Child organism in the different age periods. development of the child

Childhood is not a small adult. A child passes through distinct age periods, each with its own physiology, growth rate, nutritional needs and developmental tasks. Growth is the increase in size and number of cells, and development is the progression of function and skill. Both are continuous and follow a predictable sequence, but each child moves at an individual pace. Growth runs in three phases (infancy, childhood and puberty), each driven by different regulators. Growth is judged by serial measurement against centile charts, and development by milestones in five areas: gross motor, fine motor, speech and language, cognitive, and social-emotional. The newborn examination and a structured paediatric history are the two basic tools for approaching a child at any age.

The life of a child is divided into periods that differ in what the body and mind are doing. The names and cut-off ages vary between classifications, so the table gives the one used in these notes.

Puberty begins at about 7 to 12 years in girls and 9 to 14 years in boys, so the early part of adolescence overlaps the school-age years. The boundaries are approximate, and the rate of change differs from one child to the next.

Prenatal development runs in three stages. In the germinal stage, which lasts the first two weeks, the fertilised egg divides and implants in the wall of the uterus. In the embryonic stage, from 2 to 8 weeks, the organs form and the limbs develop. The fetal stage, from 8 weeks to birth, is a period of growth and maturation of the organs, and the brain grows rapidly. Size at birth depends on the size of the mother, the nutrient supply through the placenta and insulin-like growth factors 1 and 2. It depends much less on the father's size and on growth hormone.

Growth means an increase in the size and number of cells, which results in an increase in body size. Development means the progression of functional and skill development. Maturation means the process of becoming fully developed in body and mind. Growth and development are continuous processes that follow a predictable sequence. Children do not progress at the same rate, and not all parts of the body grow at the same rate at the same time. Each child grows in a unique way, and each stage is affected by the stages that came before it.

Health and development depend on three groups of factors. Biological factors include heredity, age, sex, the child's status at birth, the pregnancy and delivery, body development and family diseases. Social factors include nutrition, housing, parental education, the financial status of the family, family structure, parental health education, the public health care system and friendships. Lifestyle factors are the extent to which a healthy lifestyle is adopted.

Growth is continuous, but it is usually described in three phases: infancy, childhood and puberty. Each phase has its own regulator, and together they give the familiar shape of the height curve. The infancy-childhood-puberty model shows how the three components add up to the final height, and how the pubertal component appears as a separate peak in the height velocity curve.

Fetal growth is the fastest period of growth, and it accounts for about 30% of eventual adult height. The infant then continues the fetal pattern at a slower rate. Early in infancy the growth rate is rapid, about 25 cm in the first year, and the height velocity then falls steeply. Nutritional status is the major influence in this phase. Infancy accounts for about 15% of adult height, and thyroid hormone and psychosocial health are also key factors.

The childhood pattern begins at about 6 months of age and predominates from about 3 years. Height velocity is steady, at about 4 to 8 cm a year. Nutrition becomes less important, and the growth hormone and IGF-I axis becomes the principal regulator of linear growth. A normal thyroid status is a prerequisite for normal growth. Childhood accounts for about 40% of adult height.

Puberty brings an adolescent growth spurt, caused by rising androgen and oestrogen production together with increased growth hormone secretion. Girls start the spurt about 2 years before boys. It begins with the start of clinical puberty, when breast development appears. Their peak height velocity, about 8 cm a year, comes at about 12 years, after which growth slows and menarche follows. Boys start the spurt when puberty is already well established, at a testicular volume of 10 to 12 ml. Their peak height velocity is about 10 cm a year, at about 14 years. The pubertal phase contributes about 15% of adult height. On average, men are 13 to 13.5 cm taller than women as adults.

Linear growth stops when the epiphyses of the long bones fuse. The epiphyses form at 1 to 2 years of age under the stimulus of the growth hormone and IGF-I system, and their fusion marks the end of growth. A child is judged to have reached final height when the growth velocity has fallen below about 2 cm a year.

The staging of puberty uses the Tanner scale, with five stages for breast development and pubic hair in girls, and for genital and pubic hair development in boys. The figure shows breast development (front and side views), female pubic hair and male genital development, each from stage 1 to stage 5.

