Introduction
Examining children requires a fundamentally different approach to adult examination. A systematic yet flexible strategy — adapted to the child's age, temperament, and condition — allows you to gather the information you need while keeping the child calm and cooperative. In OSCE stations involving paediatric examination, marks are awarded for communication with child and parent, appropriate developmental adaptation, systematic technique, and recognition of important findings including safeguarding concerns.
The Paediatric Approach
The guiding principle is: examine from least to most distressing. Painful or invasive steps (ears, throat) should come last. Build rapport through play, distraction, and involving the parent or carer throughout.
🧠 Mnemonic
GAMES — The Paediatric Examination Framework
G — General inspection first (growth, dysmorphic features, respiratory distress, colour, behaviour)
A — Ask the parent/carer (history, concerns, developmental progress, immunisations)
M — Measurements (weight, height/length, head circumference — plot on growth chart)
E — Examine systematically, least to most distressing, with the child's cooperation
S — Safeguarding: actively consider non-accidental injury; document and act on any concerns
Before You Begin
- Introduce yourself to the child and to the parent/carer
- Get down to the child's level — kneel, sit, or crouch; never tower over a child
- Use age-appropriate language: toddlers need simple words; teenagers can be addressed like adults
- Allow the child to hold a toy or comfort object throughout
- Perform as much of the examination as possible with the child on the parent's lap
- Always offer examination to the child directly, even if you expect the parent to answer
💡 Tip
In the OSCE, narrate your examination to both the examiner and the parent: *"I'm just going to have a listen to his chest now — it won't hurt at all."* This demonstrates communication skills and wins marks simultaneously.
Growth Assessment
Measurements
| Measurement | Under 2 years | Over 2 years |
|---|---|---|
| Height/length | Lying supine (length) | Standing (height) |
| Weight | Undressed | Light clothing, no shoes |
| Head circumference | Measure at every visit to age 2 | Measure if concern |
Plot all measurements on the appropriate UK-WHO growth chart (boys and girls have separate charts). Mark the child's current centile and compare to previous measurements.
A child crossing two centile lines downwards warrants investigation for faltering growth. Plot mid-parental height to contextualise results — a child on the 2nd centile with petite parents may be growing entirely appropriately.
⚠️ Red Flag
Faltering growth — defined as weight falling through two or more centile lines — requires systematic assessment for organic cause (coeliac disease, cystic fibrosis, congenital heart disease) and, crucially, assessment of feeding adequacy and safeguarding concerns. Do not attribute to parental anxiety without appropriate investigation.
Developmental Milestones
| Age | Gross Motor | Fine Motor | Language | Social |
|---|---|---|---|---|
| 6 weeks | Head control prone, responsive smile | — | Coos, startles to sound | Social smile |
| 3 months | Head up 45° prone, no head lag | Briefly holds rattle | Coos, vocalises | Social smile established |
| 6 months | Sits with support, rolls | Palmar grasp, transfers hand to hand | Babbles (ba, da) | Laughs, recognises parents |
| 9 months | Sits unsupported, crawls | Pincer grip developing | Mama/dada non-specific | Stranger anxiety, waves bye |
| 12 months | Pulls to stand, cruises | Mature pincer grip | 1–2 words with meaning | Points to request |
| 18 months | Walks well, runs | Tower of 3–4 cubes | 6–20 words, points to pictures | Parallel play, feeds self |
| 2 years | Runs, kicks ball | Tower of 6 cubes | 50+ words, 2-word phrases | Symbolic play |
| 3 years | Climbs stairs (one foot per step), pedals | Copies circle | Sentences, strangers understand | Group play |
| 4–5 years | Hops, skips | Copies cross, draws person | Full sentences, tells stories | Cooperative play, friendships |
💎 Clinical Pearl
For the OSCE, focus on the four domains (gross motor, fine motor, language, social) and know the key milestones at 6 weeks, 6 months, 12 months, 18 months, and 2 years. Developmental regression — losing a previously acquired skill — is always abnormal and requires urgent review.
Fontanelle Assessment
| Fontanelle | Normal Closure | Clinical Significance |
|---|---|---|
| Anterior (diamond-shaped) | 9–18 months | Bulging = raised ICP; sunken = dehydration; late closure = hypothyroidism, hydrocephalus, Down syndrome |
| Posterior (triangular) | 6–8 weeks | Delayed closure: congenital hypothyroidism |
Assess the anterior fontanelle with the child upright and calm — a crying or supine child will have a normally tense fontanelle.
