Download The Paediatric History

The Paediatric History
General points
 If the child or family does not speak your language, try to find an interpreter, or arrange one for
a subsequent consultation to clarify what has been discussed.
 Specific skills and techniques need to be employed to take a good history of a child's illness.
o In very young children who have no speech or limited speech you must take the
history through the parents and learn to interpret it. Consider:


The younger the child, the more reliant one is on their account.
Parents may be extremely anxious, tired or both. This can impair
communication between doctor and parent.

o
o
o
An empathic approach is likely to improve communication and
hence the history and accuracy of diagnosis.
In older children there is a difficult line to tread between giving the child as much
autonomy as possible and getting a full account of how an illness or problem
has presented. It is often necessary to synthesise the accounts from parents
and the older child. In this situation you should remember that the child is your
patient, not the parent, and focus your attention on their story whist engaging
the parent(s) and maintaining their trust and confidence.
With teenagers, it may be difficult to give appropriate autonomy without
offending the parents.
When dealing with older children and issues of confidentiality, if you are unsure
of the legal and ethical implications of confidential medical information, seek the
advice of a medicolegal advisor. It may be appropriate to discuss difficulties with
a medical indemnity or defence organisation.
 Unfortunately some parents or carers very occasionally may not have a child's best interests at
heart. They may attempt to conceal facts and keep secrets. In such a situation it is important
to remember that your overriding duty is to the child. It can be very difficult to reach a
conclusion about such matters without multidisciplinary or expert support. 1 Where child
protection issues are important:
o Seek medicolegal advice from your medical indemnifier
o Consider current and relevant guidelines
o Access local child protection teams for support and advice on procedure
 Privacy, dignity and confidentiality
Often difficult in busy paediatric wards or general practice/child health surgeries, where
physical space is at a premium. During an average stay in hospital most patients and their
relatives will overhear confidential exchanges, and only a few will ever recall being offered a
room/screen to preserve privacy during history/examinations. 2Try to avoid such pitfalls and
put yourself in the place of the child/parent(s) before taking histories/conducting
examinations or discussing private/confidential information.
Aims of the paediatric history
The suggested aims of the paediatric history are to:
 Direct appropriate examination and investigation
 Reach a correct diagnosis (or form a differential diagnosis)
 Establish the context of a child's illness (psychological, family and social context)
 Establish and maintain a good relationship with the child and parent(s). This helps child and
parent(s) to accord with the advice given by the healthcare professional, especially where it
might conflict with their own expectations or beliefs
 Use the interaction with the child/parent(s) as part of the therapeutic process
 Use the understanding and knowledge of context and background to tailor pragmatic,
appropriate treatment strategies
 Take an overview of the child's previous and current state of health to anticipate or identify any
problems which may not be immediately apparent
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Presenting complaints
 Record the child's and parents' own words as faithfully as possible, using direct quotations if
relevant.
 Where there are multiple symptoms set each one out separately with space to document the
features of how it developed and the relationships between the symptoms.
Current illness
What to ask about the current illness:
 When and how did it startΑ
 Was the child well beforeΑ
 Have there been any previous episodes of similar illnessΑ
 How did it developΑ
 What aggravates or relieves the symptom(s)Α
 Any contact with similar illness in others/siblings or infectious outbreaksΑ
 Any recent overseas travelΑ
 How has the illness affected the familyΑ
 Have the symptoms kept the child from attending nursery/schoolΑ
In Infants:
 Pattern of feeding, bowel movements, and number and wetness of nappies
 Sleeping/waking cycle, alertness and activity
 Weight loss or gainΑ
Further directed questioning:
Having established these facts:
 Form hypotheses about the possible diagnoses/problem
 Test the hypothesis with appropriate further enquiry
Past history
Peri-conceptual history
 Was there any parental illness around time of conception that may be relevantΑ
 Was child conceived naturally or by assisted reproductionΑ
 If relevant, establish whether child is adopted (or in foster care) with due sensitivity to the
child's awareness of the facts
History of pregnancy
