Part of the TeachMe Series

History and Examination Skills

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Original Author(s): Dr James Bubb and Dr Jennifer Mann
Last updated: 5th November 2021
Revisions: 7

Original Author(s): Dr James Bubb and Dr Jennifer Mann
Last updated: 5th November 2021
Revisions: 7

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Introduction

Interacting with children and their families is at the heart of paediatrics. Whilst it may initially appear intimidating, when done effectively consultations can not only be incredibly rewarding both professionally and personally but sometimes even fun!

When drawing comparisons to adult consultations, key differences which you may encounter are:

  1. Children, generally, have a reduced ability to tell you their symptoms
  2. Children are often frightened, or miserable – partly because of their presenting complaint but often because the clinical environment can be quite intimidating
  3. The paediatric population begins with antenatal consultation and ends with the late teenage years – so communication styles must be varied according to these factors
  4. Children usually present with their parents or other legal guardians and so often it is not only the impact of the presenting complaint upon the patient but that upon the family unit which must be considered.

History Taking Top Tips

The generic structure of the paediatric history is the same as for adult medicine with a few additions. These can be remembered using the BLINDS mnemonic shown below, with the various areas covered in more or less depth depending upon the age and presentation.

Remember with your family and social history in paediatrics, it is important to establish which other members are in the family, who the child lives with and any previous or current social services involvement.  Asking about medical conditions in siblings and parents (for example asthma or diabetes) can be really useful and may reveal a potential differential diagnosis you had not considered previously.

  • Presenting Complaint and History
  • Past Medical History
  • Drug History and Allergies
  • Family History
  • Social History
  • Ideas, Concerns and Expectations

BLINDS

  • Birth and Antenatal History including
  • Looking for risk factors for neonatal sepsis
  • Immunisations
  • Nutrition
  • Developmental History
  • Screening for Mental Health

Birth and Antenatal History

  • Consider whether it is appropriate to ask about antenatal scans and antenatal blood tests which are performed in all UK booked pregnancies. Ask about the route of delivery (normal vaginal delivery, caesarean or assisted instrumental delivery) and any complications for mother or baby. This interplay between mum and baby is particularly important – for example a baby may present with jaundice and poor feeding because their mother is in a great deal of pain after an emergency caesarean and is struggling to find the right position to breast feed.
  • If you patient is a baby, also remember to ask about the risk factors for neonatal sepsis (see below). Serious infection in newborns can initially present with very few symptoms and rapidly progress to a life threatening situation without treatment. Asking specifically about these risk factors during your history taking will help identify those at increased risk so that appropriate management can be started early.
  • Gestation at birth: Infants born prematurely will need their age corrected to their gestational age. For example a baby born at 28 weeks (12 weeks earlier than the 40 week due date) will have their premature gestation corrected for until their 2nd This means when they are 8 months of chronological age, they are corrected to 5 months.

Risk factors for early-onset neonatal infection, including ‘red flags’ as per the NICE 2021 Guideline (1):

Red flag risk factor:

  • Suspected or confirmed infection in another baby in the case of a multiple pregnancy.

Other risk factors:

  • Invasive group B streptococcal infection in a previous baby or maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy.
  • Pre-term birth following spontaneous labour before 37 weeks’ gestation.
  • Confirmed rupture of membranes for more than 18 hours before a pre-term birth.
  • Confirmed prelabour rupture of membranes at term for more than 24 hours before the onset of labour.
  • Intrapartum fever higher than 38°C if there is suspected or confirmed bacterial infection.
  • Clinical diagnosis of chorioamnionitis.

Immunisations

Check that the child has been vaccinated as per the Routine Immunisation Schedule. In the unvaccinated, unwell child be wary of the possibility of serious invasive disease. In trauma it is important to ask about tetanus status. The Green Book produced by Public Health England can be found online and includes all the relevant immunisation details.

