Pediatric History Taking Points

Taking a paediatric history

General points
If the child or family does not speak your language, try to find an interpreter, or arrange one for a subsequent consultation to clarify what has been discussed.
Specific skills and techniques need to be employed to take a good history of a child's illness.
In very young children who have no speech or limited speech you must take the history through the parents and learn to interpret it. Consider:
The younger the child, the more reliant one is on their account.
Parents may be extremely anxious, tired or both. This can impair communication between doctor and parent.
An empathic approach is likely to improve communication and hence the history and accuracy of diagnosis.
In older children there is a difficult line to tread between giving the child as much autonomy as possible and getting a full account of how an illness or problem has presented. It is often necessary to synthesise the accounts from parents and the older child. In this situation you should remember that the child is your patient, not the parent, and focus your attention on their story whist engaging the parent(s) and maintaining their trust and confidence.
With teenagers, it may be difficult to give appropriate autonomy without offending the parents.
When dealing with older children and issues of confidentiality, if you are unsure of the legal and ethical implications of confidential medical information, seek the advice of a medicolegal advisor. It may be appropriate to discuss difficulties with a medical indemnity or defence organisation.
Unfortunately some parents or carers very occasionally may not have a child's best interests at heart. They may attempt to conceal facts and keep secrets. In such a situation it is important to remember that your overriding duty is to the child. It can be very difficult to reach a conclusion about such matters without multidisciplinary or expert support.1 Where child protection issues are important:
Seek medicolegal advice from your medical indemnifier
Consider current and relevant guidelines
Access local child protection teams for support and advice on procedure
Privacy, dignity and confidentiality
Often difficult in busy paediatric wards or general practice/child health surgeries, where physical space is at a premium. During an average stay in hospital most patients and their relatives will overhear confidential exchanges, and only a few will ever recall being offered a room/screen to preserve privacy during history/examinations.2Try to avoid such pitfalls and put yourself in the place of the child/parent(s) before taking histories/conducting examinations or discussing private/confidential information.

Aims of the paediatric history

The suggested aims of the paediatric history are to:

Direct appropriate examination and investigation
Reach a correct diagnosis (or form a differential diagnosis)
Establish the context of a child's illness (psychological, family and social context)
Establish and maintain a good relationship with the child and parent(s). This helps child and parent(s) to accord with the advice given by the healthcare professional, especially where it might conflict with their own expectations or beliefs
Use the interaction with the child/parent(s) as part of the therapeutic process
Use the understanding and knowledge of context and background to tailor pragmatic, appropriate treatment strategies
Take an overview of the child's previous and current state of health to anticipate or identify any problems which may not be immediately apparent

Presenting complaints
Record the child's and parents' own words as faithfully as possible, using direct quotations if relevant.
Where there are multiple symptoms set each one out separately with space to document the features of how it developed and the relationships between the symptoms.

Current illness

What to ask about the current illness:

When and how did it startΑ
Was the child well beforeΑ
Have there been any previous episodes of similar illnessΑ
How did it developΑ
What aggravates or relieves the symptom(s)Α
Any contact with similar illness in others/siblings or infectious outbreaksΑ
Any recent overseas travelΑ
How has the illness affected the familyΑ
Have the symptoms kept the child from attending nursery/schoolΑ
In Infants:



Pattern of feeding, bowel movements, and number and wetness of nappies
Sleeping/waking cycle, alertness and activity
Weight loss or gainΑ
Further directed questioning:
Having established these facts:



Form hypotheses about the possible diagnoses/problem
Test the hypothesis with appropriate further enquiry






Past history

Peri-conceptual history
Was there any parental illness around time of conception that may be relevantΑ
Was child conceived naturally or by assisted reproductionΑ
If relevant, establish whether child is adopted (or in foster care) with due sensitivity to the child's awareness of the facts

History of pregnancy

Any factors relevant to foetal wellbeing should be recorded. For example:


Antenatal infections (for example rubella)
Rhesus incompatibility and haemolytic disease
Exposure to prescribed, recreational drugs or over the counter medication
Any maternal illness or problems in pregnancy

Peri-natal history

Factors pertinent to the child's health should be identified. For example:


Gestation
Duration of labour
Mode of delivery
Birth weight
What if any resuscitation required
Birth injury
Congenital malformations identified

Neonatal period

Relevant examples include:


Jaundice
Fits
Febrile illnesses
Bleeding disorders
Feeding problems

Other relevant past history

This will include:


Any subsequent illnesses, surgery, accidents or trauma
Results and any concerns from screening tests at child health clinics or school
Immunisation record
Travel details

Developmental history
Parental recall of major milestones will usually give important information (such as sitting up, crawling, walking, talking, toilet training, reading).
It may be useful to ask how the child's progress and milestones compare with siblings and peers.
Observations from other carers (school, nursery and extended family) may be helpful.
See Internet section for useful article on assessment of development.

