---

Pediatric Assessment: Complete Step-by-Step Guide

---

STEP 1 — First Impression: The Pediatric Assessment Triangle (PAT)

1. Appearance (TICLS)

2. Work of Breathing

• Abnormal sounds: stridor, grunting, snoring, wheezing
• Abnormal positioning: sniffing position, tripod posture, refusal to lie flat
• Retractions (subcostal, intercostal, supraclavicular)
• Head bobbing (especially in infants)
• Nasal flaring

3. Circulation to the Skin

• Pallor
• Mottling
• Cyanosis (central or peripheral)
• Capillary refill time >2 seconds
• Petechiae

A normal PAT = stable child. Any abnormality guides your urgency and focus. — Rosen's Emergency Medicine, p. 3069

---

STEP 2 — Vital Signs (Age-Adjusted)

• Tachycardia is the earliest sign of cardiovascular compromise — but may also reflect fever, pain, or anxiety. Assess at rest.
• Hypotension is a late sign of shock in children. Do not wait for hypotension to act.
• Bradycardia in an ill child = ominous sign of impending cardiopulmonary failure.
• Weight-based dosing is mandatory — always record weight in kilograms.

---

STEP 3 — History Taking

3a. SAMPLE History (Emergency/Quick Focused)

3b. Full Pediatric History (Comprehensive)

• Chief complaint in the caregiver's own words
• In preverbal children, symptoms are inferred from behavior — parents are highly perceptive of subtle behavioral changes

• Onset, duration, progression
• Aggravating and relieving factors
• Associated symptoms (fever, vomiting, decreased feeding, rash, etc.)

• Gestational age, mode of delivery
• Complications during labor/delivery
• Maternal fever during labor, prolonged rupture of membranes, maternal Group B Streptococcus (GBS) status
• APGAR scores
• NICU admission, oxygen/ventilator use
• Newborn screening results (metabolic disorders, hypothyroidism, hearing)

• Breastfed or formula-fed
• Introduction of solids, current diet
• In infants: number of wet diapers/day — key indicator of hydration status (especially in breastfed newborns where intake is hard to quantify)

• Growth milestones: weight gain trajectory, height
• Developmental milestones: gross motor, fine motor, speech/language, social
• Screen for regression — loss of previously attained milestones is significant

• Up to date? Which vaccines received?
• Critical in febrile infants (bacteremia risk) and children with rash (measles, varicella)

• Previous illnesses, hospitalizations, surgeries
• Chronic conditions (asthma, cardiac disease, epilepsy, etc.)

• Current medications (note: all doses are weight-based in children)
• Drug allergies and nature of reaction

• Relevant genetic conditions, cardiac disease, sudden death in young relatives

• Living situation, primary caregivers
• School/daycare attendance
• For adolescents (asked privately, without parent): sexual history, drug/alcohol/e-cigarette use, mental health, risk-taking behaviors
• Safeguarding concerns (child maltreatment)

---

STEP 4 — Physical Examination (Head-to-Toe)

Approach by Age — This is critical

---

General Inspection

• State of alertness, interaction with environment
• Nutritional status, hygiene, signs of neglect
• Dysmorphic features (unusual facial features, limb anomalies)
• Obvious distress, posture, spontaneous movement

---

Airway Assessment

• Patency: any stridor, drooling, inability to swallow?
• In infants: the head is proportionally large — neutral or slight extension (not hyperextension) maintains airway; use a shoulder roll under infants to align
• The tongue is proportionally large; obligate nose-breathers up to ~3–6 months
• Any hoarseness or muffled voice?

---

Respiratory Assessment

• Inspection: rate (count for full 60 seconds in infants), depth, symmetry, use of accessory muscles
• Retractions: subcostal, intercostal, suprasternal, supraclavicular
• Palpation: chest wall movement, tracheal position
• Percussion: dullness (consolidation/effusion), hyperresonance (pneumothorax/hyperinflation)
• Auscultation: air entry bilaterally, added sounds (wheeze, crackles, diminished)
• Note: Breath sounds transmit easily through a child's thin chest wall — auscultate carefully and systematically

---

Cardiovascular Assessment

• Heart rate: note if at rest (a crying child's HR is unreliable — leave pulse oximeter on until calm)
• Pulse quality: central (femoral, brachial in infants) vs. peripheral — thready peripheral pulse + tachycardia = shock
• Capillary refill time (CRT): press for 5 seconds, release — normal <2 seconds
• Auscultation: heart sounds, murmurs
• Blood pressure: age-appropriate cuff size is mandatory
• Children compensate by vasoconstriction before losing BP — look for cold extremities + tachycardia as early shock signs

