Paediatric examination: the child and the infant

• Paediatric examination is driven by age: observe first while the child is comfortable, keep the unpleasant parts (ears, throat, hips) for last, and let a young child stay on a parent's lap.
• The single most useful tool is the unstructured look across the room: colour, breathing effort, posture, interaction with parents and play, and level of consciousness.
• Measure and plot every child on an age-appropriate chart; a trend across centile spaces matters more than one point.
• Count the respiratory rate and heart rate for a full minute, and know the age-banded thresholds for tachypnoea and tachycardia so that an abnormally fast rate is not missed.
• Use the NICE traffic light system (green, amber, red) to risk-stratify a child under 5 with fever, and treat any red feature as high risk.
• Present as for any system: the most important finding first, the numbers next, the negatives that change the differential after that, and a one-line summary with a plan.

By the end of this page you should be able to:

1. Approach a child of any age so that observation comes first and the child stays calm.
2. Carry out the paediatric examination in a fixed bedside order, stating what each step looks for.
3. Recognise and name the important normal and abnormal signs of growth, hydration, respiration, circulation, abdomen, hips and neurodevelopment.
4. Plot and interpret growth, including thresholds for concern.
5. Risk-stratify a febrile child under 5 using the NICE traffic light system.
6. Present the same findings aloud and in the notes, with the most important finding first.
7. Give a normal, a febrile and an acutely unwell example report.

This page teaches the paediatric examination as one sequence that changes with age, not a different examination for each age. A baby and a six-year-old are examined in the same broad order (general look, growth and vital signs, then systems), but the way you approach them differs: the younger the child, the more you get from observation before you touch, and the more you depend on the parent and on play.

The examination is for answering four questions, in this order:

1. Is the child sick or well, and if sick, how sick (severity and urgency)?
2. Is growth and development normal for age?
3. What system explains the presentation?
4. Are there safeguarding concerns or a serious underlying condition that an initial look could miss?

Setting. A warm, quiet room with good light; a parent or carer present; the child dressed appropriately but kept warm. For an infant, a firm, safe surface or the parent's arms for much of the examination. For a toddler, play materials (toys, bubbles, a pen and paper) within reach so that rapport and distraction are always available. You need a stethoscope with a small diaphragm, a thermometer appropriate for age, a tape measure, a growth chart correct for age and sex, a watch with a second hand, a torch or otoscope, a ruler or straight edge, and gloves. Write as you go: in small children, numbers remembered from the last child are often wrong.

This page does not replace the system-specific pages (respiratory examination and presentation, cardiovascular examination and presentation, cranial nerve examination, and the limb neurological examination); it links to them by name. It is the page that sets the order, the age-based approach, and how to say what you found.

Introduce yourself to the parent and to the child using name and age-appropriate language. Explain what you plan to do before you do it, using plain words, and offer to stop at any time. With a baby, talk to the baby as well; tone and eye contact matter more than the words. Ask the parent what worries them most and what the child likes, and use that to plan the order of the unpleasant steps.

Consent is from the person with parental responsibility (usually a parent), with the child's assent according to age. Offer a chaperone for any examination that requires full undressing or intimate examination, and record "chaperone offered and accepted/declined" with a name. A parent is usually present and acts as chaperone, but for adolescents examined alone, a separate chaperone is good practice, particularly when the examiner and patient are of different sexes.

Clean hands and wipe the stethoscope and otoscope speculum before and after. Have all equipment ready so the child is disturbed once, not three times. Confirm that the thermometer, pulse oximeter probe and sphygmomanometer cuff are the right size for the child's age before you start.

Expose only what you need at each step and keep the rest of the child warm. An infant lies on the parent's lap or a play mat; a toddler may be examined while standing or seated on a parent's lap; older children can lie on the couch as an adult would. Always work at the child's level, face to face, and at a pace the child accepts. Sitting the child up reduces distress and gives a better view of breathing effort; lying flat is reserved for abdominal and hip examination. Never force a position that causes crying, because crying raises the heart and respiratory rates and hides murmurs and breath sounds.

• Look first, touch later. A sleeping baby gives more information than a crying one.
• Play is assessment. Running, reaching, playing and interacting with parents are part of the examination at every age; note what the child can do before you ask them to do anything.
• Unpleasant last. Ears, throat and hips are checked after the systems that keep the child comfortable, because once a baby cries, the respiratory and cardiac examination is no longer reliable.
• Leave the room set up. The child should leave having coped, not having cried throughout.

