Paediatric Examination

See Also: The Paediatric History record.

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 further complicate things the examination changes as children develop and get older. Eventually it is similar to examination in adults. The following outline aims to highlight the important differences, give some general principles and provide an outline of the examination in different age groups.

General points

• It is important to have established rapport with parents and child when taking the history.
• The approach to the examination will be determined by the age, level of development and level of understanding of the child.
• Inspection and observation are the most important parts of the examination.
• Avoid waking sleeping children.
• Approach the child at their level, if necessary kneel on the floor. It may be impossible to examine pyrexial, irritable children without provoking crying and they should be carefully observed before attempting closer examination.
• Start examining peripherally with hands and feet as this is less threatening.
• Make the examination fun to help with their anxiety.
• Make sure the child is comfortable and warm hands, stethoscope and other instruments.
• Wherever possible avoid unpleasant procedures (for example rectal examination). These are seldom necessary and can put children off being examined for a lifetime.

Growth and pubertal development

General points

• Myelination of the nervous system at birth is incomplete.
• Pubertal development has important implications for growth. Assessment of puberty is important when assessing growth.
• Examination of children should incorporate accurate assessment of growth and pubertal development.
• There are three phases of growth:
• Infant phase:
  • Rapid first year and slowing in the second year of life
  • Good nutrition is important for normal growth
  • Metabolic hormones control growth
• Childhood phase:
  • From second to tenth year
  • Pituitary hormones and growth hormone are important factors
• Pubertal or adolescent phase:
  • From onset of puberty until adult stature reached
  • Sex hormones are the important factors

Measurement

• Head circumference routinely in under age 2 years
• Length or height in older children
• Weight
• Plotting of serial measurements to establish pattern and range of growth
• Use appropriate growth charts
• Assess and plot pubertal development where indicated

Developmental assessment

• An awareness of normal developmental milestones should be acquired by all doctors working with children.
• Detailed assessment of development is complicated but useful assessments in the course of routine examinations and consultations can be achieved with experience and practice.
• There are large variations in normal development.
• Schemes to assess development centre on:
  • Motor skills: gross motor and fine motor
  • Special senses: vision and hearing
  • Communication: comprehension and expressive language
  • Psychosocial aspects: social skills and behaviour

• It is important to distinguish between:
  • The routine examination of well babies (to screen largely for abnormalities of growth and development).
  • The examination of ill babies (to establish the nature and cause and extent of any illness or injury).
  • The examination of children for other specific purposes such as, for example:
    • To establish fitness for education or certain activities.
    • To examine for signs of sexual abuse in child protection cases.
• However this is not an absolute distinction. Whether ill or well the examining doctor should have a good working knowledge of routine examination and normal findings in children at different ages.
• Problems with development, behaviour and growth may thus be identified opportunistically whilst examining an ill child.
• Doctors working with children should have a good knowledge of normal developmental milestones, as well as routine physical development and findings at different ages.

Examination will be outlined in different age groups. These are not intended to be exhaustive checklists but aim to highlight important aspects of the examination in these selected age groups, particularly where there are notable differences to adult examination. The emphasis and detail of any examination will be determined by the particular aims and purposes of the examination outlined above.

• Newborn babies (see also Newborn Screening)
• Six week old babies (see also The Six Week Review)
• 7 to 9 month old babies
• Toddlers or children under 2 years
• Preschool children (see also The Pre-school Check)
• School age children
• Adolescents (see also Puberty: Normal and Abnormal)

Normal values

A distinctive feature of paediatric examination is that normal parameters change with growth and development. This is illustrated by the example of pulse, blood pressure and respiratory rate in different age groups in the table below.

Newborn babies

The assessment and examination of the newborn and neonates (under 4 weeks) often requires 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. The objectives are generally:

• To screen for congenital abnormalities (particularly those requiring intervention).
• About 14% of babies will have congenital abnormalities and these are often detected at the neonatal check.
• To answer questions from parents and discuss concerns they may have.

Preterm babies have particular characteristics best considered separately.

