The pediatric physical examination: General principles

and standard measurements

INTRODUCTION Sophisticated technologic advances in medicine

have proved to be remarkably beneficial in the diagnostic process, yet the

well-performed history and the physical examination remain the clinician's
most important tools. They are venerated elements of the art of medicine, the
best series of diagnostic tests we have [1].

A relatively complete physical examination should be performed on each

patient, regardless of the reason for the visit. Numerous medical anecdotes
relate instances in which the examination revealed findings unrelated to and
unexpected from the patient's chief complaint and major concerns. On
occasion, a limited or inadequate examination may miss a significant
condition, mass lesion, or potentially life-threatening condition.

The general principles, standard measurements, and overall approach to the

pediatric patient are discussed here. Examination of specific organ systems is
discussed separately.

●(See "The pediatric physical examination: HEENT".)

●(See "The pediatric physical examination: Chest and abdomen".)
●(See "The pediatric physical examination: Back, extremities, nervous
system, skin, and lymph nodes".)
●(See "The pediatric physical examination: The perineum".)

GENERAL PRINCIPLES

The approach — Before entering the room, the clinician should review the
patient's record and confirm the identity of the patient and others in the
room. This may avoid greeting the patient, parent, or caregiver by the wrong
name. The examiner should always knock on the door and await a response
before entering by gently opening the door. Small children standing on the
other side can be injured easily by the door handle or by the door's impact as
it is being opened.

Regardless of whether the clinician and caregiver have met previously, it is

appropriate to greet everyone in a cordial manner, maintaining a professional
yet friendly demeanor. Clinicians should introduce (or reintroduce)
themselves and any colleagues or students observing or participating in the
visit and ask those in the room to introduce themselves as well, particularly if
the clinician is uncertain of the relationship between the caregiver(s) and the
child.

Infants older than six months and anxious toddlers who are leery of strangers
often are more comfortable when held by their caregiver. To gain the child's
confidence and to avoid an early adversarial relationship, the clinician should
try using a calm approach, a reassuring smile, and a toy or bright object as a
diversion. An appropriate distance should be maintained during the history-
taking portion. The clinician's approach should be cautious and
nonthreatening once the physical examination is about to begin.

Infants younger than six months who have no stranger anxiety and children
older than 30 to 36 months who are familiar with the examining clinician
and/or who possess a trusting demeanor generally cooperate during the
examination without being held. Physical examination of 5- to 12-year-old
children usually is easy to perform because these children are not typically
apprehensive and tend to be cooperative.

General appearance — The examiner may gain significant insight into

important social and family dynamics by observation alone when entering the
patient's room. Terms used to describe a patient's general appearance
include:
●Degree of comfort (calm, nervous, shy)
●State of well-being (normal, ill-appearing, distressed)
●activity level (sedate, alert, active, fidgety)
●Physical appearance (neat, disheveled, unkempt)
●Behavior and attitude (happy, sad, irritable, combative)
●Body habitus (overweight, underweight, short, tall)
●Nutritional status (malnourished, normal, corpulent)

Initial observations may help the clinician form a hypothesis, further

supported by physical examination findings. As examples:
 ●If the child and caregiver make no eye contact or the patient lacks
animation and has no social smile, neglect is one possibility.
Psychosocial intervention may be warranted. (See "Child neglect:
Evaluation and management".)
●If a child appears ill, the clinician should note the patient's preferred
position.
•A child who lies completely still on the examination table, is verbally
responsive, but noticeably winces when an attempt is made to
change position may have an acute abdomen. (See "Emergency
evaluation of the child with acute abdominal pain".)
•A dyspneic patient who is sitting upright and slightly forward with
the arms extended and hands resting on the knees might be
experiencing an exacerbation of asthma or other causes of
respiratory distress.
●If an infant is crying, the pitch and intensity of the cry should be noted.
•A boisterous hardy cry is reassuring.
•A weak and listless cry may indicate a seriously ill infant.
•A high-pitched, screeching cry may indicate increased intracranial
pressure, reaction to a painful injury, toxic reaction, strangulated
inguinal hernia, or other serious disorders.
●Note the patient's breathing pattern. If the patient has rapid, shallow
respiration yet appears to be in no acute distress, the underlying cause
could be primary pulmonary disease or respiratory compensation for
metabolic acidosis. (See "Approach to the child with metabolic acidosis".)
●The examiner should evaluate the developmental status before
touching the child, including during history taking. The patient's motor
function, interaction with surrounding objects and people, response to
sounds, and speech pattern give clues about whether the patient is
developing typically or is in need of more comprehensive developmental
assessment. (See "Developmental-behavioral surveillance and screening
in primary care", section on 'Approach to surveillance'.)
History — Historical information depends almost completely upon the
caregiver for patients in the neonatal age range through early childhood. To
obtain pertinent information regarding a 5- to 12-year-old child, the clinician
must still rely primarily on the caregiver, although comments made by the
patient are often relevant.
When appropriate, adolescent patients should have some time with the
clinician in the absence of caregivers to permit more open discussion of
pertinent historical information, anticipatory guidance, and preventive health
care issues. (See "Guidelines for adolescent preventive
services" and "Confidentiality in adolescent health care".)

