1. Examination in Paediatric
Dr. Varsha Atul Shah
Senior Consultant

2. Physical Examination
 Perform physical examination from head to toe on a
pediatric patient.
 You may need to alter the order of the examination for
patient compliance for uncooperative or hyperactive
patients.
 Do not force a child to do something that may be
frightening or uncomfortable to them.
 When examining an infant, toddler, or school-aged child
it is suggested to have a parent or guardian in the room
with you.

3. Physical Examination
 Examination of an infant or toddler may be
preformed on the lap of the patient.
 With an adolescent, it may be more appropriate
not to have the parent in the room with you, this
may allow the patient to feel that they can be
more candid.
 To avoid possible legal issues, a male doctor
may want a female staff member to be in the
examination room.
 The doctor should verify confidentiality laws in
their particular state.

4. Vital Signs
 Vital signs in pediatrics include temperature, heart rate,
blood pressure, respiratory rate, weight, length, and
head circumference.

5. Weight
 Height, weight, and head circumference should be
plotted on a growth curve graph.
 Decrease in weight percentile may be due to decreased
intake (malnutrition, central nervous system
abnormality), malabsorption (cystic fibrosis, IBD, celiac
disease, parasitic infestation), or an increased metabolic
rate (hyperthyroidism, congestive heart failure).
 Increase in weight is most commonly exogenous but
may also be associated with certain genetic syndromes
(Prader- willi).

6. Height
 A child’s length (lying flat on a table) is measured until 2
to 3 years of age; after that it is measured as height
(standing).
 Decrease height may be familial, or may be seen in
conditions affecting weight or independent of weight
(Turner syndrome).
 Increase height may be familiar or associated with
certain genetic and endocrine abnormalities (Cerebral
gigantism).

7. Head Circumference
 Head circumference is routinely measured until 2 to 3
years of age.
 Microcephaly may be part of a syndrome (Rett
syndrome), congenital infection (CMV), or the result of
abnormal brain growth (schizencephaly).
 Macrocephaly may be familiar or may represent a
pathologic state (Hydrocephalus, Canavaan disease, AV
malformation).

8. Blood Pressure
 Blood pressure must be measured with a cuff wide
enough to cover at least 1/2 to 2/3 of the extremity
and its bladder should encircle the entire extremity.
 A narrow cuff elevates the pressure, while a wide cuff
lowers it.
 Systolic hypertension is seen with anxiety, renal
disease, coarctation of the aorta, essential
hypertension, and certain endocrine abnormalities.
 Diastolic hypertension occurs with endocrine
abnormalities and coarctation of the aorta.
 Hypotension occurs in hypovolemia and other forms
of shock.

9. Blood Pressure
 The level of systolic blood pressure increases gradually
throughout infancy and childhood.
 2years 96/60 112/78
 6years 98/64 116/80
 9years 106/68 126/84
 12years 114/74 136/88

10. Pulse
 An elevated heart rate is seen in infections, hypovolemia,
hyperthyroidism, and anxiety.
 A rule of thumb is that the heart rate increases by
10/minute for each 1 degree of temperature Centigrade.
 Bradycardia is seen in hypertension, increased
intracranial pressure, certain intoxications, or other
hypometabloic states.
 It is best to examine an infant’s heart first during the
exam.

11. Heart Rate
 Birth 140
 1 - 6 months 130
 6 - 12 months 115
 1 - 2 years 110
 2 - 6 years 103
 6 - 10 years 95
 10 - 14 years 85
 14 - 18 years 82

12. Respiration
 Tachypnea is seen with increased activity,
hypermetabolic states, fever, or respiratory distress.
 A decreased respiratory rate is seen with conditions
affecting the central nervous system, including
medications/toxins, congenital malformations, and
other lesions.
 A variable respiratory rate, known as periodic
breathing, is commonly seen in neonates but more
than a 20 second pause is always abnormal.
 Cheyne-Stokes breathing is seen with brainstem
abnormalities.

13. Respiratory Rate
 Newborn 30 - 75
 6 - 12 months 22 - 31
 1 - 2 years 17 - 23
 2 - 4 years 16 - 25
 4 - 10 years 13 - 23
 10 - 14 years 13 - 19
 15 + same as adult

14. Temperature
 Temperature may be elevated with infections, tumors,
hyperthyroidism, autoimmune disease, environmental
exposures, certain medications, or increased activity.
 Temperature may be decreased with infections
(especially in neonates), hypothyroidism, certain
medications, environmental exposures, shock, or CNS
disease affecting the hypothalamus.
 Control of heat production and heat loss is maintained by
the thermoregulatory center in the hypothalamus.