• Newborn and young babies become ill very quickly. The 'baby check' system of assessment can help health professionals and carers to quickly evaluate the seriousness of a baby's illness.¹
• Growth:
  • There is a steep growth curve. Weight (nude) should be accurately measured and plotted:
  • Initial weight loss of between 5% and 10% occurs in the first week.
  • Subsequent weight gain over the first 5 months is approximately 0.2Kg per month.
  • Length needs careful measurement with a stadiometer.
  • Head circumference is measured with a suitable non-stretch tape at the largest point around occiput and forehead.
• Development:
  • Social smiling is an important milestone (higher cortical function).
  • Babies show a startle reaction to sound
• General examination:
  • This is performed in the light of a history of mother's health, the pregnancy and the birth.
  • A routine of checking systematically should cover:
  • It is important to assess gestation and weight:
    • Term- born between 37 and 42 weeks gestation
    • Preterm- born before 37 weeks gestation
    • Post-term-born after 42 weeks gestation
    • 'Small for dates' or small for gestational age if below the 10th centile (weight) for gestational age
    • 'Large for dates' when over 90th centile for gestational age
    • Low birth weight babies (LBW) are important to identify (associated morbidity and mortality):
      • LBW babies are <2.5 kg at birth (7% UK births)
      • Very low birth weight (VLBW) are <1.5 kg (1% of UK births and mostly preterm)
      • Extreme low birth weight (ELBW) are < 1.0 kg (less than 0.5% and nearly all preterm)
• Cardiovascular examination. Early diagnosis of congenital heart disease, coarctation of the aorta and patent ductus arteriosus is important. Examination should include:
  • Inspect colour looking for cyanosis. Peripheral cyanosis is common in newborns (acrocyanosis). Look for central cyanosis (tongue).
  • Palpate brachial and femoral pulses and the precordium.
  • Auscultation should detect heart sounds and murmurs. Splitting of the second sound is difficult to detect with the fast heart rate. Innocent murmurs are heard in about 20% of babies.
  • Appreciation of normal findings (table above)
• Respiratory examination:
  • Observation of breathing is most important.
  • Signs of respiratory distress are distinct from those in older children and adults. A combination of the following may be observed:
    • Tachypnoea
    • Subcostal and intercostal recession
    • Tracheal tug
    • Grunting
    • Flaring of nostrils
    • Cyanosis
    • Apnoea and periodic breathing may be identified (preterm and neonates)
• Gastrointestinal examination:
  • Observation:
    • Observe the baby feeding (distinguish normal possetting from abnormal vomiting or bile stained vomiting)
    • Inspect nappy/ stools
    • Look for jaundice (distinguish normal from abnormal as in neonatal jaundice)
  • Palpation:
    • Examine mouth and palate
    • Inspect natal cleft
    • Liver edge (1cm below costal margin is normal)
    • Hernias should be detected
    • Umbilical hernias are common and need no treatment
    • Other hernias need prompt referral
    • Hydroceles are common and need no treatment
    • Genital anomalies should be identified and referred
    • Brief confirmation of normal urethral and clitoral anatomy should be made (identify for example hypospadius)
    • Ambiguous genitalia need referral
    • Hips may be examined whilst the nappy is off (Ortolani and Barlow techniques)
• Neurological and developmental assessment:
  • Observation is again the most important form of examination
  • Inspection and palpation of the baby's head is indicated:
    • Fontanelle size and tone (bulging fontanelles with raised intracranial pressure)
    • Moulding of the head is apparent in the first 24 hours (note 'chignon' after ventouse and cephalhaematomas which can take several days to resolve)
    • Head circumference should be measured and plotted
  • Eyes and hearing:
    • Babies will fix and follow with their eyes
    • The red reflex should be seen in each eye
    • Squints may be normal under 8 weeks
    • There should be a startle response to loud noises
  • Reflexes:
    • It is usually inappropriate to elicit primitive reflexes (unless asymmetry of movement or tone suspected)
    • Observation will identify symmetrical movements

Six week old babies

This is covered in the Six Week Review record.

• Important aspects of the examination:
  • Ill babies can be assessed according to the baby check system¹
  • 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

7 to 9 month old babies

• Important aspects of the examination:
  • This age group are 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 not now normally performed in this age group.
  • Assessment of growth and development is usually done opportunistically.
• Growth:
  • 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 8months.
    • Children should be babbling by 8 months.
• General examination:
  • Rashes are common with frequent viral infections particularly.
  • 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 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 behaviour 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

Toddlers

• 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).
  • It is important for there to be good communication between these different agencies.
  • 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 6 bricks can be achieved.
    • Speech develops from babbling to 6 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 a year (before 18 months).
• General examination:
  • It is usually best to examine babies on the 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.

Preschool children (age 2 to 5 years)

• Important aspects of the examination:
  • This age group also frequently attend 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.
  • An assessment of language skills should be briefly made in all children.
• General examination:
  • Again most often achieved on parent's lap or standing close to 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 not reliable until about age 5 years (see Diagnosing Childhood Asthma in Primary Care)
• 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 examiners.
• 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 preschool 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.

School age children (from 5 to 10 plus years)

• Important aspects of the examination:
  • This age group are 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.

Adolescents (from the onset of puberty)

• 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.
  • 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.