short, which may interfere with feeding. A white coating on the
tongue, which is not easily removed and may bleed when scraped,
is caused by Candida albicans (thrush). Macroglossia (a large
protruding tongue) occurs in Beckwith–Wiedemann syndrome. A
normal-sized tongue protrudes through a small mouth in Down’s
• Do not measure the blood pressure of healthy babies. In ill
babies, cuff measurements overestimate the values when
compared with invasive measurements. The cuff width
should be at least two-thirds of the distance from the
• Palpate the abdomen for hepatomegaly (see later).
In the early newborn period the femoral pulses may feel normal
in an infant who later presents with coarctation because an
open ductus arteriosus can maintain flow to the descending
aorta. Routine measurement of postductal oxygen saturation
is increasingly popular as an additional newborn screening test
for congenital heart disease. Lower limb SpO2 should be 95%
Heart rates between 80 and 160 beats per minute (bpm)
can be normal in the newborn, depending on the arousal state
Infants with heart failure typically look pale and sweaty, and have
respiratory distress (p. 298).
If the apex beat is displaced laterally, there may be cardiomegaly,
or mediastinal shift due to contralateral pneumothorax or pleural
Weak or absent femoral pulses suggest coarctation of the
aorta. Radiofemoral delay is not identifiable in the newborn.
Patent ductus arteriosus may cause a short systolic murmur in
the early days of life because the pulmonary and systemic blood
pressures are similar, which limits shunting through the duct.
The murmur progressively lengthens over subsequent weeks or
months to become the continuous ‘machinery’ murmur recognised
Transient murmurs are heard in up to 2% of neonates but only
a minority have a structural heart problem. An echocardiogram
is needed to make a structural diagnosis.
• Note chest shape and symmetry of chest movement.
• Count the respiratory rate (for 15 seconds and multiply
• Listen for additional noises with breathing.
• Look for signs of respiratory distress: tachypnoea;
suprasternal, intercostal and subcostal recession; flaring of
• Remember that percussion of the newborn’s chest is not
• Use the diaphragm to auscultate anteriorly, laterally and
posteriorly, comparing the sides. Breath sounds in the
healthy newborn have a bronchial quality compared with
Fig. 15.5 Palpating the femoral pulses. The pulse can be difficult to
feel at first. Use a point halfway between the pubic tubercle and the
anterior superior iliac spine as a guide.
Fig. 15.6 Auscultation positions in infants and children.
Recommended order of auscultation: 1, apex; 2, left lower sternal edge;
3, left upper sternal edge; 4, left infraclavicular; 5, right upper sternal
edge; 6, right lower sternal edge; 7, right mid-axillary line; 8, right side of
neck; 9, left side of neck; 10, posteriorly.
15.4 Normal ranges for heart and respiratory
Sign Preterm neonate Term neonate
Heart rate (beats per minute) 120–160 100–140
• Feel the femoral pulses by placing your thumbs or
fingertips over the mid-inguinal points while abducting the
• Auscultate the heart. Start at the apex using the
stethoscope bell (best for low-pitched sounds). Then use
the diaphragm in all positions for high-pitched sounds and
• Describe the heart sounds S1 and S2, any additional heart
sounds and the presence of murmurs. The fast heart rate
of a newborn makes it difficult to time additional sounds.
Take time to tune into the different rate of the harsh breath
sounds of a newborn, as they are easily confused with a
The physical examination of newborns • 303
Umbilical hernias are common; they are easily reduced, have a
very low risk of complications and close spontaneously in infancy.
An omphalocoele, or exomphalos (Fig. 15.7), is a herniation
through the umbilicus containing intestines and other viscera,
covered by a membrane that includes the umbilical cord. It
may be associated with other malformations or chromosomal
abnormality. Gastroschisis is a defect in the anterior abdominal
wall with intestines herniated through it, without a covering
membrane. The most common site is above and to the right
Inguinal hernias are common in the newborn, especially in
boys and preterm infants (Fig. 15.8).
Meconium in the nappy does not guarantee that the baby
has a patent anus because meconium can be passed through
• Abduct the legs and gently separate the labia.
• In preterm infants the labia minora appear prominent,
giving a masculinised appearance that resolves
spontaneously over a few weeks. Milky vaginal secretions
Male and female newborn infants at term have small buds of
palpable breast tissue. Small amounts of fluid are sometimes
discharged from the nipple in the early days after birth.
