Children are not small adults. Their airways are narrower, their metabolic rate and body surface area relative to weight are higher, and their vital signs, body proportions, and normal findings change with age. A pediatric assessment therefore always asks two questions: is this finding normal for this age, and is this child following their own growth and development curve?
Principles of the pediatric examination
- Start with a hands-off look (general appearance, breathing effort, skin color) before touching the child — crying changes heart rate, respiratory rate, and breath sounds
- Order is flexible, not head-to-toe, in young children: do quiet, non-threatening parts first (count respirations, auscultate heart and lungs while the child is calm); leave distressing parts last (ears, mouth, throat, and anything painful)
- Involve the caregiver: infants and toddlers can be examined on a parent's lap
- Adjust to developmental stage
| Age group | Approach |
|---|
| Infant | Examine on parent's lap; auscultate first while quiet; keep warm; use pacifier or feeding to soothe |
| Toddler | Least cooperative age; minimal undressing; let the child touch equipment; offer simple choices; parent holds |
| Preschooler | Explain with simple words and let them handle the stethoscope; praise cooperation; usually head-to-toe possible |
| School-age | Explain the purpose of each step; respect modesty; can teach about the body |
| Adolescent | Offer time alone without the parent; ensure privacy and explain confidentiality limits; examine head-to-toe |
Principles of growth (used to interpret findings): development is cephalocaudal (head control before sitting and walking), proximodistal (trunk and shoulders before fingers), and from general to specific; the sequence is predictable, but the rate differs among children.
Measurements
- Weight: infants undressed on an infant scale; older children in light clothing, same scale each time
- Length: recumbent (lying) with knees extended, crown to heel, until age 2; standing height after about 2 years
- Head circumference at every visit until at least age 2: tape just above the eyebrows and ears, around the most prominent part of the occiput (largest circumference)
- Plot all values on growth charts; a change across percentile lines matters more than a single value
Vital signs (approximate normal ranges, awake child)
| Age | Heart rate (/min) | Respiratory rate (/min) | Systolic BP (mm Hg) |
|---|
| Newborn | 100–205 | 30–53 | 67–84 |
| Infant (1–12 months) | 100–180 | 30–53 | 72–104 |
| Toddler (1–2 years) | 98–140 | 22–37 | 86–106 |
| Preschool (3–5 years) | 80–120 | 20–28 | 89–112 |
| School-age (6–11 years) | 75–118 | 18–25 | 97–115 |
| Adolescent (12–15 years) | 60–100 | 12–20 | 110–131 |
Ranges differ slightly between references; heart rate is lower during sleep. Hypotension (systolic): < 60 mm Hg in term newborns, < 70 mm Hg in infants, < 70 + (2 × age in years) from 1 to 10 years, < 90 mm Hg at 10 years and older.
Technique by age
- Respirations: count a full minute in infants and young children (irregular rhythm); infants and children under about 6–7 years are mainly abdominal (diaphragmatic) breathers, so watch the abdomen
- Pulse: apical pulse for a full minute in children under 2 years; brachial or femoral pulses are easy to palpate in infants; radial pulse in older children
- Blood pressure: cuff bladder width about 40% of the upper-arm circumference and length 80–100%; a cuff that is too small reads falsely high. Routine BP screening yearly from age 3 (earlier with risk factors such as prematurity, heart or kidney disease)
- Temperature: see table under Diagnostics
System findings: normal vs. needs follow-up
| System | Normal (expected) | Needs follow-up |
|---|
| Skin | Congenital dermal melanocytosis (formerly "Mongolian spots") over the sacrum and buttocks, milia, stork bites | Bruises in pre-mobile infants, petechiae with fever, jaundice in the first 24 h |
| Head | Posterior fontanel closes by about 2 months, anterior by 12–18 months; flat and soft | Bulging (increased intracranial pressure) or sunken (dehydration) fontanel; head size crossing percentiles |
| Eyes | Red reflex present bilaterally; brief intermittent eye crossing in early infancy | Absent or white reflex (leukocoria); any constant strabismus, or intermittent crossing persisting after about 4 months |
| Ears | Pull pinna down and back under 3 years, up and back at 3 years and older | Bulging red tympanic membrane, no response to sound |
| Chest/heart | Point of maximal impulse at the 4th intercostal space, just left of the midclavicular line, in young children (5th space after about age 7); soft innocent murmurs are common | Loud or harsh murmur, murmur with poor feeding, weak femoral pulses |
| Hips | Symmetric thigh and gluteal folds, full abduction | Positive Ortolani or Barlow, asymmetric folds, limited abduction, unequal knee height (Galeazzi sign) |
| Genitalia | Testes palpable in the scrotum | Undescended testes (refer if not descended by about 6 months) |
| Neuro | Primitive reflexes present and fading on schedule | Asymmetric reflexes, persistence beyond expected age, loss of skills |
Endocrine / sexual maturity: secondary sex characteristics are rated with Tanner (sexual maturity rating) stages 1–5 — breast and pubic hair in girls; genitalia and pubic hair in boys. Their appearance reflects endocrine (pubertal hormone) function.