Current medication
Prescribed medication
OTC medication
Recreational drug or solvent use- in teenagers such information is much more likely to be forthcoming if the patient is seen alone and reassured confidentiality will be maintained
Complementary formulations

It is worth remembering that the parent's memory of medication may not be accurate. Corroboration may need to be sought.3 Pharmacists, GP computerised practice records and health visitors may be useful sources of additional information.



Drug intolerances, adverse drug reactions and allergies

It is important to enquire further about any allergy. Minor adverse reactions can often be labelled inappropriately as allergies.



Family history
Relevant history. For example:
Previous miscarriages or stillbirths
Diabetes mellitus
Hypertension
Renal disease
Seizures
Jaundice
Congenital malformations
Infections such as tuberculosis
Whether siblings and parents are all alive and wellΑ
Consider conditions which may have a genetic component (such as ischaemic heart disease and cerebrovascular disease). Occasionally it is appropriate to address risk factors (such as familial hypercholesterolaemia) during childhood.
Consanguinity occurs more commonly in some cultures and may be relevant to inherited disease (particularly autosomal recessive conditions).
It can be useful to present findings by using a two-generation family tree.

Social history

This is separate from family history but allied to it.


Take care not to offend when enquiring about the structure of the family unit by making assumptions about who may or may not be present or 'involved'.
Be prepared to allow information to come out gradually. Information may come from others (for example nursing staff, play specialists, educationalists). Ask about:
Who lives at home (and any role in childcare)
Siblings (ages, health, problems)
Play
Eating and sleeping patterns
Schooling and any problems
Pets
Housing issues or problems
Childcare (if parents work)
Parental occupation(s)
Smoking in the home
Child abuse is a common problem. Child abuse comes in many guises and harm is inflicted in many different ways. Any such concerns may emerge from the social and family history and any concerns should be shared with colleagues and Social Services.

Educational history

It may be appropriate to ask specific questions about a child's experience and attainments at school. This may include, for example, asking about ability to concentrate and make progress with learning in reading, spelling and mathematics. Any fear or anxiety about school should be explored. Bullying is common and can interfere with learning. Reports from teachers can be enlightening and supplement the history.



Emotional history

Specific questions may be asked about mood, eating and sleeping habits, interests, hobbies and other activities. Life events and emotionally disturbing events can have a major effect on wellbeing and general development.



Systems review
Consider further information about other organ systems
Ask questions pertinent to the diagnostic hypothesis and the age of the child
Consider general issues particularly psychological factors which may have been overlooked.4

Summarising
At the end of the history it helps doctor and parent(s) to summarise understanding (including diagnosis, problems and any psychological factors).
It is important to give child and parent(s) an opportunity to reveal omitted details and to ask questions.




Document references
Giardino AP, Finkel MA; Evaluating child sexual abuse. Pediatr Ann. 2005 May;34(5):382-94. [abstract]
Rylance G; Privacy, dignity, and confidentiality: interview study with structured questionnaire. BMJ. 1999 Jan 30;318(7179):301.
Porter SC, Kohane IS, Goldmann DA; Parents as partners in obtaining the medication history. J Am Med Inform Assoc. 2005 May-Jun;12(3):299-305. Epub 2005 Jan 31. [abstract]
Kelly MN; Recognizing and treating anxiety disorders in children. Pediatr Ann. 2005 Feb;34(2):147-50. [abstract]
Internet and further reading
Parry TS; 12. Assessment of developmental learning and behavioural problems in children and young people. Med J Aust. 2005 Jul 4;183(1):43-8. [abstract]
Caldwell PH, Edgar D, Hodson E, et al; 4. Bedwetting and toileting problems in children. Med J Aust. 2005 Feb 21;182(4):190-5. [abstract]
Wray J, Silove N, Knott H; 7. Language disorders and autism. Med J Aust. 2005 Apr 4;182(7):354-60. [abstract]
Hiscock H, Jordan B; 1. Problem crying in infancy. Med J Aust. 2004 Nov 1;181(9):507-12. [abstract]