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Paediatric History Taking - Format

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1. Identifying Data / Demographic Details

• Name
• Age / Date of birth
• Sex
• Address
• Religion / Ethnicity
• Informant (mother, father, caregiver) and reliability

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2. Chief Complaint (Presenting Complaint)

• Main symptom(s) in the informant's own words
• Duration

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3. History of Present Illness (HPI)

• Onset (sudden / gradual)
• Duration
• Character / nature of complaint
• Severity
• Progression (improving / worsening / static)
• Aggravating and relieving factors
• Associated symptoms
• Previous similar episodes
• Treatment received so far (prior to presentation)

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4. Antenatal History (Maternal History)

• Mother's age at delivery
• Parity (G_P_L_A_)
• Antenatal check-ups (regular / irregular)
• Maternal illness during pregnancy (diabetes, hypertension, infections - TORCH, thyroid disease)
• Medications during pregnancy (folic acid, iron, teratogens)
• Radiation exposure
• Alcohol, smoking, drug use
• Blood group and Rh typing; Rh incompatibility
• Ultrasonography findings (anomalies detected)
• Fetal movements

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5. Natal / Perinatal History (Birth History)

• Place of delivery (hospital / home)
• Mode of delivery (normal vaginal, LSCS, forceps, vacuum)
• Gestation at birth (term / preterm / post-term)
• Birth weight
• Cry at birth (immediate / delayed / absent)
• APGAR score (if known)
• Complications at birth (birth asphyxia, birth trauma, cord around neck, meconium-stained liquor)
• Resuscitation required (NICU admission)

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6. Postnatal / Neonatal History

• Neonatal period (first 28 days)
  • Jaundice (onset, severity, treatment - phototherapy / exchange transfusion)
  • Cyanosis, convulsions, apnoeic spells
  • Feeding difficulties in neonatal period
  • Infections (sepsis, meningitis, umbilical sepsis)
  • Congenital anomalies detected
• Discharge from hospital (day of discharge, any concerns)

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7. Feeding History

• Breastfeeding: exclusive / mixed; duration; technique; frequency
• Time of introduction of top feeds / formula
• Weaning / complementary feeding: age of introduction, types of food introduced

• Current diet (vegetarian / non-vegetarian)
• Appetite (good / poor)
• Dietary recall (24-hour recall)
• Vitamin / iron / calcium supplementation

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8. Developmental History

• Age at which each milestone was achieved
• Any regression of milestones
• School performance (for school-age children)
• Behavioural concerns

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9. Immunisation History

• Vaccines received as per national immunisation schedule (BCG, OPV, DPT/Pentavalent, Hepatitis B, Measles/MMR, Typhoid, etc.)
• Age-appropriate or delayed
• Adverse reactions to any vaccine
• Recent vaccinations (relevant to current illness)

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10. Past Medical History

• Previous illnesses (hospitalizations, surgeries, procedures)
• Previous similar episodes
• Known chronic diseases (asthma, epilepsy, congenital heart disease, etc.)
• Allergies (drugs, food, environmental) - nature of reaction
• Previous blood transfusions

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11. Family History

• Similar illness in siblings or family members
• Consanguinity (important in paediatrics)
• Hereditary / genetic disorders in family
• Parental age and health
• Deaths in siblings (age, cause)
• Tuberculosis or other infectious disease contacts at home

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12. Socioeconomic and Environmental History

• Father's and mother's occupation and education
• Monthly income / socioeconomic status (Kuppuswamy / BG Prasad scale)
• Type of house (pucca / semi-pucca / kutcha)
• Crowding (number of persons per room)
• Water supply (safe / unsafe)
• Sanitation (latrine facility)
• Pets at home

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13. Personal History (for older children)

• Sleep pattern
• Bowel and bladder habits
• Behavioural habits (thumb sucking, nail biting, breath-holding spells)
• School attendance and performance
• Recreational activities / hobbies

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14. Review of Systems (Systemic Enquiry)

• Respiratory, cardiovascular, gastrointestinal, genitourinary, CNS, musculoskeletal, skin, ENT, eyes

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15. Summary Statement

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• The informant is usually a parent/caregiver - always note who gave the history and assess reliability.
• Antenatal, natal, and neonatal histories are mandatory in all paediatric cases.
• Developmental history is a core component - not optional.
• Feeding and immunisation histories are paediatric-specific essentials.
• Socioeconomic and family history carry more weight than in adult medicine.Here are all 9 remaining topics covered in full:

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2. Importance of Negative History

Why it matters:

Examples in paediatrics:

• Child with cough: "No blood in sputum, no night sweats, no weight loss" - excludes TB
• Child with fever: "No seizures, no neck stiffness, no photophobia" - excludes meningitis
• Child with jaundice: "No pale stools, no dark urine" - helps distinguish haemolytic from obstructive jaundice
• Child with wheeze: "No foreign body aspiration history" - excludes airway foreign body

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3. How to Collect Diet History

Step 1 - Establish the child's age group first

• < 6 months: breastfeeding / formula details
• 6 months - 2 years: weaning / complementary feeding
• > 2 years: regular family diet with 24-hour recall

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Step 2 - For Infants (< 6 months)

• Exclusive breastfeeding or mixed feeding?
• Frequency (on demand / timed) and duration of each feed
• Latching technique - correct or not?
• Night feeds present or not?
• Any breast problems (engorgement, cracked nipple, mastitis)?
• Maternal diet and medications

• Type of formula (brand, dilution - concentrated / correct / over-diluted?)
• Volume per feed, number of feeds per day
• Method of preparation and sterilisation of bottles
• Introduction of cow's milk (premature introduction is a risk)

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Step 3 - For Weaning Age (6 months - 2 years)

• Age at which complementary foods were introduced (should be 6 months)
• Type of foods introduced - cereals, pulses, vegetables, fruits, egg, meat
• Consistency - pureed / mashed / lumpy / family foods
• Frequency of complementary feeds per day
• Continued breastfeeding alongside?
• Intake of iron-rich foods (important for anaemia prevention)

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Step 4 - For Children > 2 years (24-hour Dietary Recall)

• Caloric adequacy (RDA for age)
• Protein intake (animal vs. plant sources)
• Micronutrients - iron, calcium, Vitamin A, Vitamin D, iodine
• Junk food / fast food frequency
• Fruit and vegetable intake
• Fluid intake (water, juices, carbonated drinks)

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Step 5 - Additional Questions Always Ask

• Appetite - good, poor, or selective?
• Any food allergies or intolerances?
• Vitamin / mineral supplements given?
• Who feeds the child - self-feeding or fed by caregiver?
• Any feeding difficulties (dysphagia, vomiting after feeds)?
• Socioeconomic factors affecting food availability?

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4. Developmental Milestones Till 2 Years - All Domains

Domain 1: Gross Motor

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Domain 2: Fine Motor / Adaptive

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Domain 3: Language / Speech

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Domain 4: Social / Personal

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Key "Warning Flags" (Red Flags)

• No social smile by 3 months
• No babbling by 9 months
• No words by 18 months
• No 2-word phrases by 24 months
• Any loss of previously acquired milestones at any age

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5. Points to Ask in Family and Socioeconomic History

Family History

1. Similar illness in siblings, parents, or other relatives
2. Consanguinity - are parents related (first cousins, second cousins, etc.)?
3. Hereditary / genetic diseases - thalassaemia, sickle cell, haemophilia, metabolic disorders
4. Deaths in siblings - age at death, cause; any unexplained infant deaths (may suggest metabolic disease)
5. Parental health - chronic illness in mother / father
6. Infectious disease contacts - active TB in household, COVID, hepatitis B carrier
7. Allergic conditions in family - asthma, eczema, allergic rhinitis (atopic tendency)
8. Mental health disorders - intellectual disability, autism spectrum in family
9. Number of siblings - birth order of child
10. Pedigree / family tree - three-generation pedigree if hereditary disease is suspected

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Socioeconomic History

1. Father's occupation and education level
2. Mother's occupation and education level
3. Monthly family income (for socioeconomic classification)
4. Type of house - pucca (permanent) / semi-pucca / kutcha (temporary)
5. Number of rooms and persons per room (crowding index)
6. Water supply - municipal piped / bore well / open well / tanker
7. Sanitation - flush toilet / pit latrine / open defecation
8. Electricity availability
9. Cooking fuel - LPG / firewood / kerosene (indoor air pollution)
10. Pets at home (zoonoses, allergy triggers)
11. Area of residence - urban / semi-urban / rural / tribal / slum
12. Literacy of primary caregiver (impacts compliance with treatment)

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6. Socioeconomic Classification