Stridor indicates large airway obstruction and is predominantly
inspiratory (p. 79). Stridor and indrawing beginning on days 2–3
of life in an otherwise well baby may be due to laryngomalacia
(softness of the larynx). Causes of respiratory distress include
retained lung fluid, infection, immaturity, aspiration, congenital
anomaly, pneumothorax, heart failure and metabolic acidosis.
• Inspect the abdomen, including the umbilicus and groins,
• From the infant’s right side, gently palpate with the flat of
your warm right hand. Palpate superficially before feeling
• Palpate for splenomegaly. In the neonate the spleen
enlarges down the left flank, not towards the right iliac
• Place your right hand flat across the abdomen beneath
• Feel the liver edge against the side of your index
• If you feel more than the liver edge, measure the
distance in the mid-clavicular line from the costal
margin to the liver edge. Describe it in fingerbreadths
or measure it with a tape in centimetres.
• Check that the anus is present, patent and normally
• Digital rectal examination is usually unnecessary and could
cause an anal fissure. Indications include suspected rectal
atresia or stenosis and delayed passage of meconium. Put
on gloves and lubricate your little finger. Gently press your
fingertip against the anus until you feel the muscle
resistance relax and insert your finger up to your distal
Abdominal distension from a feed or swallowed air is common.
You may see the contour of individual bowel loops through
the thin anterior abdominal wall in the newborn, particularly with
The umbilical cord stump usually separates after 4–5 days. A
granuloma may appear later as a moist, pink lump in the base
of the umbilicus. A small amount of bleeding from the umbilicus
The liver edge is often palpable in healthy infants.
In the neonate the kidneys are often palpable, especially if
In excessive umbilical bleeding, check that the infant received
vitamin K and consider factor XIII deficiency. Spreading erythema
around the umbilicus suggests infective omphalitis and requires
Fig. 15.7 Small exomphalos with loops of bowel in the umbilicus.
From Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd edn.
Fig. 15.8 Bilateral inguinal hernias in a preterm infant. An inguinal
hernia is primarily a groin swelling; only when it is large does it extend into
the scrotum. From Lissauer T, Clayden G. Illustrated Textbook of
Paediatrics. 2nd edn. Edinburgh: Mosby; 2001.
• Inspect and palpate the entire vertebral column from neck
to sacrum for neural tube defects.
Sacral dimples are common and unimportant, provided the dimple
base has normal skin and they are single, <5 mm in diameter
Pigmented patches may indicate spina bifida occulta. Dimples
above the natal cleft, away from the midline, or hairy or pigmented
patches with a base that cannot be visualised require further
This includes tone, posture, movement and primitive reflexes.
General neurological assessment
• Look for asymmetry in posture and movement, and for
• To assess tone, pick the baby up and note if they are stiff
or floppy. Note any difference between each side.
are normal. Later in the first week, there is sometimes
slight vaginal bleeding (pseudomenses) as the infant uterus
‘withdraws’ from maternal hormones. Vaginal skin tags are
common and do not require treatment.
• Do not attempt to retract the foreskin. It is normal for it to
• Check that the urethral meatus is at the tip of the penis.
• Note the shape of the penis.
• If you cannot feel the testes in the scrotum, assess for
undescended, ectopic or retractile testes. Palpate the
abdomen for smooth lumps, moving your fingers down
over the inguinal canal to the scrotum and perineum.
• A retractile testis just below the inguinal canal may be
gently milked into the scrotum. Re-examine at 6 weeks if
there is any doubt about the position of the testes.
• Transilluminate any large scrotal swellings using a torch to
see if the light is transmitted through the swelling. This
suggests a hydrocoele but can be misleading, because a
hernia of thin-walled bowel may transilluminate (Fig. 15.9).
• An inguinal hernia usually produces a groin swelling but, if
large, this may extend into the scrotum. Try to reduce it
by gently pushing the contents upwards from the scrotum
through the inguinal canal into the abdomen.
The testes are smooth and soft, and measure 0.7×1 cm across.
