What components are essential when taking a medical history in pediatrics?

Essential Components of Pediatric History Taking

The pediatric history must systematically cover eight core domains: perinatal history, past medical history, developmental milestones, family history, social/environmental context, nutritional assessment, physical activity patterns, and behavioral/mental health screening. 1

Establishing the Foundation

Creating the Right Environment

• Begin by introducing yourself and explaining the visit's purpose to both child and family to set clear expectations. 1
• Create a comfortable, non-threatening environment where sensitive information can be shared safely. 1
• For adolescents, explain confidentiality parameters at the session's start and consider seeing them alone for part of the interview to discuss sensitive topics privately. 1
• Maintain appropriate body language by orienting toward the patient and maintaining eye contact to demonstrate engagement. 1

Systematic History Components

Chief Complaint and History of Present Illness

• Start with open-ended questions allowing the patient or family to tell their story in their own words. 1
• Document the patient's exact words when recording symptoms or concerns. 1
• For witnessed injuries in nonverbal children, obtain detailed information about the child's activity and position before injury, and final position and location after. 2
• When interactional problems are suggested, obtain a detailed sequence of events, behaviors, and family interactions associated with the clinical problem. 1

Perinatal and Birth History

• Document maternal pregnancy complications, gestational age, birth weight, and neonatal ICU complications, as these factors influence later blood pressure and development even in childhood. 2
• For preterm infants, note that bone mineral content may be reduced, increasing fracture risk. 2
• Record history of total parenteral nutrition, hepatobiliary disease, diuretic therapy, hypercalciuria, or corticosteroids that may affect bone vulnerability. 2
• Inquire about umbilical catheter placement and other pertinent neonatal procedures. 2

Past Medical History

• Inquire about recent illnesses in preceding days, including fussiness, decreased activity, fever, congestion, rhinorrhea, cough, vomiting, diarrhea, decreased intake, and poor sleep. 2
• Document injuries, falls, and any previous unexplained bruising. 2
• Review previous hospitalizations, surgeries, and emergency room visits. 2, 1
• Obtain thorough dietary history and history of medications that can affect bone health. 2
• Document chronic diseases such as renal insufficiency, metabolic acidosis, malabsorption, cerebral palsy, neuromuscular disorders, or genetic diseases affecting skeletal development. 2
• Verify newborn screening results for inborn errors of metabolism and congenital heart disease. 2

Developmental History

• Assess major milestones across categories: Is development normal? Are there concerns about development or behavior? 2
• For school-age children, inquire about academic performance, attention span, and ability to complete tasks. 1
• Evaluate fine and gross motor skills through questions about writing, drawing, sports participation, and coordination. 1
• Document growth patterns and whether they are normal. 2
• Assess breathing problems, noisy breathing, and snoring. 2

Family History

• Document sudden unexplained death in first- or second-degree family members before age 35, particularly as an infant. 2
• Inquire about apparent life-threatening events in siblings. 2
• Screen for long QT syndrome, arrhythmia, and prematurity in family members. 2
• Ask about family history of multiple fractures, early-onset hearing loss, abnormally developed dentition, blue sclera, and short stature to suggest osteogenesis imperfecta. 2
• Assess family history of psychiatric and medical disorders that may be transmitted through experiential or genetic mechanisms. 1
• Document serious illnesses in family members, including age of onset and age at death. 1

Social and Environmental History

• Document family structure and individuals living in the home. 2
• Inquire about recent changes, stressors, or strife in the family. 2
• Screen for exposure to tobacco smoke, toxic substances, and drugs. 2
• Ask about housing conditions, including water damage or mold problems. 2
• Document recent exposure to infectious illness, particularly upper respiratory illness, paroxysmal cough, or pertussis. 2
• Assess support systems and access to needed resources. 2
• Inquire about previous child protective services or law enforcement involvement, including domestic violence and animal abuse. 2
• Evaluate current level of concern/anxiety and how the family manages adverse situations. 2
• Assess potential impact of the event or admission on work and family. 2

Nutritional History

• Document salt intake, including salt added in cooking and at the table, plus sodium hidden in processed and fast foods. 2
• Assess consumption of high-fat foods and sugary beverages. 2
• Identify infrequent consumption of fruits, vegetables, and low-fat dairy products. 2
• Note that high sodium intake is associated with a twofold increase in elevated blood pressure or hypertension in children 8-18 years, and threefold among those with obesity. 2

Physical Activity and Screen Time

• Obtain detailed history of physical activity and inactivity patterns. 2
• Ask about screen time habits and internet safety practices with parental monitoring. 1

Medication and Substance History

• Review all prescription medications, over-the-counter medications, and supplements. 1
• Inquire about use of over-the-counter cold medications containing decongestants (pseudoephedrine, phenylpropanolamine) that may cause blood pressure elevation. 2
• Screen for use of supplements like ephedra (ma huang) containing ephedrine and caffeine. 2
• Document recent immunizations. 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
• Ask about behavior at home and school, including following rules, impulsivity, and concerning behaviors. 1
• Inquire about friendships, social interactions, and difficulties with peers. 1
• Screen for potential trauma exposure with direct questions: "Has anything scary or concerning happened to your child since the last visit?" 1
• Use standardized screening tools such as the Pediatric Symptom Checklist or Strengths and Difficulties Questionnaire. 1

Safety Assessment

• Ask about home safety measures including smoke detectors, carbon monoxide detectors, and gun safety. 1
• Verify consistent use of appropriate car restraints (booster seats or seat belts). 1
• Inquire about helmet use during biking, skating, or other activities. 1
• Screen for environmental hazards including lead, mold, or secondhand smoke exposure. 1

Critical Red Flags for Child Abuse

History-Based Warning Signs

• Multiple or changing versions of the history or circumstances. 2
• History or circumstances inconsistent with the child's developmental stage. 2
• History of unexplained bruising. 2
• Incongruence between caregiver expectations and child's developmental stage, including assigning negative attributes to the child. 2
• No history of injury provided, or history not plausible for the type or severity of fracture. 2
• Inconsistent or changing histories provided by caregivers. 2
• Fracture in a nonambulatory child. 2
• Delay in seeking care for an injury. 2

Documentation Best Practices

• Document the patient's story in sufficient detail to accurately retell it, including the patient's own words when documenting symptoms. 1
• Ensure appropriate delineation of past medical and surgical problems, as complex histories require different evaluation approaches. 2
• The content and degree of documentation drives the remainder of the examination, assessment, decision-making process, and heavily influences subsequent reimbursement. 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 concerns. 1
• Remember that patterns of interaction may be primarily a response to a child with biological vulnerability, not just family dysfunction. 1