3 Pediatric Health Assessment

Principles of pediatric assessment

A strong pediatric assessment brings together the child’s report, caregiver observations, objective findings, and developmental stage. A calm, respectful, family-centered approach can improve comfort and accuracy. Explain what you will do, invite the child and family to share priorities, and use a qualified interpreter when needed.

The Bright Futures/American Academy of Pediatrics (AAP) Periodicity Schedule outlines preventive assessments by age. A concern may require additional evaluation between routine visits.

Gathering an age-appropriate history

Begin by asking why the child is being seen and what concerns the family most. For a current problem, clarify its onset, duration, location, character, severity, timing, aggravating or relieving factors, and associated symptoms. Ask what the child can normally do and what has changed.

Adapt the history to age and context:

• Newborns and infants: Ask about pregnancy and birth, feeding, sleep, wet and soiled diapers, jaundice, and caregiver concerns. Obtain details from caregivers and observe the infant’s behavior and interaction.

• Children: Ask about past illnesses, injuries, procedures, medications and supplements, allergies, immunizations, family history, development, school, nutrition, sleep, elimination, and relevant home or environmental exposures.

• Adolescents: Cover the same health topics, as well as mood, relationships, sexual health, substance use, safety, and future plans. Offer private time, explain confidentiality and its limits, and follow applicable law and clinical policy.

Use open-ended questions first, then focused questions to clarify. For example, ask, “What worries you most about the cough?” and then, “When did it start, and is breathing harder than usual?” Include the child’s account whenever they can communicate; caregiver observations add useful context.

Conducting the physical examination

Begin the examination by observing appearance, interaction, work of breathing, movement, and comfort. Measure growth consistently and plot the results rather than relying on a single measurement. In the United States, use WHO growth standards from birth to age $2$ and CDC growth charts from age $2$ onward; interpret the pattern over time in light of the child’s history.

Make the examination appropriate to the child’s developmental stage. Infants and young children may be examined on a caregiver’s lap when helpful; play or demonstration can support cooperation. Do less distressing steps before uncomfortable ones, and tell the child before touching them or using equipment.

For adolescents, explain sensitive parts of the examination, protect privacy, and follow consent and chaperone policies. Compare findings with the child’s baseline and examine systems relevant to the history. A normal examination does not replace follow-up of a concerning history or screen.

Measuring vital signs and blood pressure

Vital signs include temperature, heart rate, respiratory rate, and blood pressure. Add oxygen saturation when clinically indicated. Interpret measurements using age-appropriate references and the child’s condition, since normal ranges change with age and other factors.

Measure when the child is as calm as possible, use the correct equipment and technique, and repeat unexpected readings before acting when the child is stable. Count respirations carefully, especially in infants, and document the temperature route.

For blood pressure, use an appropriately sized cuff and standardized positioning. AAP guidance recommends annual measurement from age $3$. For children age $3$ or older with specified risk factors—including obesity, kidney disease, diabetes, certain medications, or aortic arch disease—measure at every health care encounter. An elevated screening value requires appropriate confirmation and follow-up; it is not by itself a diagnosis.

Assessing pain

Ask the child to describe pain whenever possible, using a consistent scale suited to the child’s age and communication abilities. A faces or numeric self-report may suit a child able to use it. For a young or nonverbal child, an observational tool such as FLACC (Face, Legs, Activity, Cry, Consolability) may help. Consider what the caregiver knows about the child’s usual pain behaviors.

Record the scale used, comfort measures or treatment, and the child’s response on reassessment.

Using preventive screening

Screening is a structured way to identify possible concerns, not a diagnosis. Follow the current Bright Futures/AAP schedule and local requirements for age-specific vision, hearing, development, behavior, and other preventive screens.

Standardized developmental screening is recommended at $9$, $18$, and $30$ months; autism-specific screening is recommended at $18$ and $24$ months. Act on caregiver or clinician concerns at other ages as well rather than waiting for a scheduled screen.

Assessing safety and offering guidance

Ask about safety in a neutral, nonjudgmental way. Topics may include:

• Safe sleep for infants.

• Car seats, seat belts, and helmets.

• Water and firearm safety.

• Medicines and other poisons, and smoke exposure.

• Bullying, violence, and whether the child feels safe at home or school.

• For adolescents, relationship safety and self-harm.

Tailor anticipatory guidance to the child’s age, abilities, and family circumstances. The Bright Futures schedule includes age-specific screening and assessment recommendations.

Responding to concerning findings

Respond immediately to signs of instability, such as severe difficulty breathing, blue or gray color, markedly reduced responsiveness, seizure, or signs of poor circulation. A rectal temperature of $100.4^\circ\mathrm{F}$ ($38^\circ\mathrm{C}$) or higher in an infant $3$ months old or younger requires prompt medical evaluation.

Arrange timely clinical follow-up for persistent abnormal vital signs; growth that departs from the child’s established pattern; developmental delay or loss of skills; abnormal examination findings; a positive screen; or ongoing pain, feeding, sleep, mood, or safety concerns. Clarify the next step, who is responsible, and when reassessment should occur.

A positive screen or isolated measurement signals a need for further assessment, not a diagnosis on its own. If a child may be unsafe or at risk of harm, follow safeguarding and reporting procedures promptly.

Putting the assessment together

Pair an age-appropriate history and examination with accurate growth and vital-sign measurement, developmentally suitable pain assessment, scheduled and concern-driven screening, and a respectful safety check. Interpret findings in context, confirm unexpected measurements when appropriate, and make a clear plan for urgent concerns and routine follow-up.

• Safety assessment