Chapter 2.3 Approach to the sick child

All children must be examined fully, so that no important sign will be missed.  In contrast to the systematic approach in adults, however, the examination of the child needs to be organized in a way that does not upset the child.  The approach to examining children should be flexible.  Ideally, you will perform the most 'invasive' part of the examiniation (e.g.the head and neck examination) last

  • Do not upset the child unnecessarily.
  • Leave the child in the arms of the mother or carer.
  • Observe as many signs as possible before touching the child:
    • Does the child speak, cry, or make any sound?
    • Is the child alert, interested and looking about?
    • Does the child appear drowsy?
    • Is the child irritable?
    • Is the child vomiting?
    • Is the child able to suck or breastfeed?
    • Is the child cyanosed or pale?
    • Does the child show signs of respiratory distress?
    • Does the child use auxiliary muscles of breathing?
    • Is there lower chest wall indrawing?
    • Does the child appear to breath fast?
  • Count the respiratory rate.

These and other signs should be recorded before the child is disturbed.  You might ask the mother or caretaker to cautiously reveal part of the chest to look for lower chest wall indrawing or to count the respiratory rate. If a child is distressed or crying, he or she migh have to be left for a brief time with its mother in order to settle, or the mother could be asked to breastfeed, before key signs such as respiratory rate can be measured.

Then proceed to signs which require touching the child but are minimally disturbing, such as feeling the pulse or listening to the chest. You obtain little useful information if you listen to the chest of a crying child.  Signs that involve interfering with the child, such as recording the temperature, testing for skin turgor, capillary refill time, blood pressure or looking at the child's throat or ears should be done last.  Measure the oxygen saturation with a pulse oximeter in all children who have fast breathing or chest indrawing.

  • Perform bedside tests if available and appopriate

Some tests may easily be performed at the point of care, sometimes called point of care tests:

  • glucostix for an urgent blood sugar
  • rapid diagnostic test for malaria or
  • any other simple bedside tests.