Introduction

The skill of clinical examination is the true art of medicine and nowhere more so than in the examination of children. Children are not small adults and as such the approach to their examination is different. The examiner needs to be flexible, opportunistic and able to tailor the structure of the examination to the individual infant, child or young person. In order to maximize the success of the examination, time must be spent trying to gain their confidence. Some discomfort is inevitable in some parts of the physical examination, but during most of the examination the child should be contented. Do not give false reassurances as this will result in a loss of trust which will hinder the examination. The consulting room must have a range of toys suitable for all ages, and the child should be allowed to play with whatever takes his fancy. Younger children may be happier sitting on their parent’s lap. If old enough, the child should be allowed to explore the room which should be free from accessible, expensive or potentially dangerous equipment. Initial suspicion can be reduced by pulling a face or offering a toy that seems to have caught the child’s attention.

As the family enters the room they should be greeted in a friendly manner and introductions made. Adapt the approach according to the age of the child. An adolescent may want to be the focus of the consultation from the start. Younger children usually will want to have time to observe and assess their surroundings before being observed themselves. They will often take a cue from their carer’s response. If everyone relaxes and laughs in the first few minutes, the child will relax and the subsequent history and examination will be easier. Ascertain who is with the child. It may not be the mother or father but another family member, who, in a mixed ethnic population, may be the only one who speaks English.

For the experienced clinician, much of the information needed to reach a diagnosis for a child is gleaned from careful observation. While talking to the parent, watch and listen to the child. Assess his behaviour and use this information to adapt the approach. Does the child look unwell? Is he interested in the surroundings and exploring them, or apathetic? Watch the child running around: are there any obvious abnormalities in the gait? Is the face normal, or are there features of abnormal development? Are there any obvious physical abnormalities? Is the breathing unusually noisy? Does the child seem well-nourished, or wasted? What is the child’s interaction with his carer like?

History

The history (Box 5.1) will normally be taken from the accompanying carer, but an older child can be invited to give his version of events first. It is appropriate to give an adolescent the opportunity for a few minutes of confidential time during the consultation. Use this to ask questions about alcohol, drugs and sexual activity which he may be uncomfortable discussing in front of his parents. Even younger children should be asked simple things in words they can understand. Involve them by asking relevant points such as the site of the pain, etc. Remember that the carer is giving their version of the problem, not the child’s. Parents may also welcome an opportunity to talk in private away from the child, and it is often during such discussion that the real reason for the consultation emerges. Always take notice of what the carer is saying, and listen to their concerns. Any interruptions should be to clarify rather than try and direct the history. Make sure they are given full attention and that they feel their concerns are being taken seriously. All the time they are talking, keep watching everything that the child is doing and their reactions.

The structure and focus of the history is slightly different from that of an adult. The core elements of the presenting complaint, a history of the present illness and a history of any previous illness are the same; however, greater emphasis will be placed on aspects such as the developmental history and less on the systems enquiry, for example. Much of the key information will be collected in the history of the presenting complaint. Most children have a single system involved and enough time needs to be spent evaluating this carefully. Consider the timing of the symptoms: do they tend only to occur at school? Are there any associating or triggering factors? Are the symptoms interrupting with daily activities such as sleep, school attendance, participation in sport or play? Is the child’s perception of the symptoms different to that of the parent? Ask about symptoms from other systems in relation to the presenting history rather than as abstract questions. For example, a child presenting with cough may be asked about symptoms of gastro-oesophageal reflux which may be an underlying cause for the cough.

In children, the previous medical history starts from birth and specific attention should be paid to the pregnancy and newborn period (Box 5.2). Is the child fully immunized? This can be checked in the parent-held ‘red book’ or child health record, which should have documentation of child health clinic attendances, weights, immunizations, etc. Enquire particularly as to the nature and severity of previous illnesses and the age at which they occurred, for example common childhood infections such as chickenpox, admissions to hospital and, in particular, to intensive care, significant injuries and accidents. Is the child taking any regular medication and is he allergic to anything? It is important to ask about the child’s developmental progress: when did the child first sit up, smile, crawl, walk and talk? Fuller details regarding the ‘milestones of development’ are given in Table 5.1. Some useful general questions are outlined in Box 5.3.

