Taking a PaediatricHistory can at first seem very daunting. There are a lot of sections to cover and it is important that no key information is missed – for the sake of patient safety and the family. With experience, there are short-cuts, but it is wise for newcomers to be thorough and work systemically through the history. In saying that, this can be a rewarding experience, working with the child and their family to develop and explore their narrative, building trust and rapport to prevent the subsequent examination being too scary or overwhelming.
First and foremost – the child’s age. This information is key in determining what will need to be asked in regards to the nature and presentation of illnesses, developmental and behavioural problems. This will also determine the way history taking and examination is undertaken and the organisation of subsequent management.
As such, it is imperative to be aware of this information before approaching the patient and family to provide yourself with a mental model for the structure of the interview. It is then also important to confirm the date of birth of the child with the parents at the beginning of the interview.
Greet not only the child, but the parentsor carers and the siblings.
Ensure you check the child’s first name and gender. It’s helpful to build rapport asking how the child prefers to be addressed.
Introduce yourself and your role and gain consent to take a history.
Ensure you initially keep a comfortable distance, establishing eye contact and rapport with the family. Young children generally feel initially more comfortable and secure in their parent’s arms or lap and may require some time to feel at ease.
Observe how the child is playing and interacting with any siblings or other children present.
Make sure to also address questions to the child, when appropriate. Depending on age, they will hold a wealth of knowledge about their current condition and their history – but may feel too shy or embarrassed to add to the conversation you may be having with their trusted adults. Be mindful to allow the child time to answer and do not interrupt.
Negotiating both talking to parents or carers without the child present and talking to the child alone requires tact and consideration. Generally, this is done to avoid embarrassing older children or adolescents and allow for the imparting of sensitive information. This can be done by talking separately to each in turn, introducing the idea through normalisation – “It is my usual practice to…”. It is a good idea to speak to the parents first, then the adolescent or young adult – to ensure they know that the confidential information imparted to the doctor is not disclosed to the parents.
The presenting complaint
Start open – allow the parents/carers and child to recount the presenting symptoms in their own words and at their own pace.
“So, what’s brought your child in today?” or “What’s brought you in today?”
History of the presenting complaint
Particular questions to have answered
When did the current problem start? What was it like?
Has the problem changed at all? If so, when and in what way?
Has medical attention been sought before now? If so, what investigations have been done so far? What treatments have been tried?
Relieving or aggravating factors?
Do the parents/carers have any photographic or video evidence on their phone? (especially when considering a rash or a seizure episode).
Some more key questions
Eating – Type of food, intake, the frequency of feeds (if applicable), dietary requirements?
Drinking – Determine oral intake of fluids.
Passing urine – The number of ‘wet nappies’ if applicable
Stool – Determine the frequency and form of the stools.
Vomiting – Determine frequency, volume and consistency (e.g. bilious, haematemesis). Also, clarify if it was projectile vomiting.
Fever – Ask about readings and how they were recorded.
Weight change – Review growth charts if available.
Pain – Explore using SOCRATES, as shown below.
Is the child acting their normal self? – i.e. How active and lively have they been generally? When were they last their normal self?
If pain is a symptom, clarify the details of the pain using SOCRATES:
Site – Where exactly is the pain? Where is the pain worst?
Onset– When did it start? Did it come on suddenly or gradually?
Character– What does it feel like (sharp stabbing/dull ache/burning)?
Radiation– Does the pain move anywhere else?
Associations– Any other symptoms associated with the pain?
Time course– Does the pain have a pattern (e.g. worse in the mornings)?
Exacerbating/relieving factors– Does anything make it particularly worse or better?
Severity– On a scale of 0-10, with 0 being no pain and 10 being the worst pain you’ve ever felt?
Ideas, Concerns and Expectations
Address the parent’s/carer’s and child’s Ideas, Concerns and Expectations (ICE):
What do they think or fear is the issue?
Have they been searching the internet or discussing with others?
What are they hoping to achieve from the consultation?
General enquiry & systems review
This section involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the parents/carers or the child failed to mention in the presenting complaint and some of these symptoms may be relevant to the diagnosis.
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
Head – History of injury, headaches or infection?
Eyes – Visual acuity/glasses? History of injury, headaches or surgery?
Nervous system – Fits, faints, or funny turns? History of hearing concerns, seizures (febrile or afebrile), abnormal or impaired movements, tremors or change in behaviour? School performance? History of hyperactivity?
ENT – Earache, throat infections, snoring or noisy breathing (stridor)?
Chest – Cough, wheeze, breathing problems? Smokers in the family? Exposure to smoke?
Heart – Cyanosis, exercise tolerance, chest pain, fainting episodes? History of heart murmurs or rheumatic fever in the child or the family?
Joints/Limbs – Gait, limb pain or swelling, other functional abnormalities?
Skin – General rashes? Birthmarks or unusual marks?