Any factors relevant to foetal wellbeing should be recorded. For example:
 Antenatal infections (for example rubella)
 Rhesus incompatibility and haemolytic disease
 Exposure to prescribed, recreational drugs or over the counter medication
 Any maternal illness or problems in pregnancy
Peri-natal history
Factors pertinent to the child's health should be identified. For example:
 Gestation
 Duration of labour
 Mode of delivery
 Birth weight
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 What if any resuscitation required
 Birth injury
 Congenital malformations identified
Neonatal period
Relevant examples include:
 Jaundice
 Fits
 Febrile illnesses
 Bleeding disorders
 Feeding problems
Other relevant past history
This will include:
 Any subsequent illnesses, surgery, accidents or trauma
 Results and any concerns from screening tests at child health clinics or school
 Immunisation record
 Travel details
Developmental history
 Parental recall of major milestones will usually give important information (such as sitting up,
crawling, walking, talking, toilet training, reading).
 It may be useful to ask how the child's progress and milestones compare with siblings and
peers.
 Observations from other carers (school, nursery and extended family) may be helpful.
 See Internet section for useful article on assessment of development.
Current medication
 Prescribed medication
 OTC medication
 Recreational drug or solvent use- in teenagers such information is much more likely to be
forthcoming if the patient is seen alone and reassured confidentiality will be maintained
 Complementary formulations
It is worth remembering that the parent's memory of medication may not be accurate. Corroboration
may need to be sought.3 Pharmacists, GP computerised practice records and health visitors may be
useful sources of additional information.
Drug intolerances, adverse drug reactions and allergies
It is important to enquire further about any allergy. Minor adverse reactions can often be labelled
inappropriately as allergies.
Family history
 Relevant history. For example:
o Previous miscarriages or stillbirths
o Diabetes mellitus
o Hypertension
o Renal disease
o Seizures
o Jaundice
o Congenital malformations
o Infections such as tuberculosis
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 Whether siblings and parents are all alive and wellΑ
 Consider conditions which may have a genetic component (such as ischaemic heart disease
and cerebrovascular disease). Occasionally it is appropriate to address risk factors (such as
familial hypercholesterolaemia) during childhood.
 Consanguinity occurs more commonly in some cultures and may be relevant to inherited
disease (particularly autosomal recessive conditions).
 It can be useful to present findings by using a two-generation family tree.
Social history
This is separate from family history but allied to it.
 Take care not to offend when enquiring about the structure of the family unit by making
assumptions about who may or may not be present or 'involved'.
 Be prepared to allow information to come out gradually. Information may come from others (for
example nursing staff, play specialists, educationalists). Ask about:
o Who lives at home (and any role in childcare)
o Siblings (ages, health, problems)
o Play
o Eating and sleeping patterns
o Schooling and any problems
o Pets
o Housing issues or problems
o Childcare (if parents work)
o Parental occupation(s)
o Smoking in the home
 Child abuse is a common problem. Child abuse comes in many guises and harm is inflicted in
many different ways. Any such concerns may emerge from the social and family history and
any concerns should be shared with colleagues and Social Services.
Educational history
It may be appropriate to ask specific questions about a child's experience and attainments at school.
This may include, for example, asking about ability to concentrate and make progress with learning in
reading, spelling and mathematics. Any fear or anxiety about school should be explored. Bullying is
common and can interfere with learning. Reports from teachers can be enlightening and supplement the
history.
Emotional history
Specific questions may be asked about mood, eating and sleeping habits, interests, hobbies and other
activities. Life events and emotionally disturbing events can have a major effect on wellbeing and
general development.
Systems review
 Consider further information about other organ systems
 Ask questions pertinent to the diagnostic hypothesis and the age of the child
 Consider general issues particularly psychological factors which may have been overlooked. 4
Summarising
 At the end of the history it helps doctor and parent(s) to summarise understanding (including
diagnosis, problems and any psychological factors).
 It is important to give child and parent(s) an opportunity to reveal omitted details and to ask
questions.
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Paediatric Examination
General points

It is important to have established rapport with parents and child when taking the
history.