Nutrition

An age appropriate nutritional history is vital. In babies, this will include discussing the method of feeding (breast / bottle / combination) and the volume and frequency of feeds. As children get older, weaning is followed by regular intake of solids. In any child, it is vital to establish their oral intake. This is particularly important when considering those presenting with chronic weight loss or acute illness where fluid and solid intake should be asked about and documented. Parents may carry their child’s Red Book to appointments, which includes useful growth charts you can look at.

Developmental History

Child development is huge topic in itself, but remembering a few key milestones is really useful for most consultations (2):

  • Social smile at 6 weeks
  • Reaches for toys at 4 months
  • Sits unsupported at 6 months
  • Takes first steps unsupported at 12 months
  • First words at 12 months

Figure 1: Social smile at 6 weeks

Screening for Mental Health

At the time of writing this article the UK was experiencing the COVID-19 pandemic, with a high number of adolescents presenting to ED with mental health issues. Identifying mental health disorders early is an important part of health promotion – and can be as simple as asking open questions like “how are you feeling in yourself at the moment?”. For older children, asking about school, sex, alcohol and drugs may be relevant. The HEADSSS tool is a useful way of structuring this assessment (3).

Everyone has their own style, but I often ask the parents to step outside when asking about sex/drugs to increase the likelihood of an honest answer. Although you may find it embarrassing to talk about, it is important to be professional and confident in your communication – otherwise you may cause undue embarrassment of get inaccurate answers from the teen. I tend to use the phrase ‘sleeping with anyone’ as opposed to ‘sexual intercourse’, as it sounds less awkward!

Relatives

In most consultations, the child will be present with a relative who will also be a useful source of information. Common pitfalls encountered when dealing with relatives are:

  • Over-reliance on their information: Always remember to include the child and listen to their answers. Toddlers can often say yes and no to simple questions e.g. “does your tummy hurt?”
  • Ignoring the relative’s concern: The parents know their child best, and their concerns should be taken seriously. A common example of this is the infant who “is just not themselves.” These subtle changes in infant behaviours can be early indicators of serious illness and therefore warrant careful consideration.
  • ‘Parental agenda’: Parents have often researched symptoms prior to coming to you which is a completely natural thing to do. This can be really useful – where parents have spotted key symptoms they would otherwise have missed. However, it can also be a hindrance – becoming focused on a certain diagnosis or treatment before your consultation. As a clinician, it is important to keep an open mind and use your history taking and clinical judgement to include or exclude these differential diagnoses, rather than allowing yourself to be biased by this information.

Examination

The specifics to each system examination will be detailed in their own articles. Below are a few general tips for examining children which can be applied to all consultations.

  1. Get down to their level: Kneeling or sitting on the floor brings you into a small child’s eye line and automatically makes you less intimidating. This is helpful for building a rapport with young children who will often fear you initially.
  2. Icebreakers: Take interest in something the child is either wearing or has brought with them, e.g. “who have you brought with you?” if they’re holding a teddy. This gives the child an opportunity to talk about something they enjoy and can be a highly effective when forming a rapport.
  3. Observation is key: Some of the most important information in clinical examination is gathered by observation – signs of respiratory distress, pain, irritability, abnormal gait, photophobia and rashes to name a few. In addition, by observing the child through the window/door before you enter, you observe their behaviour without you in the room. Being shy or afraid can mimic the withdrawn or miserable behaviour acutely unwell children often exhibit; this is an effective way to differentiate between the two.
  4. Adapt your approach as needed: Having a playful attitude whilst examining younger children helps to aid distraction, which in turn will aid you in eliciting truly tender areas as opposed to resistance to examination. Most children are naturally playful, and a child who won’t engage in play or socially smile in response to you should raise concerns about a ‘sick’ child. When examining older children, pay due attention to their dignity and privacy – gain verbal consent for examination and explain clearly what you are doing. When a parent is not in the examination room, always ensure an appropriate chaperone is.

References

(1) Neonatal infection: antibiotics for prevention and treatment(2021) NICE guideline NG195
(2) Lissauer, T., & Carroll, W. (2018). Illustrated Textbook of Paediatrics, Fifth Edition.
(3) https://www.paediatricpearls.co.uk/headsss-tool/
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