Temperature routes by age
| Route | Use |
|---|
| Rectal | Most accurate noninvasive route for infants and children up to about 3 years; insert about 1.5–2.5 cm (0.5–1 in); avoid with neutropenia, diarrhea, rectal surgery |
| Oral | When the child can hold the thermometer under the tongue with lips closed — about 4–5 years and older |
| Temporal artery | Screening for infants over 3 months and children |
| Tympanic | Acceptable after about 6 months; technique-dependent |
| Axillary | Safe screening method; less accurate — confirm an abnormal reading |
Fever is generally 38.0 °C (100.4 °F) or higher (rectal).
Screening tools
- Growth charts: WHO standards for 0–2 years; CDC charts for 2–19 years in the US; BMI-for-age percentiles from age 2
- Developmental surveillance at every visit, and a standardized developmental screening tool at 9, 18, and 30 months (e.g., Ages and Stages Questionnaire); autism-specific screening at 18 and 24 months (M-CHAT-R/F). Screening tools identify children who need further evaluation; they do not diagnose
- Hearing: newborn screening (otoacoustic emissions or automated auditory brainstem response); conditioned play audiometry in preschoolers; pure-tone audiometry (headphones, child raises a hand or presses a button when a tone is heard) from about 4 years
- Vision: red reflex from birth; instrument-based (photoscreening) at 1–5 years; picture or letter charts (LEA symbols, HOTV) from about 3–4 years; Snellen or tumbling "E" chart at its designed distance — usually 6 m (20 ft) for a standard Snellen chart, or 3 m (10 ft), one eye at a time, with glasses on if the child wears them
- Hip: Ortolani (reduces a dislocated hip — "clunk") and Barlow (dislocates an unstable hip) until about 3 months; ultrasound in young infants, x-ray after about 4–6 months
- Hemoglobin screening around 12 months. Blood lead testing at 12 and 24 months for all Medicaid-enrolled children in the US and for others per state or local risk rules; CDC blood lead reference value 3.5 µg/dL (0.17 µmol/L)
This topic covers assessment rather than one disease; management is the well-child care plan.
- Scheduled well-child visits (frequent in infancy, yearly from about age 3) combine measurement, development, immunizations, screening, and anticipatory guidance
- Weight-based calculations depend on an accurate current weight in kilograms
- Maintenance fluids (Holliday–Segar) — used to check oral or IV intake:
| Weight | Daily fluid | Hourly (4-2-1 rule) |
|---|
| First 10 kg | 100 mL/kg | 4 mL/kg/h |
| Next 10 kg (11–20 kg) | + 50 mL/kg | + 2 mL/kg/h |
| Each kg above 20 kg | + 20 mL/kg | + 1 mL/kg/h |
Example: 12 kg child = 1,000 + (2 × 50) = 1,100 mL/day (about 44 mL/h). Expected urine output: about 2 mL/kg/h in infants, at least 1 mL/kg/h in children (about 0.5 mL/kg/h in adolescents).
