Examining Children

Within primary care the challenge with children presenting outside surveillance screening is to perform a sufficiently directed examination to exclude (or confirm) illness according to parent's expectations and presenting complaint.
Time constraints may preclude building a trusting relationship before examining on every occasion.
If a child resists examination, consider whether it is absolutely essential before asking the parent to hold them firmly - depending on age. Some children may be reassured by examining their toy or parent/carer first. However it may be necessary to ask them to return for another attempt when they are more amenable e.g. just after a sleep or a feed.

Looking at the baby or child and smiling (before doing anything else) will give a friendly impression. In young children, commenting on characters on clothes or toys and being prepared to play a little, will also gain their confidence and save time that may be later spent persuading the child to let you examine them.

Observe the baby or child dressed and undisturbed. There can be a lot to observe this way - including how well the child is developing - and it also gives them time to 'warm up' to you.

Children differ in their response to being undressed.
Those that do not like it can be usually examined through vest and pants.
Others may expect you to undress them and this gives you an opportunity to handle the child which may later palpation more acceptable.
Ask the parents to help you by holding or distracting the child and ask them to undress him or her if necessary.
Be prepared to be flexible and leave one system unfinished and come back when the child is more settled.

Note weight and length or height accurately. If required measure skull circumference and occasionally skin fold thickness.

Note the childs behaviour and level of awareness and take these into account with the parents own reports.

• Consider if the childs appearance is unusual at all and in what way.
• Note the shape of the head, mould of ears, position of eyes, body proportions, posture.
• Does the child look like their parents?
• Are there any recognisable major or minor anomalies?
• Record the nature and distribution of skin lesions and rashes. Note the colouring, shape and positions of bruises. If they have suspicious appearance, consider the possibility of non-accidental injury.

It may be a good idea to start the examination here, if the child is quiet and settled. Letting the child remain seated/held on the parents or carers lap, will reassure them:

• Begin by recording pulse rate, rhythm, strength and character.
• Palpate and percuss the anterior chest wall for heart size and the site and nature of the apex beat.
• Also determine the presence of any thrill.
• Listen to the 1st heart sound, then the 2nd heart sound, then the sounds between these and then any murmurs between heart sounds.
• Note the timing, character, loudness, site and distribution of any murmur.
• Check if this is transmitted to the neck.
• If disease of the heart of kidney suspected record BP.

Note respiratory rate and movement of the diaphragm and chest wall with quiet breathing and with stronger respiratory effort (requested from older child or with crying in baby).
Percuss the upper edge of the liver to determine if lung is over inflated.

Breath sounds and additional noises can be difficult to interpret in the very young.
Noises vary from fine high pitched to low and coarse depending on the site and nature of the obstruction and the narrowness of the aperture.

• Crepitations (fine crackling noises on inspiration) can occur in apparently normal babies on careful auscultation. Persistent and bilateral crepitations in a distressed toddler usually suggests bronchiolitis or rarely left heart failure.
• Rales (intermittent noises during inspiration and expiration) normally indicates liquid debris in larger airways and may be transmitted from the back of the throat.
• Rhonchi (more persistent harsh noises added on to breath sounds) are less common in children and suggest a more persistent obstruction.
• Bronchial breathing (continuous noises that harden and extend the breath sounds) heard over the baby's upper back are usually transmitted from the main airway.
• Stridor (a harder and more vibrant noise) indicates that the airway is partially obstructed.
• Wheezing occurs with the mid-airways are narrowed and need to be checked if bilateral.

First observe the abdomen looking for swellings and movements.

• Enquire if there is any tenderness and if possible watch the childs face while you palpate the abdomen. If tenderness is present, and the child is systemically unwell, before palpating, ask the child to puff up their stomach, ("like a balloon"). This may elicit rebound, without touching and unintentionally hurting the child.
• Palpate the 4 quadrants to systematically determine the position and size of the liver, spleen, kidneys and bladder.
• Note the position, size, surface and texture of any enlarged organ, the character of the edge if it has one and whether or not it is tender.
• Consider whether digital rectal examination is appropriate and explain to parent. This examination is often neglected when useful information can be obtained e.g. with a history of constipation.¹

Observe any abnormal curvature or deformities of the spine, particularly at the lower end. In small babies, pay particular attention to the sacrum and observe any sinus or hairy naevi.

During the consultation consider whether the child has normal development in motor functions, speech and language and social interaction. Has the parent stated any specific concerns?

• Always examine the anterior fontanelle by palpation in babies and infants. Note any pulsation and if it is normal.
• Fontanelle should close by middle of 2nd year. It should be full or flat.
• Note if the child can hear, see, move eyes and head well in all directions, move all limbs and is this movement normal and full?
• Note whether contour and position of each limb is normal with good power. Handle the child and note the tone of movement of the limb and whether there is any limitation to this.
• Note if the joints are unduly lax and hyperextendable. Watch the child's face while you move the limbs.²
• Although rarely useful, you may be able to elicit reflexes with the percussing finger instead of a hammer.

Examine the eyes, eardrums and then the throat. It may be useful to warn the child that it may tickle the ears.
Do no force the child to open their mouth against their will. Consider if you really need to look down there. Use your clean finger instead of a dry stick.

Many GPs undertake the routine neonatal examination, known colloquially as 'the baby check'. It may be performed by the GP following home births. NICE recommends that the aims of the examination are fully explained to the parent(s) before it is conducted.³ The findings should be shared with the parent(s) and recorded in the postnatal care plan and the personal child health record. NICE advises that the examination should be carried out within 72 hours of birth and incorporate:

• A review of parental concerns and the baby's medical history
• Family, maternal, antenatal and perinatal history
• Fetal, neonatal and infant history including any previously plotted birth-weight and head circumference
• Whether the baby has passed meconium and urine (and urinary stream in a boy)

Other screening tests as recommended by the UK National Screening Committee should also be carried out or arranged at this time.

The six week review may also be performed as part of child health surveillance, by suitably qualified GPs.