Taking a paediatric general history
A paediatric history is a conversation with the child and caregiver, not a form to be completed mechanically. The child’s age, developmental level, communication ability and family context determine how questions are asked. A good history identifies the immediate syndrome, establishes baseline function, uncovers preventable risks and makes the caregiver a partner in care.
Start with danger signs and sick appearance before completing a long history; a critically ill child must be stabilised while information is gathered.
Learning objectives
- Conduct a respectful, age-adapted history from caregiver and child.
- Recognise general danger signs and prioritise urgent action.
- Cover presenting complaint, history of illness, background, development, nutrition, immunisation, family and social context.
- Use open questions, clarification, summarising and safety-netting.
- Present a concise problem representation and differential diagnosis.
Preparation and first impression
- Wash hands, introduce yourself, confirm the child’s identity and obtain permission to talk/examine.
- Observe before questioning: alertness, interaction, consolability, breathing effort, colour, hydration, posture, voice/cry, seizure activity and caregiver–child interaction.
- Record exact age, sex, weight, length/height, temperature, oxygen saturation and triage category.
- Ask immediately about inability to drink/breastfeed, repeated vomiting, convulsion, lethargy/unconsciousness, severe breathing difficulty, shock and severe dehydration.
Presenting complaint and history of presenting illness
Begin with an open invitation: “Tell me what brought you and what worries you most.” Then establish onset, progression, severity and functional effect. Ask about the child’s normal baseline and what has changed.
| Symptom domain | Questions that change diagnosis/urgency |
|---|---|
| Fever | Measured or felt? duration/pattern? rigors, rash, malaria exposure, immunisation, antipyretics and response? |
| Breathing | Cough, fast breathing, chest indrawing, stridor, wheeze, apnoea, cyanosis, feeding interruption or choking? |
| Diarrhoea/vomiting | Frequency, blood/mucus, bilious vomit, fluids tolerated, urine output, tears and dehydration signs? |
| Neurology | Convulsions, altered consciousness, headache, neck stiffness, weakness, regression or abnormal behaviour? |
| Feeding/weight | Breastfeeding or diet change, appetite, swallowing, weight loss, oedema, growth trend? |
| Urinary | Dysuria, frequency, loin pain, abnormal urine, reduced output, bedwetting or genital symptoms? |
| Skin | Rash onset, itch, pain, mucosal involvement, bruising, petechiae, exposure or medication? |
Past medical and birth history
- Pregnancy: antenatal care, maternal illness/infection, medicines, substance exposure and complications.
- Birth: gestational age, mode/place, birth weight, resuscitation, neonatal admission, jaundice, sepsis, feeding and discharge.
- Previous illnesses: admissions, pneumonia, malaria, diarrhoea, TB/HIV exposure, seizures, surgery, allergies and chronic disease.
- Medicines: prescribed, over-the-counter, traditional/herbal remedies, doses, adherence and adverse effects.
- Immunisation: card dates, birth vaccines, missed doses, adverse events and access barriers.
Growth, nutrition and development
Ask about breastfeeding, complementary foods, feeding frequency, appetite, food security, vomiting, diarrhoea, swallowing and special diets. Review weight/length/head-circumference trends rather than a single value. Ask milestone domains—gross motor, fine motor, language/hearing, social and adaptive skills—and whether any skill has been lost. For adolescents, ask about school, mood, sleep, substance use, sexual health and safety privately when appropriate.
Family, social and safeguarding history
- Household composition, caregiver capacity, housing, water/sanitation, smoke exposure, pets, travel and sick contacts.
- Family history of asthma, seizures, sickle-cell disease, diabetes, TB, congenital disorders, sudden death, mental illness and consanguinity.
- School attendance, learning, bullying, disability support and psychosocial stress.
- Safeguarding: unexplained injuries, inconsistent accounts, fear, neglect, sexual abuse, exploitation, child marriage or unsafe discharge.
- Ask privately when possible and document the child’s words accurately. Follow local reporting pathways.
Medication, allergy and exposure reconciliation
Ask the caregiver to show medicines. Confirm name, concentration, amount, route, timing, last dose and whether the child vomited it. Clarify drug/food/latex reactions and the exact symptoms of “allergy.” Ask about accidental ingestion, pesticides, kerosene, batteries, traditional medicines and household hazards.
Communication technique
- Use plain language and an interpreter when needed; avoid leading questions.
- Talk to the child directly, even when the caregiver answers.
- Validate concerns without assuming the diagnosis.
- Summarise and ask, “What have I missed?”
- Explain the next steps, expected warning signs, follow-up and how to return urgently.
Case presentation and problem representation
Present in one sentence: age, relevant background, duration, dominant syndrome, severity and key discriminating signs. Example: “A 14-month-old previously well child with three days of fever, cough and poor feeding, tachypnoea with lower-chest indrawing and oxygen saturation 88%, concerning for severe pneumonia with hypoxaemia.” List active problems, immediate threats, likely diagnoses, alternatives and missing information.
OSCE checklist
- Introduces self, confirms identity, consent, privacy and caregiver relationship.
- Checks danger signs and stabilises before detailed questioning.
- Covers presenting illness, birth, past illness, medicines/allergy, immunisation, nutrition, growth/development, family/social and safeguarding.
- Uses age-appropriate communication and includes the child’s voice.
- Summarises, explains plan and safety-nets.
References
- SlideShare: Paediatric clerkship.
- SlideShare: Clerkship history for paediatric patients.
- WHO/UNICEF IMCI assessment and referral guidance.