15. Methods of Taking Temperature
 Rectal 96.8* to 98.6* F
 Axillary 2* F Lower
 Oral 1* F Lower
 Infrared same as rectal
 For the appropriately clothed child a fever is considered
100.4* F rectal.
 3 months of age and less always take temperature
rectally.

16. General Inspection
 A comment should be made about the patients general
appearance.
 Activity level and whether the patient is ill, is interacting
with the surroundings, and level of distress, if any.
 Comment about unusual odors.

17. Head
 In an infant the size and topography of the anterior
fontanel should be noted.
 Ant. Fontanel is the largest 4 to 6 cm and closes between 4 and
26 months.
 Post. Fontanel is 1 to 2 cm and closes by 2 months.
 Bulging of the fontanel may indicate increased
intracranial pressure found in infections, neoplastic
diseases of the central nervous system, or obstruction of
the ventricular circulation.
 Depression of the fontanel is found in decreased
intracranial pressure and may be a sign of dehydration.

18. Head
 Symmetry should be examined from various
perspectives:
 Plagiocephaly: is characterized by flattening of the occipital
skull.
 Scaphocephaly: describes an elongated head with flattening
of the bones in the temporoparietal regions.
 Cephalhematoma: term applied when there is bleeding over
the outer surface of a skull bone elevating the periosteum.
 Caput succedaneum a localized pitting edema in the scalp
that may overlie sutures of the skull, usually formed during
labor as a result of circular pressure of the cervix on the fetal
occiput.
 Craniosynostosis refers to premature fusion of one or more
of the sutures of the cranial bones, and should be
considered in any neonate with an asymmetric cranium.

19. Head
 Craniotabes is a term for softening of the skull
bones, with pressure the skull may be
momentarily indented before springing out
again. The major clinical significance is with
congenital rickets. Rarely, osteogenesis
imperfecta or congenital hypophosphatasia may
be causes. Pressure to skull makes a sound
“Crack” like a ping pong ball.
 Macewen’s Sign: is characterized by a “Cracked
pot” sound when the cranium is percussed with
the examining finger. A positive Macewen’s sign
may be evident until fontanel closure.

20. Head
 The shape of the head can reveal much about the
baby’s trip through the birth canal.
 Palpate suture lines for abnormalities.
 Palpate for any bumps or points of tenderness.
 Examine the hair and eyebrows for texture, quantity,
and pattern.
 Abnormalities in hair may be associated with
systemic disease or abnormality. Dry, course and
brittle hair may be associated with congenital
hypothyroidism.
 Alopecia Areata: well circumscribed areas of
complete or almost complete hair loss, the scalp is
smooth w/o signs of inflammation. Hair loss usually
begins suddenly, and total loss of scalp and body hair
may develop.

21. Head
 Tinea Capitis is a fungal infection of the scalp
characterized by a patch of short broken off hairs and the
patches of hair loss may be scaly or they may be marked
with inflammation, bogginess, and pustules called
“kerion.”

22. Eyes
 The shape and position of the eyes should be noted.
 Any abnormal eye movement and the ability to focus on
the examiner are important to note.
 Hard to examine because of the bright lights.

23. Nose
 Look for deformities, obstruction of the airway, color
of the mucosa, discharge, and tenderness.
 Check the nose for foreign bodies (beans, carrots,
crayons) younger children often putting foreign
objects into the various orifices of the body and they
often get stuck their.
 A green, foul smelling, purulent discharge from only
one side of the nose is common with a foreign object
being left in the nose.
 Purulent discharge bilaterally indicates infection.
 Delivery can give nasal obstruction due to
displacement of the septal cartilage.

24. Nose
 Flaring of the nostril almost always shows respiratory
distress.
 Mucosal Assessment:
 Red: Acute infection
 Blue and Boggy: Allergy
 Gray and Swollen: Rhinitis
 Maxillary and Ethmoid are developed in infancy.
 Frontal sinus developed by 5 years of age.
 The size, shape and symmetry of the nose should be
noted.
 A horizontal crease may be seen in the skin on the
surface of the nose, this signifies repetitive wiping of
the nose commonly seen in allergic rhinitis.

