19.1 Comprehensive Acute Pediatric Health History, Developmental Surveillance & Caregiver/Environmental Risk Assessment
Key Takeaways
Gather a focused SAMPLE history during stabilization. Afterward, confirm perinatal events, immunizations, operations, devices and the child’s usual function.
Use measured weight in kilograms for weight-based medication reconciliation. Verify the exact formulation, concentration, volume, frequency and last dose, and document the specific allergy or adverse reaction.
Adapt the sequence and language to the child’s developmental and communication needs. Offer adolescents private interview time and explain the limits of confidentiality.
Check caregiver skills with teach-back and demonstration. For home ventilation, verify continuous trained coverage, backup power, equipment and a response plan before discharge.
Focused and Comprehensive Acute History
Gather a focused history alongside stabilization in a child with shock, respiratory failure or active seizures. A team member can use SAMPLE while others assess and support airway, breathing and circulation. Ask about signs and symptoms, allergies, medicines and last doses, relevant past history, last oral intake, and events preceding illness. For a possible ingestion, ask what was available and when. For an airway emergency, ask about choking, previous difficulty with intubation, and any existing airway plan. Expand the history once the child is stable enough and use records or other caregivers to confirm uncertain details. AHA/AAP pediatric advanced life support
| History domain | What to establish |
|---|---|
| Birth and perinatal history | When relevant, ask about gestational age, birth weight, maternal infections or exposures, delivery and resuscitation, newborn screening, and NICU complications or respiratory support. Verify an existing diagnosis such as bronchopulmonary dysplasia in the record. Prior preterm birth or prolonged support can inform today's differential and baseline oxygen needs. |
| Immunizations and immune risk | Verify dates in the state immunization information system or primary care record when available. An incomplete series changes the differential for infections such as pertussis, measles or invasive Hib. If the child receives chemotherapy, immunosuppressive biologics or sustained high-dose systemic steroids, verify the specific vaccine and safe timing. Antibody-containing products such as IVIG can affect timing of measles- or varicella-containing vaccines. Rotavirus vaccine is an exception to that spacing rule. With asplenia, check age- and risk-appropriate pneumococcal, Hib and meningococcal immunization and whether antimicrobial prophylaxis is indicated. In sickle cell disease, age, genotype, prior invasive infection and splenectomy affect prophylaxis decisions. |
| Surgery, hospitalizations and devices | Ask about prior intubation or post-extubation stridor, and obtain cardiac operative details and the usual saturation or perfusion plan. A modified Blalock–Taussig–Thomas shunt is an arterial source of pulmonary flow. In Glenn or Fontan circulation, positive pressure can affect passive cavopulmonary flow. Clarify symptoms that could indicate a VP shunt problem. Record feeding access, central line type and purpose, and the tracheostomy brand, size, length, cuff and last change. Confirm the home airway and ventilator settings when relevant. |
| Development and baseline function | Ask how the child usually moves, feeds, communicates, breathes and interacts. Use the child’s usual communication aids and ask caregivers which changes are new. Review prior developmental concerns and screens. New regression, altered interaction or loss of skills warrants assessment and an appropriate referral. |
CDC immunization records · CDC altered immunocompetence · CDC vaccine timing · AAP sickle cell health supervision · AHA Fontan statement
Assess a newly arrived child
Use a qualified interpreter when needed. Ask about where the child lived or traveled, household exposures, immunization records, prior screening and medicines. A child with prolonged cough, weight loss and a known household tuberculosis exposure needs prompt evaluation and appropriate airborne precautions when pulmonary TB is suspected. Base those decisions on clinical and exposure findings. For the stable child, review overseas records where available, credit vaccine doses compatible with U.S. schedules, and arrange risk-based follow-up or a domestic refugee health assessment if applicable. Confirm the appointment and address access or transportation barriers with the family. CDC post-arrival screening · CDC refugee TB guidance · CDC immunization records guidance
Measuring functional change
The Functional Status Scale (FSS) covers mental status, sensory functioning, communication, motor functioning, feeding and respiratory status. Each domain ranges from 1 (normal) to 5 (very severe dysfunction), and total scores range from 6 to 30. Compare with the child's pre-illness baseline, document when the follow-up score was obtained and identify the affected domains. In the original multicenter outcomes study, an increase of at least 3 total points from baseline at hospital discharge defined new morbidity. A score at PICU transfer can also describe change and inform support. The Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC) are coarser six-category measures of cerebral or overall function. FSS validation · New morbidity study · PCPC and POPC study
Medication reconciliation
Use a measured weight in kilograms when possible. Ask what the caregiver actually gives, including drug name, concentration, volume, route, frequency and last dose. Verify the label, pharmacy or medication list when these disagree. For a weight-based regimen, check the amount per dose, total over 24 hours and any drug-specific maximum. Use mL on instructions and provide a suitably sized oral syringe for small liquid doses. Ask the caregiver to show how they measure it.
