AFMC National Clinical Skills Working Group Evidence-Based Clinical Skills Document

Table 11: Pediatric Examination

Physical Sign / ManoeuvreRationaleTechnique(s)InterpretationEvidencePre-ClerkshipClerkship
APGAR ScoreTo assess immediate neonatal well-beingAssess heart rate, respiratory effort, colour, muscle tone & responsiveness to stimuli on scale of 0, 1 or 2. Total score is measured out of 10, and given at 1 and 5 minutes after birthLow APGAR scores alone do not predict poor neurologic outcome. Persistence of low scores at 10, 15, 20 minutes increases the risk of poor outcome.

The change in APGAR scores over time provides a useful indication of the response to resuscitation.
Poor inter-observer reliability of APGAR scores, particularly in infants who are most unwell.

O’Donnell, 2006.

American Academy of Pediatrics, Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists and Committee on Obstetric Practice, 2006.
Respiratory Exam
TachypneaClinical detection of pneumoniaObservation for 60 secondsRR>50 (2-12 months) or RR>40 (>12 months) suggests pneumonia

Sensitivity 40%, PPV 20%
Specificity 74%, NPV 88%

Shah, 2010.
Wheeze in infantsTo detect acute asthma, bronchiolitisWheezing in infants is characterized by high-pitched whistling or musical sounds, heard mainly during expirationrespiratory exam of wheezing shows good inter-rater reliability, but overall respiratory status most reliable

wheeze is often mis-used term by parents, low reliability between clinical assessment & parental report of wheeze
Stevens, 2003.
Mellis, 2009.
StridorTo detect aspiration of a foreign object, croup, epiglottitisSound must be assessed along with history (choking, aspiration, cyanosis, wheeze)

Stridor is predominantly an inspiratory noise, usually indicating extra-thoracic airway obstruction
History is most useful for diagnosis of foreign body, correlates much better than physical exam findings. Stridor is an uncommon presenting sign of foreign body aspiration (choking & cough most common)

epiglottitis generally associated with soft vibrating “snoring” rather than harsh stridor.

croup presents with harsh stridor, viral URTI symptoms, & brassy cough
Physical examination abnormal in 80.4% of children with foreign bodies (stridor in 5.4%), but specificity was only 59.5%.

Even, 2005.

Mellis, 2009.
Ear pain To detect otitis mediaObservation & historyEar pain is symptom most likely to be associated with bacterial otitis media (AOM). “Ear rubbing” has some predictive ability. Other symptoms (ear tugging/rubbing, crying, fever, poor appetite) are less specific & are commonly seen with viral illnesses.Positive LR 3 - 7.3 across studies, and negative LR 0.4 - 0.6

Powers, 2007.
Rothman, 2003.
Abnormal Tympanic Membrane FindingsTo detect bacterial cause of AOMLook at tympanic membrane anatomic landmarks, color, mobilityPhysical examination findings of AOM are often taken in combination. Significant overlap in clinical findings & symptoms between bacterial & viral causes of tympanic membrane abnormalities.Examination findings indicative of AOM are TM that is cloudy (LR 34), bulging (LR 51), immobile (LR 31), strongly red (LR 8.4)13
Cardiovascular Exam
Blood pressureScreening for hypertensionPreferred method for BP measurement is auscultation. Measurements should be taken in the child’s right arm, with child in the seated position.

Screen with BP measurements in children >3 yrs of age unless risk factors present
Hypertension in children is defined as SBP or DBP greater than or equal to 95% for gender, age & height on 3 occasions. Comparison to standardized reference charts for BP.

Secondary hypertension (from underlying medical cause) is more common in children than in adults, and investigations should be undertaken to find cause of HTN.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, 2004.

Ogedegbe, 2010.
Gastrointestinal Exam
Abdominal pain migration to RLQ, abdominal wall rigidity, and psoas signTo predict/ diagnose appendicitisMigration of abdominal pain to RLQ generally found on history.

Abdominal wall rigidity reflects involuntary guarding (does not resolve with distraction)

Psoas sign is assessed by pain on hip flexion against resistance with the patient supine, or with pain on hip extension while patient lies on left side

RLQ abdominal pain is a stronger predictor of appendicitis in adults than in children.

