Diagnosis in paediatric surgery relies heavily on history and examination. This ensures the number of distressing or harmful investigations performed, such as venepuncture and radiation, are kept to a minimum. A history is usually taken in combination from the child and family members; proportions depend on the level of speech and language comprehension of the child. As well as a change in approach, the history components are modified according to the age of the child:

Completing an examination of a child can be difficult, and it is important to develop a good rapport with both parent and child. This means tailoring the examination according to their age, developmental stage and temperament. For instance, while asking an adolescent directly for consent is important, the same request made to a three year old may often yield a resounding ‘no’. Sometimes you may need to adapt your examination to the position in which the child is most comfortable, such as sat in their parent’s lap. In general, the examination relies heavily on observation, especially with younger children and babies: a lot of information about the state of the child can be obtained from appearance, behaviour and vital signs.

Abdominal pain is one of the most common reasons for children to be admitted under paediatric surgery. There are over 2000 diagnoses which may lead to abdominal signs and symptoms: you can narrow these down by knowing which have peak frequencies at particular ages (Table 24.2). Instead of a history of abdominal pain in neonates and infants, parents will often report repeated episodes of excessive crying, not responding to comforting as normal. Babies may not want to feed, and may pull up their knees. This is known as “colic” and is a non-specific sign that the baby is in discomfort. Other features such as reduced weight gain, poor feeding, vomiting (especially bilious), abdominal distension and other associated symptoms may indicate a more serious pathology.

The child should be lying straight and on their back, arms by their side. Analgesics should be given to children in pain, to put the child at ease and allow accurate assessment.

Children behave differently to adults in the face of shock. They have much greater reserves and therefore compensate better to loss of volume. This means that signs of an ill child are often masked until the child is at least 10 % dehydrated. A child will often be shocked beyond the point of recovery when they drop their blood pressure and exhibit severe acidosis.

The lesson to be learnt is to be aggressive with fluids in children. Children have a higher body composition of water than adults. In addition, the overall fluid, calorie and mineral needs of children vary to adults; neonates need specialist fluids which you can ask about on your placement. Under normal circumstances, maintenance fluids for infants and children are shown below (Table 24.3). The child’s maintenance fluids are supplemented depending on the level of dehydration (expressed as a percentage of their weight). Deficits are corrected over 48 h to prevent complications such as cerebral oedema.

For physiology and procedure see general surgery chapter; note minimal access instruments in children may be of smaller calibre then their adult counterparts.

It is said that there is no greater test of a paediatric surgeon’s ability than the repair of an oesophageal atresia: a congenital abnormality of the oesophagus affecting 1 in 3500 newborn babies [9]. Delayed diagnosis and treatment can lead to inflammation and poor lung function. Therefore, repair is typically performed within the first day or two of life.