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Paediatric history

Firstly, observe the child; in the waiting area, we can see play, interaction and behaviour. In the corridor, a gait can be observed.

Know the child's first name, age and gender. Check their preferred name, and check and record relationships of accompanying adults.

Age dependent illness; record the age!

  • Neonate : <4 weeks

  • Infant : <1 year

  • Toddler: 1-2 years

  • Preschool/young child: 2-5 years

  • School age/Older child: 5-11 years

  • Adolescent: 12-18 years

Disease of childhood are very age dependent; vomiting in a neonate versus a school age child will have very different aetiologies; thus it is important to record and consider the age. It is also important to consider the development of the child. Adapt the history to the child's age - pain in a pre or non-lingual child, bowel/bladder problems in a toddler, breathing problems in an infant.

Proxy and modification of a history to a child's age and development level

We must ask more questions in PMHx compared to a normal history, especially if the child is of a younger age:

  • Pregnancy and birth

  • Growth, diet, sleep

  • Developmental history

  • Education

  • Vaccinations

Nonetheless, although the history may be a proxy/collateral, we must speak to the child and maximise participation. Establishing a good rapport, asking the child views about problem, their health and life. As soon as they can take, they can provide information, but we must communicate at the right level and the child may need privacy. For pre-lingual children or children with communication problems, we must look behind what we are being told - etc implications of change in behaviour.

Structure

  • PC

  • HPC: Find out what prompted referral to doctor, what parents think is the matter (ICE), onset, duration, getting worse, frequency.

  • SE

  • PMHx including birth and development

  • DHx and immunisations

  • AHx

  • FHx

  • Think more widely

3-year-old with speech delay history

  • When did parents/carers first have concerns; enquires about developmental milestones

  • Any words or sounds with meaning?

  • Non-verbal communication? Eye contact? Gestures

  • Interactions

  • Child's understanding of speech?

  • Behaviour - repetitive behaviours?

  • Routines/change

  • Sensory

  • Play/social

  • Pregnancy and birth history

  • Family history of neurodevelopmental/speech problems

Systems review

Respiratory : Cough, wheeze, stridor, SOB

Cardiovascular: SOB, exercise, sweating, cyanosis

Gastrointestinal: Vomit, diarrhoea, Abdo pain, stools

Genitourinary: Frequency, wetting, dysuria, toileting

Neurological: Headaches, fits, abnormal movements

Musculoskeletal: Gait, limb pain, functions, joints

Past medical history - pregnancy and birth

Foetal

  • Antenatal USS

  • Teratogens - alcohol, antiepileptics

  • Infection - rubella, CMV, herpes

  • Maternal illness - diabetes

  • Maternal diet - thrifty phenotype

Perinatal factors

  • Asphyxia/infection/prematurity

Neonatal

  • Birthweight

  • Gestation

  • Term baby needing tube feeding

  • Irritability - hypoglycaemia, hypercalcaemia, drug withdrawal

Diet

Baby

  • Breast? Bottle? Frequency & quantity

Infant

  • Infant : Milk, weaning

Sleep

  • Importance of sleep increasingly recognised

  • Impact on wellbeing, behaviour and education

  • Good sleep routines important

  • Sensible adjustments to routine and bedroom

Growth

Past and present growth is a clue to wellbeing. Growth issues can identify or illuminate morbidity:

  • Growth failure may indicate turners, hormonal problems or chronic illness

  • Poor weight gain: Coeliac, dietary deficiency or neglect

  • Weight loss is very concerning in growing children

  • Underweight for height

  • Overweight and obesity

Development

We should take a developmental history - has the child progressed normal or not? If not, is there a simple delay or is it development disordered:

  • Is the child currently at developmentally appropriate level for age?

  • Exclude regression

  1. Gross motor

  2. Fine motor and vision

  3. Speech and hearing

  4. Social emotional

What do they like to do? Play? Behaviour

Education history

  • What school?

  • School year?

  • Children spend alot of time in school:

    • Problems can have impact on their health and happiness

    • School attendance

    • Need idea of educational/cognitive ability eg: in ADHD assessment

Vaccinations

8 weeks

  • 6 in 1 (DTaP, IPV, HiB, HepB) : Diphtheria, tetanus, pertussis, polio, haemophilus influenzae type b & Hepatitis B)

  • Rotavirus - ORAL drops

  • Meningitis B

12 weeks

  • 6 in 1 (DTaP, IPV, HiB, HepB) 2nd dose

  • PCV (Pneumococcal conjugate vaccine)

  • Rotavirus - ORAL drops 2nd dose

16 weeks

  • 6 in 1 (DTaP, IPV, HiB, HepB) 3rd dose

  • Meningitis B 2nd dose

1 year

  • Hib/MenC

  • PCV

  • MMR

  • Meningitis B 3rd dose

3 years 4 months

  • DTaP/IPV (polio)

  • 2nd MMR

12-13 years

  • Cervical cancer and genital warts (HPV 16,18,6,11)

14 years

  • TDP/IPV

  • Meningococcal ACWY

Family history

  • Inform diagnosis and aetiology

    • Family members ill

    • Family/genetic history

    • Pets

    • Bereavement

    • Siblings unvaccinated

  • Family context - prenatal

    • Mental health

    • Drug abuse

    • Domestic abuse

    • Smoking

Social history

  • Who looks after child at home? takes and collects them from school? looks after them at the weekend?

  • Housing

    • Size of house

    • Owned house or rented

    • Damp, smokers, pets, cohabitants

  • Social support (grandparents?)

  • Social worker? DLA?