The right testis usually descends later than the left and sits
A hydrocoele is a collection of fluid beneath the tunica vaginalis
of the testis and/or the spermatic cord (p. 234). Most resolve
In hypospadias the meatal opening is on the ventral aspect
of the glans, the ventral shaft of the penis, the scrotum or
more posteriorly on the perineum (Figs 15.10 and 15.11A). In
epispadias, which is rare, it is on the dorsum of the penis.
Chordee is curvature of the penis and is commonly associated
with hypospadias and tethering of the foreskin (Fig. 15.11B).
Fig. 15.9 How to transilluminate a scrotal swelling.
Fig. 15.10 Varieties of hypospadias.
Fig. 15.11 Hypospadias and chordee. A Penile shaft hypospadias.
B Lateral view showing the ventral curvature of the penis (chordee). From
Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd edn.
The physical examination of newborns • 305
Facial nerve palsy causes reduced movement of the cheek
muscles, and the side of the mouth does not turn down when
the baby cries. Most cases are transient.
Primitive reflexes in newborn and
The primitive reflexes are lower motor neurone responses that are
present at birth but that become suppressed by higher centres
by 4–6 months. They may be absent in infants with neurological
depression or asymmetrical in infants with nerve injuries.
Persistence into later infancy may indicate neurodevelopmental
abnormality (p. 141). There are many examples and there is no
need to elicit them all because their individual value is limited.
• Gently stimulate the palm or sole with your finger to
produce a palmar or plantar grasp.
Ventral suspension/pelvic response
• Hold the baby prone and look for neck extension. Stroke
the skin over the vertebral column to produce an extensor
response with pelvic elevation.
• Hold the baby upright and touch the dorsum of their
foot against the edge of a table. The baby will flex
the knee and hip, placing their foot on the table
• Lower the upright baby towards the table surface.
When the feet touch the surface, a walking movement
• Support the supine baby’s trunk and head in a
semi-upright position. Let their head fall backwards
slightly. The baby will quickly throw out both arms and
spread their fingers (Fig. 15.13B).
• Gently stroke the baby’s cheek. The baby turns to that
side and their mouth opens, as though looking for a
nipple. This is ‘rooting’. If you place your finger in a healthy
infant’s mouth, they will suck it vigorously.
• Turn the supine infant’s head to the side. The arm and leg
on the same side will extend and the arm and leg on the
opposite side will flex. This reflex is present at term and
maximal at 1 month (Fig. 15.13C).
• Inspect the limbs and count the digits.
• If the foot is abnormally positioned, gently try to place it in
a normal position. If the abnormal position is at all fixed,
• Examine the hips to check for developmental dysplasia of
• Lay the baby supine on a firm surface.
• Inspect the skin creases of the thighs for symmetry.
• Power is difficult to assess and depends on the state of
arousal. Look for strong symmetrical limb and trunk
• Tendon reflexes are of value only in assessing infants with
neurological or muscular abnormalities.
• Check sensation by seeing whether the baby withdraws
from gentle stimuli. Do not inflict painful stimuli or use a
• Check eyesight by carrying the alert baby to a dark
corner. This normally causes the eyes to open wide. In a
bright area the baby will screw up their eyes.
Ideally, electronic audiological screening should also be
performed in the newborn period.
Movements should be equal on both sides.
Tone varies and may be floppy after a feed.
Reflexes are brisk in term infants, often with a few beats of
The plantar reflex is normally extensor in the newborn.
Hypotonic infants may have a ‘frog-like’ posture with abducted
hips and extended elbows. Causes include Down’s syndrome,
Increased tone may cause back and neck arching and limb
extension; the baby feels stiff when picked up. Causes include
meningitis, asphyxia and intracranial haemorrhage.
Brachial plexus injuries include Erb’s palsy, which affects
brachial plexus roots C5 and C6, producing reduced movement
of the arm at the shoulder and elbow, medial rotation of the
forearm and failure to extend the wrist (Fig. 15.12). Klumpke’s
palsy may be seen after breech delivery due to damage to roots
C8 and T1, with weakness of the forearm and hand. These
injuries can be associated with ipsilateral Horner’s syndrome
and/or diaphragmatic weakness in severe cases. Most perinatal
brachial plexus injuries recover over subsequent weeks.