Combination of physical examination signs are more helpful in predicting likelihood of appendicitis in children. Combined scores (Alvarado/ Pediatric Appendicitis scores which combine these findings can be used)

Inter-rater reliability of physical examination signs highest for RLQ pain and Rovsing signs. Better agreement between examiners re: overall risk of appendicitis.
Pain that starts mid-abdominally and migrates to RLQ has positive LR 1.9-3.1, negative LR 0.41-0.72 involuntary guarding (rigidity) has positive LR 1.6-2.6, negative LR 0.21-0.61 Psoas sign has positive LR 2.0-2.5, negative LR 0.75-0.86

When examiners had high clinical suspicion for appendicitis, 79-80% of the time, they were correct, when they felt extremely unlikely, they were correct 94-95% of the time.

Bundy, 2007.
Kharbanda, 2008.
Dry mucous membranes, sunken eyes/fontanelle, drowsiness, irritability, acidotic breathing, cool mottled periphery, capillary refill > 2 sec.To detect dehydrationSkin turgor measured by pinching skin fold lateral to umbilicus

Capillary refill time evaluated by blanching an area of skin & awaiting time for normal color to return. Should be done in a warm room.
Combination of physical examination signs are more useful than single signs in isolation

Abnormal skin turgor, prolonged capillary refill and abnormal respiratory pattern are best individual signs to use in assessment of dehydration
Prolonged capillary refill had positive LR 4.1, abnormal skin turgor LR 2.5, abnormal respiratory pattern LR 2.0

Sunken eyes & dry mucus membranes had LR 1.7, remainder of signs had imprecise results or positive LR < 0.5

Steiner, 2004.
Musculoskeletal Exam
Adams Forward-Bending TestTo identify scoliosisChild bends forward with knees straight, examiner looks for asymmetry and/or rotation of the back or prominence of ribs/scapula on one sideCobb angle > 10% on AP radiograph defines scoliosis

Forward bending test is more accurate when combined with other measures (ie. scoliometer). High false positive rates with the test used alone.
sensitivity 84%
specificity 93%

PPV 23.2%

Fong, 2010.
Karachalios, 1999.
Barlow and Ortolani tests To identify developmental dysplasia of the hipHips are tested individually in the flexed position while the child is on a hard surface. Diaper must be removed.

For Barlow test, the hip is pushed back in order to dislocate a hip, and for the Ortolani test, the hip is abducted so that a dislocated hip can relocate.
Skill of the examiner correlates with the sensitivity of these tests, as well as with age of the child (more difficult to detect dislocation with Ortolani and Barlow tests in older infants. In these children, Galeazzi sign, leg length discrepancy and abnormal thigh/gluteal folds are used for detection)Hips are tested individually in the flexed position while the child is on a hard surface. Diaper must be removed.

Repeated clinical examination is recommended routinely in all infants (up to 12 months of age)
Barlow NPV 0.99, PPV 0.22

Combined (Ortolani & Barlow)
sensitivity 0.87-0.99
specificity 0.98-0.99

Patel, 2001.
Neurological Exam
Primitive reflexes and postural reactionsTo screen for cerebral palsy and other neuro-developmental conditionsCommon primitive reflexes include Moro, palmar and plantar grasp, rooting, sucking, placing, Galant, asymmetric tonic neck reflex. They generally are present at birth and decrease within the first year of life.

Postural reactions (vertical suspension, horizontal suspension, etc.) require cortical integrity and develop after birth in the first year as the CNS matures.
Persistence of primitive reflexes beyond 12 months of age is often seen in children with cerebral palsy

Infants with 5 or more abnormal postural reactions are considered to be at risk for cerebral palsy or developmental retardation
Zafeiriou, 2004. 12
Denver Developmental Screening Test - Denver IIUsed as a screen for developmental delayStandardized test which combines examiner observation as well as parental report of the child’s skills in personal-social, fine motor, language and gross motor areasChildren with an abnormal Denver II are at higher risk of poor school performance, and lower IQ (<89)26% of children with abnormal screens had poor school scores (compared to 10% of children with normal screens)

Abnormal Denver II screens had higher incidence in low SES children.

