The main elements of paediatric history are:
1. To build rapport with the child and his/her parent
2. To establish a differential diagnosis, and place it in the context of the child's life
Open the consultation by introducing yourself and your role in the clinic or ward. You will need to confirm the child's demographics including: name, age (date of birth) and gender, and find out the relationship of the accompanying adult(s) to the child.
It is important to bear in mind that paediatric patients can range from infants to adolescents. You must, therefore, tailor the consultation to suit each patient individually; for instance, older children may want to be more involved in the management of their own health and would prefer to be addressed directly.
Neonate |
Infant |
Toddler |
Preschool |
School age |
Adolescent |
| < 28 days | 1-12 months | 1-3 years | 5 years | 5-12 years | >13 years |
You will need to gather information regarding the child's presenting symptom(s) and the reason why he/she has come to see you. Start by asking an open-ended question, "What was the problem that brought you in to the clinic/hospital today?" or "How can I help you?" You should encourage the child and the parents to describe the symptom(s) and events leading up to the consultation in their own words.
Special circumstances (the acute patient): In an emergency or in a deteriorating patient it may not be possible to use open questions or to give families as much time to respond.
Each of the presenting complaints should be explored in details. Ask questions about: site, onset, exacerbating factors, relieving factors, associated symptoms, timing, severity and history of previous episodes. The mnemonic OPERATES+ can be helpful in remembering questions which are applicable to most presenting symptoms/problem:
O: onset. Ask when the symptom(s) first started; this will help you place the events leading up to the consultation in chronological order. Find out whether the symptom(s) came on suddenly or had gradually worsened over time. Also, you will need to identify whether the symptom is continuous or intermittent in nature.
P: progress. It is important to find out whether the symptom has worsened, improved or remained constant over the period up until the consultation. If the symptom has worsened or improved, take note of when the change occurred and if there have been any triggers noted.
E: exacerbating factors. Try to establish what makes the symptoms worse
R: relieving factors. Find out what improves the symptom(s). Check whether the child had been given any medication and, if so, if it had made any difference.
A: associated symptoms/problems. Many patients present with more than one symptom. Determine whether the child and/or the parents notice any other symptoms/problems which are associated with the presenting problem. You may need to repeat the entire OPERATES+ process for each associated symptom/problem.
T: timing associated symptoms/problems. Ask about the duration of the symptom. If the symptom is intermittent, find out how long each of the episodes lasted for. Does the symptom occur at a regular time point or interval?
E: previous episodes. It is helpful to ask whether the child had experienced any similar symptom(s) in the past. Often previous illnesses can have ongoing effects on the child's health.
S: severity. How severe is the problem. If pain is the problem you may wish to quantify this either with simple numbers or with a scoring system (e.g. Wong-Baker FACES Pain rating scale) to aid communication with children (http://wongbakerfaces.org/)
+ functional aspects. How severe is the problem in functional terms. For example is pain interfering with walking/mobility, does the cough keep the patient awake at night, or lead to time off school etc.
If the presenting problem is pain then it is important to also ask about the site of the pain and if there is any radiation. In a pain history the SOCRATES mnemonic can be used: Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating features, Severity.
Previous hospital admissions, operations and childhood illnesses should be sought from the child and the parent/guardian. Past and long-standing illnesses may have a continuing effect on the current wellbeing of the child. Therefore, it is important to find out what investigations, treatments and supervision have been previously provided, and consider the possibility that any new symptoms could relate to the child's past illnesses.
Following on from history of past medical history, there are additional components to paediatric history that you will have to cover. The mnemonic BINDS can help provide a structural framework to ensure that you have covered all of the key components in paediatric history:
B - Birth history
I - Immunisation
N - Neonatal period
D - Developmental history
S - Social history
It is important to find details about the pregnancy, maternal health, any problems during labour and the method of delivery.
Pregnancy details. Antenatal, post-natal and neonatal problems can predispose the child to adverse health outcomes and have continuing effects over the course of his/her life. Early-life risk factors should, therefore, be identified in paediatric patients.
Maternal Health. It is essential to determine maternal health during pregnancy as part of paediatric history. Maternal illnesses (e.g. depression, hypertension and TORCH infection) and exposure to teratogenic substances (medications, recreational drugs, alcohol, and smoking) can affect the child's cognitive and physiological development.