Pubertal development – Age of menarche?
Summarising & Signposting
Summarise what the patient/parent/carer has told you about the presenting complaint.
This allows you to check your understanding regarding everything the patient/parent/carer has told you.
It also allows the patient/parent/carer to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient/parent/carer if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting involves explaining to the patient/parent/carer:
What you have covered
What you plan to cover next
“Ok, so we’ve talked about the symptoms.”
“Now I’d like to discuss any previous medical history.”
Past medical history
The scope and detail of the following section of the history is determined by the nature and severity of the presenting complaint and the child’s age.
For example, if a young child presents with delayed speech, a detailed birth and neonatal history, as well as details of developmental milestones, are required – vs. an adolescent with headaches.
Prenatal history – Were there any obstetric problems including antenatal scans and screening tests? Were any medications taken during the pregnancy?
Birth history – Concerns during delivery? Interventions required? Birthweight and gestation?
Neonatal period – Admission to special care baby unit? Jaundice?
Child development – When did the child achieve key milestones – smiling, rolling over, sitting unaided, standing, speaking and toileting skills?
Normal growth – Following weight and height centiles?
Immunisation – Ideally this should be checked using the personal child health record. Identify any reasons for missed immunisations.
Past illnesses, hospital admissions, operations, accidents and injuries?
Medications and allergies? Including over the counter or alternative preparations.
Known to any other clinicians? What for?
Have any family members or friends had similar problems or any serious disorder?
At this point, drawing a family tree or genogram to assist in your note-taking – identifying key family and social history information.
Age of the parents and siblings?
Consanguinity? (approach with sensitivity)
Do any conditions run through the family? If so, who has been affected (over several generations)
History of seizures, asthma, cancer, heart disease, tuberculosis, or any other medical condition?
Deaths in the family – cause and age, especially if in infancy or childhood.
A social history involves clarifying the details of the child’s family and community:
Individuals livingwith the child
Parental/Carer smoking status
The child’s preferred play or leisure activities? Are they happy at home?
Are they happy at school/nursery?
Impact of this illness on the family (especially if chronic or ongoing)?
Is the child under the care of social services, subject to a child protection plan or has there been any social services involvement?
“Do you have a health visitor? A social worker?”
When taking a history from an adolescent or young adult, it is important to address the health risk behaviours that are more prevalent in this population, as well as the young person’s resilience factors. A way to structure this part of the history is through the HEEADSSS acronym (as outlined below, with examples of questions to be asked in each section).
It’s important that the content of the conversation remains confidential, and that you will not discuss any aspect of it with their parents/carers without their express permission. However, it’s also important the young person knows that confidentiality cannot be assured if they’re at risk of harm – to themselves, or others. An opening statement similar to this may be helpful in establishing this verbal contract:
“Anything we talk about today is confidential. That means I cannot tell others, including your parents, about it without your permission. The only exceptions would be if I thought you, or someone else, was at risk of serious harm. In that case I would need to tell someone else.”
Home and relationships
Who lives at home with you?
Do you have your own room?
Who do you get on with best and/or fight with most?
Who do you turn to when you’re feeling down?
Education and employment
Are you in school/college at the moment?
Which year are you in?
What do you like the best/least at school/college?
How are you doing at school?
What do you want to do when you finish?
Do you have friends at school?
How do you get along with others at school?
Do you work? How much?
Are you worried about your weight or body shape?
Have you noticed any change in your weight recently?
Have you been on a diet? Do you mind telling me, how?
Activities and hobbies
How do you spend your spare time?
What do you do to relax?
What kind of physical activities do you do?
Drugs, alcohol and tobacco
At this stage – reassure about confidentiality
Does anyone smoke at home?
Lots of people your age smoke. Have you been offered cigarettes? How many do you smoke each day?
Many people start drinking alcohol around your age. Have you tried or been offered alcohol? How much/how often?
Some young people use cannabis. Have you tried it? How much/how often?
What about other drugs, such as ecstasy and cocaine?
Sex and relationships
Are you seeing anyone at the moment?
Are they a boy or a girl?
Young people are often starting to develop intimate relationships? How have you handled that part of your relationship?
Have you ever had sex?
What contraception do you use?
Self-harm, depression and self-image
How is life going in general?
Are you worried about your weight?
What do you do when you feel stressed?
Do you ever feel sad and tearful?
Have you ever felt so sad that life isn’t worth living?
Do you think about hurting or killing yourself?
Have you ever tried to harm yourself?
Safety and abuse
Do you feel safe at school/at home?
Is anyone harming you?
Is anyone making you do things that you don’t want to?
Have you ever felt unsafe when you’re online or using your phone?
Closing the consultation
Thank the patient and the family.
Summarise the history and explain the next step in the consultation (if applicable).
Lissauer, T., Clayden, G., & Craft, A. (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
Tasker, R. C., McClure, R. J., & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.