IQ < 89 in 43% of children with abnormal Denver II

Bayoglu, 2007.
Rourke Baby Record: Evidence Based Infant/Child Health Maintenance GuideEvidence-based structured form used by primary care practicioners at each well-baby/well-child visit from 0-5 yrs. Used as a screen to identify concerns in growth, nutrition, development, behaviour and immunizations as well as to identify abnormal physical findings and congenital anomalies At age-specific visits assess:
-eyes (red reflex, cover/uncover)
-femoral pulses
-testicles, urinary stream
-hearing (clap test)
Specific targeted evidence-based maneuvers at appropriate ages help to screen for feeding difficulties, congenital dislocation of the hips, vision and hearing abnormalities

Targeted exam does not imply lack of general physical exam, but highlights areas of focus at each visit (1 week, 2, 4, 6, 12, 18 months, and 2-3, 4-5 years)

Panagiotou, 1998.
Developmental testing
WHO and CDC growth chartsGrowth charts that plot weight, length, head circumference, BMI, weight-for-length Measurements taken at different ages are plotted on the appropriate curve to assess growth percentiles. Children generally follow along a given percentile curve.

Length is measured for children < 24 months, and stature is measured for children > 24 months.
WHO growth curves were developed using longitudinal data to reflect growth of exclusively breastfed infants across different cultures. They describe how healthy children should grow under optimal growth conditions. There was almost no variation among different ethnic groups.

This contrasts with the CDC curves which describe how certain children grew in the United States over a span of 30 yrs.

Suggestion is to use WHO growth curves for the first 24 months of life. May use CDC or WHO curves for children > 24 months.
Grummer-Strawn, 2010.23
Red reflex examination (neonate) To identify eye abnormalities including refractive errors, glaucoma, retinoblastoma, retinal abnormalitiesDirect opthalmoscope held to examiner’s eye, set to “0”. Test performed in a darkened room at a distance of 18 inches away from the child. Both eyes are examined simultaneously.

Examining for diminished reflex, asymmetric reflex, white reflex
Diminished reflexes may result from cataracts, unequal reflex may be seen with strabismus or unequal/high refractive errors.

Leukokoria (white reflex) is highly suggestive of retinoblastoma.
American Academy of Pediatrics, Section on Ophthalmology, American Association for Pediatric Ophthalmology And Strabismus, American Academy of Ophthalmology, American Association of Certified Orthoptists, 2008.13
Cover/Uncover testTo test for strabismusHave the child look at a distant object, then place an occluder over each eye. Watch for movement in the eye that is not occluded. (inwards indicates underlying exotropia, outwards indicates underlying esotropia).

Test each eye individually
Strabismus is a term for ocular misalignment.

Normal visual pathway development relies on equally clear, focused images from both eyes.
Consensus for screening

American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, 1996.
Visual Acuity TestingTo detect refractive errors & eye diseases leading to amblyopia & strabismusIn young children (0-3 yrs), the child’s ability to fix and follow objects is assessed

Older Children:
-LEA/LH symbols
-Allen cards
-Snellen letters
-Snellen numbers
-tumbling E

Full eye examination is necessary including inspection, pupil response and extra-ocular movements
Abnormalities on exam may lead to diagnosis of conditions that cause amblyopia and strabismus (ie. refractive errors and glaucoma)Visual acuity measurement should be performed at earliest time practical (approx. 3 yrs)

Committee on Practice and Ambulatory Medicine Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology, 2003.
Hearing testEarly intervention in children with hearing loss improves later language skills Physical examination of the skin, eyes & ears is necessary

Screening tests (any age)
-evoked otoacoustic emissions
-automated ABR

-play audiometry (2-4 yrs)
-conventional pure tone audiometry (4 yrs +)
-visual reinforced audiometry (6-24 months)
-automated ABR (3-6 months)
Abnormal hearing screens necessitate further diagnostic testing

For any parental concerns regarding hearing in their child, audiometry should be undertaken
Parents identify subtle hearing loss as early as 12 months prior to the physician identifying a problem

Harlor, 2009.