Health history Taking in Newborns

Introduction

The health history provides the nurse with an overall picture of what the child has experienced, highlighting the areas of concern.

Prerequisites

• The consultation room or patient’s room should be well lighted, comfortable, and quiet and decorated with toys and pictures to allay the anxiety of the child.
• There should be chairs for parents (informants) and the nurse and a bed or examining table for the child.
• Materials to record the history data (either a computer or chart paper and pen).

Approaching the Parent or Caregiver

• Greet the parent or caregiver by name.
• Maintain a friendly, warm, unhurried, informal, and relaxed attitude throughout the interaction with the family.
• Assess the quality of parent-child and parent-parent interactions while recording history.
• Use open-ended questions and avoid making judgmental comments.
• Show respect by remaining approachable.

Approaching the Child

• The nurse can wear variety of professional outfits, for example, colorful uniforms, tops rather than all white uniforms to avoid anxiety of the child.
• Infants and young children should be offered soft toy or a rattle to establish rapport while taking history.
• Make physical contact with the child in a non-threatening way at first. Briefly cuddling the newborn before returning it to the caregiver, warmly shaking the hands of old children and teens, and laying your hand on head or arms of toddlers and preschoolers will convey a gentle demeanor.
• Maintain eye-to-eye contact.

Performing Health History

Basic Information/Identifying Information

Informant (mother, father, relative, child, etc.), name, age (preferably date of birth), and sex of the patient should be enquired. Parent’s name age, address, telephone number, income, occupation, education, and religion should be recorded. The history may be unreliable due to informant’s poor memory, intelligent, or education. The origin and ethnic background of the family is important in some genetic diseases. For example, glucose-6-phosphate dehydrogenase deficiency is common among Parsis and north Indians whereas sickle cell disease is seen in tribal population.

Presenting Complaints/Chief Complaints

The chief complaint is the specific reason for the child’s visit to the hospital. The chief complaints for which the patient has been brought to the hospital should be recorded in chronological order according to the sequence of events, for example, fever for 5 days, headache 3 days, vomiting 3 days, convulsions 1 day, and loss of consciousness 2 hours.

History of Present Illness

The history of present illness is a narrative of the chief complaints from its earlier onset through its progression to the present. Its four major components are (1) the details of onset, (2) a complete interval history, (3) the present status, and (4) the reason for seeking help now

Components of history of present illness:

The informant should be encouraged to give details of sequence of events during the course of illness without the help of leading questions. The mode of onset, course of illness, and details of treatment already received must be recorded. The symptoms referable to various body systems should be reviewed. Detailed information pertaining to various symptoms manifested by the patients should be elicited, for example, pain, duration, frequency, timing, site and severity, character, radiation, precipitating, aggravating and relieving factors, and associated symptoms.

History of Past Illness

Ask for past history of common childhood diseases. Ask specifically about cold, earache, allergic manifestations, etc. In addition to illness, ask about injuries that required medical interventions, operations, and any other reason for hospitalization, including the date. Ask about commonly known allergic disorders, such as asthma, unusual reactions to drugs, food, latex products, and reaction to other contact agents, such as poisonous plants, household products, animals, or fabrics.

Birth History/Perinatal History

The birth history covers the series of events that occurred during the birth of the incumbent child. There may be an association between present illness and these events. Hence, the nurse should enquire about the important events either from the mother or significant family members (if the mother is not present or not aware) or birth records.

• The birth history includes all data concerning:
• The mother’s health during pregnancy.
• The labor and delivery.
• The newborn conditions immediately after birth.

Maternal diseases or medications during pregnancy (especially during first trimester), presentation, mode and place of delivery, first cry after the birth, feeding difficulties during neonatal period, birth weight, gestation, etc. should be recorded.

Developmental History

In children suspected to have delayed development or central nervous system (CNS) disorder, a detailed developmental screening should be done. Precise timing of social smile; head control; rolling over; sitting; standing; walking; self-feeding and dressing; bladder and bowel control; speech; weight at 6 months, 1 year, and 2 years of age; approximate length at ages of 1-4 years; dentition; etc. to be enquired. Use specific and detailed questions when enquiring about each developmental milestone.