Fig. 15.12 Erb’s palsy. The right arm is medially rotated and the wrist is
flexed. From Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd
A small percentage of normal babies have single palmar creases
but this is also associated with Down’s syndrome (see Fig. 3.31B)
and other chromosomal abnormalities. Tibial bowing is common
It is common to hear or feel minor ligamentous clicks during
hip examination. These are of no consequence and feel quite
different to the dislocation and relocation of DDH. If in any doubt,
obtain an expert opinion. Never use the term ‘clicky hips’.
Oligodactyly (too few digits), polydactyly (too many) or syndactyly
(joined digits) may occur. In talipes equinovarus the foot is
plantar-flexed and rotated, with the sole facing medially. In
talipes calcaneovalgus the foot is dorsiflexed so that the heel is
prominent and the sole faces laterally.
Many cases of DDH have associated risk factors, including
a family history, breech delivery, positional talipes (especially
calcaneovalgus) or oligohydramnios.
Some centres offer hip ultrasound screening.
• Weigh the infant fully undressed using electronic scales
• Use a paper tape to measure the maximal occipitofrontal
circumference round the forehead and occiput (Fig.
15.15). Repeat the measurement three times, noting the
largest measurement to the nearest millimetre.
• Measure the crown–heel length using a neonatal
stadiometer (Fig. 15.16). Ask a parent or assistant to hold
the baby’s head still and stretch out the legs until the baby
• Examine each hip separately. Hold the thigh with the
knee and hip flexed and your thumb on the medial
• Move the proximal end of the thigh laterally and then
push down towards the examining table (Barlow
manœuvre, Fig. 15.14A); a clunk indicates that the hip
• Now abduct the thigh; if you feel a clunk, this is the
head of the femur returning into the acetabulum
(Ortolani manœuvre, Fig. 15.14B). If the femoral head
feels lax and you feel a clunk with an Ortolani
manœuvre without first performing the Barlow
manœuvre, then the hip was already dislocated.
Fig. 15.13 Primitive reflexes. A Placing
reflex. B The Moro reflex. C Tonic neck reflex.
Fig. 15.14 Examination for developmental dysplasia of the hip.
A The hip is dislocated posteriorly out of the acetabulum (Barlow
manœuvre). B The dislocated hip is relocated back into the acetabulum
is fully extended (the least reproducible of the three
• Record the results on a centile chart appropriate to the
Perform a final top-to-toe inspection to avoid missing anything
and to allow the parents a further opportunity to ask questions.
The physical examination of infants
Examination of young infants beyond the newborn period is
similar to the newborn examination. Transient neonatal findings
will no longer be present. Older infants are usually happier when
examined on their parent’s lap than on an examination table.
The examination of the ears should include otoscopy (p. 314).
You should check the hips whenever you examine an infant
until they are walking normally. After the first few months the
Ortolani and Barlow manœuvres cannot be performed and
the most important signs are limitation of abduction in the hip,
and thigh skin crease asymmetry. Neurological history and
examination should take account of the developmental stage
of the child. The primitive reflexes disappear by 4–6 months.
In later infancy, ask additional questions to obtain information
about neurodevelopmental progress (Box 15.5).
Fig. 15.15 Measurement of head circumference.
Fig. 15.16 Measuring length accurately in infants.
15.5 Developmental attainment of preschool children at different ages*
Skills 4 months 6 months 10 months 1–2 years 2–3 years 3–5 years
Gross motor Has good head control on
Individuals between 12 months and 16 years are known
by non-specific terms, including toddlers, preschoolers,
schoolchildren, adolescents, teenagers or young adults.
Obtaining a history from children
There are many similarities in taking a history from a child and
from an adult. Introduce yourself to the child and accompanying
adult, and begin to observe the child. Establish who the adult
is – a parent, grandparent or foster carer, for example – and
consider to what extent the child will be able to contribute to
the history. Let the child become accustomed to you before
Start with open-ended questions. Most often a parent will
wish to explain their perspective on their child’s problem and it is
important to enable them to do so. Some teenagers may welcome
this but most often they do not. Once the presenting symptoms
have been outlined, the history should focus on questions that
aim to elucidate the differential diagnosis; children are often good
at helping with these more specific questions. Respect age ability
to recall events and adopt a balanced perspective on whether
Diagnosis is built on patterns of symptoms; rarely will any one
symptom or sign lead to a ‘spot diagnosis’. The initial history
suggests a differential diagnosis and prompts additional questions
to assess the probability of particular diagnoses. As with adults,
presenting symptoms should be described in terms of onset,
frequency, severity, duration, aggravating and relieving factors,
associated features and impact on function. Pain and the need
for analgesia can be particularly difficult to assess in young
children; objective scoring systems may help (Box 15.6).
