Overview
Paediatric history taking can be difficult as it requires asking lots more questions compared to a standard history for adults, and the questions asked may need adjusting.
Some differences include having to ask more general questions in a systems review (due to many children presenting with non-specific features) and asking about birth, development, growth, feeding, immunisation, and social situations.
Communication and confidentiality
How one is performed varies depending on the age of the child, such as an older child or adolescent who may not want to discuss sensitive information in front of parents, or an infant or very young child with limited or no speech, requiring the history to be taken from the parents. In older children, finding the balance between autonomy and getting a full history can be tricky. In general, where possible, histories from both children and parents should be collected and interpreted.
In cases where speaking to the child or young person alone is necessary, normalising the idea by saying something along the lines of “We usually do this with all patients…” helps alleviate awkwardness and offending parents.
Remember, the child is your patient, not the parent.
Problems encountered in paediatric history taking
Asking closed questions may be problematic in children. Children may often say yes to closed questions as they may think it is the ‘correct answer’, especially if they are anxious. It is better to use open questions where possible.
- For example, it is better to ask “Where does it hurt?” and let the child point to where it hurts rather than asking “Do you have stomach pain?” and the child says yes.
As well as this, only taking the history from the parent/carer and not involving the child (where possible) may be problematic. The carer may state a feature that they think is going on based on what they think the child’s behaviour means. This impairs the ability to collect a good history and the parent/carer may have biases and influence their reporting of symptoms.
Safeguarding concerns
Always remember that unfortunately, child maltreatment is possible, and some people may conceal facts, tell inconsistent histories, or keep secrets. If child safeguarding issues arise, speak to a senior doctor and the safeguarding lead.
History of Presenting Complaint
With each symptom, always (if relevant) ask about:
- When did it start?
- Did it come on suddenly or gradually?
- Is it continuous or intermittent?
- Has this ever happened before?
Paediatric systems review
Briefly screen for the following, and adjust where appropriate:
- Screening for general features:
- Fever, chills, rigours, sweating
- Crying – is it consolable or inconsolable?
- Growth, weight loss
- Behaviour, appetite, alertness, activity, sleeping
- Screening for cardiorespiratory features:
- Cough, shortness of breath
- Noisy breathing (stridor, wheezing), rapid breathing
- Cyanosis
- Screening for gastrointestinal features:
- Vomiting, diarrhoea, constipation, stool character (e.g. mucus, blood, melaena etc.)
- Bloody diarrhoea is generally rare in children and may be due to infection or inflammatory bowel disease
- Abdominal pain, abdominal distension
- Vomiting, diarrhoea, constipation, stool character (e.g. mucus, blood, melaena etc.)
- Screening for genitourinary features:
- Urine output and hydration – number of wet nappies, number of times using the toilet
- Dysuria, frequency, urgency, enuresis, loin pain
- Haematuria
- Scrotal swelling
- Screening for neurological features:
- Screening for ear, nose, and throat features:
- Ear: pain, discharge, hearing changes
- Nose: epistaxis, discharge, congestion
- Throat, mouth, and neck: sore throat, neck swelling, limited neck movement, mouth ulcers
- Screening for haematological features:
- Screening for skin features:
- Rash, itching, crusting, oozing, changes in skin pigmentation
- Screening for musculoskeletal features:
- Limp, limitation in movement
- Joint pain, joint swelling, joint stiffness
Past Medical History
Birth
- How was the pregnancy?
- Any abnormal scan results or extra scans? Why?
- Any problems? – including maternal illness, diabetes, alcohol, drinking, drug use
- What happened during birth?
- Number of weeks gestation?
- Weight at birth?
- Birth location? – such as in hospital, at home?
- Mode of delivery? – vaginal delivery, caesarean section?
- Any complications to both the mother or child during or after birth?
- Did they need to stay in hospital for longer/was there any admission to neonatal intensive care?
Feeding and toileting
- Ask about diet and appetite:
- What is their diet and appetite usually like and what is it like now?
- Breastfed or formula milk?
- When and how did weaning start?
- Ask about toileting:
- Are they toilet trained?
- How often do they go to the toilet/how many wet nappies?
Growth
- How is their weight?
- Are they gaining weight, staying the same, or struggling to gain weight?
- Do they have their personal child health record (PCHR, the ‘red book’)
- Have they started puberty?
- Usually 8-13 for girls, 9-14 for boys
Development
- Is the child meeting developmental milestones?
- Are there any concerns with development?
- How is school/nursery progress and attendance?
- Perform a developmental assessment if necessary
Immunisations
- Are they up to date with their immunisations?
General questions
- Do they have any other medical conditions?
- Have they ever had any previous surgery?
- Do they take any regular medications?
- Do they take any over-the-counter medications, herbal remedies, or supplements?
Family History
- Is there any family history of anything similar?
- In some autosomal recessive inherited diseases, consanguinity may be possible, ask about this sensitively if necessary
Allergy History
- Are they allergic to anything?
- What happens during the allergic reaction?
Social History
- Ask about their home situation:
- Who’s at home?
- Ask about parents/carers, siblings, other people at home
- What support does the child and parent/carer have?
- What is their housing situation? – e.g. cramped housing
- What are the parent’s occupations?
- How is the parents’/carers’ mental health?
- Who’s at home?
- Ask about the child’s activities including school and nursery:
- Does the child go to school/nursery?
- Has the child had to stay home from school/nursery?
- Ask about smoking, drinking, and illicit drug use sensitively:
- Does anyone smoke inside or outside of the house?
- Does anyone drink alcohol inside the house?
- If relevant, does the young person drink alcohol?
- Does anyone at home use illicit drugs?
- If relevant, does the young person use illicit drugs?
- Ask questions regarding safeguarding:
- Are they known to social services?
- Are there any safeguarding concerns?
- You may need to separately ask the child about safeguarding concerns including:
- Are they at risk of harm?
- Are they being made to do things they don’t want to do?
- Ask about possible infectious contacts:
- Is anyone else at home ill?
- Has anyone in school/nursery been ill?
- Has there been any recent foreign travel?
For specific presentations, histories, and approaches to investigations and differentials, see the OSCE Skills section.