Key elements in the history-taking process include establishing a warm, caring

atmosphere and asking questions in a nonconfrontational, unhurried manner.
The terminology and language used by the examiner should be appropriate
for the health literacy of the caregiver and the patient. Good eye contact and a
sense of undivided attention should be maintained. The clinician should sit
opposite the caregiver and/or patient at a comfortable distance,
unencumbered by large objects, such as desks or tables. Outside interruption
by the medical staff and by telephone calls should be kept to a minimum.
Before beginning the history, clinicians should explain that they may
occasionally need to refer to the electronic or written medical record to review
laboratory results, imaging reports, or other pertinent information. An effort
should be made to maintain an uninterrupted dialogue, to write few notes,
and as much as possible to refrain from turning their back to the
patient/caregiver to look at the medical record.

Physical examination — Examiners should wash their hands thoroughly

before beginning and after completing the examination. Protective gloves
should be worn when appropriate.

Skilled clinicians employ different techniques to gain pediatric patient

cooperation. The use of toys, distracting objects, and pictures helps in the
examination of young children, infants, and toddlers. Engaging the two- to
four-year-old in stories or a discussion of imaginary animals frequently
creates an effective diversion. Food, in the form of chewable snacks or liquid
refreshments, can be used as a means of pacification, depending upon the
stage of the examination.

When an otherwise typically behaving child older than four years fails to
cooperate for an examination, even in the presence of a familiar caregiver, it
may be an indication of either an earlier traumatic encounter between the
patient and another examiner or that the current examining clinician should
try a different approach. The possibility of an underlying psychosocial
problem or behavior disorder should be considered if a child older than four
years is extremely uncooperative or combative.

For patients old enough to understand but who appear apprehensive, the
examiner should explain what is going to be done during the examination and
allow them to look at and touch any of the instruments to be used. Older
patients should be warned in advance of potential pain or discomfort.

The examination of an infant, toddler, or child should be performed in the

presence of a parent or guardian; if the parent's or guardian's presence may
interfere with the examination (eg, suspected child abuse), a chaperone
should be present [2,3]. The use of a chaperone is appropriate for the
examination of the anorectal and genital areas and/or breasts of male and
female adolescent patients. The clinician should explain the reason for the
examination and describe how the examination will proceed. The gender of
the chaperone should be determined by the patient’s wishes and comfort (if
possible). Ideally, the utilized chaperone should be a staff member rather than
a family member. The use and identity of the chaperone should be identified
in the medical record.

If the patient has a complaint, sign, or symptom that appears to involve a

particular part of the anatomy, that part of the examination should be
performed last. As an example, consider a patient complaining of right-lower-
quadrant abdominal pain thought to be attributable to appendicitis; by not
examining that part of the body first, the clinician may be able to divert the
patient's attention away from the involved area and rule out other possible
causes for the pain.

Patient privacy should be respected. If a patient objects to being unclothed or

to wearing an examination gown, allow them to remain clothed until a specific
part of the anatomy must be checked. When an area needs to be examined,
the patient should be asked to remove or pull free the garments that are
hindering visualization, palpation, or auscultation.

The order in which the physical examination is conducted often is age-specific

and depends upon examiner preference. For an infant and younger child, the
clinician may prefer to begin by examining the eyes, noting the red-light
reflex, extraocular eye muscle movements, and visual tracking and then move
to other parts of the body or organ systems before finally performing the
often sensitive ear examination. For the older, more cooperative child, the
examination might begin at the head and progress down the body, with the
neurologic examination performed last. In general, the portions of the
pediatric examination that require the most patient cooperation, such as
blood pressure measurement, lung and heart auscultation, and eye and
neurologic examinations, are performed initially. These examinations are
followed by the more bothersome portions, including abdominal and ear
examinations and measurement of head circumference.

