01Purpose and principlesWhat the assessment is for and the core concepts behind it.
Begin with the room. Watch how the child enters, separates, plays, makes eye contact, speaks, moves and responds to the caregiver. Note respiratory effort, colour and hydration before formal observations or undressing. A sleeping infant may be assessed for respiratory rate and perfusion before being woken. A mobile toddler is often best examined on a caregiver's lap. Introduce yourself to both child and adult, use the child's preferred name and explain each step in concrete, age-appropriate language.
Clarify who is present, their relationship and whether they have parental responsibility. Establish the presenting concern in the family's words, then build a timed sequence: last completely well, first change, progression, treatments tried and current state. Characterise symptoms with child-appropriate prompts and observable effects. Instead of asking a preschool child to grade dyspnoea, ask about talking, playing, walking, feeding and sleep. Record the source when histories conflict and explore differences neutrally.
Infant history requires antenatal, birth and neonatal context. Record gestation, delivery, birth weight, resuscitation, neonatal-unit care, jaundice, screening and maternal infection or medicines where relevant. Define feeding precisely, including breast effectiveness, formula preparation, solids, choking and reflux. Wet nappies and stool pattern help assess hydration. Ask about safe sleep, smoke exposure, immunisations, growth and developmental milestones. Correct age for prematurity when interpreting early growth and development according to the chart or developmental service.
In toddlers and preschool children, behaviour and function are central. Ask what the child can usually do and what has changed: walking, speech, play, toilet use, feeding and sleep. Use simple choices and demonstrate equipment on a toy or caregiver. Avoid offering a choice when an examination is necessary; say what will happen and give control over a minor detail. Explore nursery, infectious contacts, home environment and accidental or possible non-accidental exposure while maintaining a non-judgemental tone.
School-aged children can usually describe location, timing and impact of symptoms and should be addressed first. Ask about attendance, learning, friendships, sport, sleep and worries. Use concrete time anchors such as meals, school lessons and bedtime. Assess pubertal development only when clinically indicated, with explanation, assent and a chaperone. Consider neurodiversity, learning disability, sensory needs and preferred communication; behaviour that looks oppositional may reflect pain, fear, overload or difficulty processing language.
Adolescent consultation includes private time unless immediate safety or communication needs prevent it. Explain that information is private unless there is concern about serious harm to them or someone else. Use a structured psychosocial review such as home, education, activities, drugs, sexuality, mood and safety while adapting to the presenting issue. Ask about self-harm, exploitation and abuse directly when indicated. Assess decision-making capacity for the specific choice rather than using age alone, and involve parents with the young person's agreement where safe.
Past history covers diagnoses, admissions, operations, pregnancy and birth, development and immunisation. Medicines require prescribed, over-the-counter, herbal and caregiver-administered products, formulation, strength, dose, device and adherence. Confirm allergies and describe the reaction rather than recording an unqualified label. Family history should include consanguinity, early deaths and conditions relevant to the symptom. Social history includes household, housing, smoking or vaping, pets, travel, school, caregiver health and access to food or medicines.
Structure the examination around cooperation. First record general appearance and age-adjusted observations. Assess hydration and perfusion. Examine non-threatening systems while the child remains settled, then the relevant painful or invasive area. Listen to heart and lungs before crying when possible. Inspect before palpating, compare sides and observe gait or play instead of forcing formal manoeuvres. Throat examination, otoscopy and procedures come near the end. Stop and regroup if restraint would create harm or invalidate findings, unless the examination is immediately necessary for safety.
Growth is a clinical investigation. Measure without shoes and bulky clothing using calibrated equipment; use length below 2 years and standing height thereafter when possible. Plot on the appropriate UK-WHO chart and review serial centile movement, parental heights and corrected prematurity. Head circumference is important in infants and selected older children. Crossing centiles can reflect measurement error, nutritional or endocrine disease, chronic illness or normal catch-up, so confirm technique before interpreting.
Safeguarding is integrated rather than a separate accusation. Speak with the child alone when appropriate, use open non-leading questions and record spontaneous words verbatim. Examine the whole child when concern exists, document injury site, size, colour and shape and use body maps and clinical photography only under policy. Do not promise secrecy or confront an alleged perpetrator. Seek senior safeguarding advice and share information proportionately when a child may be at risk.