Follow the same order each time. The sequence moves from the undisturbed child at a distance inward to the systems, and only then to the steps that upset the child. Variation is allowed when a step is impossible, but the steps should be accounted for in your notes.

Before touching or even introducing yourself formally, watch. The best assessment of how sick a child is comes from a distance, for a short while, while the child is unaware of you. Count breathing from here. Note whether the child is asleep and easy towake, quietly playing, irritable, or lethargic. Note posture: well children sit up and reach; a distressed child may lie still, be held facing the parent, or be unable to be settled. Listen for noisy breathing (stridor, wheeze, grunting) and look for colour (pallor, cyanosis, mottling, jaundice). This step is the most commonly skipped and the most commonly missed diagnosis.

Weight is the most useful single measure in a sick and well child; measure it accurately, undressed or in a known weight of nappy. Measure supine length in infants and small children with a length board, and standing height once the child can cooperate. Head circumference is plotted when head growth is a concern. Plot each measurement on the chart correct for the child's sex and gestational age (use the UK-WHO or WHO charts), using the previous points where available, and always look at the trend over time rather than the single point. ^{[4] [5]}

Record weight centile, height or length centile, head circumference centile, and body mass index centile over 2 years. In an infant in the early weeks, remember that some weight loss is normal and usually settles by 3 to 4 days, with most infants back at birth weight by 3 weeks; loss of more than 10% of birth weight is a reason to assess. ^[3]

Thresholds for concern from the NICE faltering growth guideline, where a centile space is the space between adjacent centile lines on the UK-WHO growth charts: a fall of 1 or more weight centile spaces if birth weight was below the 9th centile, 2 or more spaces if it was between the 9th and 91st centiles, and 3 or more if it was above the 91st centile; a current weight below the 2nd centile for age, regardless of birth weight; and a height or length more than 2 centile spaces below the mid-parental centile. ^[3] The specialist review threshold for faltering growth uses the same charts. ^[4]

Look at the whole child before the system-by-system examination. Tone, posture and alertness tell you much of the story: a floppy or hypotonic infant in a ragdoll posture, an older child who will not be separated from the parent, or a child who is interacting normally with toys.

Hydration. In a well-nourished infant or child, check fontanelle (sunken when dehydrated), eyes (sunken), mouth and tongue (dry mucous membranes), skin turgor (pinched skin that returns slowly), tears (absent when crying in a child who normally produces them), and wet nappies or urine output. In infants, a capillary refill time of 3 seconds or longer is an intermediate-risk marker for serious illness. ^[1] Because oral intake and urine output are what parents notice, ask about them directly and record the answer, and note whether the child is tolerating small frequent feeds or refusing everything.

Nutrition and skin. Look for pallor (anaemia), jaundice, mottling, bruising patterns, rashes (blanching versus non-blanching), cyanosis (central is on the tongue and mucous membranes; peripheral is on the extremities), and signs of chronic illness such as muscle wasting or oedema. Note any unusual patterns of bruising or injury and keep them in mind for the safeguarding review at the end, using the NICE child maltreatment guidance as the reference list of concerns. ^[2]

Always count, do not estimate, and count for a full 60 seconds in an infant or in any child whose rate is irregular or fast. Measure temperature with an appropriate method for age; measure oxygen saturation in any acutely unwell or breathless child. ^[1]

The NICE traffic light system gives age-banded thresholds that define tachypnoea and tachycardia in children under 5: tachypnoea is a respiratory rate more than 60 breaths per minute from 0 to 5 months, more than 50 from 6 to 12 months, and more than 40 after 12 months; these are amber or red markers depending on the other findings. ^[1] Tachycardia by age is more than 160 beats per minute under 12 months, more than 150 at 12 to 24 months, and more than 140 at 2 to 5 years (Advanced Paediatric Life Support criteria, reproduced in the NICE guideline). ^[1] A capillary refill time of 3 seconds or longer is an amber marker. ^[1] NICE advises measuring blood pressure in a febrile child if the heart rate or capillary refill is abnormal and the facilities are available. ^[1]

Recording "heart rate normal" without a number is of no use; record the number, the rhythm, and whether it was counted for 60 seconds. Note the temperature with the method (axillary, tympanic, rectal) because the number depends on it, and note the reference range used locally. A non-blanching rash, a temperature of 38 C or more under 3 months or 39 C or more from 3 to 6 months, and a fever of 5 days or longer are all red or amber markers in the same table and should be checked in every febrile child. ^[1]

Development is part of the routine examination of every child, not only when parents raise a concern. Use age-appropriate milestones across four domains (gross motor, fine motor and vision, speech and language, social and cognitive), checking what the child does spontaneously first and then, if needed, eliciting it by play.