25. Ears
 The size and any aberration in shape of the external
ear (Pinna) should be noted.
 A low position (below the level of the eyes) or small
deformed auricles may be an indication of a brain
defect or congenital kidney abnormality, especially
renal agenesis.
 Inspection of the auricle and pariauricular tissues can
be done by checking the 4 D’s:
 Discharge
 Discoloration
 Deformity
 Displacement

26. Ears
 Discharge: from the ear canal can be a result of otitis
external or chronic untreated otitis media.
 Discharge may be thick and white, it may accompany
a bright pink or red canal.
 To differentiate between otitis externa and otitis
media, pull on the pinna, if this elicits pain, it is most
likely otitis externa.
 Prolonged moisture in the ear canal promotes
bacteria and fungal growth which predisposes the
child to otitis externa (swimmers ear).
 Equal mixture of alcohol and vinegar used as a rinse
will keep the ears dry and keep bacteria from
growing.

27. Ears
 If the discharge is accompanied with perforation of the
tympanic membrane, otitis media is suspected.
 The presence of a foreign bodies in the ear is common
and if left in the ear for a period of time may cause an
inflammatory response which may produce a foul-
smelling purulent discharge.
 Discoloration in the form of eccymosis over the mastoid
area is called “Battle Sign”, and is associated with
trauma and should be considered an emergency.

28. Ears
 Deformity of the ears may develop from intrauterine positioning or
could be the results of hereditary factors.
 These deformities are of minor concern unless gross deformities are
present.
 Gross deformities of the external ear are often associated with
anomalies of the middle and inner ear structures.
 Displacement of the auricle away from the skull is a distressing sign
associated with mastoiditis, other signs of mastoiditis are erythema
and tenderness over the mastoid and pinna, fever, and purulent
discharge.
 Other conditions associated with displacement of the auricle are
parotitis, primary cellulitis, contact dermatitis, and edema.

29. Throat
 Examine the external mouth for symmetry, such as
drooping of the corner of the mouth.
 The lips and mucous membrane should be examined
for evidence of cyanosis.
 The tongue should be palpated for movement and
strength of suck, this evaluates the function of the
glossopharyngeal, vagus, and hypoglossal nerves
 The soft palate should be examined for presence of
the gag reflex, evaluates the vagus nerve.
 The hard palate should be evaluated for structure,
absence of clefts, and alignment of the arch. A high
arched palate may possibly indicates future dental
problems associated with insufficient space for teeth (
high arched palate may indicate syndromes like
Marfan syndrome).

30. Mumps

31. Throat
 The color of the oropharynx should be noted,
the size of the tonsils and tonsillar pillars and
any discharge should be noted.
 Cobblestoning of the posterior pharyngeal
wall is a sign of chronic allergic disease.
 The quality of the patient’s voice should also
be noted.
 The tongue should be examined for size,
shape, color, and coating.
 A coated tongue is nonspecific
 A smooth tongue is found in avitaminosis
 A strawberry or raspberry tongue is seen in
specific stages of Scarlet Fever.
 A geographic tongue is a common finding.

32. Thrush

33. Thrush on the Tongue

34. Oral Thrush

35. Acute Tonsillitis

36. Diphtheria Bull Neck

37. Diphtheria Psudomembrane

38. Stomatitis

39. Stomatitis of the Tongue

40. Mastoiditis

41. Mastoiditis

42. Mumps

43. Throat
 Examine the oral mucosa may have creamy
white reticular plaques commonly seen with
thrush caused by Candida Albicans.
 A gray/white, sand grain sized dots on the
buccal mucosa opposite the lower molars,
called Koplik Spots are seen with Rubeola.
 Examine the teeth for dental caries, color of
the teeth, number of teeth and for dental
occlusion.
 Examine the neck for masses, enlarged
glands, tracheal tugging, carotid bruits,
mobility, and webbed neck.