The approach to the examination will be determined by the age, level of development
and level of understanding of the child.


Inspection and observation are the most important parts of the examination.

Approach the child at their level, if necessary kneel on the floor. It may be impossible
to examine pyrexial, irritable children without provoking crying and they should be
carefully observed before attempting closer examination.

Start examining peripherally with hands and feet as this is less threatening.

Make the examination fun to help with their anxiety.

Make sure the child is comfortable and warm hands, stethoscope and other
instruments.

Wherever possible avoid unpleasant procedures (for example rectal examination).
These are seldom necessary and can put children off being examined for a lifetime.
Avoid waking sleeping children.
Growth and pubertal development
General points
 Myelination of the nervous system at birth is incomplete.
 Pubertal development has important implications for growth. Assessment of puberty is
important when assessing growth.
 Examination of children should incorporate accurate assessment of growth and
pubertal development.
 There are three phases of growth:
 Infant phase:
o Rapid first year and slowing in the second year of life
o Good nutrition is important for normal growth
o Metabolic hormones control growth
 Childhood phase:
o From second to tenth year
o Pituitary hormones and growth hormone are important factors
 Pubertal or adolescent phase:
o From onset of puberty until adult stature reached
o Sex hormones are the important factors
Measurement
 Head circumference routinely in under age 2 years
 Length or height in older children
 Weight
 Plotting of serial measurements to establish pattern and range of growth
 Use appropriate growth charts
 Assess and plot pubertal development where indicated
Developmental assessment

An awareness of normal developmental milestones should be acquired by all doctors
working with children.

Detailed assessment of development is complicated but useful assessments in the
course of routine examinations and consultations can be achieved with experience
and practice.

There are large variations in normal development.

Schemes to assess development centre on:
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o
o
o
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Motor skills: gross motor and fine motor
Special senses: vision and hearing
Communication: comprehension and expressive language
Psychosocial aspects: social skills and behaviour
Aims and purposes of paediatric examination

It is important to distinguish between:
o The routine examination of well babies (to screen largely for abnormalities of
growth and development).
o The examination of ill babies (to establish the nature and cause and extent of
any illness or injury).
o The examination of children for other specific purposes such as, for example:
 To establish fitness for education or certain activities.
 To examine for signs of sexual abuse in child protection cases.

However this is not an absolute distinction. Whether ill or well the examining doctor
should have a good working knowledge of routine examination and normal findings in
children at different ages.

Problems with development, behaviour and growth may thus be identified
opportunistically whilst examining an ill child.

Doctors working with children should have a good knowledge of normal developmental
milestones, as well as routine physical development and findings at different ages.
Examination
Examination will be outlined in different age groups. These are not intended to be exhaustive checklists
but aim to highlight important aspects of the examination in these selected age groups, particularly
where there are notable differences to adult examination. The emphasis and detail of any examination
will be determined by the particular aims and purposes of the examination outlined above.

Newborn babies (see also Newborn Screening)


Six week old babies (see also The Six Week Review)

Toddlers or children under 2 years


Preschool children (see also The Pre-school Check)