Key points
- Observe before touching: interaction, colour, posture, spontaneous movement, cry or speech and work of breathing provide high-value information before distress changes physiology.
- Use three sources deliberately: the child's account, the caregiver's longitudinal knowledge and the clinician's observations; record who supplied each important fact.
- Open with the child when development permits, then clarify with the caregiver without correcting or dismissing either account in front of them.
- For infants, define feeding by breast or formula pattern, volume or duration, wet nappies, stools, vomiting, weight trajectory, birth history and immunisation.
- For school-aged children and adolescents, offer part of the consultation alone, explain confidentiality and its safety limits and ask directly about mood, school, relationships, substances and sexual health when relevant.
- Use chronological age, corrected age for prematurity during early development, developmental level and communication needs rather than assuming ability from size.
- Examine least invasive areas first and leave throat, ears and painful sites until later; use play, caregiver positioning and warmed equipment.
- Count respiratory rate before auscultation while the child is quiet, count infant respirations for a full minute and record whether asleep, calm, febrile or distressed.
- Plot weight, length or height and head circumference on the correct sex- and age-appropriate UK growth chart when clinically relevant; a trend is more informative than one centile.
- Assess development across gross motor, fine motor and vision, language and hearing, and social domains; developmental regression is always abnormal.
- A complete examination includes hydration, skin, lymph nodes, abdomen, heart, lungs, neurology, joints and growth as directed by presentation, not just the symptomatic organ.
- Document positives and meaningful negatives, observations with units, growth centiles, chaperone, consent or assent, safeguarding findings and the safety-net plan.
02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.
Poor feeding, fewer wet nappies, weak cry, abnormal tone, reduced interaction or apnoea may be more informative than a localising symptom.
Loss of play, walking, speech, school attendance, feeding or sleep often expresses severity better than an adult-style symptom score.
Examination, injury account or expectations that do not match the child's developmental ability need clarification and possible safeguarding review.
A young person who can engage should receive direct questions, private consultation and a decision-specific competence assessment.
Serial centile crossing, disproportion, faltering weight or abnormal head growth warrants measurement confirmation and cause-directed assessment.
A credible report that the child is unusually sleepy, difficult to settle or unlike themselves should influence escalation and observation frequency.
03Method and interpretationA systematic approach to the test and its findings.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
First-line: unobtrusive observationFirst stepFirst line - Why
- Assess appearance, interaction, breathing, colour and movement before distress alters findings.
- Interpretation and limitations
- Abnormal tone, response, work of breathing or perfusion triggers immediate physiological assessment rather than completion of a routine history.
- 02
First-line: age-adjusted observationsFirst line - Why
- Quantify temperature, pulse, respiratory rate, oxygen saturation, blood pressure and consciousness where indicated.
- Interpretation and limitations
- Interpret against age, state and trend; crying, fever, sleep, pain and medicines can shift values without making an abnormal trend benign.
- 03
Growth measurements and chart - Why
- Assess nutritional status, proportional growth and head growth over time.
- Interpretation and limitations
- Confirm measurement and chart selection, then interpret serial centiles, gestation and parental context rather than one isolated percentile.
- 04
Developmental surveillance - Why
- Identify delay, asymmetry, sensory impairment or regression across developmental domains.
- Interpretation and limitations
- Variation in milestone timing is common, but regression, persistent asymmetry or loss of communication requires prompt specialist assessment.
- 05
Whole-child examination - Why
- Detect systemic, multisite and safeguarding findings beyond the presenting organ.
- Interpretation and limitations
- Use a cooperative sequence, document relevant negatives and relate every finding to age, development and physiological state.
- 06
Safeguarding and psychosocial assessment - Why
- Identify abuse, neglect, exploitation, self-harm and barriers to safe care.
- Interpretation and limitations
- Use factual observation and non-leading accounts, discuss concern with the safeguarding team and avoid deciding credibility from demeanour alone.
04Clinical next stepsHow the result changes management or prompts escalation.
01Opening assessmentObserve, include and prioritiseFirst stepAny child arrives for clinical assessment.+
- 1Observe appearance, breathing and circulation before approaching and decide whether ABCDE is needed immediately.