Growth hormone is a single-chain polypeptide of 191 amino acids. Most of the circulating hormone (about 75%) is the 22 kDa form. It is secreted by the somatotrophs of the anterior pituitary in pulses. Growth hormone-releasing hormone (GHRH) stimulates its release, and somatostatin inhibits it. Nutrition, exercise, stress and sleep all influence growth hormone secretion.

Growth hormone acts on the liver to release insulin-like growth factor I (IGF-I), and much of its effect on linear growth is mediated through IGF-I. On muscle, growth hormone promotes amino acid transport and nitrogen retention. On adipose tissue it promotes lipolysis and gluconeogenesis, and it inhibits lipoprotein lipase. On bone it promotes epiphyseal growth and bone mass. IGF-I stimulates amino acid uptake and protein synthesis in muscle, increases the activity of osteoblasts and osteoclasts, and drives the proliferation and differentiation of chondroblasts at the growth plate.

Growth is shaped by intrinsic (genetic and hormonal) and extrinsic (environmental) factors. The table lists them.

Growth is measured as weight, length or height, and head circumference. Body mass index and body surface area (often used for dosing some drugs) are calculated from these measurements. A single measurement says little. The pattern of serial measurements, compared with the child's own previous values, is what shows whether growth is normal.

Children aged 2 years and under are measured lying down. Length is measured on a measuring board by two people. The child's head is placed against the headpiece, both feet are pressed against the footpiece with the soles at a right angle to the legs, and the toes point straight up.

Children older than 2 years are measured standing, without shoes, on a stadiometer. The head is held so that the Frankfurt plane is horizontal, meaning a line from the external ear to the lower edge of the eye socket. Sitting height is also measured when the proportions need to be assessed. Measurements are plotted on a chart for the child's sex and age, and each set is compared with earlier sets from previous visits.

Height is compared with population norms by centile or by a height standard deviation score (SDS), which is the child's height minus the mean height for age, divided by the standard deviation for that age. The SDS allows data from children of both sexes to be pooled and compared statistically.

Height velocity is the growth in centimetres a year. It is measured as the difference between two height measurements taken 6 to 12 months apart, and it is compared with the age-appropriate population values.

The mid-parental height estimates the child's adult height from the parents. The average of the parents' heights is calculated, and 6.5 cm is added for a boy and subtracted for a girl. This gives the target height. Children tend to follow their parents' growth pattern, although there are many exceptions, and the target is only a guide.

Significant abnormalities of height include a height below the 0.4th or above the 99.6th centile, or a height outside the mid-parental height range. Any discrepancy in weight should also be evaluated.

These benchmarks help to judge whether growth is on track in the first year.

Head circumference should be measured and plotted at every visit until the child is 2 years old, because the brain grows most rapidly in this period. A child is microcephalic when the head circumference is below the 3rd centile, even if length and weight are also low.

Bone age shows skeletal maturity. It is read from an X-ray of the left hand and wrist, either by comparison with the Greulich and Pyle atlas or by scoring the number, size and shape of the metacarpal and phalangeal bones (Tanner-Whitehouse method). Bone age correlates with final height and with the pubertal development. It can help to predict the timing of puberty: puberty usually starts when the bone age is about 10.5 years in girls and 11.5 years in boys. Bone age may be appropriate, delayed or advanced for the chronological age. An X-ray of the growth plates also shows whether growth has finished. Bone age is not a diagnostic investigation in itself, and the knee and foot epiphyses can already be seen before birth.

The first teeth erupt at 5 to 8 months. The second dentition begins at about 6 to 7 years, when the first permanent molars appear. The chart shows the eruption times of the individual teeth, by number, for the primary and permanent sets.

Short stature is a real or perceived impairment of linear growth, which may bring a child to the doctor because of physical, psychological or social difficulties. It is defined as a height 2 standard deviations or more below the mean for the population, which is a height below the 2nd centile. In most children the cause is a normal variant of physiology rather than a disease, but the diagnosis needs a logical process of clinical and laboratory assessment.

The main causes are familial short stature (the most common), constitutional growth delay and puberty, intrauterine growth restriction with no catch-up growth, dysmorphic syndromes including skeletal dysplasias, endocrine disorders (growth hormone deficiency, hypothyroidism, Cushing syndrome), chronic disease (cystic fibrosis, inflammatory bowel disease, renal disease, chronic anaemia), and psychosocial deprivation.