The most common presenting problems in the child affect
the respiratory, gastrointestinal and nervous systems (covered
in Boxes 15.7–15.9), and the skin.
answers from parents are more likely to be accurate than those
from the child. Children under 6 years often provide little history,
those aged 6–11 years can do so if they are sufficiently confident,
and those aged 12 years and above should be able to provide
a valuable history in the correct environment and with the use
of questions that are framed in appropriate terminology. As you
would for adult history taking, include reflective summing up: for
example, ‘So what you are saying is that …’.
A paediatric history includes elements that are not part of the
adult history (obstetric, developmental, immunisation histories),
systematic enquiry has different components from those in
adults (see later), and the differential diagnosis may include
conditions seen only in children such as abdominal migraine,
toddler diarrhoea, croup, viral wheeze and febrile convulsion.
Most other diagnoses also occur in adults.
15.6 Pain assessment tool: FLACC scale
Face No particular expression or
Occasional grimace or frown, withdrawn,
Frequently or constantly quivering chin, clenched jaw
Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal position,
Squirming, shifting back and forth, tense Arched, rigid or jerking
Consolability Content, relaxed Reassured by occasional touching,
hugging or being talked to, distractible
Difficult to console or comfort
if associated with Differential diagnosis
LRTI, asthma, acute episodic wheeze, inhaled foreign
body. Rarely, supraventricular tachycardia, congenital
heart disease, heart failure or muscular weakness
Cough *** Low SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Wheeze *** Moderate SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Musculoskeletal pain, empyema, reflux oesophagitis,
Stridor *** High URTI, high fever, choking Croup, foreign body, epiglottitis (if not immunised)
** Low Cough, wheeze, failure to
Lack of fitness, respiratory pathology, cardiac pathology,
Cough *** Low Wheeze, SOBoe, failure
Isolated cough with sputum suggests infection,
commonly bronchitis, rarely bronchiectasis, cystic
fibrosis, inhaled foreign body. If also wheezy, consider
asthma or viral-induced wheeze
Wheeze *** Moderate SOBoe, failure to thrive Isolated, persistent ‘wheeze’ usually arises from the
nose (stertor, e.g. adenoidal hypertrophy) or the largest
airways (stridor, e.g. laryngomalacia). Episodic wheeze
with cough suggests asthma or viral-induced wheeze
Chest pain * High Exercise Non-specific chest pain, musculoskeletal chest pain,
the next room, is not genuine wheeze. b
Coexistent failure to thrive or weight loss always increases the significance of any symptom.
LRTI/URTI, lower/upper respiratory tract infection.
not blanch with pressure are of most concern. These may be viral
in origin but importantly can be an early sign of meningococcal
disease (particularly if the child is febrile). A differential diagnosis
of a purpuric rash is idiopathic thrombocytopenic purpura.
Chronic skin excoriation, most commonly in the flexures,
suggests eczema, while plaques on the elbows/knees may
Hair loss is distressing to a child. If associated with itch, it
is often due to tinea capitis; with a history of preceding illness,
Skin symptoms can be acute or chronic. Acute-onset rash
is common in children and can be described using the same
terminology as for adults (p. 286). Most rashes are viral and
Rash with blisters is often itchy. It may be urticaria (with an
environmental, viral, food or medicine trigger) or an insect bite.
Blisters with associated yellow crusting may be infected bullous
impetigo (most commonly caused by Staphylococcus aureus).
