How to perform a pediatric abdominal exam

There are some important differences in the abdominal exam of a child versus an adult. For example, children have a small and underdeveloped stature. Because of this, their intraabdominal organs are smaller and need deeper palpation to accurately identify abdominal organ pathology.

Also, children often do not express pain as well as adults. It may be necessary to indirectly ask them about pain and pay close attention to their facial expressions and body language.

First, be sure to get consent from at least one of the child’s parents before the exam. Most importantly, introduce yourself to the child. Talk to them and make sure that they feel included in the discussion.

Often, children won’t feel comfortable expressing themselves. Or, they may not know how to explain their symptoms. As a result, it’s important to note the child’s behavior:

• Is the child alert and playful, or quiet and reserved?
• Does the child appear sick or well?
• Is the child flexed forward while walking (e.g., psoas irritation)?

Remember to keep a parent in the room when performing a pediatric abdominal exam, as this helps keep the child calm. A pediatric abdominal exam includes the same four components as an adult’s abdominal exam:

1. Inspect
2. Auscultate
3. Percuss
4. Palpate

Step 1: Inspect

To examine the abdomen of a child, start by doing a visual inspection:

• Examine the contour of the abdominal wall
• Look for distension (may indicate constipation, ascites, organomegaly, or malignancy)
• Notice any pulsations
• Look for asymmetry
• Notice any peristalsis of the intestines
• Notice any skin changes on the abdomen
• Look for scars, discoloration, striae, sinuses, and fistulas
• Check for peripheral vascular irregularities
• Inspect the abdomen for any visible masses
• Look for signs of an inguinal or umbilical hernia
• Observe the abdomen for motion with respiration

Pay attention to certain features of the child’s stature (such as height and weight) and face that may be syndromic. These might hint at an underlying genetic condition. An example of a syndrome that affects the gastrointestinal system is Down syndrome.

Evaluation of a child with a chronic illness may be associated with equipment such as feeding tubes. So, work around the equipment during the exam.

Step 2: Auscultate

The provider may need to skillfully distract a child to auscultate and percuss the abdomen. This may not be an easy task in an active, uncooperative, or crying child, but it is an important step. Make sure that the child is in a calm environment. Then, help them to sit still by using a distraction such as a small toy, or promise them a sticker after the exam.

As you would in an adult patient’s abdominal exam, listen to the nine regions and four quadrants of the abdomen. With young children, don’t forget to use the bell of the stethoscope.

Similar to adults, children may have overactive bowel sounds with gastroenteritis. With appendicitis or an intestinal obstruction, bowel sounds are usually decreased or absent. An audible abdominal bruit may present with stenosis of the aorta, iliac, femoral, or renal arteries.

Step 3: Percuss

Next, percuss the nine regions and four quadrants of the abdomen as you would in an adult exam. Tympany and dullness during percussion, as well as fluid waves and shifting dullness (for ascites), can also be elicited in children.

Step 4: Palpate

To help the palpation go smoothly, comfort the child, ensure that a parent is present, and prepare them for palpation. Sit on a chair by the bedside so that your face is level with the child’s face.

Ensure the abdominal wall muscles are relaxed by having the child lay down with their hands at their sides. Completely expose the abdomen and cover the rest of the body with a blanket or a sheet.

Have the child take in a deep breath and exhale completely before palpation to help relax the abdominal wall muscles. Palpate the abdominal regions and quadrants using a one-handed technique (in younger and smaller children) or a two-handed technique (in older, more adult-sized children).

Communicate with the child throughout the exam, but avoid words such as pain and hurt since they can make the child fearful or upset. As previously mentioned, an alternative method is to observe the child’s body language and facial expressions to determine if they are in pain.

Apply deeper pressure to assess intraabdominal structures. Relaxation of the muscles is important to palpate intraabdominal structures, which can be much smaller in children. If tender, determine if the tenderness is localized or generalized.

Here are three additional tips to get more information from children about their abdominal symptoms:

1. Ask if they have pain with coughing, moving around, walking, or with bumps during a car ride.
2. Instruct the child to blow out their tummy as big as they can, and then suck it in as far as they can. This can help indicate peritoneal inflammation.
3. Ask the child to jump up and down to evaluate for guarding.