How to elicit a paediatrics history?
Taking a paediatrics history can be daunting if you are not accustomed to work with children. Paediatrics include patients from neonate to adolescent, ranging from the age of 0-16 years old. Children are resilient and tend to compensate when they are ill. However, they can decompensate and deteriorate rapidly. Identifying the age of a child is key in paediatrics history.
Neonate <28 days
Infant 1-12 months
Toddler 1-3 years
Pre-schooler 3-5 years
School age 5-12 years
Adolescent 13-17 years
The child is generally accompanied by a parent/carer. In very young children who do cannot speak, the history is taken through the parent. It is important to be aware that parent with a sick young child might be anxious. When you take a history, be empathetic. In older children, the history can be taken directly from them. Some children are shy and might be embarrassed to talk. It’s important to be friendly and engage with the child early on. Children like to play. Do not ignore the child and talk only to the parent. Greet the child, be playful if appropriate. Interact with the child and address your questions to the child who is your patient. Communication is key to gather a good paediatrics history. The child might not be able to answer all your questions so you could encourage the parent to pitch in the history. It is vital to get the full account of the problem from both the child and the parent. With older teenagers, maintaining autonomy without offending the parent can be tricky. Sometimes, teenagers might feel uncomfortable to share personal information if their parents are in the room. It might be necessary to invite parent to leave to achieve privacy. The teenager might be more at ease to answer personal questions about sexual behavior, smoking or alcohol.
The paediatrics history consists of specific elements not generally explored in a traditional medical history.
First thing first, you need to introduce yourself and gain permission to take a history from the child and parent as appropriate. If your patient is a newborn, you might want to congratulate the parents before you jump in the history.
What bring you today?
How can I help?
Establish the reason for the consultation
Presenting complaint
symptoms that brought the patient in
History of presenting complaint
When did the problem start?
How did it develop? Has it changed? Chronological order
Fever, breathlessness, rash, coryzal symptoms, pain, seizure
Aggravating or relieving factors
Have there been any previous episodes of similar illness?
Any contact with similar illness in others/siblings
Any recent overseas travel
Has the child been kept from going to nursery/school?
Feeding history
Intake of food/feed, bottle/breast milk, oral fluid
If formula, which one? How much?
Wet and dirty nappies
Toilet trained
ICEpatient and parent
Birth history
Antenatal
Gestation 37-40 weeks, birth weight 2.5-4.5kg
Mode of delivery & birth complications
Passed meconium
Developmental history
Gross motor, fine motor and vision, speech and hearing & social
Smile by 6 weeks
Sit by 9 months
Speech first words by 18months
Walk by 18 months
Growth history
Weight and height
Red book
PMH
Immunization history
Drug/ allergies
Family history- who lives at home with child, siblings, medical conditions in the family
Social history- parental occupation, smoking, involvement with social services
Systems review
A review of all systems