Adolescents (see also Puberty: Normal and Abnormal)
7 to 9 month old babies
School age children
Normal values
A distinctive feature of paediatric examination is that normal parameters change with growth and
development. This is illustrated by the example of pulse, blood pressure and respiratory rate in different
age groups in the table below.
Normal ranges for pulse, blood pressure and respiratory rate in children
Newborn and young
babies
Older
babies and
toddlers
Preschool
children
School
children
Adolescents
Pulse: 110- 160
P: 110- 160
P: 110 to 160
P: 80 to 120
P: 60 to 100
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beats per minute
Tachycardia: over
180 beats per minute
beats per
minute
T: over 160
beats per
minute
beats per
minute
T: over 160
beats per
minute
beats per
minute
T: over 120
beats per
minute
beats per
minute
T: over 160
beats per
minute
Systolic blood
pressure: variable,
but range 50 to 85
mmHg
SBP: 80 to
95 mmHg
SBP: 80 TO
100 mmHg
SBP: 90 to
110 mmHg
SBP: 100 to
120 mmHg
Respiratory rate: 30
to 50 breaths per
minute
Tachypnoea: over 60
breaths per minute
RR: 25 to
35 breaths
per minute
T: over 40
breaths per
minute
RR: 25 TO 30
breaths per
minute
T: over 30
breaths per
minute
RR: 20 to
25 breaths
per minute
T: over 25
breaths per
minute
RR: 15 to 20
breaths per
minute
T: over 25
breaths per
minute
Remember importance of cuff size for blood pressure: cuff width (2/3 of shoulder to
elbow distance) and cuff length (2/3 of limb circumference)
Newborn babies
The assessment and examination of the newborn and neonates (under 4 weeks) often requires a
specific and detailed series of checks, observations and measurements supplemented with detailed
history from the parents. Babies are routinely checked and examined at birth and at between 6 and 8
weeks. The objectives are generally:

To screen for congenital abnormalities (particularly those requiring intervention).

About 14% of babies will have congenital abnormalities and these are often detected
at the neonatal check.

To answer questions from parents and discuss concerns they may have.
Preterm babies have particular characteristics best considered separately.

Newborn and young babies become ill very quickly. The 'baby check' system of
assessment can help health professionals and carers to quickly evaluate the
seriousness of a baby's illness.1
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Growth:
o
o
o
o
o

There is a steep growth curve. Weight (nude) should be accurately
measured and plotted:
Initial weight loss of between 5% and 10% occurs in the first week.
Subsequent weight gain over the first 5 months is approximately 0.2Kg
per month.
Length needs careful measurement with a stadiometer.
Head circumference is measured with a suitable non-stretch tape at the
largest point around occiput and forehead.
Development:
o Social smiling is an important milestone (higher cortical function).
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o

Babies show a startle reaction to sound
General examination:
o This is performed in the light of a history of mother's health, the
pregnancy and the birth.
o A routine of checking systematically should cover:
o It is important to assess gestation and weight:
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Term- born between 37 and 42 weeks gestation
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'Large for dates' when over 90th centile for gestational age
Preterm- born before 37 weeks gestation
Post-term-born after 42 weeks gestation
'Small for dates' or small for gestational age if below the 10th
centile (weight) for gestational age
Low birth weight babies (LBW) are important to identify
(associated morbidity and mortality):


LBW babies are <2.5 kg at birth (7% UK births)

Extreme low birth weight (ELBW) are < 1.0 kg
(less than 0.5% and nearly all preterm)
Very low birth weight (VLBW) are <1.5 kg (1% of
UK births and mostly preterm)

Cardiovascular examination. Early diagnosis of congenital heart disease, coarctation
of the aorta and patent ductus arteriosus is important. Examination should include:
o Inspect colour looking for cyanosis. Peripheral cyanosis is common in
newborns (acrocyanosis). Look for central cyanosis (tongue).
o Palpate brachial and femoral pulses and the precordium.
o Auscultation should detect heart sounds and murmurs. Splitting of the
second sound is difficult to detect with the fast heart rate. Innocent
murmurs are heard in about 20% of babies.
o Appreciation of normal findings (table above)

Respiratory examination:
o Observation of breathing is most important.
o Signs of respiratory distress are distinct from those in older children and
adults. A combination of the following may be observed:
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Tachypnoea
Subcostal and intercostal recession
Tracheal tug
Grunting
Flaring of nostrils
Cyanosis
Apnoea and periodic breathing may be identified (preterm
and neonates)
Gastrointestinal examination:
o Observation:
o

Observe the baby feeding (distinguish normal possetting
from abnormal vomiting or bile stained vomiting)