Useful markers across the first two years include: a social smile by 3 months; head control by 4 months; sitting without support by 9 months; a pincer grasp by 10 months; independent walking by 18 months; babbling by 9 to 12 months; meaningful words by 15 to 18 months, and two-word combinations by 24 months. ^[6] Red flags that should prompt assessment for a neurodevelopmental disorder include absence of a social smile by 3 months, inability to hold the head up by 4 months, inability to sit without support by 9 months, absence of babbling by 9 to 12 months, absence of independent walking by 18 months, absence of meaningful words by 15 to 18 months, and absence of two-word combinations by 24 months, as well as asymmetrical motor patterns and loss of previously acquired skills. ^[6] Hearing and vision should be considered (startle to loud sound, eye contact and fixation, following a small toy), because delayed acquisition often has a sensory cause.

For the school-aged child, development is judged from language, behaviour, play and school performance reported by parents and teachers, from coordination and writing, and from a focused neurological examination.

Perform this while the child is calm, because an agitated child hides the findings. Inspect breathing from across the room first (rate, effort, noise, posture, colour), then sit the child up and observe recession, grunting, tracheal tug, nasal flaring, head bobbing, use of accessory muscles, and whether the effort is symmetric. Put your hand on the abdomen of an infant to feel the respiratory effort. Auscultate with a warm stethoscope over all lobes, anterior and posterior, listening for air entry, equality, crackles, wheeze and the quality of breath sounds; percussion is harder in infants and is used when asymmetry is suspected. Note the shape of the chest (pectus, Harrison's sulcus, hyperinflation), and remember that a cough and bronchial breathing in a well child is normal over the main bronchi.

Feel the pulses (radial or brachial rate and rhythm for 60 seconds, compare radial and femoral, and check for radio-femoral delay in infants); measure blood pressure when indicated. Look at colour and perfusion, and check capillary refill. Palpate the precordium for the apex beat, parasternal activity and thrills, and auscultate all areas in a systematic pattern with the child quiet; sit an older child forward for aortic regurgitation and place the left lateral decubitus position for the mitral area. Hepatomegaly in a child with respiratory distress can be a sign of heart (rather than lung) disease, so palpate the liver in every unwell child.

Expose the abdomen fully, keeping the child warm. Inspect first (scars, distension, movement with respiration, visible peristalsis, herniae at the umbilicus and groin). Auscultate briefly. Palpate with a warm hand, starting away from the pain, using gentle pressure and, in infants, the flat of the hand or even the parent's hand over the child's. Always feel for the liver edge and spleen tip, and for kidneys in the neonate. Check the hernial orifices and the genitalia if there is a clinical indication. Guarding, a rigid abdomen, and marked tenderness with an ill child are red flags.

In a newborn and young infant, examine the hips supine with the nappy off: flex the hips and knees to 90 degrees and abduct gently to feel for a smooth clunk of reduction (Ortolani) and, with the hips flexed, apply gentle posterior pressure with adduction to feel for a clunk of dislocation (Barlow). Check for symmetry of the thigh and gluteal folds and for a difference in leg length (Galeazzi sign). Clicks without instability are common and not the same as the clunk of dislocation; clicky hips are managed by local arrangement. ^[7] After the first few weeks, abduction becomes the more reliable sign of a dislocated hip, with restricted abduction that is clearly less than the other side or unusually limited, needing referral. ^[7] From toddlerhood, watch the child walk, run, squat and climb, and test gait, alignment of the legs and spine (look for scoliosis or a hairy patch or dimple over the lower spine) and joint range.

Save these for last, because otoscopy and a throat view reliably upset young children, after which useful auscultation can no longer be obtained. Otoscope the ears with the parent holding the child, never with the child held down against their will if avoidable. Pull the pinna correctly for age (down and back in infants, back and up in older children) and look at the canal and the tympanic membrane (colour, light reflex, position, mobility, bulging or perforation). Inspect the oropharynx with good light and, in a cooperative child, a tongue depressor, noting tonsil size, exudate, palatal movement, uvula position, and the state of the teeth and gums. Count how many teeth are present against age. A throat swab or ear swab is taken when the result would change management.

