Case Review: Child's Play - Paediatric Assessment
This case review will allow you to explore the intricacies and arguably, the dark art of paediatric assessment. This is an especially relevant area of practice to explore, as some paramedics are not confident managing sick children (Stevens and Alexander, 2005). Yet there is an expectation for paramedicsand student paramedicsto competently assess and appropriately manage paediatric patients (HCPC, 2014). This case will look at ‘Tom’ a 3-year-old boy with a 4-day history of a runny nose and dry productive cough. Tom was seen in the community after an emergency referral to the ambulance service from a telephone advice service.
Croup is a condition experienced by children that affects their respiratory system (Everard, 2009). It is generally cause by a viral infection that causes swelling in the upper airways. Commonly croup affects children between the ages of 6 months and 3 years. However children as young as 3 months and up to 15 years have been diagnosed with croup, although this is less common. It is extremely rare for croup to occur in adulthood (NICE, 2012). Croup is commonly viral in origin; the parainfluenza virus is present in 75% of croup sufferers (Johnson, 2009). Due to an infiltration of a pathogen the body responds with an inflammatory process (Harrison, 2011). In croup, the virus is affecting the subglottic and supraglottic region (see figure 1) of the upper airway. Inflammation of this region occurs, broadly speaking, due to the presence of white blood cells fighting the infection (Cherry, 2008). Consequently Cherry (2008) discusses how the inflammation causes the airways to become narrowed, causing the harsh ‘seal-bark’ cough. Symptoms are normally limited to 48 hours in duration, although rarely can last up to 1 week. It is common that croup presents, as it has with Tom, subsequent to coryzal symptoms. A good understanding of common conditions paediatric patients present with will help your clinical decision-making. Further to this understanding the anatomy and development of children will also allow to understand the physiological norm. Subsequently you will then be able to determine the presence or absence of any disease pathology.
Tom (pseudonym): specimen clinical record
PC - Hoarse cough, irritable child and shortness of breath
HxPC - Tom’s mum reported 4 day history of a runny nose and a dry (non-productive) cough. Today mum was concerned the ferocity of the coughing had increased. Tom was short of breathing whilst crying. She rang NHS 111 who referred to 999.
PMH - Seen GP yesterday, advised possible viral infection (GP recommended oral hydration and paracetamol).
DHx - Paracetamol 4 times a day, mum reported it was difficult to administer medication to Tom (increased distress).
DvHx - Born at 39+2/40 by normal delivery, uncomplicated birth.
Development normal, mum reports no concerns
FMHx - No history of respiratory disease
SHx - Lives with Mum and 5-year-old sister. All family members are well, no pets or smokers in the house. Appears well cared for.
O/A- Tom is playing on the mat with sister. Meets our gaze on arrival and totters behind sister. Appears well perfused and breathing is comfortable at rest.
CNS - Alert and orientated, GCS 15, Interacts well with parents and wary of strangers. Mum reports no abnormal behaviour.
RS - RR 30, Cries well. Equal chest expansion, no gross anatomical changes. No accessory muscle use, recession or nasal flaring. Bilateral air entry, vesicular sounds no crepitations or wheeze, inspiratory and expiratory stridor. Seal Bark cough, non-productive.
CVS - HR 116, CRT 1 sec (centrally), no pallor
GI - Tom is feeding well although a reluctant drinker last 2 hours. Appetite and weight good. Mucous membranes appear moist.
Abdomen is undistended, soft, non-tender and no masses noted. Frequent wet and heavy nappies.
MSK - Totters about and play in a coordinated way, does not appear in pain.
IG - No evidence of rash and skin turgor is good.
E-No discharge or inflammation noted. Visualised normal tympanic membrane
N-Rhinitis noted, breathing not noisy through nose
T-visualised oropharynx, not inflamed or swollen appears healthy
Rhinitis = upper respiratory tract infection
Cough = lower respiratory tract/chest infection
Stridor = obstruction or croup
Imp - Seal-Bark cough = croup
Reassure mum, health education about croup
Examination as document above Mild presentation and absence of concerning symptoms, consider management in the community.
Advise simple health care measures (oral hydration and paracetamol, steam filled room)
To visit GP if symptoms persist and do not resolve.
Clearly it is vital in the initial stages of any examination to gauge the severity of the patient’s disease to determine the need for any immediate intervention by the clinician (Harris, 2011). It is engrained in pre hospital education that clinician perform a primary survey to detect life threatening presentations (Hodgetts et al, 2006). However, the majority of patient presenting to the ambulance service do not have life threatening conditions (DoH, 2005). Although it is potentially more important to remember that the patient’s presentation may be life threatening. The use of the paediatric assessment triangle (PAT) has been an enduring feature of paediatric advanced life support (PALS) training, it has been shown effective as an initial method of triage by clinician to detect potentially significant disease processes. It can be used to observe the patient’s neurological status, effort of breathing and signs of perfusion (see figure 2 adapted from AAoP (2004) guidance).