Inspect nappy/ stools
Look for jaundice (distinguish normal from abnormal as in
neonatal jaundice)
Palpation:

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
Examine mouth and palate
Inspect natal cleft
Liver edge (1cm below costal margin is normal)
Hernias should be detected
Umbilical hernias are common and need no treatment
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Other hernias need prompt referral

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Ambiguous genitalia need referral
Hydroceles are common and need no treatment
Genital anomalies should be identified and referred
Brief confirmation of normal urethral and clitoral anatomy
should be made (identify for example hypospadius)
Hips may be examined whilst the nappy is off (Ortolani and
Barlow techniques)
Neurological and developmental assessment:
o Observation is again the most important form of examination
o Inspection and palpation of the baby's head is indicated:
o

Fontanelle size and tone (bulging fontanelles with raised
intracranial pressure)

Moulding of the head is apparent in the first 24 hours (note
'chignon' after ventouse and cephalhaematomas which can
take several days to resolve)
 Head circumference should be measured and plotted
Eyes and hearing:




o
Babies will fix and follow with their eyes
The red reflex should be seen in each eye
Squints may be normal under 8 weeks
There should be a startle response to loud noises
Reflexes:

It is usually inappropriate to elicit primitive reflexes (unless
asymmetry of movement or tone suspected)

Observation will identify symmetrical movements
Six week old babies
This is covered in the Six Week Review record.

Important aspects of the examination:
o Ill babies can be assessed according to the baby check system 1
o The examination is similar to that for newborn babies
o Progress with feeding should be discussed

Growth:
o
o
Weight, length and head circumference should be plotted
Deviation from centiles should be discussed and followed up

Development:
o Milestones should be briefly reviewed in all babies

General examination:
o The parameters and methods are as for those outlined in young and
newborn babies
o Hips may be examined again
7 to 9 month old babies

Important aspects of the examination:
o This age group are frequently seen by doctors.
o From the age of about 3 months viral illnesses are very common.
o It is a period of rapid growth and development.
o Routine checks are not now normally performed in this age group.
o Assessment of growth and development is usually done opportunistically.

Growth:
o
Growth is very rapid (with a doubling on average of birth weight by 5
months).
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o
o

Length and weight should be plotted and compared with previous
readings.
It can be very difficult to obtain an accurate length in this age group.
Development:
o Parents will often present with children when there are concerns over
developmental progress.
o It is a period of rapid developmental progress.
o Developmental milestones should be reviewed opportunistically. For
example:



Social smile should have appeared by 8 weeks.
Children should be sitting unsupported by 8months.
Children should be babbling by 8 months.

General examination:
o Rashes are common with frequent viral infections particularly.
o Doctors should be familiar with important rashes (such as the purpuric
rashes of meningococcal septicaemia, idiopathic thrombocytopenic
purpura and Henoch- Schönlein Purpura).

Cardiovascular examination:
o Cardiac output is regulated mostly by changes in heart rate (as with
newborn and younger babies). Tachycardia is an important sign which
needs explanation.

Respiratory examination:
o This is frequently performed in this age group.
o Observation is again very important.
o It is important to distinguish wheeze from stridor.

Gastrointestinal examination:
o Observation is again important. For example, with peritonitis. The child
lies very still with flexed knees and shallow breaths.
o Inspect anogenital area if appropriate. This is an increasingly difficult
examination as children get older and requires sensitive handling.
o Warm hands and reassurance are needed to palpate the abdomen of an
ill child.

