How to maximize the physical examination of a child with abdominal pain?
In approaching any child with abdominal pain, one must take time to establish rapport. Essential information can be obtained before even touching the patient. Begin with observation, often best accomplished from outside the room. Notice the general appearance of the child. Is he lying still on the stretcher, suggesting peritonitis, or writhing with colicky pain? Is she running around the room playing with toys? Continue by examining the least threatening areas first and saving particularly invasive aspects of the examination for last (e.g., otoscopy). Distracting the child with a toy or by conversation will allow for a more reliable examination. Laying the child with his or her knees flexed may facilitate relaxation of the rectus muscles. The child’s “help” can be elicited during the abdominal examination by allowing him to place his hands on top of the examiner’s during palpation. Apply gentle pressure beginning in a location away from the area identified by the child as the most painful. To assess for peritoneal signs, ask the child to hop up and down; or ask parents to gently bounce a baby in their lap to elicit presence of pain. If a digital rectal examination is deemed necessary, insert a small finger into the rectal vault.
Marin JR, Alpern ER: Abdominal pain in children. Emerg Med Clin North Am 2011;29:401-428.