- 2Introduce yourself to child and caregiver, establish relationship and parental responsibility and identify communication needs.
- 3Invite the child's account first when development permits, then integrate caregiver chronology and clinical observation.
02Infant historyLink symptom to feeding and developmentThe patient is pre-verbal or in early infancy.+
- 1Establish gestation, birth, neonatal course, baseline growth, development and immunisation.
- 2Quantify feeds, vomiting, stools, wet nappies, sleep, interaction, breathing and temperature against the infant's normal pattern.
- 3Examine while settled, including fontanelle, tone, colour, perfusion, hydration, cardiorespiratory findings and a fully exposed skin review.
03Adolescent reviewCreate confidential, safe spaceA young person can participate in private history and decisions.+
- 1Explain confidentiality and its limits and offer time without parents, using an interpreter rather than family when needed.
- 2Explore relevant psychosocial domains, mood, self-harm, substances, sexual health, exploitation and safety with direct non-judgemental questions.
- 3Assess competence for each decision, agree what will be shared and create a safe follow-up and safeguarding plan.
04Safeguarding concernRecord facts and escalateEscalationHistory, injury, interaction, neglect or disclosure raises concern about harm.+
- 1Treat urgent injury and immediate safety needs and obtain the child's account with open non-leading prompts only.
- 2Document exact words, objective findings, developmental ability and explanation, using approved body maps or images.
- 3Seek named safeguarding or senior paediatric advice and share information through the statutory pathway without confronting a suspected perpetrator.
05Child becomes distressedPreserve both safety and diagnostic valueFear or restraint is compromising the examination.+
- 1Pause, return the child to the caregiver, reduce sensory load and use play or demonstration.
- 2Complete quiet observations and least invasive elements first and decide which remaining findings are essential now.
- 3Use proportionate help only for an urgent necessary examination or procedure, with analgesia, explanation and documentation.
05Risks, monitoring and follow-upComplications, safety checks and further assessment.
- Repeat observations after settling, analgesia or antipyresis when state may have influenced the first set, but never explain away persistent abnormality.
- Plot serial growth using the same accurate technique and review velocity rather than reacting to one uncertain measurement.
- Reassess function described at presentation—feeding, urine, interaction, mobility, school activity or sleep—to judge improvement.
- Confirm results and plans directly with both child and caregiver in developmentally appropriate language and use teach-back.
- Document safety-net symptoms, who to contact, expected time course and follow-up responsibility, including access barriers.
- When safeguarding concern exists, maintain a dated chronology and confirm that referrals, information sharing and immediate placement decisions were received.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Behaviour is an observation
Play, eye contact, consolability and spontaneous movement are examination findings, not distractions from a formal paediatric assessment.
Corrected age has limits
Prematurity correction supports early growth and developmental interpretation but should follow the relevant chart and service rather than being applied indefinitely.
Conflicting histories are data
Differences may reflect perspective, fear, separation or risk; record and explore them neutrally instead of choosing a narrator prematurely.
Pain distorts physiology
Treat pain and repeat pulse, breathing and blood pressure, while recognising that severe illness can coexist with distress.
Examination order is flexible
A complete assessment is defined by clinically necessary information, not by performing systems in an adult textbook sequence.
Safeguarding language stays factual
Describe what was said and seen, distinguish observation from interpretation and avoid terms that imply a conclusion unsupported by evidence.
07Common pitfallsFrequent interpretation and management errors.
- 01
Do not begin with throat examination or another invasive step when quiet cardiorespiratory findings are still obtainable.
- 02
Do not address only the caregiver when the child can communicate.
- 03
Do not use adult symptom language or pain scales without checking developmental understanding.
- 04
Do not record an allergy without the drug, reaction and timing.
- 05
Do not treat one normal vital sign as reassurance when appearance or trend is abnormal.
- 06
Do not assume a person accompanying the child automatically has parental responsibility.
- 07
Do not promise absolute confidentiality to an adolescent before explaining safety exceptions.
- 08
Do not use leading questions or repeatedly interview a child after a disclosure.
- 09
Do not interpret growth without confirming measurement, chart, gestation and serial trajectory.