Neurological and developmental examination:
o Formal examination is very difficult. Improvisation is often required.
o Cranial nerves are examined by observation for example, of behaviour
and facial movements. Cranial nerve abnormalities in this age group
include:



Bell's palsy
Eighth cranial nerve impairment (sensorineural deafness)
Sixth cranial nerve deficit (convergent squint) with raised
intracranial pressure
Toddlers

Important aspects of the examination:
o Toddlers are infants who are walking (usually over 1 year) but under 2
years of age.
o Again this group consults often.
o Attendance is likely to be distributed between different settings (for
example hospital, primary care, clinics, walk-in centres).
o It is important for there to be good communication between these
different agencies.
o Growth and development is rapid.
o Checks of growth and development will often have to be done
opportunistically.
o Genu varus is physiological in this age group.
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
Growth:
o
o

Growth decelerates from the end of the first year.
Head growth is rapid as the brain grows with myelination in cortical areas.
Development:
o Important milestones should be identified. Briefly:

Hand dexterity improves along with visual acuity from palmar
grasp to pincer grip in the first year. By the second year a
tower of 6 bricks can be achieved.

Speech develops from babbling to 6 or more words at 18
months and short phrases during the second year.

Comprehension allows simple instructions to be followed by
about a year.

Babies progress from crawling to cruising and then walking
by about a year (before 18 months).

General examination:
o It is usually best to examine babies on the parent's lap and establish
relaxed rapport.
o Engage in play to facilitate the examination.
o It may be necessary to be quite selective and examine important or
relevant systems first.
o Leave more intrusive or unpleasant examinations until the end (for
example throat examination).

Cardiovascular examination:
o Refer to normal values.
o Identify innocent murmurs (often heard).

Respiratory examination:
o Observe and identify normal rate, breathing sounds and pattern.

Gastrointestinal examination as above.

Neurological and developmental examination as above.
Preschool children (age 2 to 5 years)

Important aspects of the examination:
o This age group also frequently attend for medical care and advice.
o Illness and increasingly, accidents will prompt attendance.
o Again rapport and confidence have to be established and maintained for
easier examination. Trust can be built for future examinations.
o Genu valgus is physiological in this age group.

Growth:
o
o
Growth is decelerating at this stage.
Centile charts should be used and checked.

Development:
o The most marked advances are in communication skills and use of
language.
o An assessment of language skills should be briefly made in all children.

General examination:
o Again most often achieved on parent's lap or standing close to parent.
o Explain and commentate on procedures as they progress. Answer
questions, they are usually very inquisitive at this age.

Cardiovascular examination:
o Examination is easier in this age group.
o Again innocent murmurs are common.
o Heart sounds are more easily identified with slower heart rates.

Respiratory examination:
o Observation is again most important.
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o
Peak flow measurement not reliable until about age 5 years (see
Diagnosing Childhood Asthma in Primary Care)

Gastrointestinal examination:
o It is often best to examine kneeling down alongside the patient.
o Children may prefer palpation to be done with their hand underneath the
examiners.

Hip and knee examination:
o Irritable hip and other hip conditions can occur at this age and require
assessment.
o Normal genu varus (physiological in the toddler) and valgus
(physiological in the preschool child) often require reassurance at this
age.

Neurological and developmental examination:
o This increasingly approaches what is possible in adults.
o Vision can be checked by shape or letter matching at 3 years of age.
o A circle will be copied by 3 years, a cross by 4 years, a square by 4.5
years and triangles by about 5 years.
School age children (from 5 to 10 plus years)

Important aspects of the examination:
o This age group are examined less often by doctors.
o Psychological factors begin to play more of a part in how problems
present.

Growth:
o
o
Growth will be steady leading up to the pubertal growth spurt.
Concerns may begin to be expressed about growth and development in
relation to puberty.

Development:
o Social and behavioural aspects of development become more important.
o Other aspects of development approach those of adults.

Examination:
o There are now few differences from adult examination.
Adolescents (from the onset of puberty)

Important aspects of the examination:
o Adolescents attend for medical advice infrequently.
o Rapport and good communication may be difficult to establish.
o Psychological factors are likely to be very important.
o Most adolescents are very self-conscious and this can impede adequate
examination.
o It is recommended to have a chaperone.
o Confidentiality and consent become more important issues.

Growth:
o
o

Puberty initiates a period of rapid growth.
Normal and abnormal puberty should be recognised.
Examination:
o Examination is very similar to that undertaken in adults.
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