A child should be evaluated further when the growth chart levels off, when growth decelerates, when the height SDS is below minus 2.5, or when the height SDS is below minus 1.3 together with disproportion, dysmorphic features or small size for gestational age without catch-up growth. Baseline investigations include a full blood count and ESR, renal function, calcium and phosphate, liver function tests, ferritin, coeliac antibodies, a karyotype in girls, thyroid function tests, cortisol and prolactin, and a skeletal survey in dysmorphic children.

Development is assessed in five areas: gross motor, fine motor, speech and language, cognitive, and personal-social (social-emotional). A milestone is a discrete behaviour that the clinician can observe, or accept as present from the parents' report. Each milestone appears in a uniform sequence within a specific age range, and the development of the neuromuscular system is first determined by genetic endowment and then shaped by the environment.

Milestones are a reliable guide only to about 6 years of age. Later development needs other tools, such as school performance, intelligence tests and personality profiles, which require time and expertise.

The table gives the milestones for each age, with the timing used in these notes.

Further milestones from the same sources are as follows. At 1 month the infant lifts the head briefly when prone, keeps the fists mostly clenched, and cries and coos. At 2 months the infant begins to track objects with the eyes. At 4 months the infant grasps objects and recognises familiar people. At 9 months the infant crawls, uses a pincer grasp, understands "no" and plays peek-a-boo. At 1.5 years the child walks independently, stacks two to three blocks and uses 10 to 20 words. At 5 years the child skips, prints some letters, speaks in full sentences and understands rules.

The Oxford Handbook of Paediatrics adds further landmarks. Most infants sit without support by 6 to 8 months and cruise round furniture by about 10 months. About half of infants walk independently by 12 months, although the range is wide. Children run and jump by 2 years, kick a ball by 2 years, stand on one leg briefly at 3 years, and balance on one leg for a few seconds at 4 years. They skip on both feet by 5 years. Fine motor skills follow vision: a newborn fixes and follows a face, a 6-week-old turns the head through 90 degrees to follow an object, and at 3 to 4 months the baby watches its own hands. Pencil skills progress from scribbling at 18 months to building a six-brick tower at 2 years, copying a circle at 2.5 years, and drawing a square at 4.5 years and a triangle at 5 years.

Primitive reflexes are found in normally developing infants and disappear as the nervous system matures. The table gives the common ones.

Asymmetric movement or altered muscle tone may signal a central nervous system abnormality or a nerve palsy from the delivery, and it needs further evaluation. A delay in the expected disappearance of the reflexes also warrants evaluation of the central nervous system. Sitting depends on two reflexes that develop before it: the propping (parachute) reflex, which protects against a fall, and the righting reflex, which returns the head and body to the vertical when the body tilts. A child who cannot sit by 9 months, or cannot walk by 18 months, should be referred for evaluation.

Jean Piaget described cognitive development in terms of schemas, which are the basic building blocks of the mental models that a child uses to represent the world. A child takes in new information by assimilation, using an existing schema to deal with a new object or experience. When the new information does not fit an existing schema, the schema is changed by accommodation to take in the new knowledge. The cycle is shown in the figure.

Piaget identified four cognitive stages. The sensorimotor stage (0 to 2 years) brings the development of object permanence. The preoperational stage (2 to 7 years) brings the ability to think conceptually, with a child-centred view of the world and "magical" thinking, in which toys are treated as if they were alive. The concrete operational stage (7 to 11 years) brings logical, operational thought. The formal operational stage (from about 11 years) allows abstract thought and the logical testing of hypotheses.

The primitive structures of the hindbrain and midbrain mature within the first three years of life, and by the age of 2 years the brain is about 80% of its adult size. The frontal lobe does not begin to function fully until about 5 to 7 years of age.

Bonding and attachment describe the affective relationship between parent and infant. Bonding occurs shortly after birth and is largely one-directional, reflecting the parents' feelings towards the newborn. Attachment is reciprocal and develops gradually over the first year. Infants whose crying is answered promptly cry less by the end of the first year. Stranger anxiety usually appears between 9 and 18 months, when the infant becomes insecure about separation from the main caregiver. The result can be swings from stubborn independence to clinging dependence.