STANDARD MEASUREMENTS

Growth parameters — Measurement of the standard growth parameters

throughout childhood and adolescence is essential for assessing normal
development [4]. Data obtained should be plotted on standard growth curves
to determine progress.
Weight — Weight is measured at each periodic well-child visit (figure 1A-
B and figure 2A-B) (calculator 1). The evaluation of children with abnormal
weight or weight trajectory is discussed separately.
●Poor weight gain (see "Poor weight gain in children younger than two
years in resource-abundant settings: Etiology and evaluation" and "Poor
weight gain in children older than two years in resource-abundant
settings", section on 'Diagnostic approach')
●Overweight and obesity (see "Clinical evaluation of the child or
adolescent with obesity")
Height (length) — Height (length) is measured at each periodic well-child
visit. Children younger than two years and older children who are unable to
stand should be measured in the supine position (length) because standing
measurements (height) are unreliable (figure 3). Children older than two years
who are able to stand should be measured while standing (figure 4).

The length or height for age are compared with growth standards:

●For children <2 years (figure 5A-B) (calculator 2)

●For children ≥2 years (figure 6A-B) (calculator 3 and calculator 4)
The evaluation of children with abnormal height (length) is discussed
separately. (See "Diagnostic approach to children and adolescents with short
stature" and "The child with tall stature and/or abnormally rapid growth".)
Head circumference
●When to measure – Occipitofrontal circumference (OFC) should be
measured in all children at health maintenance visits between birth and
three years of age. OFC should also be measured at each visit in children
of all ages with neurologic or developmental complaints.
Measurement of OFC in the newborn may be unreliable until the third or
fourth day of life since it may be affected by caput succedaneum,
cephalohematoma, or molding [5].
●Measuring technique – The measuring tape should encircle the head
and include an area 1 to 2 cm above the glabella anteriorly (ie, just above
the eyebrows) and the most prominent portion of the occiput posteriorly
(picture 1).
In older infants, the accuracy of the measurement may be affected by
thick hair and deformation or hypertrophy of the cranial bones.
●Normal head growth – Normal head growth in infants and children is
discussed separately. (See "Normal growth patterns in infants and
prepubertal children", section on 'Head growth'.)
●Reference standards – OFC should be plotted on a standardized head
circumference chart. A disproportionately large head may be indicative
of hydrocephalus or macrocephaly. A disproportionately small head may
be indicative of neurologic deficits or microcephaly, although in some
children a small head size is normal. (See "Macrocephaly in infants and
children: Etiology and evaluation", section on
'Etiology' and "Microcephaly in infants and children: Etiology and
evaluation".)
It may be inappropriate to use a single head circumference standard for
children in all countries or ethnic groups. A study that compared mean
head circumference from a variety of studies including >11,000,000
children from economically advantaged populations (1988 to 2013) with
the World Health Organization (WHO) reference standards found that
the mean head circumferences in certain national or ethnic groups were
sufficiently different from the WHO means to affect diagnosis of
microcephaly or macrocephaly [6].
Standardized charts for monitoring OFC in children between 0 and 18
years of age include [7-10]:
•For routine measurement in children younger than two years – The
Centers for Disease Control and Prevention (CDC) recommends that
the WHO child growth standards be used for children 0 to 2 years
(figure 7A-B) (calculator 5) [10].
The WHO child growth standards for children 0 to 5 years of age are
based on data from the Multicentre Growth Reference Study of
breastfed children living under optimal environmental conditions.
•For routine measurement in children between age two and three
years – The CDC recommends that the CDC growth charts be used for
children older than two years (figure 8A-B) (calculator 6) [10].
These charts are based on a nationally representative demographic
sample.
 •For individuals older than three years with concerns about
microcephaly or macrocephaly – The following OFC reference
standards are available for children in whom there are concerns
about microcephaly or macrocephaly:
-The Nellhaus head circumference charts for children 0 to 18
years of age – These charts are based on a 1968 international
meta-analysis [7]. They are available in the full text of the
reference [7].
-The Fels head circumference charts for children 0 to 18 years –
These charts are based on data from the Fels Longitudinal Study
of 888 White children from the United States [8]. They are
available in the full text of the reference [8].
-The United States Head Circumference Growth Reference charts
for children 0 to 21 years of age – These charts combine growth
reference data from the CDC, Nellhaus, the Fels Longitudinal
Study, and others [9]. They are available in the full text of the
reference [9].
-The Bushby charts for adults – These charts are based on data
from 354 White adults (median age 40 years, range 17 to 83
years) in two British centers; OFC percentiles are related to height
[11]. Bushby charts are available in the full text of the reference
[11].
●Special populations
•Premature infants – Most clinicians use the standard growth curves
to monitor the head growth of premature infants, with correction for
gestational age), until approximately 18 to 24 months of age [12].
(See "Growth management in preterm infants", section on
'Monitoring of growth'.)
•Children with conditions associated with macrocephaly – The
standard growth curves are not appropriate for monitoring the head
size of children with certain medical conditions associated with
macrocephaly (eg, achondroplasia, neurofibromatosis).
(See "Achondroplasia", section on
'Management' and "Neurofibromatosis type 1 (NF1): Pathogenesis,
clinical features, and diagnosis".)
•Children with conditions associated with microcephaly – The
standard growth curves are not appropriate for monitoring the head
size of children with craniosynostosis, craniofacial syndromes, and
children with certain medical conditions associated with microcephaly
 (eg, Williams-Beuren syndrome). Growth curves for children with
Williams-Beuren syndrome are available through the American
Academy of Pediatrics.
Chest circumference — Chest circumference is measured at the time of the
