2 Pediatric Initial Assessment and Triage

First impressions and pediatric priorities

Children can worsen quickly, and early signs of serious illness may be subtle. Triage is an ongoing process: identify immediate threats, begin appropriate care within your training and local protocol, and reassess for change.

Interpret findings in light of the child’s age and developmental stage. A value that is normal for an older child may be abnormal for an infant. Do not wait for low blood pressure before escalating concern, because hypotension can be a late sign of Pediatric shock.

Observe the child before handling them. The Pediatric Assessment Triangle (PAT)—appearance, work of breathing, and circulation to the skin—provides a rapid visual first impression of possible critical illness, but does not replace a full assessment.

The ABCDE primary assessment

Use the ABCDE sequence to assess and address threats. If you find a life-threatening problem, intervene and call for appropriate help before moving on. In trauma, consider cervical-spine injury and use suitable precautions while maintaining airway care.

Airway

Check whether the airway is open. Listen for air movement, abnormal sounds, secretions, or obstruction. Apnea, inability to maintain the airway, stridor, choking, and markedly reduced air movement are concerning findings. For infants, keep the head and neck in a neutral position while assessing the airway.

Breathing

Observe breathing rate and effort, chest movement, and symmetry. Assess breath sounds and oxygen saturation when available. Grunting, nasal flaring, retractions, head bobbing in an infant, cyanosis, exhaustion, apnea, and poor air entry are concerning. A child who becomes quieter or less responsive after working hard to breathe may be deteriorating rather than improving.

Circulation

Check heart rate, pulse strength, skin color and temperature, Capillary refill, bleeding, and blood pressure when feasible. Weak pulses, cool or mottled skin, prolonged capillary refill, significant bleeding, and worsening tachycardia are concerning. Children may maintain blood pressure until shock is advanced.

Disability

Assess responsiveness and age-appropriate interaction. Check pupils and blood glucose when indicated and available. New confusion, unusual sleepiness, poor response to voice or touch, seizure, and reduced consciousness are concerning.

Exposure

Look for injuries, rash, bleeding, or other clues, and obtain temperature when appropriate. Protect privacy and prevent heat loss during the examination.

Gathering a focused SAMPLE history

Once immediate threats are being addressed, obtain a brief SAMPLE history, preferably from the caregiver and child together when appropriate. Do not delay urgent assessment or treatment to complete it.

• Signs and symptoms: Ask what changed and when. Ask about breathing, color, responsiveness, pain, fever, intake, and urine output.

• Allergies: Ask about medication, food, or other allergies and the reaction.

• Medications: Ask about regular medicines and anything given for the current illness or injury.

• Past history: Ask about medical conditions, prior similar episodes, surgeries, immunizations when relevant, and baseline function.

• Last intake: Ask when the child last ate or drank and about recent feeding or hydration.

• Events: Ask what happened before symptoms began. For injury, clarify the mechanism, timing, and any loss of consciousness.

In trauma, the reported mechanism may help identify risk, but assess the child’s actual condition and look for injuries that may not be obvious. Eye contact, consolability, feeding, and interaction with a caregiver can help establish whether the child is behaving normally for them.

Recognizing deterioration and setting urgency

Escalate promptly for airway obstruction, severe respiratory distress, central cyanosis, poor perfusion, major bleeding, seizure, or markedly altered responsiveness. Take a worsening trend seriously, including increasing work of breathing, fading interaction, weaker pulses, cooler skin, or falling oxygen saturation.

The WHO pediatric triage tool categorizes patients by acuity and flags emergency signs such as unresponsiveness, stridor, respiratory distress or central cyanosis, weak and fast pulse, cold extremities, and high-risk trauma. Apply the triage system and response times used in your setting.

Caregiver concern and deviation from the child’s usual behavior are useful assessment information. When uncertain, seek senior or emergency support early rather than relying on a single measurement.

Reassessment and response to change

After every intervention—and whenever the child’s condition changes—repeat the relevant ABCDE checks. Recheck and document vital signs, oxygenation, mental status, work of breathing, perfusion, and response to care.

Compare findings with the initial assessment and note the direction of change, not just isolated numbers. If improvement is absent or temporary, reassess for an unresolved or new threat, escalate care, and arrange appropriate monitoring, transfer, or handover.