Step-by-Step Pediatric Examination: What Healthcare Professionals Need to Know

Performing a head-to-toe pediatric examination is a crucial skill for medical students and healthcare professionals. It requires not only technical knowledge but also the ability to approach children with sensitivity and care. This guide will walk you through each step of the examination, providing detailed instructions, tips for maintaining the child's comfort, and ensuring that all aspects of the pediatric assessment are covered.


Preparation and Approach

Before starting the examination, it is essential to create a comfortable and safe environment for the child. Begin by greeting both the child and the parents, and explain what will happen during the examination in simple, reassuring terms. Children may feel anxious, so engaging them with a calm, friendly demeanor is crucial.

1. Gathering History:
   • Birth History: Ask about the child’s birth history, including gestational age, birth weight, and any complications during delivery.
   • Developmental Milestones: Review the child's developmental milestones. Ask the parents if the child has been meeting age-appropriate milestones such as crawling, walking, and speaking.
   • Immunization Status: Ensure the child is up-to-date with vaccinations.
   • Dietary History: Assess the child's diet, including breastfeeding or formula feeding in infants, and the introduction of solid foods.
   • Family History: Inquire about any familial diseases or conditions that may be relevant to the child's health.

General Inspection

Start with a general inspection of the child. Observe their behavior, posture, gait, and interaction with the environment and parents. Look for signs of distress, pain, or discomfort.

1. Behavioral Observation: Note the child's level of alertness and responsiveness. A well child should be active and curious.
2. Nutritional Status: Assess the child's weight, height, and body mass index (BMI) in relation to growth charts.
3. Skin Condition: Observe for rashes, bruises, birthmarks, or other abnormalities.
4. Hydration Status: Check for signs of dehydration, such as dry mucous membranes, sunken eyes, or poor skin turgor.

Head Examination

Examine the head for shape, size, and symmetry.

1. Skull: Palpate the fontanelles in infants. The anterior fontanelle should be soft and flat. Bulging may indicate increased intracranial pressure, while a sunken fontanelle can be a sign of dehydration.
2. Scalp: Inspect the scalp for lesions, rashes, or abnormalities such as alopecia.
3. Eyes:
   • External Inspection: Check for the alignment of the eyes, presence of strabismus, or ptosis.
   • Pupillary Reaction: Shine a light in each eye and observe the pupillary response. Both pupils should constrict equally.
   • Red Reflex: Use an ophthalmoscope to check for the red reflex, which should be present and symmetrical. Absence may indicate conditions such as retinoblastoma.
4. Ears:
   • External Ear: Inspect the size, shape, and position of the ears. Look for any abnormalities, such as preauricular tags or pits.
   • Otoscopy: Examine the ear canal and tympanic membrane for signs of infection, effusion, or perforation.
   • Hearing: Perform age-appropriate hearing assessments, such as observing the child's reaction to sounds.
5. Nose:
   • External Nose: Inspect for symmetry, nasal flaring, or discharge.
   • Nasal Patency: Check each nostril for patency by occluding one nostril at a time and observing the child's breathing.
6. Mouth and Throat:
   • Lips and Oral Cavity: Inspect the lips, gums, and tongue for color, lesions, or swelling.
   • Teeth: Assess dental hygiene and look for caries or malalignment.
   • Tonsils: Examine the size and condition of the tonsils. Look for signs of infection, such as erythema or exudates.

Neck Examination

Examine the neck for symmetry, mobility, and the presence of any masses or lymphadenopathy.

1. Thyroid Gland: Palpate the thyroid gland for enlargement or nodules.
2. Lymph Nodes: Palpate the cervical lymph nodes. Note any enlargement, tenderness, or consistency.
3. Neck Mobility: Assess the range of motion of the neck. Limited mobility may indicate torticollis or other conditions.

Chest and Respiratory Examination

Examine the chest for shape, symmetry, and respiratory effort.