Family history

Social history

Approach the social history with diplomacy; sometimes it is more prudent to leave deeper probing to a later occasion. It is useful to know about living conditions, and whether either or both parents are employed. Who is the main carer for the child? Is the child in any form of day care? Ask if the child has ever been separated from the main carer for any time in the past, as this may be the basis of a variety of behavioural difficulties. Find out if the child’s parents live together, and whether there is any difficulty in the relationship. Is there a supportive family structure involving other relatives, for example grandparents? If the family are immigrants, it is important to know how long they have been in their new country. The depth of enquiry in a paediatric social history must always be judged on an individual basis. Prying too deeply risks losing the initial rapport that will have been built up.

After forming an impression of the child, the family and their relationship, the examination can now proceed. By now, a younger child should have found the occasion so fascinating that he will be prepared to cooperate in most parts of the physical examination. Alternatively, the child may have become so bored that he is asleep. If the child is now crying loudly, things will be difficult and strategies to calm him down to allow examination will be needed.

Examination

A key principle in the examination of children is that most of the information needed to make a diagnosis will be gleaned from careful observation, including listening to the child and playing with him. Findings can then be consolidated with the remaining techniques requiring laying on of hands. Older children will usually cooperate sufficiently to be examined lying down, and routine physical examination is similar to an adult examination. A younger child should be examined sitting on his carer’s lap, as any attempt to get him to lie down will result in instant distress. Always talk to children however young; do not be afraid of looking silly if the result is a cooperative child. Those parts of the examination that are painful or unpleasant should be left until last: if an attempt is made to examine a child’s throat at the outset, the immediate response will be crying. Offer the child something to play with – even a stethoscope will be a source of amusement to a young infant. Children often find it amusing if their toy is examined first. The scheme set out in Box 5.4 can be adapted opportunistically, provided all areas are covered.

Always wash your hands before and after the examination in front of the parent. This will inspire confidence and show that you take infection control seriously. The examination techniques include the usual methods of inspection, palpation, percussion and auscultation; however, no set routine can be followed, and the examination is by regions rather than by systems. The older the child, the more the examination will be akin to that for an adult. Bear in mind the age of the child and his level of understanding and ability to cooperate, when planning the examination. Infants and younger children will need alternative strategies and adapted techniques to elicit clinical signs. The examination may have to be opportunistic, as each child will dictate the order of the examination by his reactions to various procedures.

The head, face and neck

Look at the child’s face and ask the following questions:

Does it look normal? If not, try to identify which features seem unusual. There are many hundreds of syndromes diagnosable by the facial appearance, and the salient features should be carefully noted.

If the baby looks dysmorphic, then do not forget to look at the parents. It may then be obvious that what seems abnormal may be nothing more than a family trait. If the appearance is still not too clear, ask who the baby looks like.

Does the child have a large or protruding tongue?

Are the ears in the normal position, or are they low set and abnormal in any way?

Are the eyes small (microphthalmus)? Are they set close together or wide apart (hypo- or hypertelorism)?

Next note the shape of the head. This needs to be done by viewing the child’s head from the front, sides and from above. It may be small if the baby is microcephalic, globular if the baby is hydrocephalic, sometimes with dilated veins over the skin surface, or brachycephalic (flattened over the occiput), for example in trisomy 21. It is often asymmetrical (plagiocephalic) in normal infants who tend to lie with their heads persistently on one side (Fig. 5.1). This is now much more common because babies are placed on their backs to sleep in order to reduce the risk of sudden death in infancy. It becomes much less noticeable as the child grows older.

Figure 5.1 Plagiocephalic skull.