- Abnormal screening → referral (audiology, ophthalmology, developmental pediatrics, orthopedics), never "wait and see" alone
Listed in priority order.
- Rapid first look — Pediatric Assessment Triangle: appearance (tone, interaction, consolability, gaze, cry), work of breathing (nasal flaring, retractions, grunting, head bobbing, abnormal sounds), and circulation to skin (pallor, mottling, cyanosis). An abnormal triangle → immediate intervention before a full examination
- Count respirations and assess oxygenation first while the child is calm; apply pulse oximetry when breathing looks abnormal
- Measure vital signs with age-appropriate technique and equipment; interpret against age norms and the child's baseline
- Safety during the exam: never leave an infant unattended on a table — keep one hand on the child; keep small equipment out of reach
- Accurate weight in kg documented and double-checked before any medication is given
- Plot growth and compare with previous values; flag crossing of two major percentile lines
- Developmental and sensory screening at the recommended ages; refer abnormal results
- Build trust: explain, allow play with equipment, use distraction, praise; perform painful or invasive parts last
- Adolescents: time alone, private questioning using a structured interview (HEEADSSS — Home, Education/employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety)
- Bring the child for all well-child visits and bring the immunization record
- Home temperature: use a digital thermometer; rectal for young infants; call for any fever of 38.0 °C (100.4 °F) or higher in an infant under 3 months
- Growth: a smaller or larger child can be healthy if they follow their own curve steadily
- Report concerns about hearing, vision, speech, or loss of skills early — early intervention works best
- Teach adolescents that parts of the visit are confidential, with limits when safety is at risk
- Abnormal Pediatric Assessment Triangle, grunting, severe retractions, cyanosis
- Bradycardia in a sick or hypoxic child — a late, pre-arrest sign
- Hypotension is a late sign of shock in children; tachycardia and delayed capillary refill (> 2 seconds) appear first
- Fever in an infant under 3 months (serious bacterial infection risk)
- Bulging or sunken fontanel; rapidly increasing head circumference
- Leukocoria (possible retinoblastoma or cataract)
- Loss of previously acquired skills (developmental regression) at any age
- Injuries inconsistent with developmental ability (e.g., bruises in a non-mobile infant) — consider maltreatment and follow reporting rules
- Examine quiet parts first (heart, lungs, respirations), invasive parts (ears, mouth) last
- Infant and young child: apical pulse and respirations for a full minute; young children breathe abdominally
- Ear exam: pinna down and back under 3 years, up and back after
- Rectal is the most accurate noninvasive route in young children; oral from about 4–5 years
- Hypotension threshold for 1–10 years: 70 + (2 × age) mm Hg
- Congenital dermal melanocytosis is normal; asymmetric thigh folds, and undescended testes are not
- Ortolani and Barlow test for developmental dysplasia of the hip
- Maintenance fluid: 100 / 50 / 20 mL/kg/day; 12 kg → 1,100 mL/day
- Snellen chart at its designed distance (usually 6 m/20 ft, or 3 m/10 ft), one eye at a time; pure-tone audiometry needs the child to respond (hand or button)
- Standardized developmental screening at 9, 18, 30 months; autism screening at 18 and 24 months
- Tanner stages assess pubertal (endocrine) maturation
Country Notes
United States
- Well-child care generally follows the AAP Bright Futures periodicity schedule; growth is plotted on WHO charts to age 2 and CDC charts from age 2.
- Newborn hearing screening is performed in all states.
Philippines
- Republic Act 9709 (Universal Newborn Hearing Screening Act of 2009) requires hearing screening for infants born in hospitals before discharge (unless parents object), and screening of infants born elsewhere within the first 3 months.
- The Early Childhood Care and Development (ECCD) Checklist, validated on Filipino children, is used by day care workers, teachers, and health workers to monitor development of children under 5.