ABC's of Pediatric Respiratory Assessment: The Basics

Once you become a nurse, “ABCs” no longer refer to the beginning of the alphabet. They are the first critical steps of the primary assessment: Airway, Breathing and Circulation. Learning how to assess children with respiratory problems begins with learning about what makes pediatric respiratory systems unique, as well as learning some basics regarding the pediatric approach. This article is the first in a series on pediatric respiratory issues. Specialties Emergency Article


ABC's of Pediatric Respiratory Assessment: The Basics

Respiratory issues represent a significant proportion of pediatric illness and hospitalizations.1 Viruses such as the common cold, croup, and RSV, while often benign, can wreak havoc when, for example, they occur in infants who have tiny airways or in children with pre-existing conditions such as asthma or allergies.

Several anatomic and physiologic differences place infants and children at an increased risk of respiratory distress and failure. To put it simply, their airways are smaller. They get obstructed easier, they swell faster. Added to that is the inherent age-associated hazard of foreign body ingestion- young children who decide they want to eat the coin they find on the floor or the battery they find in a toy. However the differences in pediatric airways and adult airways go beyond simply size, and any nurse who assesses children should have a core knowledge of what makes the pediatric respiratory system unique. The following are some of the primary differences, with nursing considerations for each:

Anatomy & Physiology

Infants and young children have higher metabolic rates, increased oxygen demands, fewer alveoli, weaker chest walls and lower residual capacities.1 The diaphragm is the younger child's major muscle of breathing, hence the phrase that children are "abdominal breathers".

Nursing Considerations: Hypoxia occurs more quickly when a child is in respiratory distress. Retractions secondary to distress may be seen anywhere from the substernal area to the supraclavicular area. Observation and auscultation is crucial; infants and children cannot be adequately evaluated through layers of clothing or blankets.2

Other factors which increase the metabolic rate, such as fever, can also elevate the respiratory rate. Antipyretics should bring the respiratory rate down in children who have tachypnea due to fever only.

A Child-Centered Approach

Crying and agitation, anything that increases respiratory effort, can also increase respiratory distress.

Nursing Considerations: The child should be kept as calm as possible during assessment and treatment. Sitting down while assessing the child, to meet them at eye level, can go a long way to reduce their anxiety. Telling them what you are doing before you do it, ("I am going to place my stethoscope on your chest and listen to your breathing") can foster trust. Parents should be allowed at the bedside (or even in the bed, with the child in their lap if appropriate).

Auscultation and the Respiratory Rate

For a thorough pediatric respiratory assessment, listen to breath sounds both anteriorly and posteriorly, and under the axilla. If the child will cooperate, ask them to take deep breaths with their mouth open, and listen to both the inspiratory and expiratory phase of each breath prior to moving your stethoscope. The normal respiratory rate varies with age; it is higher in infants and eventually reaches that of an adult in adolescence. Count the respirations for one full minute and don't tell the child that you are counting their respirations; this will often cause them to breathe abnormally.3 Children with a sustained respiratory rate over 60 breaths per minute are considered at risk for respiratory arrest.1

Nursing Considerations: Being aware of the age-based norms for respiratory rates and other vital signs is very important in helping determine the degree of respiratory distress and risk for failure. The following is an example of pediatric respiratory rates as stated in one Emergency Medicine Textbook.4

Age (yr) Resp. Rate (breaths/min)

1-2 24-40

2-5 22-34

6-12 18-30

>12 12-16

A sustained respiratory rate over 60 reflects a higher risk presentation in any pediatric patient 1,2 and should serve as a red flag. Note that infants who are born prematurely, or children with chronic illnesses, may have different normal baselines.

Pulse Oximetry

Any infant or child who presents with respiratory symptoms or respiratory distress should have a pulse oximetry reading.2 Factors such as cool extremities, anxiety/movement and impaired perfusion can make it challenging to obtain a pulse oximetry reading.

Nursing Considerations: Infants and young children may tolerate a pulse oximeter probe wrapped around their large toe, or the top or bottom of their foot1 and covered by a sock or blanket, more than one wrapped around a finger.