A. Kuppuswamy Scale (Urban - most widely used in India)

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B. BG Prasad Classification (Modified, used for both urban and rural)

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C. Pareek Scale (Rural areas)

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7. Consanguinity Degrees

Coefficient of Relationship (r) / Coefficient of Inbreeding (F)

Clinical relevance in paediatrics:

• First cousin marriage (most common form in India, Middle East) raises risk of autosomal recessive diseases significantly
• The closer the consanguinity, the higher the inbreeding coefficient
• Always ask: "Are you and your spouse related to each other?" and if yes, "How are you related?"
• Important for diseases like: thalassaemia, sickle cell, G6PD deficiency, metabolic disorders, congenital anomalies

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8. Family Pedigree Chart - Symbols and Interpretation

Standard Symbols

Generations:

• Labelled with Roman numerals (I, II, III...) from top to bottom
• Individuals within a generation labelled 1, 2, 3... from left to right
• Proband is identified with an arrow

How to Interpret a Pedigree:

1. Autosomal Dominant: Every generation affected; both sexes equally; affected parent to affected child (vertical transmission)
2. Autosomal Recessive: Skips generations; both sexes; consanguinity often present; horizontal pattern (siblings affected, parents normal)
3. X-linked Recessive: Only males affected; carrier females; no male-to-male transmission; maternal uncles may be affected
4. X-linked Dominant: Both sexes affected; affected father passes to ALL daughters, no sons; more females than males
5. Mitochondrial: Transmitted only through mother; all children of affected mother are affected; father cannot pass it on

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9. Tuberculosis Contact History - Points to Ask

Points to Ask:

• Is there any family member / household contact with TB?
• Any visitor who stays frequently (domestic worker, relative)?
• Any contact at school, crèche, or neighbourhood?

• Pulmonary TB (most infectious) or extrapulmonary?
• Is it sputum smear positive (highly infectious) or smear negative?
• Is it drug-resistant TB (MDR/XDR)?

• How long has the child been in contact?
• Is the contact a household / close contact or casual contact?
• Does the child share the same room / bed with the contact?

• Is the contact on anti-TB treatment (ATT)?
• For how long have they been on treatment?
• Are they adherent to treatment?
• Have they been declared cured or still under treatment?

• Previous TB infection or treatment in the child
• BCG vaccination status (scar present?)
• Previous Mantoux / TST / IGRA test results
• Previous chest X-ray done?

• Prolonged fever (> 2 weeks)
• Weight loss / failure to thrive
• Cough > 2 weeks
• Night sweats
• Lymph node enlargement
• Loss of appetite

• Child's HIV status (HIV increases TB risk significantly)
• Maternal HIV status

Note: Any child < 5 years with household TB contact should receive isoniazid preventive therapy (IPT) regardless of Mantoux result, after ruling out active TB.

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10. Types of Inheritance Patterns - With 2 Examples Each

1. Autosomal Dominant (AD)

• Mechanism: One mutated copy of gene on autosome is sufficient to cause disease
• Pedigree pattern: Every generation affected; male = female; 50% risk to offspring
• No carrier state (heterozygote is affected)

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2. Autosomal Recessive (AR)

• Mechanism: Both copies of gene must be mutated to cause disease
• Pedigree pattern: Skips generations; horizontal pattern; consanguinity common; 25% risk if both parents carriers
• Carrier state present

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3. X-linked Recessive (XLR)

• Mechanism: Mutated gene on X chromosome; females are carriers (protected by second X); males are affected
• Pedigree: Males affected; no male-to-male transmission; carrier females
• Key rule: Affected father cannot pass to son; passes to all daughters (who become carriers)

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4. X-linked Dominant (XLD)

• Mechanism: One mutated copy on X chromosome sufficient; both sexes affected but females milder (due to lyonisation)
• Pedigree: Both sexes; affected father passes to ALL daughters but NO sons

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5. Y-linked (Holandric) Inheritance

• Mechanism: Gene on Y chromosome; passed from father to ALL sons, never to daughters

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6. Mitochondrial Inheritance

• Mechanism: Mitochondrial DNA (mtDNA) mutations; inherited exclusively through mother; heteroplasmy may cause variable severity
• Pedigree: All children of affected mother are affected; father cannot transmit; affects organs with high energy needs (brain, muscle, heart)

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7. Codominance

• Mechanism: Both alleles expressed simultaneously in heterozygote

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Quick Summary Table

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