Family Pedigree

Family pedigree should be enquired and genetic diagram should be constructed History of contact with possible -), infections, childhood infections, and diseases should be sought. The contact may be in the family, neighborhood, or school. History of similar ailments in the family member should be asked when genetic, infective, or allergic disorders are strongly suspected. Ask for history of consanguineous marriage among d parents. In case a particular disease is manifesting only among male siblings, it is suggestive of X-linked inheritance.

Social History

Enquire about occupation, education, and income of parents. If mother is working who looks after the child at home when she is away or is the child in a crèche. Ask whether the family is nuclear or joint and whether grandparents are staying with the family or not. Calculate the per capita income by dividing total income of the family by the number of family members. Housing conditions, sewage disposal, and water source should be asked. Harmful social and cultural practices regarding child-rearing should be identified, for example, use of pacifier.

Spiritual History

Spiritual history helps to identify spiritual and religious beliefs that family follows (e.g., rituals related to health and illness, dietary restrictions, etc.) and the role of faith or spirituality in their family (such as comfort, joy, hope, and coping). The components of spiritual history include (1) values; (2) source of support in time of stress and discomfort; (3) meaning/purpose of life, health, illness and death; (4) spiritual beliefs; (5) affiliation to any specific religion, worship practices, and religious schooling; and (6) food/dress practices. Collecting spiritual history can help in decision-making for individualized nursing care.

Habits

Ask whether the child is attending school or not. What is his/her rank in the class and whether the disease has interfered with his studies or not. Assess the interactive behaviors, habits hobbies, interest, and personalities of the child and how he differs from other siblings.

Ask about the eating, sleeping, and toilet habits of the child. Adolescent children should be encouraged to talk regarding their worries, anxiety, psychosexual difficulties, and substance abuse tendencies. Ask whether any pet animals are kept in the home. Enquiry should be made regarding smoking, intake of alcohol, and drug abuse by parents, which can adversely affect the family dynamics and child-rearing practices.

Feeding History

History of dietary intake is of special importance in children because they need food for growth and development. The energy or caloric requirement of infant per unit body weight is at least four times as compare to adults. Ask whether the child received breastfeeding or not, frequency, type of schedule, duration, reasons for discontinuation, etc. If top fed, age at starting, name of formula, dilution, and amount, and frequency, mode of feeding (bottle or cup and spoon), etc. should be enquired in detail.

Age at weaning, nature and amount of semisolid food or other supplementary foods or vitamins/minerals given to the child should be asked. Dietary intake just before the onset of illness and during illness should be enquired. Ask the food intake during the last 24 hours in detail to calculate approximate caloric and protein intake per day.

Immunization History

Ask for various immunizations received so for. This information is useful to guide the diagnosis and ensure comprehensive management of the child. Look for scar of BCG vaccination during physical examination.

There are two types of immunization schedules commonly followed

To know about immunization history, we have to ask whether the child is been immunized with any other vaccines apart from immunization schedule especially in – the epidemic areas of certain communicable disease.

National immunization schedule:

Pediatric Vaccination schedule

Special Consideration

• Medical conditions: Diabetes, hypertension, infections, or genetic disorders.
• Medications during pregnancy: Some drugs can affect fetal development.
• Substance use: Alcohol, tobacco, or drug exposure can lead to complications.
• Gestational age: Determines prematurity or full-term status.
• Antenatal complications: Pre-eclampsia, infections, or fetal distress.
• Ultrasound findings: Any detected anomalies or growth concerns.
• Mode of delivery: Vaginal, cesarean, or assisted delivery.
• Apgar score: Assesses neonatal well-being at birth.
• Birth weight: Determines small, appropriate, or large for gestational age.
• Resuscitation needs: Oxygen support or interventions required.
• Cord complications: Prolapsed cord or nuchal cord.
• Feeding patterns: Breastfeeding or formula feeding initiation.
• Urine and stool passage: Ensures normal gastrointestinal function.
• Congenital anomalies: Any visible abnormalities.
• Infections: Signs of neonatal sepsis or jaundice.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Naveen Bajaj, Rajesh Kumar, Manual of Newborn Nursing, 2nd Edition, 2023, Jaypee Publishers, ISBN:978-9354659294
6. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

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