Physical Examination of the Child
Why it doesn’t pay to mechanically copy the adult examination sequence in children — and how to change the order of steps by age
With an adult patient, a paramedic generally proceeds systematically from head to toe. In children, this approach remains the target framework, but the order of steps adapts to the developmental stage — with a single fixed principle across all ages: the least invasive steps come first, the most unpleasant last. This fifth installment of the PED series builds on the Pediatric Assessment Triangle from the previous installment and covers how to conduct the hands-on examination itself.
Approach by age category
Newborn and infant
The examination ideally takes place in the parent’s arms or on their lap — changing position and separation from the parent increase distress and make assessment harder. Proceed “toe-to-head” or at least in order from least to most disruptive: the heart, lungs, and abdomen are examined first, ideally while the child is calm or asleep; the ears, mouth, and throat (most unpleasant) are left for last. The examiner’s hands must be warm — a cold touch by itself provokes crying and invalidates subsequent steps.
Toddler (1–3 years)
This group offers the greatest resistance. Minimal direct contact at the start is recommended, examining from the child’s level (crouching, not from above), and keeping the child on the parent’s lap. Letting the child “explore” equipment (e.g., a stethoscope) before its use reduces fear. As with an infant: heart and lungs first, ears/mouth last.
Preschool age (3–6 years)
The approach is similar to a toddler’s, but the child usually responds better to play and simple explanations (“I’ll check if your tummy sounds good”). From this group onward, it’s generally possible to move closer to the classic head-to-toe order, though the most unpleasant steps still belong at the end.
School age and adolescent
The examination can be conducted systematically from head to toe, similarly to an adult. It’s important to explain the procedure in advance, respect privacy (particularly in adolescents), and actively ask for consent before individual steps — not just for cooperation, but also for building trust.
| Age | Recommended order | Note |
|---|---|---|
| Infant | Heart/lungs/abdomen → rest of the body → ears/mouth/throat | Examine on the parent’s lap while calm |
| Toddler | Same as infant | Minimal contact at the start, let them “explore” equipment |
| Preschool age | Closer to classic head-to-toe | Most unpleasant steps at the end |
| School age / adolescent | Classic head-to-toe | Explain the procedure in advance, respect privacy |
The role of the parent / legal guardian
The parent isn’t just a source of history — they’re an active tool for soothing the child and often the person best able to recognize a deviation from usual behavior. Keeping the child on the parent’s lap instead of isolated positioning on a stretcher significantly reduces separation anxiety and improves the quality of examination, particularly in infants and toddlers.
Practical implications for the paramedic
- Actively involve the parent — as someone holding the child, soothing them, and as a source of information about the child’s usual behavior.
- Always proceed from the least to the most invasive step, regardless of exact anatomical order.
- Let the child (from toddler age up) “explore” equipment before using it — it reduces fear and improves cooperation.
- With adolescents, actively communicate and respect privacy — in some situations, consider part of the examination without the parent present, in accordance with the sensitivity of the topic and the child’s/guardian’s consent.
Connection to the next part of the series
In PED-06, we’ll return to the numbers — reference vital-sign values by age category and how to correctly interpret them in the context of the overall clinical picture, not in isolation.
- Chiocca EM. Assessment of a Pediatric Patient. In: Advanced Pediatric Assessment, Springer Publishing.
- How to Approach Pediatric Patients. American Association of Critical-Care Nurses (AACN), 2023.
- Physical Assessment of Children. In: Wong’s Nursing Care of Infants and Children, Elsevier.
- Assessment Sequence and Techniques in the Pediatric Patient. Osmosis.