44. Kippel Feil

45. Congenital Muscular Torticollis

46. Thorax and Heart
 Note the symmetry of the chest, asymmetric expansion may be
seen with pneumothorax or diaphragmatic paralysis. Also note
any abnormal shapes (Pectus Excavatum or Pectus carinatum.
 Barrel-shaped chest are sometimes seen in patients with
chronic obstructive pulmonary disease(chronic asthma or cystic
fibrosis).
 A rechitic rosary may be seen or palpated in rickets.
 Widely-spaced nipples may be a sign of Turner Syndrome.
 Note the pubertal development of the breast (Tanner staging) in
females.
 Note any masses, tenderness, or discharge of the breast and
describe in detail.
 Breast buds are commonly seen in neonates.
 The integrity of the clavicles should be noted in newborns
 Males sometimes develop unilateral or bilateral breast
hypertrophy during puberty, called gynecomastia, with milk
production may or may not be present.Approximately 40% of all
males between the ages of 10 and 16.

47. Pectus Excavatum

48. Pectus Excavatum

49. Pigeon Breast

50. Gynecomastia

51. Gynecomastia

52. 
Thorax and Heart
Female breast usually develop
asymmetrically.
 Inspect the thorax for color,
respiration, type of breathing.
 Auscultate breath sounds (rate,
ease, depth, rhythm).
 Palpate thorax (tenderness,
respiratory excursion, vocal or
tactile fremitus, and areas of
abnormality)
 Measure chest circumference at
nipple line.
 Auscultate the heart (murmurs,
rubs, clicks, or gallops) should be
noted.

53. Thorax and Heart
 A history of excessive perspiration and difficulties in
feeding are two of the most common complaints of early
congestive heart failure.
 Important questions to ask the parent:
 How has the infant been feeding?
 Does he or she get out of breath or appear exhausted?
 Has the child’s growth pattern changed recently?
 Does the child tire easily, with eating or with playing?
 Does the child perspire excessively, especially with efforts such
as feeding?
 Does the infant breathe rapidly, even at rest.

54. Upper Extremity
 Examination of the upper extremities should
include inspection for normal anatomy and
limb position, palpation for structural integrity,
and joint range of motion.
 The extremities should be examined for
clubbing, cyanosis, and edema.
 Acrocyanosis is a common finding in
neonates, characterized by cyanotic
discoloration, coldness, and sweating of the
extremities, especially the hands.
 Any deformities or extra digits should be
noted.
 Range of motion, swelling, erythema, and
warmth should be noted of any joint.
 Check for signs of contusions, abrasions, and
edema which are common signs of trauma.

55. Polydactyly

56. Polydactyly

57. Upper Extremity
 Check for muscle tone and strength of the upper
extremity.
 Evaluate all range of motion of each joint.

58. Abdomen
 Inspection is the most important first step.
 The order of examination has been changed slightly
in that palpation is done last.
 It is a good idea, before performing abdominal
examination, to ask the child if they need to use the
restroom.
 For the examination of the infant or toddler the knees
may be bent in order to relax the abdomen and the
child’s arms down at their sides.
 Inspect for rashes, scars, lesions, or discoloration.
 Observe overall contour and symmetry.
 Inspect the umbilicus for shape, signs of inflammation
or hernia

59. Abdomen
 Auscultation of the abdomen should be done before
palpation or percussion since the latter may alter the
frequency and quality of bowel sounds.
 Listen to the 4 quadrants noting the frequency and
quality of the bowel sounds.
 Abnormal sounds:
 gurgles
 clicks
 growls
 Frequency of sounds is from 5 to 34 times per minute.

60. Abdomen
 An increase in frequency or pitch of bowel sounds
may be associated with intestinal obstruction or
diarrhea.
 Decreased or absent sounds may be associated with
paralytic ileus or peritonitis.
 To be certain that bowel sounds are absent listen for
2 minutes in the area just inferior and to the right of
the umbilicus.
 Percussion in the pediatric patient is the same as the
adult patient.
 Because children tend to swallow a lot of air when
eating or crying the stomach and intestines has a
great amount of air in them.

61. Abdomen
 A distended abdomen may signify an obstruction,
infection, celiac disease, ascites, or an abdominal
mass.
 Palpation will reveal masses (note size and location)
hepatosplenomegaly, and any sources of pain.
 If the liver is felt below the costal margin (it commonly
is 1 cm below the margin) its span in the
midclavicular line should be percussed.
 Danforth’s sign is right shoulder pain with RUQ
palpation (represents an irritated diaphragm) is
strongly suggestive of liver injury.
 Kehr’s sign is left shoulder pain with LUQ palpation
(represents an irritated diaphragm) is strongly
suggestive of splenic injury.