---

Abdominal Assessment

• Inspection: distension, visible peristalsis, umbilicus
• Auscultation first (before palpation): bowel sounds
• Palpation: start away from the area of pain; use the child's hand under yours to reduce guarding in toddlers; assess for organomegaly (liver, spleen), masses, tenderness
• Percussion: tympany, dullness over organomegaly/ascites

---

Neurological Assessment

• Level of consciousness: use AVPU (Alert, Voice, Pain, Unresponsive) or GCS (age-modified)
• Fontanelle (infants): anterior fontanelle normally closes by 18 months
  • Bulging = raised ICP; Sunken = dehydration
• Pupils: size, symmetry, reaction to light
• Tone: assess at rest — hypotonia vs. hypertonia
• Reflexes: deep tendon reflexes; primitive reflexes in neonates (Moro, rooting, grasp, stepping)
• Developmental reflexes: expected to disappear at specific ages — their persistence is abnormal
• Gait (ambulatory children): symmetry, posture, base width, heel-toe

---

Musculoskeletal Assessment (especially relevant for physio students)

• Inspect for deformity, swelling, asymmetry
• Palpate bones and joints for tenderness, warmth, swelling
• Range of motion (active and passive)
• Physeal injuries: children's ligaments are stronger than their growth plates — suspect growth plate fracture even with normal X-ray if physis is tender
• Limping: age-based differential (DDH, Perthes, slipped capital femoral epiphysis, septic arthritis)
• Scoliosis screen: Adams forward bend test
• Foot alignment: flat feet normal until ~3 years; tibial torsion; toe walking
• Note: Greater degrees of fracture angulation are acceptable in children due to bone remodeling capacity

---

Skin Assessment

• Color: cyanosis, jaundice, pallor, mottling, petechiae
• Rashes: distribution, morphology (macular, papular, vesicular, petechial)
• Bruising: location and pattern — accidental bruising typically on shins/forehead; unexplained or patterned bruising raises safeguarding concerns
• Turgor: pinch test for dehydration (though less reliable in obese children)
• Capillary refill at forehead, sternum, fingertips

---

ENT Assessment

• Ears: otoscopy — tympanic membrane appearance (erythema, effusion, perforation)
• Eyes: conjunctiva (pallor = anaemia, injection = infection), sclera (jaundice), red reflex
• Nose: flaring, secretions
• Throat: pharyngeal erythema, tonsillar enlargement/exudate — examine last in toddlers as most distressing
• Lymph nodes: cervical, axillary, inguinal — size, tenderness, mobility

---

Genitourinary

• Assess as indicated
• For neonates: check external genitalia, undescended testes, hypospadias
• Document Tanner staging in adolescents when relevant

---

STEP 5 — Developmental Assessment (Milestones)

• Not rolling by 6 months
• Not sitting independently by 9 months
• Not walking by 18 months
• Persistent toe walking after 2–3 years
• Asymmetric movement (hemiplegia)
• Loss of previously achieved milestones at any age

---

STEP 6 — Immunologic and Risk Stratification

• Young infants (<1 month) with fever have ≥10% risk of serious bacterial infection — treat as high risk regardless of appearance
• Vaccination status modifies risk (e.g., vaccinated children have lower bacteremia risk from H. influenzae, Streptococcus pneumoniae)
• Premature infants have adjusted developmental age for milestones (use corrected age up to 2 years)

---

STEP 7 — Documentation and Communication

• Record weight in kilograms always
• Document age in appropriate units: days (neonates), months (infants/toddlers), years (older children)
• For physiotherapy: clearly document:
  • Functional mobility level
  • Gross motor developmental stage
  • Pain assessment using age-appropriate scale (FLACC for <3 yrs, Wong-Baker FACES for 3–7 yrs, NRS for ≥8 yrs)
  • Caregiver/parent input on baseline function

---

Summary: Sequence at a Glance

1. PAT → First impression from doorway (sick/not sick)
2. Vital signs → Age-adjusted interpretation
3. History → SAMPLE + detailed age-specific history
4. Head-to-toe exam → Adapt approach to age/development
5. Developmental screen → Milestones across 4 domains
6. Risk stratification → Age, vaccination, prematurity
7. Document → Kg weight, corrected age, functional baseline

---