Being able to identify respiratory distress in an infant or child starts with knowing the basics about pediatric anatomy, physiology and vital signs. A developmentally appropriate approach assists the nurse in gathering the pertinent information efficiently without causing additional distress.


1. Emergency Nurses Association (2012), Emergency Nursing Pediatric Course. The Association (ENA).

2. Gilboy, N., Tanabe, P., Travers, D., Rosenau, A., Eitel, D. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publication No. 12-0014, December 2011. Agency for Healthare Research and Quality, Rockville, M. Emergency Severity Index (ESI): A Triage Tool for Emergency Department | Agency for Healthcare Research & Quality (AHRQ)

3. ATI Nursing Education. "Physical Assessment: Child". Accessed online 1/23/2015.

4. Marx, J., et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia: Saunders, 2013.

I'm a pediatric emergency nurse of 12+ years and a clinical instructor for UNC-Chapel Hill's School of Nursing.

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anon456, BSN, RN

3 Articles; 1,144 Posts

This is good, basic info! Very useful! You are so right about the challenge of that pulse-ox staying on!

Here are some things I've learned- I work mostly pulm/stepdown

When an infant stays above 60 for too long, they can "poop out" and just get tired and need emergency intubation. Especially if they are also needing a lot of effort to breathe with bronchiolitis or other airway issues.

Don't be afraid to suction infants if they seem to have a lot of mucous in the way of breathing. Deep suction as necessary. Sometimes we get a baby who looks awful, transferred from another unit. I do some deep suction and nasal lavage and oftentimes they improve significantly and immediately.

Also reposition with neck rolls to the CPR position- it helps open airways on the little ones. But if you have to do that to keep an open airway, call the doc right away, too.

When assessing a peds patient for respiratory issues, always pull the shirt up enough to see the belly and chest. You can better see retractions and chest movement. A couple weeks ago I had a patient with severe pleural effusion come in. Patient had a history of asthma so at first they assumed it was that-- but then xrays showed fluid. I could see that one side of her chest was not moving very well when I lifted the shirt.


5 Articles; 41 Posts

Specializes in Pediatric Emergency & Nurse Education.

Thank you, and your points are excellent! The next article will be about respiratory distress, and many of your points will be in it! The whole "poop out" concept is so true- some kids can look great, but have, for example, a high fever and pneumonia (both which elevate the respiratory rate) and a RR of 60-80. they just can't sustain that kind of breathing for very long, even if their lungs are working relatively well. and suctioning - omg- it amazes me how many people (often parents) are afraid to suction an infant's nose, not realizing how much it can help them. it sounds like you are an expert at it! thank you for your input.


130 Posts

Thanks for the article! I am trying to download a copy and when I hit the printer-friendly tab, it keeps bringing me to a Mediterranean boneless pork chop!


Specializes in Pediatrics, Emergency, Trauma.

Article had great points; strategies I have implemented while working in a Pedi ER. :yes:

JustBeachyNurse, LPN

1 Article; 13,952 Posts

Specializes in Complex pedi to LTC/SA & now a manager.

I always remembered from decades ago working in the ED as a tech...children look great and compensate until they don't. They cannot sustain high just above normal vital signs for very long until they tire. Children just don't have the reserves of energy.

This was handy today when one of my complex tech dependent kiddos was just above normal and my gut said too much change, too much effort and increased work of breathing and put kiddo back on the vent. Continuous assessment looking for the trend of small changes that helped me make a quick care decision within my scope and plan of care. The relief was immediate even the mom commented how comfortable he looked when she came to relieve me at the end of my shift.

I think the hardest thing for many non-pediatric specialists to realize is that children are not small adults and have their own unique needs and challenges. Many are "afraid" of the medically complex population I work with but having a strong knowledge background, a willingness to learn/research and knowing the child's baseline has served me well over the years.

All of my continuous pulse ox kiddos have the probe on the foot or great toe (depending on age/size). Knowing normals for age is great but finding out the baseline for a complex child is just as important. I have 18-30) a 7yo child who has baseline respirations 40-50/min and HR 100-130. If respirations stay 54 or HR sustained >140 kiddo needs to be put on the vent to prevent exhaustion or "pooping out"

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