1. Inspection: Look for chest deformities such as pectus excavatum or carinatum. Observe the respiratory rate, rhythm, and depth.
2. Auscultation: Use a stethoscope to listen to the breath sounds. Note any wheezing, crackles, or diminished breath sounds.
3. Percussion: Gently percuss the chest to assess for dullness or hyperresonance, which may indicate conditions such as pleural effusion or pneumothorax.
4. Respiratory Effort: Check for signs of respiratory distress, such as intercostal retractions, nasal flaring, or grunting.

Cardiovascular Examination

Assess the heart and vascular system.

1. Inspection: Look for signs of cyanosis, pallor, or clubbing of the fingers, which may indicate cardiovascular disease.
2. Palpation:
   • Apical Pulse: Palpate the apical pulse for position and strength.
   • Peripheral Pulses: Check the radial, femoral, and dorsalis pedis pulses. Note their presence, symmetry, and amplitude.
3. Auscultation: Listen to the heart sounds using a stethoscope. Identify the heart rate, rhythm, and any abnormal sounds such as murmurs or gallops.
4. Capillary Refill: Press on the nail bed or skin and observe how quickly color returns. Normal capillary refill time is less than 2 seconds.

Abdominal Examination

Assess the abdomen for shape, tenderness, and organomegaly.

1. Inspection: Look at the shape and contour of the abdomen. Note any distention, visible peristalsis, or hernias.
2. Auscultation: Listen for bowel sounds in all four quadrants. Absence of bowel sounds may indicate an obstruction.
3. Percussion: Gently percuss the abdomen to assess for tympany or dullness. Dullness may indicate the presence of fluid or masses.
4. Palpation:
   • Light Palpation: Start with light palpation to assess for tenderness or muscle guarding.
   • Deep Palpation: Use deep palpation to evaluate the size and consistency of organs such as the liver and spleen.
   • Rebound Tenderness: Check for rebound tenderness, which may indicate peritonitis.

Genitourinary Examination

This part of the examination requires sensitivity and respect for the child's privacy. Explain the procedure clearly and ensure that a chaperone is present.

1. Inspection: Inspect the external genitalia for normal development, signs of infection, or congenital abnormalities.
2. Palpation:
   • Males: Palpate the testes for position and size. Look for signs of inguinal hernias or hydroceles.
   • Females: Examine the labia and clitoris for normal appearance. Look for signs of irritation or infection.
3. Urinary System: Ask about urinary habits, frequency, and any history of infections.

Musculoskeletal Examination

Assess the musculoskeletal system for normal development and function.

1. Inspection: Look for any deformities, asymmetry, or abnormal gait. Assess the child’s posture and spine alignment.
2. Palpation: Palpate the bones and joints for tenderness, swelling, or deformities.
3. Range of Motion: Evaluate the range of motion in the major joints, including the shoulders, elbows, hips, knees, and ankles.
4. Strength Testing: Test muscle strength by asking the child to push against resistance.

Neurological Examination

The neurological examination should be age-appropriate and adapted to the child's developmental level.

1. Cranial Nerves: Assess the cranial nerves, focusing on age-specific functions such as facial expressions, eye movements, and hearing.
2. Reflexes: Test deep tendon reflexes and primitive reflexes in infants. Look for asymmetry or hyperreflexia.
3. Motor Skills: Evaluate the child’s motor skills by asking them to perform tasks such as walking, jumping, or picking up objects.
4. Sensory Function: Test sensory function by gently touching the skin and asking the child to identify the sensation.
5. Coordination: Assess coordination by observing tasks such as finger-to-nose testing or heel-to-shin movement.

Conclusion of the Examination

After completing the examination, it’s important to discuss the findings with the parents. Offer reassurance if everything appears normal and provide clear explanations for any concerns that arise during the examination. Document all findings accurately and plan for any necessary follow-up.

Tips for a Successful Pediatric Examination

1. Build Trust: Establish a rapport with the child and their parents. A calm and friendly approach can make the child more cooperative.
2. Use Distraction Techniques: Toys, stories, or games can help distract the child during uncomfortable parts of the examination.
3. Be Gentle: Use gentle techniques, especially when palpating sensitive areas.
4. Be Patient: Allow the child time to get comfortable with the examination process.
5. Involve the Parents: Encourage parents to comfort and support their child during the examination.