If your pediatric patient is too young, too ticklish, or too grumpy to cooperate with the abdominal exam, it can be tough to be sure there is nothing abnormal. Here are a few tips and tricks that I use to assess the pediatric abdomen:

If the child is not already crying, listen to the heart & lungs and then do the abdominal exam before upsetting him/her with an HEENT exam.

You can move the stethoscope directly from the chest to the abdomen, then press down with it to assess tenderness.

For ticklish children, place your hand on top of the child’s hand and palpate with the chiild’s own hand.

If a toddler just doesn’t like you, go as far away as you can, don’t make direct eye contact, and ask the parent to press on the abdomen to assess tenderness.

Observe & document: toddler upright in parent’s arms twisting around to look, child lays down and sits up for exam easily, child climbs on and off the gurney, child jumps up and down (or does jumping jacks), with no apparent pain.

For crying infants, let them suck on a pacifier, clean gloved finger, or bottle during the exam, and flex the hips to relax the abdominal musculature.

In young children, start palpation for hepatosplenomegaly very low in the abdomen as the liver and spleen can normally be a few cm below the subcostal margin. Consider using the scratch test for organomegaly.

No cold hands directly on skin!

And finally, never skip the GU exam if there is a question of abdominal pain.