The pediatric history, like the adult history, is obtained before the examination is performed. During this period, the child can get accustomed to the clinician. Unlike the adult history, however, much of the pediatric history is taken from the parent or guardian. If the child is old enough, interview the child as well.
Good communication with the child is the key to a successful work-up, just as with an adult. An infant communicates by crying and, in so doing, indicates that something is wrong. Although older children can communicate through language, they also often use crying as a response to pain or to express emotional unrest. This mode of communication merits attention. Newborns can also communicate by cooing and babbling, which indicates contentment.
In infancy, children use sounds to mimic words, as well as using gestures to communicate. At about 10 to 12 months of age, children usually speak their first word, usually "dada" or ''mama.'' By 15 months of age, children are expected to say between 3 and 10 words, and by 2 years of age, their vocabulary may contain more than 200 words;it is at this age that we expect children to be able to put 2 or more words together in a phrase, such as ''Juice gone'' or ''Up me!'' By 3 years of age, children are able to put together sentences of 5 or 6 words from a 1500-word vocabulary, and should be 50% intelligible to an adult who does not know the child. By the time they are 6 years of age, they are able to communicate in longer sentences, with a vocabulary of several thousand words, and use most of the grammar of their native language. Three-year-olds can give the clinician a good idea of what hurts, where, and how it feels. The 6-year-old can give some idea of how and when the complaint started. The examiner must pay attention to everything the child says, because the words used may give insight into the child's physical, emotional, and developmental state, as well as his or her home situation and other factors in his or her environment.
A good relationship with a child begins by making friends with him or her. Not wearing a white coat may alleviate some of the child's fears, but there are other ways as well. Start by admiring the child's shoes or toy;his possessions are more neutral topics for the child to talk about at first than his or her own body or behavior. One of the best ways to make a child feel comfortable is through praise. When talking to a child, it is useful to say, ''Thank you for holding still. That makes the examination easier.'' The use of ''You're a good boy'' or ''You are such a sweet girl'' may produce embarrassment. Therefore, praise should be given for a child's behavior and not for his or her personality. Sharing a book with the child (e.g., as part of the ''Reach Out and Read'' program*) is another useful way to engage the toddler or preschooler.
It is important not to talk down to children. The examiner must assess the developmental level of the child and choose words that are appropriate to that child's level of understanding. This is especially important in dealing with a preteenage child; in fact, when interviewing such a child, the interviewer may gain more cooperation from the child by treating him or her as a bit older than his or her actual age, rather than younger.
Although most of the history is obtained from the parent or guardian, some questions are asked of the child. There are two simple rules in asking questions of children:
1. Use simple language.
Interviewers are often amazed by how well a child can respond to questions phrased according to these rules. School-aged children can respond to structured, open-ended questions. Asking ''How do you like school?'' may elicit only a shrug. Asking ''What do you like best about school?'' is likely to get the child talking. It is useful to spend time observing the child at play while interviewing a parent. It is also rewarding to allow a toddler to play with a stethoscope, tongue blade, or penlight to ''make friends'' with the equipment that will be used later in the physical examination.
The pediatric history consists of the following:
# Chief complaint
History of the present illness
• Birth history
# Past medical history Nutrition
• Growth and development Immunizations
Social and environmental history
• Family history
# Review of systemsBox 24-1
The chief complaint and the history of the present illness are obtained in the same manner as with the adult patient. The history should identify the informant, and the interviewer should try to establish whether and where the child has a regular source of medical care. The history of the present illness should always include information about the effect of an acute illness on the child's oral intake, activity level, hydration status, and ability to sleep. For a chronic problem, the examiner should look for effects on the child's growth and development.
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