Clinical assessment of children

Attention

  • A child’s parent or guardian should always be present to provide legal consent and help with communication and on-going care
  • Keep child development chart on clinic wall for easy reference
  • Charter of rights for children in healthcare

What you need

What you do

Before starting consult

  • Check file notes for
    • Paediatrician letters
    • Operations, hospitalisations, accidents, injuries
    • Mother's health in pregnancy, birth and neonatal problems
    • Immunisation status, medicines and allergies
    • Any overdue recalls
  • Ensure privacy, have a comfortable well lit room and adequately equipped
  • Have toys or paper and pencils to occupy child
  • Consider own AND person’s safety 

Starting consult

  • Open consult — greet child and parent/carer by name and introduce yourself
  • Check name, next of kin, DOB, record name of parent/carer and who is legal guardian

Reason for presentation 

  • If new problem — start by taking a history
  • If review or follow-up — check file notes for earlier consult and follow-up plan
  • If child has chronic condition 
    • Check file notes for latest letters from specialists and management plans
    • Check recall register for scheduled follow-up
    • Take history, examine child with focus on chronic disease
  • Establish concerns and expectations with child and carer

History taking

  • When did child start getting sick
  • What was the first thing parent/carer noticed
  • How has the child acted since then
  • Has the child been eating and drinking
  • What does the child usually eat and drink
  • Any vomiting, diarrhoea, cough, rash or fever
  • Any change in urine output and bowel actions
  • Any concerns about child’s development including
    • At school — specific problems, interactions with peers
    • Behaviour — enuresis (bladder control), temper tantrum, thumb sucking, pica (abnormal eating of non-food items), nightmares
  • Any other concerns
  • Social issues — who is in the family, income, food supply, washing facilities for child, pets
  • Environment — smoke exposure, domestic violence, child safety, can they swim, heating and cooling of home, refrigeration, insect screens, dust control

Clinical examination

To assess young child properly you must undress them. Young child may be more comfortable sitting on parent/carers lap

Observe — before touching

  • Appearance — tone, interactivity, consolability, look and gaze, speech or cry 
  • Conscious state
  • Work of breathing — body position/posture, abnormal airway sounds, nasal flaring, sternal/intercostal recession/indrawing, tracheal tug, respiratory rate
  • If crying — character of cry (eg irritable, high pitched, whimpering)
  • Circulation — skin colour, rash, musculoskeletal tone

Head-to-toe exam — do ENT exam last, likely to upset child

  • Fontanelle — sunken, bulging
  • Eyes — colour, discharge
  • Head/hair — scalp sores/lumps, hair clean, thick/sparse
  • Neck — look and feel for lymph nodes
  • Chest — remove clothing
    • Look at work of breathing (eg indrawing, nasal flaring)
    • Listen for heart sounds (eg murmur)
    • Listen for breath sounds (eg crackles, wheeze)
  • Abdomen — soft, check for tenderness, masses, guarding, bowel sounds
  • Genital area — nappy rash, lesions, testes descended in boys
  • Skin — look all over for bruises, sores, other lesions
  • Check hydration/dehydration — fontanelle, mucous membranes
  • Look in ears with otoscope
  • Look in mouth at teeth, tongue and throat
  • Calculate age-appropriate REWS — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL

Negotiate management plan

Close consult

  • Cover contingencies — ensure parent/carer knows when to return, how to contact services if needed
  • Check parent/carer and child understanding and agreement with management plan
  • Provide referrals, prescriptions/medicines as needed

Documentation

  • Update persons record using organisations documentation process (eg SOAP, SODA-F)
  • Update required recalls using organisations process
  • Send letters/summaries/referral to other services identified by parent/carer

Reflect on consult

  • How did it go
  • What did you notice about person, about yourself or your reactions
  • Consider self-care, learning needs

Supporting resources