A full neurological examination in every child is not always needed, but tone, movement, reflexes, and alertness are assessed in all sick children. In a baby, assess posture, spontaneous movement, head control, primitive reflexes where age-appropriate, and muscle tone by handling. In older children, assess gait, coordination, power, reflexes and, where indicated, cranial nerves. Asymmetry of movement, unusual posturing, or a child who is not the same on the two sides needs a careful repeated examination and, if confirmed, further assessment.

At the end of the examination, step back and ask the three questions again, now with data: is this child sick, is growth and development normal, and is there any sign that does not fit the offered history (NICE child maltreatment guidance lists the injury and bruising patterns that are suspicious). ^[2] Document the review, not just the individual signs.

The table collects the findings you are most likely to be asked to elicit and to name. "How to elicit" is the practical action; "what it means" is the clinical inference. Thresholds are taken from the sources in the references.

A paediatric presentation at the bedside has the same four parts, in this order: the headline, the system findings, the negatives that matter, and a summary with a differential and plan. Keep to about a minute; the listener is matching your findings to the history the parent gave.

1. Headline. Lead with the single most important thing, or say the examination is normal. In a child, this is often the general state rather than a sign: "The most striking finding is a quiet, floppy infant who does not make eye contact."
2. System findings. Go in the order examined: general state and growth (weight and centile, whether plotted); vital signs with numbers; hydration; systems; development. Use numbers, not adjectives: "respiratory rate 64, capillary refill 3 seconds" rather than "tachypnoeic with poor perfusion".
3. Negatives that matter. State only the negative findings that change the differential: no stridor, no recession, oxygen saturation 97% in air, no meningeal signs, no non-blanching rash, femoral pulses present and synchronous, no hip clunk. Silence on a normal finding is read as normal.
4. Summary and differential. End with one sentence on what you think, one on the important alternatives, and one on what you will do next: "In summary, this is a well-grown 4-month-old with bronchiolitis, currently with increased work of breathing but no features of serious illness; I would observe, give nasal suction and review the oxygen saturation, and admit if it rises above the traffic light threshold."

Age and who the patient is. Open with age rather than name, and include the parent's concern briefly if it changes management: "This is a 9-month-old boy, growing along the 25th centile, brought because of two days of fever."

Leading with the most important finding. Choose the lead by what determines management, not by what you found first. In a febrile child the lead is the traffic light colour and any red feature; in a breathless infant the lead is the work of breathing and the oxygen saturation; in a growth problem the lead is the centile crossing, not the ear you found at the end.

Matching written notes. Write short lines in the same order as your spoken presentation, one finding per line, with numbers and centiles: "Weight 8.2 kg, 25th centile. Temp 38.6 (tympanic). RR 48, no recession, O2 sat 96% air. HR 150, no murmur. CRT 2 s. Fontanelle soft, mouth moist. Lungs clear. No rash." Do not add a diagnosis the findings do not support, and do not copy prose.

Presenting a febrile child. Report the temperature, the traffic light features you found, and the colour: "He has one amber feature (tachycardia 152) and no red features, so he is at intermediate risk; I would assess for a source, give antipyretics and reassess."

All patient details below are invented and illustrative; they are not real patients.

Well child, 18-month-old girl, routine check. "On examination this is a well, interactive 18-month-old growing along her established centiles: weight 10.4 kg on the 50th, length 82 cm on the 50th, head circumference on the 25th. She is playful, alert and makes good eye contact; she stands and walks independently and uses single words. Vital signs are normal for age, oxygen saturation is 99% in air, and there is no fever. Hydration is normal with a soft fontanelle. The chest is clear, heart sounds are normal with no murmur, the abdomen is soft with no organomegaly, the hips abduct fully and there is no clunk, and the ears and throat are clear. In summary, this is a well 18-month-old with normal growth and development, no abnormality detected on examination."

Febrile child, 8-month-old boy, 38.5 C. "On examination this infant is alert and irritable but consolable. Weight is 8.5 kg on the 25th centile (plotted). Temperature is 38.5 C (axillary), respiratory rate 46 per minute with mild nasal flaring but no recession, grunting or tracheal tug, and oxygen saturation 95% in air. Heart rate is 162 per minute, regular, with good perfusion and a capillary refill time of 2 seconds; there is no murmur. Blood pressure was not measured. The fontanelle is soft, the mouth moist, and there are no focal signs of a source. There is no rash. Development is appropriate for age. In summary, this infant has one red feature not present in this case and only one amber feature, namely tachypnoea above 40 and a saturation of 95%, so he is at intermediate risk; I would look for a source, consider a urine test and chest review, give antipyretics, and reassess within 2 hours."

