Growth after infancy is extremely variable. Use gender- and
ethnic-specific growth charts (such as those shown in Fig. 15.17).
These compare the individual with the general population and
with their own previous measurements. Each child should grow
along a centile line for height and weight throughout childhood.
Failure to thrive is failure to attain the expected growth trajectory.
A child on the 0.4th centile for height may be thriving if this has
always been their growth trajectory, while a child on the 50th
centile for height may be failing to thrive if previously they were
A child’s height is related to the average of their parents’
height centile ± 2 standard deviations. Parents whose average
height lies on the 50th centile will have children whose height will
normally lie between the 2nd and 98th centiles (approximately
10 cm above and below the 50th centile).
Normal development is heterogeneous within the population, which
makes identifying abnormalities difficult. Important determinants
are the child’s environment and genetic potential. Developmental
The physical examination • 311
The school-age child (5+ years)
By this age, developmental problems are usually known to parents
and relevant agencies, such as educational ones, may already be
engaged. However, more subtle developmental problems such as
dyslexia (learning disability affecting fluency and comprehension
in reading) may be unrecognised and can be a major handicap.
Ask general questions such as, ‘How is your child getting on at
school?’ and follow up by enquiring specifically about academic
assessment requires patience, familiarity with children and an
understanding of the range of normality for a given age.
The preschool child (1–5 years)
At the younger end of this range, questions relating to gross
motor skills are most sensitive; as the child becomes older,
questions relating to fine motor and personal social skills are
more meaningful. Delayed speech with normal attainment of
motor milestones is not uncommon, particularly in boys, but
should prompt hearing assessment (see Box 15.5).
1 2 345 6 7 8 9 10 11 1 2 345 6 7 8 9 10 11
Age (completed months and years)
12345678 9 10 11 12345678 9 10 11
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
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