What is the recommended approach to taking a full and complete pediatric history?

How to Take a Complete Pediatric History

A complete pediatric history follows a structured, systematic approach that begins with establishing rapport and documenting demographic information, then proceeds through chief complaint, history of present illness, comprehensive past medical history including birth and developmental milestones, medications, family history, social context, and review of systems—all while adapting communication style to the child's developmental age and ensuring both parent and child perspectives are captured. 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 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 and consider seeing them alone for part of the interview to allow discussion of sensitive topics privately 1
• Document the identity of the historian and their relationship to the patient, noting any language barriers that may exist 2

Demographic Data and Initial Documentation

• Record sex, date of birth, and identity of parent/caregiver 2
• Document the identity and relationship of the historian to the patient 2
• Identify other pertinent health care providers involved in the child's care 2

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
• Document the patient's own words when recording symptoms or concerns 1
• For behavioral or interactional problems, obtain a detailed sequence of events, behaviors, and family interactions associated with the clinical problem 1
• Assess the meaning and function of the behavior in relationship to the child's family context 1
• For specific complaints, document date of onset, frequency, duration, and associated symptoms 2

Past Medical History

Birth and Perinatal History

• Document birth weight, gestational age, and pertinent prenatal history including maternal alcohol, tobacco, and drug use during pregnancy 2
• Record perinatal complications, NICU admissions, or need for intensive care support 3
• Note any serious perinatal problems that required medical intervention 3

Medical History

• Inquire about recent illnesses, injuries, hospitalizations, or emergency room visits 2, 4
• Document past hospitalizations and operations 2
• Record any serious illnesses in the child's past history 3
• For children with chronic conditions, ask specific questions about symptom management, medication adherence, and impact on daily activities 4

Ocular and Sensory History (when relevant)

• Document other eye problems, injuries, diseases, surgery, and treatments including eyeglasses and amblyopia therapy 2
• Review photographs and/or videos of the patient when evaluating visual concerns 2

Current Medications and Allergies

• Review all prescription medications, over-the-counter medications, and supplements 2, 4
• Document recently adjusted medications 2
• Record all known allergies 2

Developmental History

• Obtain a systematic developmental history including motor, language, social, and cognitive milestones 1
• For infants, assess feeding patterns (should be 8-12 times per 24 hours), stool and urine patterns (at least 6 wet diapers and 3-4 stools per day by 4 days of age) 5
• Document breastfeeding status and duration 3
• For school-age children, inquire about academic performance, attention span, and ability to complete tasks 1, 4
• Evaluate fine and gross motor skills through questions about writing, drawing, sports participation, and coordination 1, 4
• Document current developmental status: walking ability, speech development, and toilet control 3
• Note the presence of developmental delay 2

Family History

• Assess family history of psychiatric and medical disorders that may be transmitted to children through experiential or genetic mechanisms 1
• Document serious illnesses in family members, including age of onset and age at death 1
• Record family history of eye conditions including strabismus, amblyopia, eyeglass use, and eye surgeries 2
• Note family history of genetic diseases 2
• Obtain a systematic developmental history of each parent, including their experiences in family of origin 1
• Conduct a marital/relationship history to understand family dynamics 1

Social History and Family Context

Family Structure and Composition

• Ask about family composition, including who lives in the home and any recent changes in family structure 1, 4
• Document grade level in school for school-age children 2

Psychosocial Stressors

• Inquire about family stressors such as financial concerns, housing stability, or family conflicts 1, 4
• Screen for exposure to violence, substance abuse, or mental illness in the home 1, 4
• Assess for social risk factors including untreated parental substance use, history of child abuse or neglect, parental mental illness, and lack of social support 5
• Screen for potential trauma exposure with direct questions like "Has anything scary or concerning happened to your child since the last visit?" 1, 4

Cultural and Educational Context

• Assess cultural practices or beliefs that might impact healthcare decisions 1, 4
• Document learning difficulties, behavior problems, or issues with social interactions 2

Behavioral and Mental Health Screening

• Screen for symptoms of anxiety, depression, or mood disorders using age-appropriate questions about feelings, worries, and emotional regulation 1, 4
• Ask about behavior at home and school, including following rules, impulsivity, and concerning behaviors 1, 4
• Inquire about friendships, social interactions, and difficulties with peers 1, 4
• Use standardized screening tools such as the Pediatric Symptom Checklist or Strengths and Difficulties Questionnaire 1, 4
• For mothers of newborns, screen for maternal postpartum depression using a validated screening tool 5
• Assess quality of mother-infant attachment and details of infant behavior 5

Safety Assessment

Home Safety

• Ask about home safety measures including smoke detectors, carbon monoxide detectors, and gun safety 1, 4
• Screen for environmental hazards including lead, mold, or secondhand smoke exposure 1, 4

Transportation and Activity Safety

• Verify consistent use of appropriate car restraints: rear-facing car seats until age 2, booster seats, or seat belts as appropriate 1, 4, 5
• Inquire about helmet use during biking, skating, or other activities 1, 4

Digital Safety

• Assess screen time habits including television, computer, video games, and mobile devices 4
• Inquire about internet safety practices and parental monitoring of online activities 1, 4

Review of Systems

• Conduct a pertinent review of systems including history of head trauma and relevant systemic diseases 2
• Ask about physical symptoms or concerns including headaches, stomachaches, fatigue, or other physical complaints 4
• Document allergic manifestations 3
• Inquire about diet and nutrition patterns, including typical meals, snacks, food preferences, and allergies/intolerances 4
• Assess sleep patterns, including bedtime routines, sleep duration, difficulties falling or staying asleep, snoring, or bedwetting 4

Communication Techniques Throughout the History

• 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
• Document the child's level of cooperation with the examination, as this can be useful in interpreting results and comparing over time 2

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 1

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 1
• Failing to directly observe breastfeeding when there are concerns about weight loss or feeding adequacy in infants 5
• Not screening for maternal postpartum depression in newborn visits 5
• Overlooking social risk factors that may compromise infant safety 5