The Pediatric Neurological History

Establishing rapport

Parents and guardians are often very worried about the seriousness of their child’s illness.
It is important to put the child and caregiver at ease and present an empathetic demeanor.
Establish expectations, understanding and fears regarding the child’s presentation.

History is crucial for evaluation of a child with a suspected neurologic problem.
Children 3 or older should be encouraged to participate in providing the history.
History in children is always a composite of the parent/guardian and the child’s input.
Be sure to confirm and clarify symptoms ie. dizziness could be lightheadedness, confusion, vertigo, weakness, etc.

Chief complaint

Elicit a succinct reason that prompted the parents and child to seek medical attention

History of presenting illness

detail the onset, duration, frequency, character, palliating and provoking factors, and associated symptoms
Focused review of systems relevant to chief complaint
- Hypotonia
  - Infection: fever, nuchal rigidity, rash, seizures
  - Family history of muscular disorders, consanguinity
  - Progressive hypotonia?
  - Limbs affected
  - Developmental milestones
  - Seizures
    - Duration, frequency
    - Infection: Fever, rash, diarrhea, vomiting, sore throat, nasal discharge, cough
    - Changes in consciousness, focal vs generalized
    - Underlying medical conditions
    - Timing of seizure relative to fever (if present)
    - Presence of a postictal phase?
      - Paralysis
      - Breathing difficulties
      - Cyanosis
      - Aspiration
  - Headache
    - Infection: fever, nuchal rigidity, rash, nausea, vomiting, diarrhea
    - Severity and impact on function (absence from school?)
    - Worst headache ever experienced?
    - Migraine symptoms
      - Presence of an aura
      - Triggers
    - Changes in consciousness
    - Personality changes, visual disturbances,

If seizure lasts > 30 minutes without child regaining consciousness = status epilepticus and should be managed accordingly
Benign febrile seizures < 15 minutes

try to obtain history of headache (especially pain) directly from child
progressively worse headache may suggest increasing intracranial pressure/space-occupying mass

General review of systems

The review must include all of the organ systems because neurological function is adversely affected by dysfunction of many systems, including the liver, kidney, gastrointestinal tract, heart, and blood vessels
Include sleep habits, diet, bowel and bladder habits, activity level, personality, and mood

Alarm symptoms

Past medical history

Review of pregnancy, labor and delivery

Developmental History (see table)

Loss of skills (regression) over time suggests an underlying degenerative disease
Information from teachers or kindergarten staff may be helpful regarding academic performance and social skills

Medications – dose, frequency, indication, response, side effectsAllergies – document nature of reaction

Family History

Extremely important
Parents may be unwilling to discuss neurological disorders that run in the family openly

Social history

TABLE Screening Scheme for Developmental Delay: Upper Range

AGE (month)	GROSS MOTOR	FINE MOTOR	SOCIAL SKILLS	LANGUAGE
3	Supports weight on forearms	Opens hands spontaneously	Smiles appropriately	Coos, laughs
6	Sits momentarily	Transfers objects	Shows likes and dislikes	Babbles
9	Pulls to stand	Pincer grasp	Plays pat-a-cake, peek-a-boo	Imitates sounds
12	Walks with one hand held	Releases an object on command	Comes when called	1–2 meaningful words
18	Walks upstairs with assistance	Feeds from a spoon	Mimics actions of others	At least 6 words
24	Runs	Builds a tower of 6 blocks	Plays with others	2–3 word sentences

Berstein D, Shelov SP, editors. Pediatrics. Baltimore: Williams and Wilkins;1996.
Behrman RE, Jenson HB, Kliegman RM, Stanton BF. Nelson Textbook of Pediatrics. 18^th ed. Elsevier; 2007.
Bradley WG, Daroff RB, Fenichel G, Jankovic J. Neurology in Clinical Practice. 5^th ed. Butterworth-Heinemann; 2008.