newborn examination, but it is not a part of the routine examination for well-
child visits. The chest circumference is measured at the nipple line. Chest
circumference is 1 to 2 cm smaller than head circumference in most newborns
and children 12 to 18 months old. Provided that the head circumference is in
the normal range for age and sex, if the chest circumference is more than 2
cm smaller or larger than the head circumference, examination of the chest
wall and imaging of the thoracic cavity may be warranted (eg, to evaluate
asphyxiating thoracic dystrophy, pectus excavatum, pectus carinatum) [13].
(See "The pediatric physical examination: Chest and abdomen", section on
'Chest wall' and "Chest wall diseases and restrictive physiology", section on
'Congenital and childhood abnormalities'.)
Vital signs
Temperature — Routine measurement of the patient's temperature is not
always necessary. When a temperature measurement is needed, appropriate
site for measurement varies with age, ability to cooperate, and clinical
scenario. Temperature measurement techniques and indications are
discussed separately. (See "Fever in infants and children: Pathophysiology and
management", section on 'Temperature measurement'.)
Respiratory rate — The respiratory rate varies with activity in infants and
young children, and in these patients is best assessed by counting for a full 60
seconds [14-17]. Accurate determination of the respiratory rate should be
attempted only when the patient is asleep or at rest. It can be obtained by
auscultation, palpation, or direct observation. Observation of chest wall
movements is preferable to auscultation because auscultation may stimulate
the child, falsely elevating the rate [14].
The normal range for the respiratory rate depends upon the age of the child.
A systematic review of 20 studies provided respiratory rate percentiles for
healthy children who were typically awake and at rest (table 1) [18]. A
sustained breathing rate in excess of the upper limit of normal generally
indicates primary respiratory tract disease; it may also occur secondary to a
metabolic disorder, infectious disease, high fever, or underlying heart disease.
Although the respiratory rate may increase with fever [19-21], the relationship
between temperature and respiratory rate is not linear. Thus, a simple rule for
use in clinical decision making is not possible.
Heart rate — The heart rate can be measured by direct auscultation or
palpation of the heart or by palpation of peripheral arteries (carotids,
femorals, brachial, or radials).
Like the respiratory rate, the normal heart rate varies with age. A systematic
review of 59 studies provided heart rate percentiles for healthy children who
were typically awake and at rest (table 1) [18]. A heart rate above the upper
limit of normal may indicate primary cardiac disease; it also can occur
secondary to an underlying systemic or metabolic disorder, infectious disease,
or high fever.
Blood pressure — Blood pressure should be measured annually at well-child
visits for all children age three years and older, and more frequently in those
with risk factors for hypertension.
Blood pressure generally is not measured in children younger than three
years unless they have evidence of underlying renal disease (eg, tumor,
nephrotic syndrome, glomerulonephritis, pyelonephritis, renal artery
stenosis), suspicion of acute cardiovascular disease (eg, coarctation of the
aorta, patent ductus arteriosus), or acute illness. Obtaining an accurate blood
pressure reading in children younger than three often is difficult. (See "Clinical
manifestations and diagnosis of coarctation of the aorta" and "Clinical
manifestations and diagnosis of patent ductus arteriosus (PDA) in term
infants, children, and adults".)
Blood pressure devices include the standard extremity cuff and mercury bulb
sphygmomanometer, the hand-held aneroid manometer, and the Doppler
and oscillometric devices. Patients old enough to understand should be
shown the blood pressure device before the examiner attempts to take a
measurement. The patient should be allowed to play with the device or feel
the cuff inflate to gain their cooperation. The proper technique for blood
pressure measurement is discussed separately. (See "Definition and diagnosis
of hypertension in children and adolescents", section on 'Measurement of
blood pressure'.)
As with pulse and respiratory rates in children, blood pressure varies with age
and height percentile. Standard reference charts that give the ranges of
normality should be consulted (table 2A-B) [22].
The systolic pressure measured in the lower extremity generally is
approximately 20 mmHg higher than that measured in the upper extremity.
Definitions for hypertension in children in the United States (table 3) and
other countries are provided separately. (See "Definition and diagnosis of
hypertension in children and adolescents".)
 ●Elevated blood pressure – In addition to the disorders mentioned
above, elevated blood pressures are associated with neuroblastomas,
pheochromocytomas, thyroid disease, neurofibromatosis, Cushing
disease, intoxication from or ingestion of various substances, increased
intracranial pressure, and myriad other disorders. It is wise to keep in
mind that elevated systolic pressures alone frequently are noted in
patients after vigorous exercise, excessive agitation, or during febrile
illnesses. (See "Epidemiology, risk factors, and etiology of hypertension
in children and adolescents", section on 'Secondary hypertension'.)
●Low blood pressure – Abnormally low blood pressure recordings are
noted in patients with heart failure from numerous causes and in
patients in shock from causes such as sepsis or hypovolemia. A rapid
change in the patient's position from supine to standing or sitting may
result in orthostatic hypotension. (See "Initial evaluation of shock in
children".)
●Pulse pressure – Pulse pressure is the difference between systolic and
diastolic blood pressure.
•Wide pulse pressure – Widened pulse pressures can occur in patients
with aortic regurgitation, arteriovenous fistulas, patent ductus
arteriosus, or hyperthyroidism. (See "Aortic regurgitation in
children" and "Clinical manifestations and diagnosis of patent ductus
arteriosus (PDA) in term infants, children, and adults" and "Clinical
manifestations and diagnosis of Graves disease in children and
adolescents".)
•Narrow pulse pressure – Narrowed pulse pressures are found in
patients with subaortic or aortic valve stenosis and occasionally in
those with hypothyroidism. (See "Subvalvar aortic stenosis (subaortic
stenosis)" and "Valvar aortic stenosis in children" and "Acquired
hypothyroidism in childhood and adolescence".)

