The Paediatric Assessment Triangle (often shortened to PAT) is a simple, rapid visual check to help you quickly decide how sick a child is and how urgently they need help. Children can mask symptoms and may not immediately appear as sick or injured as they actually are. This assessment triangle offers a clear, simple approach to help you to swiftly assess and prioritise how to help a sick or injured child.

The Paediatric Assessment Triangle is used by paramedics, emergency staff and many other healthcare professionals around the world. It takes less than a minute and does not need any equipment. You simply look and listen to the child as you approach them. It is designed to answer one key question: “Is this child seriously unwell and do they need immediate help?” 

What is the Paediatric Assessment Triangle?

The Paediatric Assessment Triangle is a quick way to form a first impression of an unwell child. It looks at three linked areas:

• Appearance – how the child looks and behaves
• Work of breathing – how hard they seem to be working to breathe
• Circulation to the skin – what their skin colour and pattern look like
• These three “arms” of the triangle help you decide whether a child is: Well or unwell
  Stable or unstable
  Likely to have a breathing problem, a circulation problem or has some other medical or emotional problem. 

NHS-linked training resources and international paediatric life support courses recommend this approach as part of the rapid assessment of any seriously unwell or injured child. It fits neatly alongside the familiar ABCDE assessment used in first aid and emergency care. 

How to use the Paediatric Assessment Triangle

The beauty of the Paediatric Assessment Triangle is that you can start it the moment you see the child – even from the doorway or across a room. You do not touch the child at this stage; you simply observe. 

As you calmly move towards them, you ask yourself three questions:
1. What is their appearance like?
2. How hard are they working to breathe?
3. What does their circulation to the skin look like? 

Appearance – how does the child look and behave?

A child’s appearance tells you a lot about how their brain and vital organs are functioning. You are looking at their overall “vitality” – do they seem bright and engaged, or flat and floppy? This reflects their oxygen levels, circulation, blood sugar and general wellbeing.
 

Many teaching resources use the acronym TICLS (pronounced “tickles”) to guide this part of the assessment:

• Tone – Are they floppy like a rag doll or holding themselves up normally?
• Interactiveness – Do they follow you with their eyes, look interested and respond to people around them?
• Consolability – If they are crying, can they be comforted by a familiar adult?
• Look / gaze – Do they make eye contact or stare blankly into space?
• Speech / cry – Is their cry strong and normal for them, or weak, grunting or unusually quiet? 

A child who is alert, moving normally, making eye contact and reacting to their surroundings generally has a good appearance. A child who is floppy, difficult to rouse, not making eye contact or impossible to comfort is much more concerning and should be treated as potentially seriously unwell. 

Work of breathing – how hard are they breathing?

Children can become unwell very quickly if they have difficulty breathing. The work of breathing part of the triangle focuses on what you can see and hear without using a stethoscope. 

Ask yourself:

• Are they breathing faster than you would expect for their age?
• Are they using extra muscles to help them breathe – for example, sucking in under the ribs or at the neck (recessions), or flaring their nostrils?
• Have they made any noises when they breathe – such as grunting, wheezing, or noisy, high-pitched breathing (stridor)?
• What position are they in – they lying flat, or they sitting up, leaning forward or struggling to stay comfortable?

A child who is breathing quietly, with a normal rate and no extra effort, is usually less concerning. A child who is breathing fast, struggling for breath, making loud breathing noises or unable to speak in full sentences needs urgent assessment and treatment. 

Circulation to the skin – what does their skin look like?

The colour and pattern of a child’s skin can give early clues about how well their heart and circulation are working. Particularly look at the face, lips and hands, but you may need to see more of the body to be sure. 

You are checking for:

• Normal colour – Pink and warm is usually reassuring.
• Pallor – Unusually pale skin and lips, which may suggest poor blood flow or anaemia.
• Mottling – A patchy, blotchy pattern (often described as “marbled” skin), which can be a sign of poor circulation.
• Cyanosis – A blue or dusky tint to the lips, tongue or skin, often linked with very low oxygen levels.
   

Any child with pale, mottled or blue-tinged skin, especially if they also appear drowsy or are working hard to breathe, should be treated as seriously unwell and needs urgent medical help. 

Putting it all together – what might be wrong?

Once you have quickly looked at appearance, work of breathing and circulation to the skin, you put the pieces together to form an overall impression. 

Examples:

• Abnormal appearance + abnormal work of breathing – suggests a serious breathing problem or respiratory failure.
• Abnormal appearance + abnormal circulation to the skin – may indicate shock, severe infection or blood loss.
• Abnormal work of breathing but normal circulation and appearance at first – often points to early respiratory distress, such as an asthma attack or bronchiolitis.
• Abnormal appearance alone – can occur with problems affecting the brain, blood sugar, seizures, poisoning or severe infection.
   

The Paediatric Assessment Triangle does not give you a diagnosis by itself, but it helps you spot the very unwell child early and guides what to do next. If any side of the triangle is abnormal – and especially if more than one is – you should seek urgent medical help. 

How the Paediatric Assessment Triangle fits with DR ABCDE

In first aid and emergency care, many people are taught to use the DR ABCDE approach – Danger, Response, Airway, Breathing, Circulation, Disability and Exposure. The Paediatric Assessment Triangle works beautifully alongside this.
 

You can think of it like this:

• Before you reach the child, you use the Paediatric Assessment Triangle from a distance to decide if they look critically unwell.
• As you reach them, you follow DR ABCDE to check and treat life-threatening problems in order.
• As you go on, you keep repeating both the PAT and DR ABCDE whenever the child’s condition changes. 

A calm, structured way to help a sick child

The Paediatric Assessment Triangle does not replace proper medical assessment, but it gives you a calm, structured way to look at a child and make safer decisions in those first few worrying moments. Whether you are a parent, carer, first aider or healthcare professional, using this simple visual check can help you:

• Spot the seriously unwell child earlier.
• Explain clearly what you are worried about when you call for help.
• Monitor changes in the child’s condition while you wait for an ambulance or further review.
   

If in doubt, always seek medical advice urgently. Call 999 if a child is struggling to breathe, very drowsy, unusually floppy, has blue lips or skin, or you are seriously worried about them for any reason. 

About us

Written by Emma Hammett for First Aid for Life

First Aid for Life is a multi-award-winning, fully regulated first aid training provider. Our trainers are highly experienced medical, health and emergency services professionals. They will tailor the training to your needs. Courses for groups or individuals at our venue or yours. Please visit our site and learn more about our practical and online courses. It is vital to keep your skills current and refreshed.

We strongly advise that you attend a fully regulated Practical or Online First Aid course to understand what to do in a medical emergency. In addition, please visit First Aid for Life or call 0208 675 4036 for more information about our courses.

First Aid for life provides this information for guidance and it is not in any way a substitute for medical advice. First Aid for Life is not responsible or liable for any diagnosis made, or actions taken based on this information.

Author: Emma Hammett