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General child assessment

Clinical examination > Paediatric

A general assessment should be done for every unwell child along with an in-depth relevant system examination.

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent

Airway

  • Listen: stridor (croup, foreign body), secretions, grunting (bronchiolitis, pneumonia, asthma)

Breathing

  • Inspect
    • Respiratory rate 
    • Recession (subcostal, intercostal, sternal), nasal flaring, tracheal tug, accessory muscle use
  • Oxygen saturation (>97% normal, <94% significant illness, <90% alarming)
  • Auscultation: if the child is crying, try to listen during inspirations. Listen anteriorly and posteriorly.

Auscultation abnormalities

  • Wheezing (asthma, viral-induced wheeze)
  • Crepitations (secretions, bronchiolitis, infection)
  • Bronchial breathing (pneumonia)

Circulation

  • Colour: pallor, mottled arms/legs, blue (poor perfusion)
  • Radial pulse rate (brachial if <6 months)
  • Hydration signs
    • Wet nappies
    • Mucous membranes
    • Skin turgor
    • Capillary refill (central and peripheral; press for 5 seconds; normal refill time is <2 seconds) and 
    • Temperature of hands and feet compared with trunk (peripheries will be cooler in sepsis or dehydration due to peripheral vasoconstriction)
  • Auscultate heart sounds
  • Blood pressure if very unwell (maintained until late in shock) 
  • Palpate for hepatomegaly (sign of cardiac failure)

Disability (neurological)  

  • Alertness and activity
    • Note how alert and reactive to surroundings (may be drowsy after fit or fever)
    • Look at behaviour (true irritability, i.e. cannot be consoled = raised intracranial pressure or meningitis)
    • AVPU score/GCS
    • Fontanelle (bulging = raised intracranial pressure)
  • Pupils: check with torch if very unwell (sluggish response = post-ictal or drug toxicity; changing sizes = seizure; asymmetrical = SOL, e.g. sub-/extradural; gaze may be abnormal after a seizure) 
  • Limb tone and movement (also check for joint swelling)
  • Rash (inspect everywhere) and check for neck stiffness
  • Capillary glucose: measure if decreased alertness
 <1 year1-2 years2-5 years5-12 years>12 years
Resp rate30-4025-3525-3020-2515-20
Heart rate110-160100-15095-14080-12060-100
Normal paediatric observations

Everything else

ENT

Ensure you tell the parent what you need to do and give clear instructions.

  • Ears: the child must be stable and held tight, sitting sideways on parent’s lap. The parent should keep one hand on the child’s head and the other encircling their arms and body. Use your free hand to hold the head in against the parent’s chest. NB: healthy eardrums often pink.

  • Throat: position the child facing you on parent’s lap. They should use one arm to hold the child’s forehead back and the other to encircle their arms. You may need to use a tongue depressor. NB: children often have large red tonsils.

Temperature

  • Measure temperature (axilla recommended in babies)

Abdomen

Best if lying flat but child can be examined in parent’s lap

  • Ask child to point to pain with finger (start away from painful areas)

  • Palpate gently first, then deeper

  • Check for organomegaly (liver, spleen, kidneys)

  • Check inguinal region and umbilicus for hernias

  • Auscultate for bowel sounds

Warning features

Amber flagsRed flags
A Stridor  
BNasal flaring, tachypnoea, sats ≤95%, cracklesRespiratory distress (RR>60), grunting, moderate-severe chest in-drawing 
CPallor, tachycardia, reduced capillary refill, reduced UO, dry mucus membranes, poor feeding Pale/mottled/ashen/blue, reduced skin turgor
DReduced activity, not responding normally to social cuesNo response to social cues/won’t stay awake, non-blanching rash, neck stiffness, seizures/neurology, bulging fontanelle
EFever in 3-6month old (or for ≥5 days), rigors, limb or joint swelling/not using limb Fever in <3 month old
Reference: NICE ‘NG143 fever in under 5s: assessment and initial management’ 2021

Try some questions

You are presented with a drowsy child who has a non-blanching rash. What are you concerned about? What would be your initial management?

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A child with type 1 diabetes presents unconscious with confirmed hypoglycaemia. How would you correct the glucose? Intravenous access has already been established.

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You identify a child has a significant fluid deficit due to pneumonia (reduced skin turgor, reduced capillary refill, tachycardia, reduced urine output). How would you manage this?

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You assess a child who has presented with stridor and severe recession. You suspect Croup. What initial actions would you take?

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Paediatric

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