Red, circular lesions with a pink centre are most often erythema
multiforme (target lesions). Petechial or purpuric rashes that do
associated with Differential diagnosis
Vomiting *** Low: a very non-specific
Acute gastritis/gastroenteritis, any infection (otitis media,
pneumonia, urinary tract infection, meningitis), head injury,
Diarrhoea *** Moderate Fever, dehydrationa Acute gastroenteritis/colitis, appendicitis
** Moderate Fever, bloody stools Acute gastroenteritis/colitis, acute surgical causes, e.g.
Vomiting *** Moderate Failure to thrivec
Gastro-oesophageal reflux (rare in older children compared
with infants), raised intracranial pressure, food allergy
Diarrhoea *** Moderate Failure to thrivec Commonly toddler’s diarrhoea, also lactose intolerance. If
failure to thrive, consider coeliac disease, inflammatory
*** Low Pain that is not periumbilical
If isolated and periumbilical, non-specific abdominal pain
is common and other diagnoses include abdominal
migraine, renal colic. If associated with other symptoms
and/or failure to thrive, consider coeliac disease,
inflammatory bowel disease, constipation
Symptoms of dehydration include dry mouth, foul-smelling breath, anuria and lethargy. b
Abdominal pain can be difficult to identify in young children who are not able to
Coexisting failure to thrive or weight loss always increases the significance of any symptom.
associated with Differential diagnosis
Vomiting, fever, neck stiffness,
Acute (simple) headache, migraine, meningitis/
Unsteady gait * High Varicella encephalomeningitis, vestibular neuronitis
Seizurea * High Febrile seizure, meningitis/encephalitis
* High Encephalitis, intoxication/drug ingestion
Brain tumour, migraine, chronic non-specific
* Moderate Widening gap between age and
* High Muscular dystrophy, inborn error of metabolism,
Seizure * High Epilepsy; rarely, long QT syndrome or inborn error
headache can also arise from the mouth (e.g. dental abscess) or face.
Has the child regularly seen a healthcare professional (current or
past) or are they currently taking any regular medication? Have
they been in hospital before, and if so, why?
The impact of preterm birth goes beyond early childhood and
• Was the child born at term or preterm (if so, at what
• Was the neonatal period normal? For example, did the
child need to go to a special care baby unit?
• If the child is under 3 years of age: what was the
birthweight and were there any complications during
Are the child’s immunisations up to date according to
country-specific schedules? If not, explore why and consider
how best to encourage catch-up.
This is particularly important for children under 3 years of age
or those with possible neurodevelopmental delay (see p. 307
Prescribing errors often arise from poor reconciliation of medication
lists between different healthcare professionals. It is a doctor’s
duty to ensure that medicines are accurately reconciled within
documentation. Transcribe the medication, dose and frequency
direct from the medication package or referral letter if possible.
Enquire about any difficulties in taking medication to establish
adherence. Clarify any adverse or allergic reactions to medications.
• Who lives in the family home and who cares for the child?
• Are there any pets? Are any symptoms associated with
• Are there any similar symptoms in the child’s first- or
Sketch a family tree, noting any step-parents, step-siblings
or shared care arrangements Consider parental consanguinity,
which is not uncommon in some ethnic groups. Children at risk
of neglect may have complex domestic arrangements such as
Occasionally, chronic symptoms are associated with anxiety
or potential ‘secondary’ gain for the child; these include
chronic cough, abdominal pain and headache in a well-looking
8–12-year-old in whom examination is normal. Look carefully
at the child’s facial expression, eye contact and body language
when asking questions. Ask specifically about school (avoidance
and bullying), social interactions (does the child have many
friends?) and out-of-school activities. School avoidance should
be addressed if it is related to anxiety or if the pretext of medical
This screens for illnesses or symptoms that may be not recognised
as important or relevant by the child or parents. For children aged
over 12 years, the questions used for adults are appropriate. In
younger children, ask age-related questions. Specific areas include:
• Ear, nose and throat: ask the parents about their
perception of a child’s hearing ability (reduced in chronic
otitis media) or the presence of regular snoring with
periods of struggling to breathe (symptomatic obstructive
• Gastrointestinal system: ask whether growth is as
expected and whether there is pain or difficulty in opening
• Respiratory system: ask whether the child has regularly
coughed when otherwise well or had wheeze on a
recurrent basis (consider asthma).
• Urinary system: 15% of children at 5 years of age will
continue to have primary nocturnal enuresis.
An understanding of child development is vital to identifying
whether symptoms and signs are consistent with age.
Infants born prematurely should have their age adjusted to
their expected date of delivery instead of their date of birth
for the first 2 years of life when growth and development are
assessed. Failure to make this correction would otherwise create
a false impression of poor growth and developmental delay.
Prematurely born infants are at increased risk of impaired growth
and development, and merit increased surveillance; most develop
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
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
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