What questions should be asked when taking a history for a 3-year-old female (3yoF) presenting with vaginal discharge?

History-Taking for Vaginal Discharge in a 3-Year-Old Girl

When evaluating a 3-year-old girl with vaginal discharge, you must immediately assess for sexual abuse while simultaneously gathering information about hygiene practices, discharge characteristics, and associated symptoms, as any sexually transmitted infection in this age group mandates reporting to child protective services. 1, 2

Critical Red Flag Questions (Ask First)

• Has anyone touched the child's private parts inappropriately? Direct questioning about possible sexual contact or abuse is mandatory, as STIs in prepubertal children are highly suspicious for sexual abuse 1, 2
• Has the child disclosed any concerning interactions with adults or older children? Document exact words used by the child without interpretation 1
• Who has access to the child and under what circumstances? Identify all caregivers and potential contacts 1

Discharge Characteristics

• What color is the discharge? (Clear, white, yellow, green, brown, or blood-tinged) 2, 3
• What is the odor? (Foul-smelling discharge suggests foreign body or bacterial infection; fishy odor suggests bacterial vaginosis) 2, 4
• How long has the discharge been present? (Acute vs. chronic presentation affects differential diagnosis) 5
• Is there any blood in the discharge? (Blood-stained discharge raises concern for trauma, foreign body, or tumor) 4
• Has the discharge been recurrent or persistent despite treatment? (Suggests foreign body, non-compliance with hygiene, or alternative diagnosis) 5

Associated Symptoms

• Is there pain, itching, or burning in the genital area? (Indicates vulvovaginitis or dermatologic condition) 6, 3
• Does the child have dysuria or urinary frequency? (May indicate urinary tract involvement or severe vulvar irritation) 4
• Is there perianal itching, especially at night? (Suggests pinworm infection) 6
• Are there any skin lesions, warts, or ulcers visible? (May indicate HSV, HPV, or other STIs) 1, 2

Hygiene and Behavioral History

• How does the child wipe after using the toilet? (Back-to-front wiping introduces fecal contamination) 6
• What products are used for bathing? (Bubble baths, soaps, shampoos can cause chemical irritation) 6, 3
• What type of underwear does the child wear? (Synthetic materials and tight clothing increase moisture and irritation) 6
• How frequently is underwear changed? (Infrequent changes perpetuate bacterial overgrowth) 6
• Does the child take baths or showers? (Prolonged sitting in soapy water causes irritation) 3

Foreign Body Assessment

• Has the child been observed inserting objects into the vagina? (Toilet paper, toys, or other objects are common causes of persistent discharge) 4
• Does the child have unsupervised time alone? (Increases likelihood of foreign body insertion) 4
• Has there been treatment failure with antibiotics? (Persistent discharge despite appropriate antibiotics strongly suggests foreign body) 5, 4

Medical and Developmental History

• Is the child toilet-trained? (Affects hygiene practices and contamination risk) 3
• Does the child have any chronic medical conditions or immunodeficiency? (Increases susceptibility to infections) 3
• Is there a history of recent antibiotic use? (Can alter vaginal flora and predispose to yeast overgrowth, though uncommon in prepubertal girls) 6
• Has the child had any recent respiratory or skin infections? (Group A Streptococcus can cause vulvovaginitis) 6
• Are there any skin conditions elsewhere on the body? (Eczema, psoriasis may also affect genital area) 6

Exposure History for STI Risk Assessment

• Has the child been in contact with anyone diagnosed with an STI? (Direct exposure risk) 1
• Are there household members with known STIs? (Potential for abuse or non-sexual transmission in rare cases) 1
• Has the child been in foster care or multiple living situations? (Increases risk of undetected abuse) 1

Timing for Follow-Up Planning

• When was the last potential exposure if abuse is suspected? (Determines timing of testing—initial, 2-week, and 12-week follow-ups may be needed) 1, 2
• Has the child been evaluated previously for this problem? (Review prior culture results and treatments) 5

Common Pitfalls to Avoid

• Never dismiss the possibility of sexual abuse based on caregiver reassurance alone—any STI finding requires mandatory reporting regardless of the history provided 2, 6
• Do not assume yeast infection without confirmation—candidiasis is uncommon in healthy prepubertal girls, and empiric antifungal treatment without microscopic confirmation leads to unnecessary medication exposure 6
• Do not overlook foreign body as a cause—this is frequently missed and presents with persistent, foul-smelling, blood-tinged discharge that fails antibiotic treatment 5, 4
• Avoid leading questions when asking about abuse—use open-ended questions and document the child's exact words without interpretation 1