SUMMARY

●General appearance – Assessment of the general appearance should

include the child's state of well-being, activity level, physical appearance,
behavior and attitude, body habitus, nutritional status, preferred
position (particularly for ill-appearing children), pitch and intensity of the
cry (in crying infants), breathing pattern, skin color, and developmental
status. (See 'General appearance' above.)
●History – The history is generally obtained from the caregiver for
infants and preschool children. Children aged 5 through 12 may
contribute to the history if they are willing and able. Adolescent patients
should be interviewed in the absence of caregivers when appropriate.
(See 'History' above.)
●Physical examination – The order in which the physical examination is
conducted often is age specific and depends upon examiner preference.
The portions of the examination that require the most cooperation
usually are performed first, and the more bothersome portions are
performed last. If the patient has a localized complaint, sign, or
symptom, that part of the examination should generally be performed
last. (See 'Physical examination' above.)
●Standard measurements – Measurement of the weight, length/height,
and head circumference is essential for assessing normal development.
Data obtained should be plotted on standard growth curves to
determine progress. (See 'Growth parameters' above.)
•Children <2 years of age
-Weight (figure 1A-B)
-Length (figure 3 and figure 5A-B)
-Head circumference (figure 7A-B)
•Children ≥2 years of age
-Weight (figure 2A-B)
-Height (figure 4 and figure 6A-B)
●Vital signs
•Temperature – Routine measurement of the patient's temperature
is not always necessary at health supervision visits. When a
temperature measurement is needed the appropriate site of
measurement varies with age, ability to cooperate, and clinical
scenario. (See "Fever in infants and children: Pathophysiology and
management", section on 'Temperature measurement'.)
•Respiratory and heart rates – The respiratory rate can be obtained
by auscultation, palpation, or direct observation. The heart rate can
be measured by direct auscultation or palpation of the heart or
peripheral arteries (carotids, femorals, brachial, or radials). Normal
values for age are provided in the table (table 1). (See 'Respiratory
rate' above and 'Heart rate' above.)
•Blood pressure – Yearly blood pressure measurements are routinely
obtained in children ages three years and older. Blood pressure
measurements also should be obtained in children younger than
three years if there is evidence or suspicion of underlying renal or
cardiovascular disease or acute illness. Standard reference values
according to height percentile are provided in the tables (table 2A-B).
(See 'Blood pressure' above.)
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