Young children with respiratory illness and lung hyperinflation may appear to have an enlarged liver and abdomen based on the liver edge being several cm below the right costal margin. Percussion will determine accurate liver size.

A pathologically enlarged liver in children is usually palpable more than 2 cm below the costal margin, has a round, firm edge, and is often tender. Causes in older children include neoplasms, infectious or inflammatory disease, metabolic or genetic diseases, and congestive heart failure.

One method to determine the lower border of the liver involves the scratch test, shown in the figure below. Place the diaphragm of your stethoscope just above the right costal margin at the midclavicular line. With your fingernail, lightly scratch the skin of the abdomen along the midclavicular line, moving from below the umbilicus toward the costal margin. When your scratching finger reaches the liver's edge, you will hear a change in the scratching sound as it passes through the liver to your stethoscope.

The spleen, like the liver, is felt easily in most children. It too is soft with a sharp edge, and it projects downward like a tongue from under the left costal margin. The spleen is moveable and rarely extends more than 1 cm to 2 cm below the costal margin.

Palpate the other abdominal structures. You will commonly note pulsations in the epigastrium caused by the aorta. This is felt most easily to the left of the midline, on deep palpation.

Palpating for abdominal tenderness in an older child is the same as for the adult; however, the causes of abdominal pain are often different, encompassing a wide spectrum of acute and chronic diseases. Localization of tenderness may help you pinpoint the abdominal structures most likely to be causing the abdominal pain.

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