious, requiring immediate
investigation and management (Box 15.10).
Children become ill quickly. If a child has been unwell for less
15.10 Serious signs requiring urgent attention
• Poor perfusion with reduced capillary refill and cool peripheries
• Listless, poorly responsive, whimpering child (suggesting sepsis)
• Petechial rash over the trunk (suggesting meningococcal sepsis)
• Headache with photophobia or neck stiffness (suggesting meningitis)
• Respiratory distress at rest (rapid rate and increased respiratory
effort, indicating loss of respiratory reserve due to pneumonia or
Head straight, eyes and ears level
Gentle upward traction on mastoid process
Barefoot with feet flat on floor
Fig. 15.20 Stadiometer for measuring height accurately in children.
Healthy tonsils and pharynx look pink; when inflamed, they are
Inspecting the throat reveals the presence, but not the cause, of
the infection; pus on the tonsils and pharynx does not differentiate
a bacterial from a viral infection (p. 185).
• Sit the child across their knees with the child’s ear
• Place one arm around the child’s shoulder and upper
arm that are facing you (to stop them pushing you
• Place their other hand over the parietal area above
the child’s ear that is facing you (to keep the child’s
• Use an otoscope with the largest speculum that will
comfortably fit the child’s external auditory meatus.
• To straighten the ear canal and visualise the canal and
tympanic membrane, hold the pinna gently and pull it out
and down in a baby or toddler with no mastoid
development, or up and back in a child whose mastoid
Palpable neck and groin nodes are extremely common in children
under 5 years old. They are typically bilateral, less than 1 cm in
diameter, hard and mobile with no overlying redness, and can
persist for many weeks. In the absence of systemic symptoms
such as weight loss, fevers or night sweats, these are typically
a normal, healthy immune response to infection. Only rarely are
they due to malignancy (Box 15.12).
Normal ranges for vital signs vary according to age (Box 15.11).
• Sit the child on their knees, both facing you.
• Give an older child the opportunity to open their mouth
spontaneously (‘Roar like a lion!’). If this is not
successful, proceed as described here.
• Place one arm over the child’s upper arms and chest
(to stop the child pushing you away, Fig. 15.21).
• Hold the child’s forehead with their other hand (to stop
the child pulling their chin down to their chest).
• Hold the torch in your non-dominant hand to illuminate the
• Slide a tongue depressor inside the child’s cheek with
your dominant hand. The child should open their clenched
teeth (perhaps with a shout), showing their tonsils and
Fig. 15.21 How to hold a child to examine the mouth and throat.
Fig. 15.22 How to hold a child to examine the ear.
15.11 Physiological measurements in
want to move, and if they are forced to do so, the neck remains
aligned with the trunk. With a young child, move a toy to catch
their attention and see if they move their head.
It can be difficult to identify a child with severe illness. With
experience you will learn to identify whether a child is just miserable
or really ill. Early-warning scores (such as PEWS or COAST, Fig.
15.23) can help. Certain features correlate with severe illness
Children who experience neglect or physical and/or emotional
abuse are at increased risk of health problems. At-risk children
are often already known to other agencies but this information
may not be available to you in the acute setting. Injuries from
physical abuse can be detected visually. Consider non-accidental
injury if the history is not consistent with the injury, or the injury
is present in unusual places such as over the back. It may be
difficult to detect neglect during a brief encounter but consider
it if the child appears dirty or is wearing dirty or torn clothes
that are too small or large. The parent–child relationship gives
insight into neglect; the child is apparently scared of the parent
(‘frozen watchfulness’) or the parent is apparently oblivious to
the child’s attention (Box 15.14).
Feel the brachial pulse in the antecubital fossa in children below
2–3 years. Do not palpate the carotid or radial pulses in young
children. Measure blood pressure using a cuff sized two-thirds
the distance from elbow to shoulder tip. Repeat with a larger
cuff if the reading is elevated. If in doubt, use a larger cuff, as
smaller cuffs yield falsely high values.
The child under 3 years has a soft chest wall and relatively
small, stiff lungs. When the lungs are made stiffer (by infection
or fluid), the diaphragm must contract vigorously to draw air into
the lungs. This produces recession (ribs ‘sucking in’ – tracheal,
intercostal and subcostal) and paradoxical outward movement
of the abdomen (wrongly called ‘abdominal breathing’). These
important signs of increased work of breathing are often
noticed by parents. Older children may be able to articulate
the accompanying symptom of dyspnoea.
Children’s small, thin chests transmit noises readily, and
their smaller airways are more prone to turbulence and added
sounds. Auscultation may reveal a variety of sounds, including
expiratory polyphonic wheeze (occasionally inspiratory too), fine
end-expiratory crackles, coarse louder crackles transmitted from
the larger airways, and other sounds described as pops and
squeaks (typically in the chest of recovering patients with asthma).
In children aged 6 months to 3 years, examine the abdomen
with the child sitting upright on their parent’s knee. In the
young child, splenic enlargement extends towards the left iliac
fossa. In older children the enlarged spleen edge moves towards
the right iliac fossa. Faecal loading of the left iliac fossa is common
in constipation. Rectal examination is rarely indicated in children.
