Expansion
Birth, development, feeding, immunisation and social history
Expansion
In addition to the standard history
- Birth history: gestation, birth weight, mode of delivery, antenatal problems, maternal illness and medication, neonatal unit admission, jaundice, feeding difficulty, newborn screening results
- Developmental history: milestones in the four domains, being gross motor, fine motor and vision, speech, hearing and language, and social. Any regression is a red flag
- Feeding and nutrition: breast or formula, weaning, current diet, appetite, and in infants the volume and frequency, wet nappies and stools
- Growth: plot weight, length or height and head circumference on the centile chart, and look for crossing centiles
- Immunisations: up to date, and any missed
- Past medical history: hospital admissions, operations, atopy
- Family history: consanguinity, inherited disease, deaths in childhood, atopy
- Social history: who lives at home, who has parental responsibility, nursery or school and attendance, housing, smoking in the home, financial circumstances, and involvement of social services
Safeguarding must be actively considered: delayed presentation, an inconsistent or changing history, an account not compatible with the developmental stage, injuries in unusual sites, and previous concerns.
The parent’s own concern is a strong signal, and older children should be given the opportunity to speak alone, particularly adolescents, where the HEADSS framework of home, education, activities, drugs, sexuality and suicide is used.