⚠️ Red Flag
A bulging fontanelle in a febrile child is a red flag for bacterial meningitis until proven otherwise. Immediate assessment, LP (unless contraindicated), blood cultures, and IV ceftriaxone are required. Do not delay antibiotics for imaging in an unwell child.
Systematic Paediatric Examination
General Inspection
Observe from the doorway:
- Colour: pallor (anaemia), central cyanosis, jaundice, plethora
- Respiratory distress: tachypnoea, subcostal/intercostal recession, nasal flaring, grunting
- Activity level: playing, alert, lethargic, drowsy, inconsolable
- Dysmorphic features: low-set ears, epicanthic folds, widely spaced eyes, micrognathia
- Nutritional status: wasted, obese, appropriate for age
Hands and Peripheries
- Peripheral vs central cyanosis: assess tongue and mucous membranes
- Clubbing: cystic fibrosis, cyanotic congenital heart disease, IBD
- Capillary refill time (CRT): press central sternum for 5 seconds — normal <2 seconds
Cardiovascular Examination
- Normal heart rate varies: neonates 120–160 bpm; 1 year ~120 bpm; 5 years ~100 bpm; 10 years ~80 bpm
- Precordial bulge suggests cardiomegaly
- Active precordium may indicate left-to-right shunt
- Auscultate in all five areas; note murmur character, timing, and radiation
Respiratory Examination
- Tracheal tug, sternal recession, and subcostal recession indicate increased work of breathing
- Bronchial breathing, reduced air entry, and wheeze have the same significance as in adults
Abdominal Examination
- Hepatomegaly: a normal liver edge may be palpated 1–2 cm below the costal margin in infants
- Splenomegaly: always abnormal at any age — consider haematological malignancy, storage disease, infection
- Check for hernias and undescended testes in boys
Paediatric GALS
The paediatric GALS screen adapts adult musculoskeletal screening for children:
- Gait: observe walking, running, hopping on one foot (age ≥4)
- Arms: arms out palms up/down; make a fist; squeeze hands
- Legs: squat, stand; internal rotation of hips lying supine
- Spine: forward flexion, lateral flexion, look for scoliosis
Safeguarding
Always maintain an active index of suspicion for non-accidental injury (NAI):
- Bruises in non-mobile infants or in unusual locations (ears, neck, trunk, buttocks)
- Multiple bruises of different ages
- Delay in presentation or history inconsistent with the injury
- Fractures in non-ambulant infants (spiral fractures, posterior rib fractures)
- Torn frenulum in infants (forced feeding)
- Subdural haematoma with retinal haemorrhages (abusive head trauma)
⚠️ Red Flag
If you have any concern about NAI in an OSCE, always state: *"I have safeguarding concerns. I would discuss immediately with the senior paediatric doctor on call and the named nurse for safeguarding. I would not discharge this child until a full safeguarding assessment has been completed."* This is a pass/fail statement in many OSCEs.
FAQs
"How do I approach a child who refuses to be examined?"
Remain calm and patient — never force an examination. Use distraction (bubbles, stickers, phone), allow the child to examine a toy or doll first, let the parent assist, and perform as much as possible visually before touching. State in the OSCE that you would give the child time to settle and use play techniques before proceeding.
"What are the red flags in a child that signal immediate escalation?"
The NICE traffic light system stratifies risk: red features include pale/mottled/ashen skin, no response to social cues, does not wake or stay awake, grunting, severe respiratory distress, or reduced skin turgor. Any red feature mandates immediate senior review and potential hospital admission.
"How should I interpret a single growth measurement?"
A single measurement cannot identify faltering growth — you need at least two measurements over time plotted on a centile chart. Context is essential: parental heights, birth centile, feeding history, and developmental progress all inform interpretation.
"When should I refer a child for a developmental assessment?"
Refer if: not smiling by 8 weeks; not sitting by 12 months; not walking by 18 months; not using any words by 18 months; regression in any domain; parental concern; or your own clinical concern. The principle is: if in doubt, refer — early intervention is evidence-based.
"What is the normal anterior fontanelle and when is it abnormal?"
The normal anterior fontanelle is soft and flat when the child is upright and calm. It may bulge slightly when crying — this is normal. Persistent bulging at rest suggests raised intracranial pressure (meningitis, hydrocephalus, cerebral oedema). A sunken fontanelle indicates dehydration. Late closure beyond 18 months suggests hypothyroidism, Down syndrome, or hydrocephalus.
Related Posts
- Paediatric History Taking OSCE — structured history taking in children including birth, developmental, immunisation, and feeding history
- Neurological Examination OSCE — neurological signs in children including tone, reflexes, and cranial nerves
- A–E Assessment OSCE — recognising and managing the acutely unwell child using ABCDE