Test power initially by watching the child demonstrate their
strength against gravity. Ask them to lift their arms above their
head, raise their leg from the bed while they are lying down,
and stand from a squatting position. If appropriate, test power
Neck stiffness in a child is usually apparent when you are
talking to them or their parents. A child with meningitis will not
15.12 Causes of lymph node enlargement
• Tonsillitis, pharyngitis, sinusitis
• ‘Glandular fever’ (infectious mononucleosis/cytomegalovirus)
• Tuberculosis (uncommon in developed countries)
• Febrile illness with a generalised rash
• Systemic juvenile chronic arthritis (Still’s disease)
• Mucocutaneous lymph node syndrome (Kawasaki disease)
15.13 Clinical signs associated with severe
• Hypotension (a late sign in shocked children where blood pressure
is initially maintained by tachycardia and increased peripheral
15.14 Signs that may suggest child neglect or abuse
• Identifiable bruises, e.g. fingertips, handprints, belt buckle, bites
• Circular (cigarette) burns or submersion burns with no splash marks
• Long-bone fractures or bruises in non-mobile infants
• Subconjunctival or retinal haemorrhage
• Dirty, smelly, unkempt child
Nurse in Charge review. Hourly observations.
Nurse in Charge & Doctor to review patient. Half-hourly observations.
Nurse in Charge & SpR to review patient. Consider informing Consultant.
*nb: BP, GCS and Pain Score values do not contribute to the overall COAST score.
Nurse in Charge & Senior Doctor to see immediately.
If airway compromise, call ITU Registrar immediately.
CHILDREN’S OBSERVATION AND SEVERITY TOOL
SOUTH COAST CHILDREN’S EARLY WARNING SCORE: CHILDREN’S UNIT
treatment unit; SpR, specialist registrar. Courtesy Dr Sandell.
OSCE example case 1: Cyanotic episodes
Please perform a newborn examination, focusing on the cardiovascular system
• Introduce yourself to the parent and clean your hands
• Carry out a general inspection: are there any signs of congenital heart disease?
• Look for signs of respiratory distress (tachypnoea, indrawing, accessory muscle use).
• Check for scars on the chest.
• Look at the colour and perfusion of the patient (cyanosis, pallor, sweatiness).
• Look for signs of dysmorphic features that might indicate an associated chromosomal abnormality.
• Look for signs of poor weight gain.
• Palpate: is the infant warm and well perfused? Are there any palpable cardiac abnormalities?
• Check central capillary refill. Feel the temperature.
• Palpate peripheral pulses (brachial, femoral).
• Assess whether there is palpable hepatomegaly or finger clubbing.
• Auscultate: is there a murmur?
• Auscultate the heart in a systematic fashion.
• Auscultate the back to check whether the murmur radiates.
• Clean your hands and thank the parent.
Finger clubbing is not usually present in young infants.
Pulse oximetry, echocardiogram, electrocardiogram, chest X-ray.
Please perform a chest examination, focusing on the respiratory system
• Introduce yourself to the parent and patient, and clean your hands.
• Carry out a general inspection: are there any signs of acute or chronic respiratory distress?
• Look for chest wall deformity (pectus excavatum, Harrison’s sulcus).
• Look for signs of respiratory distress (tachypnoea, indrawing, accessory muscle use).
• Count the respiratory rate over 1 minute.
• Look at the colour and perfusion of the patient (cyanosis, pallor, sweatiness).
• Look for finger clubbing and poor weight gain.
• Auscultate: warm the stethoscope.
• Heart sounds are normal with no murmur.
• Clean your hands and thank the parent and patient.
This child has tachypnoea and a widespread, loud, polyphonic wheeze on expiration.
skin-prick testing) and, if required, a trial of a stepwise increase in baseline asthma therapy.
Suggest initial investigations
Peak expiratory flow or spirometry, and oxygen saturation.
Integrated examination sequence for the newborn child
• Perform a general examination:
• Skin: note cuts, bruising, naevi (haemangiomas or melanocytic), blisters or bullae.
• Head: check shape, swellings, anterior fontanelle, cranial sutures.
• Eyes: check for jaundice, ocular movements and vestibular function; perform ophthalmoscopy.
• Mouth: check mucosa, tongue, palate, jaw and any teeth.
• Ears: note size, shape and position; check the external auditory meatus.
• Neck: inspect and palpate for asymmetry, sinuses and swellings.
• Examine the cardiovascular system:
• Inspect: pallor, cyanosis and sweating.
• Palpate: apex, check for heave or thrill, count heart rate, femoral pulses, feel for hepatomegaly.
• Auscultate: heart sounds I and II, any additional heart sounds or murmurs.
• Examine the respiratory system:
• Auscultate anteriorly, laterally and posteriorly, comparing sides.
• Inspect: abdomen, umbilicus, anus and groins, noting any swellings.
• Palpate: superficial, then deeper structures. Spleen, then liver.
• Both sexes: check normal anatomy.
canal if the testes are not in the scrotum. Transilluminate scrotal swellings.
• Examine the spine and sacrum:
• Examine the neurological system:
• Inspect: asymmetry in posture and movement, any muscle wasting.
• Pick the baby up to note any stiff or floppy tone.
• Sensation: does the baby withdraw from gentle stimuli?
• In dim light, the eyes should open; in bright light, babies screw up their eyes.
• Check the primitive reflexes:
• Inspect: limbs, counting digits and checking feet are, or can be, normally positioned.
• Check hips for developmental dysplasia/dislocation.
• Weigh the infant to the nearest 5 g.
• Measure: occipitofrontal circumference, crown–heel length (neonatal stadiometer).
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