What is the recommended approach to taking a medical history in pediatrics?

Recommended Approach to Pediatric History Taking

The American Academy of Pediatrics recommends establishing rapport in a comfortable environment, using patient-centered communication, and following a structured systematic approach that includes chief complaint, history of present illness, past medical history, medications, family history, social history, and review of systems. 1

Creating the Right Environment and Establishing Rapport

• Begin by introducing yourself and explaining the purpose of the visit to set clear expectations with both the child and family 1
• Create a comfortable, non-threatening environment where the patient feels safe sharing sensitive information 2, 1
• Maintain appropriate body language by orienting yourself toward the patient and maintaining eye contact to demonstrate engagement 1
• For adolescents, explain confidentiality parameters at the beginning of the session, as confidentiality concerns may prevent them from seeking or continuing care 2, 1
• Consider seeing adolescents alone for part of the interview to allow them to discuss sensitive topics privately 1

Structured History Taking Components

Chief Complaint and History of Present Illness

• Start with open-ended questions about the presenting complaint, allowing the patient or family to tell their story in their own words 1
• When interactional problems are suggested, obtain a detailed sequence of events, behaviors, and family interactions associated with the clinical problem 2
• Document the patient's own words when recording symptoms or concerns 1
• Assess the meaning and function of the behavior in relationship to the child's family context 2

Past Medical History

• Gather comprehensive prenatal, perinatal, and postnatal history 3
• Ask about any serious perinatal problems requiring intensive care support 3
• Review breastfeeding history and current feeding patterns 3
• Document vaccination status completely 3
• Inquire about recent illnesses, injuries, hospitalizations, or emergency room visits 4
• Review all prescription medications, over-the-counter medications, and supplements 4

Family History

• Assess family history of psychiatric and medical disorders that may be transmitted to children through experiential or genetic mechanisms 2
• Document serious illnesses in family members, including age of onset and age at death 5
• Recognize that family history is firmly embedded in pediatric practice and serves multiple purposes beyond risk assessment 6

Developmental History

• Obtain a systematic developmental history of each parent, including their experiences in family of origin 2
• Assess developmental milestones: walking status, speech development, and toilet control 3
• For school-age children, inquire about academic performance, attention span, and ability to complete tasks 4
• Evaluate fine and gross motor skills through questions about writing, drawing, sports participation, and coordination 4

Social and Family Context

• Conduct a marital/relationship history to understand how the choice of partner facilitated strengths or perpetuated weaknesses in each parent 2
• Ask about family composition, including who lives in the home and any recent changes in family structure 4
• Inquire about family stressors such as financial concerns, housing stability, or family conflicts 4
• Screen for exposure to violence, substance abuse, or mental illness in the home 4
• Assess cultural practices or beliefs that might impact healthcare decisions 4

Behavioral and Mental Health Screening

• Screen for symptoms of anxiety, depression, or mood disorders using age-appropriate questions about feelings, worries, and emotional regulation 4
• Ask about behavior at home and school, including following rules, impulsivity, and concerning behaviors 4
• Inquire about friendships, social interactions, and difficulties with peers 4
• Screen for potential trauma exposure with direct questions like "Has anything scary or concerning happened to your child since the last visit?" 4
• Use standardized screening tools such as the Pediatric Symptom Checklist or Strengths and Difficulties Questionnaire 4

Safety Assessment

• Ask about home safety measures including smoke detectors, carbon monoxide detectors, and gun safety 4
• Verify consistent use of appropriate car restraints (booster seats or seat belts) 4
• Inquire about helmet use during biking, skating, or other activities 4
• Screen for environmental hazards including lead, mold, or secondhand smoke exposure 4
• Assess screen time habits and internet safety practices with parental monitoring 4

Communication Techniques

• Practice active listening by maintaining eye contact, nodding, and providing verbal acknowledgment 1
• Use motivational interviewing techniques, particularly for sensitive topics or when addressing health behavior change 1
• Employ developmentally appropriate language and approaches based on the child's age 1
• Avoid rushing through the history; allow sufficient time for the patient and family to tell their story 1

Documentation Best Practices

• Document the patient's story in sufficient detail to accurately retell it 1
• Include the patient's own words when documenting symptoms or concerns 1
• Ensure appropriate delineation of past medical and surgical problems, as patients with complex histories may be evaluated differently than those with negative past medical histories 2

Common Pitfalls to Avoid

• Do not focus exclusively on biomedical aspects while ignoring psychosocial factors 1
• Avoid overreliance on templates or electronic health records at the expense of patient engagement 1
• Do not rush through the history without allowing adequate time for the family to share their concerns 1
• Remember that patterns of interaction may be primarily a response to a child with biological vulnerability, not just family dysfunction 2
• When assessing family risk factors, keep in mind the reciprocal nature of family influences—while family interaction may be associated with symptoms in the child, the child's symptoms may also provoke family responses 2