Paediatric History Taking Techniques and Best Practices

Before the examination, it is necessary to contact the child, as far as his condition allows. Older children should get to know each other better: find out their names, take an interest in academic success, hobbies, habits.

Use simple language for younger children and gradually adapt to more complex vocabulary for older ones. Ask questions in a non-threatening manner to encourage honest responses.

The doctor should:

• have an even, calm mood
• show patience, self-control
• never get annoyed with the child, his mother and other loved ones.

Involving parents and caregivers

Parents and caregivers play a crucial role in providing important medical and developmental information about the child. Encourage their active participation, ask for insights, and ensure they understand the importance of their input into the diagnostic process.

Prioritizing the chief concerns

Identify the chief concerns early in the history-taking process. Allow the child or caregiver to express their main worries, and then gather information related to those concerns. This helps focus the assessment and prevents essential details from being overlooked.

Сonditions for the premises

During the physical examination of the child you should remember:

1. to examine the patient in good light (preferably daytime), placing the child closer to the light source;
2. before the age of 3, the child should be stripped naked, and school-age children (especially girls during puberty) should be undressed gradually as the study progresses. However, the child should not be kept undressed for too long because of the risk of hypothermia;
3. the room should be warm, 71-77℉ (22-25℃).
   
   

The Process of Paediatric History-Taking

Paediatric practice collects anamnesis from relatives, most often from the mother. Nevertheless, it is important to question the child himself, especially if the child is older.

The questioning is the first stage in the child's study and is carried out in 5 main directions:

• Clarification of passport data (name, date of birth).
• Signs of the disease (presenting complaints).
• The past history of the disease’s development.
• The patient's social history, including heredity, birth history and living conditions, etc.
• Epidemiological and drug history (information about contacts with infectious patients).

The collection of disease anamnesis begins with the sign that appears first. In chronological order, you should identify the detailed characteristics of the signs, and how one changes when the other appears. This section should include the results of all previously conducted studies, therapeutic measures and effectiveness. The collection of disease anamnesis is a step-by-step process and is supplemented with additional information as the patient is monitored.

Here are lists of the must-asked questions during examinations of children.

A young child’s history taking (up to 3 years old)

• How did the pregnancy of this child proceed?
• Prenatal regime and nutrition. Was maternity leave used and how?
• How did the birth proceed (duration, complications, mode of delivery)?
• Did the child cry out immediately after birth?
• Birth weight and height.
• Characteristics of the newborn period: assessment on the Apgar scale 1 and 5 minutes after birth, feeding technique (free, by the hour, night feeding, etc.), immunisation in the maternity hospital.
• Borderline conditions of newborns (physiological weight loss and recovery time, jaundice, uric acid infarction, etc.).
• Diseases during the newborn period: rhesus conflict; birth trauma; rashes, septic diseases; wheeze; gastrointestinal diseases, etc.).
• Dynamics of the child's development: holding the head, sitting, walking, mental development.
• Sleep, its features and duration.
• Kind of feeding (natural, artificial, mixed).

An older child’s history taking

• How did he develop at an early age?
• The child's behavior at home and in a team, for schoolchildren - school performance, what subjects does he prefer?
• Past medical conditions and surgical interventions.
• Preventive vaccinations.
• Tuberculin tests, when conducted, their results.
• Sexual development of the child.

Family history

• Surname, first name, profession of parents.
• The state of health of parents and immediate relatives on the mother's and father's side.
• The state of the family tree within three generations, starting from a sick child to grandparents up, i.e. vertically, and up to brothers and sisters - horizontally.
• How many children are in the family, their health.

Social and living conditions

• Where do parents work, their profession, total earnings, the number of family members?
• Characteristics of housing conditions (illumination, heating, temperature, ventilation, dampness, etc.), the number of children and adults living.
• The quality of child care (does the child have a separate bed, how often does he wash, is he provided with linen, does he have clothes for the season, toys, a children's library, does he observe the daily routine, the diet, what is the duration of walks and sleep, etc.).

Epidemiological history

• Ask about possible contacts with sick children, adults at the place of residence (in the family, in the neighborhood) or clarify this information with the district doctor.

A carefully collected anamnesis of life, especially family history, makes it possible to identify a child's predisposition and risk factors for a particular disease. This is often realized at later stages of ontogenesis and even in adults.

Let’s look at the example of a history taking for abdominal pain in a paediatric patient.

Example of History Taking for Abdominal Pain

Patient information

Name: Sarah
Age: 8 years
Gender: Female
Date of Visit: July 20, 2024

Chief complaint

Sarah has presented with abdominal pain for the past 2 days.

History of the present illness

• When did the pain start? (2 days ago)
• Onset: Was the pain sudden or gradual? (Gradual)
• Location: Where is the pain located? (Sarah points to the lower right side of her abdomen)
• Character: How would you describe the pain? (Sarah's mother explains that it is a dull, constant ache)
• Intensity: On a scale of 1 to 10, how intense is the pain? (Sarah rates it as a 6)
• Aggravating Factors: Does anything make the pain worse? (Sarah's mother says that movement and eating seem to worsen the pain)
• Alleviating Factors: Does anything provide relief? (Sarah finds some relief when lying down and resting)
• Timing: Is the pain constant or does it come and go? (Intermittent pain)
• Associated Symptoms: Are there any other symptoms accompanying the pain? (Sarah's mother mentions mild nausea but no vomiting or diarrhea)

Past medical history

• Any previous history of abdominal pain or gastrointestinal issues? (No)
• Has Sarah experienced any surgeries or hospitalizations in the past? (No)
• Are there any known allergies to medications, supplements or food? (No)

Family history

• Is there a family history of gastrointestinal conditions or other relevant medical issues? (No)

Social history

• Does Sarah attend school regularly? (Yes, she is in the third grade)
• Are there any significant recent life events or stressors? (No)

Systems review

• Any recent changes in appetite or dietary habits? (Sarah's mother says she's eating less due to the pain)
• Changes in bowel movements or urinary patterns? (No unusual bowel movements or changes in urination)
• Recent travel or exposure to sick individuals? (No travel history or known exposure to sick individuals)

Developmental milestones

• Is Sarah meeting age-appropriate developmental milestones? (Yes, she is achieving developmental milestones as expected)

Conclusion

Based on the history provided, Sarah, an 8-year-old female, is experiencing abdominal pain localized to the lower right side of her abdomen. The pain is dull, constant, and rates at 6 out of 10. It started gradually two days ago and is aggravated by movement and eating. Sarah feels relief when lying down. There are no significant associated symptoms except mild nausea. Her past medical and family history is unremarkable. Further assessment and physical examination are needed to determine the cause of her abdominal pain and recommend appropriate management.

Practice Management Software for Paediatric History Taking