photophobia

Acute (simple) headache, migraine, meningitis/

encephalitis

Unsteady gait * High Varicella encephalomeningitis, vestibular neuronitis

Seizurea * High Febrile seizure, meningitis/encephalitis

Epilepsy, metabolic disorder

Disturbed level of

consciousness

* High Encephalitis, intoxication/drug ingestion

(accidental/ deliberate)

Chronic

Headacheb ** Low Vomiting

Abdominal pain

Brain tumour, migraine, chronic non-specific

headache

Failure to pass

developmental

milestones

* Moderate Widening gap between age and

age when ‘normal’ milestone

should have been passed

Cerebral palsy, neglect

Developmental

regression

* High Muscular dystrophy, inborn error of metabolism,

neurodegenerative conditions

Seizure * High Epilepsy; rarely, long QT syndrome or inborn error

of metabolism

}

15.9 Nervous system

a

An acute seizure can be confused with a rigor in a febrile child. A seizure involves slow (1 beat per second), coarse, jerking that cannot be stopped, loss of consciousness

and postictal drowsiness. A rigor is characterised by rapid (5 beats per second), fine jerking that can be stopped by a cuddle with no loss of consciousness. b

Chronic

headache can also arise from the mouth (e.g. dental abscess) or face.

310 • Babies and children

Past medical history

Has the child regularly seen a healthcare professional (current or

past) or are they currently taking any regular medication? Have

they been in hospital before, and if so, why?

Birth history

The impact of preterm birth goes beyond early childhood and

so it is helpful to ask:

• Was the child born at term or preterm (if so, at what

gestation)?

• Was the neonatal period normal? For example, did the

child need to go to a special care baby unit?

• If the child is under 3 years of age: what was the

birthweight and were there any complications during

pregnancy?

Vaccination history

Are the child’s immunisations up to date according to

country-specific schedules? If not, explore why and consider

how best to encourage catch-up.

Developmental history

This is particularly important for children under 3 years of age

or those with possible neurodevelopmental delay (see p. 307

and Box 15.5).

Drug history

Prescribing errors often arise from poor reconciliation of medication

lists between different healthcare professionals. It is a doctor’s

duty to ensure that medicines are accurately reconciled within

documentation. Transcribe the medication, dose and frequency

direct from the medication package or referral letter if possible.

Enquire about any difficulties in taking medication to establish

adherence. Clarify any adverse or allergic reactions to medications.

Family and social history

Ask:

• Who lives in the family home and who cares for the child?

• Does anyone smoke at home?

• Are there any pets? Are any symptoms associated with

pet contact?

• Are there any similar symptoms in the child’s first- or

second-degree relatives?

Sketch a family tree, noting any step-parents, step-siblings

or shared care arrangements Consider parental consanguinity,

which is not uncommon in some ethnic groups. Children at risk

of neglect may have complex domestic arrangements such as

several caregivers.

Occasionally, chronic symptoms are associated with anxiety

or potential ‘secondary’ gain for the child; these include

chronic cough, abdominal pain and headache in a well-looking

8–12-year-old in whom examination is normal. Look carefully

at the child’s facial expression, eye contact and body language

when asking questions. Ask specifically about school (avoidance

and bullying), social interactions (does the child have many

friends?) and out-of-school activities. School avoidance should

be addressed if it is related to anxiety or if the pretext of medical

symptoms is used.

Systematic enquiry

This screens for illnesses or symptoms that may be not recognised

as important or relevant by the child or parents. For children aged

over 12 years, the questions used for adults are appropriate. In

younger children, ask age-related questions. Specific areas include:

• Ear, nose and throat: ask the parents about their

perception of a child’s hearing ability (reduced in chronic

otitis media) or the presence of regular snoring with

periods of struggling to breathe (symptomatic obstructive

sleep apnoea).

• Gastrointestinal system: ask whether growth is as

expected and whether there is pain or difficulty in opening

the bowels (constipation).

• Respiratory system: ask whether the child has regularly

coughed when otherwise well or had wheeze on a

recurrent basis (consider asthma).

• Urinary system: 15% of children at 5 years of age will

continue to have primary nocturnal enuresis.

The physical examination

Normal growth and development

An understanding of child development is vital to identifying

whether symptoms and signs are consistent with age.

Infants born prematurely should have their age adjusted to

their expected date of delivery instead of their date of birth

for the first 2 years of life when growth and development are

assessed. Failure to make this correction would otherwise create

a false impression of poor growth and developmental delay.

Prematurely born infants are at increased risk of impaired growth

and development, and merit increased surveillance; most develop

normally, however.