Labour and delivery. Find out the location, duration and mode of delivery (vaginal delivery, caesarean section). Risk factors relevant to the child's health, including birth trauma, congenital malformation and neonatal resuscitation, should be noted. You will also need to record the gestational age and birth weight of the child. This information can aid early identification of neonatal pathology and health complications associated with preterm birth, including retinopathy of prematurity, respiratory distress syndrome and, developmental and/or cognitive delays.
Extremely preterm |
< 28 weeks |
Very preterm |
Very preterm 28 to < 32 weeks |
Moderate to late preterm |
32 to < 37 weeks |
Check what immunisations the child has had. For up to date schedule:
https://www.gov.uk/government/publications/the-complete-routine-immunisation-schedule
Confirm with the child's parents of any episodes of neonatal jaundice, fits, birth injuries, and feeding problems. If the child had been admitted to Special Care Baby Unit (SCBU), record the length of stay and any use of ventilation or antibiotics prescribed.
You should obtain information regarding the child's development from the parent/guardian. Look carefully through the personal child health record (red book) for key developmental milestones e.g. dry by night, smiling, sitting unaided and walking. You should gather information regarding bladder/bowel control, feeding, sleep pattern and temperament. Check for parental worry regarding development of vision and hearing, and any concerns regarding ability to sit/stand and walk alone, and language development. Performance at nursery or school should also be discussed. If necessary you should carry out a developmental assessment (see below).
It is incredibly important to take a detailed social history as a multitude of childhood problems can be linked back to parental issues (parental psychiatric problems, drug/alcohol abuse, poverty and poor housing). You should obtain relevant information about the parents, such as occupation, economic status, relationships and parental stress. Gather information about the housing environment of the child, whether there is any smoking in the home, and whether the family have any pets. Consider how happy the child is at home, at nursery/school, and any activities they are involved in recreationally. Also obtain information regarding health visitors or if there is a social worker involved.
It is important to gather as much information as possible about any medication the child is currently taking or has previously taken. You should also gather a full list of known allergies in order to determine whether this could be a contributing factor and to ensure nothing is prescribed that could cause more problems.
Family history is important as some conditions have strong familial disposition, such as febrile fits, pyloric stenosis, congenital dislocation of the hips etc. You should ask if any family members or close friends have had any similar problems or if there is any family history of serious illness. If necessary draw a family tree, and if there is a positive family history then extend the pedigree over several generations. It is also important to determine if there is any history of child/neonatal deaths, or if there is any consanguinity.
Questions regarding ideas, concerns and expectations are often better addressed to the parent, particularly in the younger patient. You should find out what the patient's thoughts are regarding their symptoms, what worries they have about their presenting complaint (it may not be as you expect), and finally what they hope to gain from this visit to the clinic/hospital. You can make use of trigger questions such as 'Can you tell me about what you think might be causing this?', 'What are you concerned that it might be?' and 'What were you hoping we might be able to do for this?' It is important to gather this information so that you might better be able to formulate a management plan that makes sense to the patient and their family.
Before completing the history, it is incredibly useful to ask about common symptoms in other body systems which not been covered in the consultation. This helps ensure that important health problems have not been missed or overlooked.
Start by asking an open-ended question - "is there any other problems you would like to tell me about?" This can then be followed by an enquiry about common symptoms in each of the body systems. It is important to note that you are not required to cover all of symptoms listed below. You should tailor the questions to each patient individually based on the presenting complaint(s) and history that they have provided.
General |
Respiratory |
Genitourinary |
|
|
|
Cardiovascular |
Nervous system |
Gastrointestinal |
|
|
|
Musculoskeletal |
||
|
It is crucial you introduce yourself and establish your role. Be thorough and systematic throughout the history taking. At the end of the consultation you should summarise the problem and write a summary in the personal record. List the diagnoses or differential diagnoses (in order of probability/severity), providing a clear explanation to the child (if old enough) and parent. Draw up a detailed management plan, both short and long term to manage the problem, whether this is reassurance, observation, further tests or a therapeutic intervention. It may also be necessary to discuss what information should be shared with other family members or if any other professionals need to be informed. Consider whether you need to provide any further information in the form of leaflets or internet resources. At the end of the entry in the notes it is imperative it is signed, dated and state your position e.g. student doctor (see contemporaneous notes chapter).