The Paediatric History

See also: Paediatric Examination record

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

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.