62. Abdomen
 Rovsing’s sign is RLQ pain with LLQ palpation is
suggestive of appendicitis.
 McBurney’s point is 2/3 of the way from the umbilicus to
the anterior superior iliac crest in the RLQ and
tenderness there is also suggestive of acute
appendicitis.

63. Rectum
 A chaperone may be necessary.
 The anus should be inspected for position (an
imperforated anus is associated with a host of other
anomalies; an abnormally places anus can also be
associated with constipation or encopresis,
depending on the position of the orifice with respect
to the sphincter).
 Any fissures, trauma, or parasites should be noted.
 A rectal prolapse may be seen with many conditions
including malnutrition, constipation, and cystic
fibrosis.
 The rectal exam is mandatory for any child
complaining of abdominal pain, encopresis,
constipation, hematochezia, or melena.

64. Rectum
 A lubricated small finger is used to palpate
for any masses, tone of the sphincter, and
any focal pain, as may be seen with
appendicitis.
 The stool should be tested for occult
blood.
 Rectal examination on infants and young
children should be performed in the supine
position.

65. Genitalia
 Patient’s should always be examined is the presence of
a parent or a caretaker or in the case of a pre-teen or
teenager with a staff member present.
 It is not common for Doctors of Chiropractic to do female
genitalia or pelvic exam.
 It is common for the D.C. to give a hernia examination
and Tanner Staging for school or sports physicals.
 Tanner Staging is the measurement for sexual
maturation.

66. Lower Extremity
 Visually inspect the lower extremity for abrasions,
contusions, rashes, edema, cyanosis, clubbing, and
discoloration.
 Visually inspect for any abnormalities or deformities
(any extra digits should be noted).
 Measure the extremity as to circumfrencial
measurements, actual leg length (ASIS to Medial
malleolus) and apparent leg length (Umbilicus to
Medial Malleoolus).
 A way to determine true leg length is to take a
Scanogram (this is a x-ray procedure where three
views are taken of the extremities the first is through
the head of the femurs, the second is through the
knees, and the third is through the ankles) using a
Bell Thompson Ruler.

67. Lower Extremity
 Range of motion should be preformed and any joint
swelling, erythemia, and warmth should be noted.
 Hips are routinely examined in infants (see orthopedic
sect.)
 Foot abnormalities are common in infancy but not in later
life.
 The peripheral pulses, especially the femoral pulses.

68. Orthopedic Testing
 Infant orthopedic testing should include all rang of motion
testing, static and motion palpation.
 Ortolani’s Test is a common test performed on the infant.
 It is a reduction test.
 With the baby relaxed in the supine position, the hips
and knees are flexed to 90*, the examiner grasp the
baby’s thigh with middle finger over the greater
trochanter and lifts the thigh an simultaneously gently
abducting the thigh, thus reducing the dislocation and
a “clunk” will be observed

69. Orthopedic Testing
 Barlow’s Test is a provocative test (dislocation) also
called Reverse Ortolani’s test.
 Barlow’s Test is performed to discover any hip instability.
 The baby’s thigh is grasped with the middle finger along
the baby’s thigh adducted and with a gentle downward
pressure.
 Dislocation is palpable as the femoral head slips out of
the acetabulum.

70. Orthopedic Testing
 Allis’ or Galeazzi’s Sign is another orthopedic test
used to test for a dislocatable hip and is preformed by
flexing the child’s knees and hips placing feet on the
table the lower one the femoral head lies posterior to
the acetabulum.
 Another test for a dislocated hip, shortening of the
thigh will bunch up the soft tissue and will
accentuation of the skin folds.
 Telescoping of the thigh is elicited because the
femoral head is not contained within the acetabulum.
 Trendelenburg’s Test with the child standing with
weight on the affected side the normal hip drops
down, indicating weakness of the abductor muscles
of the affected side.

71. Neurological Testing
 Much of the neurologic exam comes from
observation of the child.
 Any limitation in the use of the hands, legs, or
pupillary light response.
 Babinski Reflex the baby’s foot is stroked from heel
toward the toes. The big toe should lift up, while the
other toes fan out: absence of the reflex may suggest
immaturity of the CNS, defective spinal cord, or other
problems. This reflex may be seen up to age 12 to 24
months. Then it will reverse with toes curling
downward.
 Doll’s Eye while manually turning baby’s head, his
eyes will stay fixed, instead of moving with the head.
While normally vanishing around one month of age, if
it reappears later, there may be damage to the CNS.