Assuming that the child is still being friendly, there should be little objection to feeling the child’s head now. Leave the measurement of the head circumference until near the end of the examination, as some babies find this a little threatening and may start crying. Feel the anterior fontanelle. It is normally small at birth, enlarges during the first 2 months, and then gradually reduces until final closure. It is normally closed by 18 months but can close much earlier, and has been reported as staying open in a few normal girls until 4 years of age. Delayed closure may be seen, however, in rickets, hypothyroidism and hydrocephalus. An assessment of the tension of the anterior fontanelle is important. In health, it pulsates and is in the same plane as the rest of the surrounding skull. A tense, bulging fontanelle indicates raised intracranial pressure, but it does also become tense with crying. A sunken fontanelle is a feature of severe dehydration. The posterior fontanelle is located by passing the finger along the sagittal suture to its junction with the lambdoid sutures. It should normally be closed after 2 months of age. Sometimes, when passing the finger along the sagittal suture, a small notch is felt over the vault of the cranium. This is the third fontanelle and, although it can be normal, it is seen in some chromosome abnormalities and in congenital infections such as rubella. While feeling the head, any ridging of the sutures should be noticed, suggesting premature fusion (craniostenosis). In the neonatal period, the sutures tend to be separated, and there is sometimes a continuous gap from the forehead to the posterior part of the posterior fontanelle. Sutures close rapidly, and are normally ossified by 6 months of age.

Having assessed the skull, the neck can be checked, paying particular attention to the presence of lymph nodes. It is common in childhood to feel small lymph nodes in the anterior and posterior triangles of the neck. They change in size in response to local infections such as tonsillitis (reactive lymphadenopathy). Enlarged glands in the neck are a common reason for referral to a paediatrician, but parents can generally be reassured that they are of no major significance as they can persist for some years. Examination of other lymphatic areas can be carried out at a later stage of the examination – the inguinal nodes when the napkin area is checked, and the axillary nodes when the chest is examined. In young babies, the sternomastoid muscles should be checked for the thickened area known as a sternomastoid tumour. This is a benign lesion occuring usually as a result of birth trauma but can lead to difficulties with neck movement and an abnormal head and neck posture. Torticollis is a potentially more sinister sign and can be associated with posterior fossa tumours, vertebral osteomyelitis and urinary tract infections.

The abdomen

The abdomen can be a little difficult to examine if the baby is crying, which is why it is important to have gained the child’s cooperation by this point in the examination. Most infants and toddlers will need to be examined while sitting on their carer’s lap (Fig. 5.2). It is sometimes possible to quieten a crying infant by placing him over his mother’s shoulder and examining him from behind. Small infants can be given a feed to quieten them. Older children can be asked if they would be happy to lie on an examination couch.

Figure 5.2 Baby sitting on mother’s lap while the abdomen is examined.

The examination needs to be structured along the three essential components of looking (observation), feeling (palpation) and listening (auscultation). During the first 3 years of life, the abdomen often gives an impression of being protuberant due to the laxity of the rectus muscles. Causes of true abdominal distension are shown in Box 5.5. Look for any obvious distension or for peristaltic waves suggesting intestinal obstruction. Note the umbilicus, and whether or not there is a hernia. Palpation should be gentle and light. Always ask the child if his tummy hurts anywhere and watch his facial expression during palpation. The liver edge can be felt in normal children up to the age of 4 years; it can be anything up to 2 cm below the costal margin. When enlarged, the spleen may be felt below the left costal margin, and in infancy it is more anterior and superficial than in the older child or adult. Slight enlargement of the spleen can occur in many childhood infections. Causes of hepatosplenomegaly are listed in Table 5.2. Faecal masses can be felt in the left iliac fossa in constipated children. They often feel like a sausage which can be rolled underneath the finger tips. A full or distended bladder presents as a mass arising from the pelvis. Deep palpation of the kidneys can be carried out last. Although it would be logical to examine the groin area at this time, it is often better to do this at a later stage. If the child has cried persistently, it is still possible to examine the abdomen. When the baby breathes in and the abdominal muscles relax, the abdominal viscera and other masses, if present, can be palpated.

Box 5.5 Causes of abdominal distension

Obesity

Faeces (constipation, Hirschsprung’s disease)

Ascites (nephrotic syndrome, cirrhosis)

Gas (intestinal obstruction, swallowed air)

Pregnancy in adolescent girls

Distended bladder (lower abdomen)

Pyloric stenosis (upper abdomen)

Table 5.2 Causes of hepatomegaly and splenomegaly in children

Hepatomegaly	Splenomegaly	Hepatosplenomegaly
Glycogen storage disorders Congenital infections Heart failure Haemolytic disease of the newborn

Sickle cell disease

Spherocytosis

Malaria

The chest