On this occasion, the PAT was used as a first look or ‘snap shot’ of Tom’s condition. Due to the lack of worrying signs when considering the PAT clinicians could be reassured that Tom’s initial presentation is not dire. The simplicity of the PAT lends it to being reviewed frequently for early recognition of sudden deterioration. Further more, if any concerning signs featured on initial assessment using the PAT the clinician would be prompted to intervene. PAT is very child friendly as it allows you to observe the child from afar and as such does not require their cooperation, as it is passive in nature!
Paediatric patients interact with clinicians differently to adults. As such you must adopt a ‘child friendly’ approach and this must be reflected in your examination and management (Gill and O’Brien, 2007). When examining children there is a need for you to make them your friend; you will not win in a battle of wills with a child! On this occasion Tom was calmed when the physical examination involved him in play, it was much easier to assess him while he was calm (Spotting the Sick Child, 2011a).
The use of a systematic approach when assessing a patient allows a clinician to confidently examine a patient and elicit as much pertinent information as possible. As discussed, paediatric patients are different to adults, their bodies are at a different developmental stage and respond differently to disease. However, the format of your assessment does not have to be complicated.
Prior to attending to Tom I undertook some self-directed study and revised the ‘3 minute toolkit’ for assessing paediatric patients proposed by (Spotting the Sick Child, 2011b).An overview of the salient points when examining a paediatric patient can be seen in the table below:
It is particularly important in young children to listen to parents about their children:
‘A smart mother makes often a better diagnosis than a poor doctor’.
August Bier (1861-1949).
If you can ascertain a good history this will often elude to the final diagnosis correctly: 75% of the time (Hampton et al, 1975). This can be invaluable when evaluating paediatric patients, as there is a potential they will be reluctant to be examined. As such, a good history can lead to a targeted examination to confirm a diagnosis causing a little distress to a patient as possible. Clearly if there is any doubt a more comprehensive examination should be carried out. If in doubt, refer on!
Ultimately paediatric patients will present to paramedics for various reasons and with expanding role of the paramedic in a multitude of settings. It will take time to become proficient at assessing children and practice will make it easier. To start a child friendly approach and a systematic approach will stand you in good stead. Hopefully this review has been thought provoking and allowed some insight into paediatric assessment.
Paediatric patient are not just smaller adults, they are little people too
Getting good with children takes practice.
Know your paediatric anatomy and physiology (it will help)
Listen to children and parents
Perfect your clinical examination skills
Safety net the patient
AAoP (American Academy of Pediatrics) (2004) Pediatric Education for Prehospital Professionals, 2nd ed. London: Jones and Bartlett.
aboutcancer.com (nd) Available at: (accessed 9th October 2015).
Cherry, J.D. (2008) ‘Croup’, New England Journal of Medicine, 358 pp. 384-391.
DoH (Department of Health) (2005) Taking healthcare to the patient: transforming the NHS ambulance service. Available at: (accessed 9th October 2015).
Everard, M.L. (2009) ‘Acute Bronchiolitis and Croup’ Pediatric Clinics of North America, 56 (1) pp. 119-133.
Gill, D. and O’Brien, N. (2007) Paediatric Clinical Examination Made Easy. 5thedn. London: Elsevier.
Hampton, J.R., Harrison, M.J., Mitchell, J.R., Prichard, J.S. and Seymour, C. (1975) ‘Relative contributions of history-taking, physical examination, and laboratory investigations to diagnosis and management of medical outpatients.’ British Medical Journal, 2(5969), pp. 486-489.
Harris, G. (2011) ‘general principles of assessment’ in Blaber, A.Y. & Harris, G., (eds) Assessment Skills for Paramedics.Maidenhead:McGraw-Hill.
Harrison, M. (2011) ‘Immune Response’ in Harrison, M. (eds) Revision Notes for MCEM Part A. Oxford: Oxford University Press.
HCPC (Health and Care Professions Council) (2014) Standards of Proficiency-Paramedics. Available at: (accessed 3rd October 2015).
Hodgetts, T.J., Mahoney, P.F., Russell, M.Q. and Bryers, M., (2006) ‘ABC to <C>ABC: Reddefining the military trauma paradigm.’ Emergency Medicine Journal, 23 pp. 745-746.
Johnson, D.W. (2009) Croup. Available at: (accessed 9th October 2015).
NICE (National Institute for Health and Care Excellence) (2012) Clinical Knowledge Summary: Croup- prevleance.Availabe at: (accessed 9th October 2015).
Spotting the Sick Child (2011a) Assessing and treating children. Available at: (accessed on 6th October 2015).
Spotting the Sick Child (2011b) 3 Minute Toolkit. Available at: (accessed 6th October 2015).
Stevens, S. and Alexander, J. (2005) ‘The Impact if Training and Expereience on EMS Providers’ Feelings Toward Pediatric Emergencies in a Rural State’, Pediatric Emergency Care, 21 (1) pp. 12-17.