Worked example: A 2.5 mL volume contains 50 mg from a bottle labeled 100 mg/5 mL and 100 mg from a bottle labeled 50 mg/1.25 mL. In a 10 kg child those amounts are 5 and 10 mg/kg, respectively. Confirm the intended dose before changing products or telling the family which volume to use. AAP medication safety policy · Children's Wisconsin dosing materials
Ask about nonprescription, herbal and imported products and check for duplicate ingredients. FDA advises against giving cough and cold products containing an antihistamine or decongestant to children under 2 years, and many manufacturers label these products against use under age 4. For an allergy label, document the drug, timing, symptoms, treatment and prior tolerance. Immediate hives or breathing symptoms, severe delayed reactions with mucosal or systemic involvement, and isolated gastrointestinal intolerance call for different decisions. Arrange risk-based allergy evaluation when indicated. FDA pediatric cough and cold safety · U.S. drug allergy practice parameter
Developmental Surveillance and the Examination
Base the sequence on clinical urgency and the child's developmental and communication abilities. Developmental surveillance includes caregiver concerns, history and observation. At routine health supervision visits, AAP recommends general standardized screening at 9, 18 and 30 months and autism screening at 18 and 24 months. In acute care, clarify concerns, document the child's baseline and arrange follow-up or evaluation as indicated. AAP developmental surveillance and screening
| Patient | Approach when stable |
|---|---|
| Newborn or young infant | Observe feeding and breathing when relevant. Listen to the heart and lungs while quiet. Assess tone, symmetry and age-appropriate reflexes when needed. |
| Older infant or toddler | Keep a trusted caregiver close. Use the caregiver's lap when safe and tolerated. Do quiet observations and auscultation before more distressing steps when clinically feasible. |
| Preschool or school age | Use concrete explanations, demonstrate equipment and offer meaningful choices. Ask the child directly about symptoms and adapt to their preferred communication method. |
| Adolescent | Offer private time, explain confidentiality and its limits, and include the adolescent in decisions. Use a chaperone for sensitive examinations as appropriate. |
HEEADSSS can organize a private conversation about home, education or employment, eating, activities, drugs, sexuality, suicide or mood, and safety. When indicated, use a validated suicide risk screen such as ASQ and follow a positive screen with the appropriate safety assessment. Explain before asking sensitive questions how disclosures may be handled if there is serious risk or a reporting obligation. Apply local law and institutional policy. AAP adolescent confidentiality · AAP pediatric chaperones · NIMH ASQ toolkit · Pediatric assessment and distress guideline
Caregiver Capacity, Home Safety and Access
Ask who provides care, who can make medical decisions, and who can step in if the usual caregiver is unavailable. Ask about fatigue, competing work or family needs and barriers to learning. Use a qualified interpreter when needed for meaningful communication and appropriate aids such as sign-language interpretation or accessible materials. Use plain language and ask the caregiver to explain the plan or demonstrate the skill. Teach-back tests how well the team explained the task. Re-teach if the demonstration reveals a gap. AHRQ teach-back and show-me · HHS language and disability access standards
Home airway and ventilation: Agree on the individualized discharge plan with respiratory therapy, case management, home nursing and the equipment provider. For chronic invasive home ventilation, ATS recommends an awake, attentive trained caregiver at all times and suggests training at least two family caregivers. For a child with a tracheostomy at risk of immediate deterioration, the 2025 ATS guideline recommends a continuously awake, trained caregiver. Confirm the family can recognize and manage obstruction, accidental decannulation and equipment failure. Check the emergency bag and transport setup for the prescribed same-size and smaller tracheostomy tubes, obturator, ties, suction supplies, portable suction and a manual ventilation device with appropriate connectors or mask. Confirm the backup ventilator and power plan, prescribed monitoring and an emergency location or transfer plan if power fails. Utility medical-priority programs can be useful where available. Resolve a current shutoff threat or arrange a safe alternative setting before discharge. ATS home invasive ventilation guideline · ATS pediatric tracheostomy guideline
Home risks and resources: Ask about access to food, housing, electricity, transportation, medications and equipment. The two-item Hunger Vital Sign can screen for household food insecurity. Work with social work, case management or pharmacy to address specific barriers and confirm follow-up arrangements. Discuss relevant injury prevention, including storing firearms unloaded and locked with ammunition locked separately, storing medicines and button batteries out of reach, and placing infants on their backs in a separate, firm, flat sleep space free of loose bedding. Hunger Vital Sign validation · AAP firearm injury prevention · AAP infant sleep policy
A 14-month-old with bronchiolitis is stable but cries whenever the clinician approaches. The child settles in her mother’s lap. Which approach best helps the clinician assess breath sounds and reduce distress?
Ask the mother to step behind a curtain so the toddler focuses on the clinician, then begin with an ear and throat examination
Examine the toddler while seated on the mother's lap, auscultating the heart and lungs first and deferring the ear and oropharyngeal exam until the end
Ask the toddler, "May I listen to your chest now?" and postpone the pulmonary examination until she verbally agrees
Perform a rapid head-to-toe sequence starting with pupillary reflexes and oral mucosa while staff gently immobilize the child supine
A 6-year-old with cerebral palsy uses a wheelchair, communicates with eye gaze and receives all nutrition through a gastrostomy tube. He needed no respiratory support before sepsis. At hospital discharge he needs nocturnal bilevel ventilation and has a new reduction in alertness. Which tool best measures the change across specific functional domains?
Glasgow Coma Scale alone
SAMPLE history
Functional Status Scale, comparing pre-illness and discharge scores
Apgar score from the birth record
A 12-year-old who recently arrived in the United States has had a cough and weight loss for several weeks. The caregiver reports that someone in the household is being treated for pulmonary tuberculosis. The child is breathing comfortably. The caregiver prefers a language that the clinician does not speak. What is the best first plan?
Wait for the routine domestic screening visit, then review whether isolation is needed.
Ask the child to interpret the exposure history and wait for a positive screening result before changing precautions.
Review the vaccine record and arrange catch-up vaccination before evaluating the cough.
Start Airborne Precautions, use a qualified interpreter to clarify the exposure, and arrange prompt evaluation for pulmonary tuberculosis.
Sections you finish are checked off in the contents.