similarities in taking a history from a child and
from an adult. Introduce yourself to the child and accompanying
adult, and begin to observe the child. Establish who the adult
is – a parent, grandparent or foster carer, for example – and
consider to what extent the child will be able to contribute to
the history. Let the child become accustomed to you before
Start with open-ended questions. Most often a parent will
wish to explain their perspective on their child’s problem and it is
important to enable them to do so. Some teenagers may welcome
this but most often they do not. Once the presenting symptoms
have been outlined, the history should focus on questions that
aim to elucidate the differential diagnosis; children are often good
at helping with these more specific questions. Respect age ability
to recall events and adopt a balanced perspective on whether
Diagnosis is built on patterns of symptoms; rarely will any one
symptom or sign lead to a ‘spot diagnosis’. The initial history
suggests a differential diagnosis and prompts additional questions
to assess the probability of particular diagnoses. As with adults,
presenting symptoms should be described in terms of onset,
frequency, severity, duration, aggravating and relieving factors,
associated features and impact on function. Pain and the need
for analgesia can be particularly difficult to assess in young
children; objective scoring systems may help (Box 15.6).
The most common presenting problems in the child affect
the respiratory, gastrointestinal and nervous systems (covered
in Boxes 15.7–15.9), and the skin.
answers from parents are more likely to be accurate than those
from the child. Children under 6 years often provide little history,
those aged 6–11 years can do so if they are sufficiently confident,
and those aged 12 years and above should be able to provide
a valuable history in the correct environment and with the use
of questions that are framed in appropriate terminology. As you
would for adult history taking, include reflective summing up: for
example, ‘So what you are saying is that …’.
A paediatric history includes elements that are not part of the
adult history (obstetric, developmental, immunisation histories),
systematic enquiry has different components from those in
adults (see later), and the differential diagnosis may include
conditions seen only in children such as abdominal migraine,
toddler diarrhoea, croup, viral wheeze and febrile convulsion.
Most other diagnoses also occur in adults.
15.6 Pain assessment tool: FLACC scale
Face No particular expression or
Occasional grimace or frown, withdrawn,
Frequently or constantly quivering chin, clenched jaw
Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal position,
Squirming, shifting back and forth, tense Arched, rigid or jerking
Consolability Content, relaxed Reassured by occasional touching,
hugging or being talked to, distractible
Difficult to console or comfort
if associated with Differential diagnosis
LRTI, asthma, acute episodic wheeze, inhaled foreign
body. Rarely, supraventricular tachycardia, congenital
heart disease, heart failure or muscular weakness
Cough *** Low SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Wheeze *** Moderate SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Musculoskeletal pain, empyema, reflux oesophagitis,
Stridor *** High URTI, high fever, choking Croup, foreign body, epiglottitis (if not immunised)
** Low Cough, wheeze, failure to
Lack of fitness, respiratory pathology, cardiac pathology,
Cough *** Low Wheeze, SOBoe, failure
Isolated cough with sputum suggests infection,
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