Acutely unwell infant, 10 weeks old, fever 38.2 C. "On examination this infant is pale and quiet, with little spontaneous interaction. Weight is 4.9 kg, on the 25th centile. Temperature is 38.2 C (rectal), respiratory rate 36 per minute with mild recession, and oxygen saturation 94% in air. Heart rate is 178 per minute with weak pulses and a capillary refill time of 4 seconds. The fontanelle is full but not bulging, the extremities are cool and mottled, and the abdomen is soft with no organomegaly. There is a petechial rash on the trunk and limbs (non-blanching). In summary, this is a high-risk febrile infant with red features (age under 3 months with fever 38.2 C, poor perfusion, mottled skin and a non-blanching rash) consistent with serious bacterial infection or septicaemia; he needs urgent senior paediatric review, intravenous access and parenteral antibiotics without delay, and he should be managed as a sepsis pathway patient."

Abnormal growth, 9-month-old boy. "On examination this infant is alert and interactive but thin, with visible muscle wasting and a large head for his small body. Weight is 6.2 kg, which has fallen from the 25th to below the 2nd centile over four months, while length is 68 cm (9th centile) and head circumference remains on the 50th centile. Hydration is normal. Vital signs are normal; the chest, heart, abdomen, hips and neurology are normal. Development is broadly appropriate for age, though sitting has been delayed. In summary, there is faltering growth with weight disproportionately low and a crossing of more than two centile spaces; the leading concerns are inadequate intake and a possible organic cause, and I would take a detailed feeding and social history, check for coeliac disease and other causes according to NICE, and support feeding."

• Touching before looking. Once a child cries, the respiratory rate, the chest signs and the diagnostic murmur are lost. Observe from the doorway first.
• Not counting long enough. Infants breathe fast and irregularly; a 15-second count multiplied by four is inaccurate. Count for a full minute whenever the rate matters, which in young children is almost always.
• Wrong normal for age. A heart rate of 150 is normal in a crying infant and alarming in a school-aged child; a respiratory rate of 30 is normal in a neonate and high in a teenager. Use the age-banded thresholds. ^[1]
• Forgetting the parent. The parent is part of the examination: they hold, comfort and distract, and they provide the history that makes the signs meaningful. Working against them wastes everyone's time.
• Leaving the ears and throat until the child is crying. There is a reason they are last.
• Treating a click as a clunk. Many newborns have benign hip clicks; the smooth clunk of reduction (Ortolani) is different from a benign click, and restricted abduction is the important later sign. ^[7]
• Not plotting. A weight in kilograms means nothing without the centile and the previous points; the trend is the diagnosis.
• Missing safeguarding clues by looking only at the presenting complaint. Always review the whole child and record anything that does not fit the history, using the NICE child maltreatment guidance as the list of concerns. ^[2]
• Quoting an oedema grade or a developmental age without saying what you actually saw or tested. Describe the behaviour and the test.
• Adding a diagnosis in the notes that the findings do not support, or copying prose instead of short lines.
• Not stating the traffic light colour for a febrile child under 5, which is the single most useful summary for the receiving clinician.

• Approach by age: observe first, use play and the parent, keep unpleasant steps until last, and never force.
• The undisturbed general look across the room is the most informative part of the examination.
• Measure and plot weight, length or height and head circumference on the correct chart; the trend matters. ^{[3] [4]}
• Count respiratory rate and heart rate for a full minute; know the age-banded thresholds for tachypnoea and tachycardia. ^[1]
• Hydration is assessed at the fontanelle, eyes, mucous membranes, skin turgor and urine output; capillary refill at or above 3 seconds is an amber marker. ^[1]
• The NICE traffic light system (green, amber, red) risk-stratifies a child under 5 with fever; temperature 38 C or more under 3 months is always high risk. ^[1]
• A non-blanching rash, a bulging fontanelle, status epilepticus and decreased consciousness are red features. ^[1]
• Development is checked in every child; loss of skills or red-flag milestones needs assessment. ^[6]
• Developmental dysplasia of the hip is sought with Ortolani and Barlow in early infancy and with abduction and gait later. ^[7]
• Safeguarding is reviewed for every child using the NICE child maltreatment guidance. ^[2]
• Present with the headline first, then numbers, then the negatives that change the differential, then a one-line summary and plan.
• Write short lines with numbers and centiles, not prose.