Between 2 and 3 years the child develops autonomy, which allows separation from the parents. This is the "I can do it myself" age, and limit setting is needed to balance the child's growing independence. By 24 months children copy the actions they see around them, such as feeding a doll or cleaning. They then move from parallel play to interactive play, with turn-taking and simple rules, from about 3 years.

Toilet training is very variable. Some children are dry by day at 2 years, but others are much older. Night-time dryness always takes longer, and about 10% of 5-year-olds still wet the bed at night.

Temperament varies widely among normal children. About 40% of children are "easy", with regular biological routines, a positive approach to new things and a positive mood. About 10% are "difficult", with irregular routines, withdrawal from new things, intense responses and a negative mood. About 15% are "slow to warm up", with low activity, slow adaptation and mildly negative mood. The rest have mixed temperaments. Recognising the child's temperament prevents normal behaviour from being labelled abnormal.

School readiness depends on emotional maturity, peer and individual social skills, cognitive ability, and fine and gross motor skills. A child does better in kindergarten if the fifth birthday falls at least 4 to 6 months before the school year starts, and girls are usually ready earlier than boys. A child with a developmental delay should not be forced into early school, and holding a child back in the hope that the delay will resolve is also unhelpful. Educational planning should start early for any deficiency.

Adolescence is better described by its developmental stages than by its age range, which is commonly given as 10 to 25 years. Early adolescence is focused on the body's physical changes and on the peer group, and young adolescents are often hard to interview. Middle adolescence brings abstract thinking, experiment with ideas, and a search for identity that goes beyond the body. It is also the time of high-risk behaviour, including unprotected sex, substance use and dangerous driving. Late adolescence is marked by formal operational thinking and by thought about the future, including education, work and relationships. Adolescents need an annual comprehensive health assessment, including sexual maturity rating, to make sure that puberty is progressing without problems. Scoliosis, obesity and trauma are also issues of physical development at this age.

Developmental and behavioural problems are more common than any other category of problem in paediatrics, except acute infections and trauma. Nelson Essentials of Pediatrics reports that 15% of children aged 3 to 7 years had a developmental disability in 2008, and that as many as a quarter of children have serious psychosocial problems. Parents often do not mention these problems, because they think the doctor is not interested or cannot help. Development must therefore be monitored at every visit.

The American Academy of Pediatrics recommends routine health visits in the first week of life, at 2 weeks, at 1, 2, 4, 6, 9, 12, 15 and 18 months, at 2, 2.5 and 3 years, and then annually through adolescence. The visits in the first two years are more than physical examinations: nutrition, behaviour, development, safety and anticipatory guidance are discussed at them.

The Denver Developmental Screening test is a quick way to check whether a child has reached the milestones expected for the age. A vertical line is drawn at the child's chronological age, and for a premature child the months of prematurity are subtracted from the chronological age until the child is 2 years old. Development should always be considered as progress over time within each area of skill, because the pattern and rate of acquiring milestones vary.

The newborn is examined soon after delivery, with a routine check, and then fully before discharge home. The aims of the examination are to diagnose congenital malformations and common neonatal problems, with advice about management or reassurance when no intervention is needed; to continue the screening that began antenatally, so that babies who need specific intervention are identified; and to give health education on breastfeeding, cot death prevention and safe transport in cars, together with general reassurance for the parents.

The average newborn weighs 3.5 kg, measures 50 cm in length and has a head circumference of 35 cm. The haemoglobin is about 18 g/dl, and the blood volume is about 300 ml.

Before the examination, collect the background. Note the baby's sex, birth weight and gestational age, and the mother's age and social background. Ask about chronic maternal disease and its treatment, and about drug, alcohol and tobacco use. Take the family history, the outcome of any previous pregnancies, and any complications of this pregnancy. Note the results of pregnancy screening, such as the 19-week ultrasound, and any special diagnostic procedure, such as amniocentesis. Ask about signs of fetal distress, the drugs and anaesthesia given in labour, how the baby was delivered, and the condition at birth. That includes any signs of perinatal asphyxia, the Apgar scores at 1 and 5 minutes, any resuscitation, how long it took to establish sustained breathing, and whether the baby was admitted to the neonatal unit and why.

Remove the baby's clothes and feel the anterior fontanelle, leaving it until later if the baby is crying. Look at the face for colour and peculiarities. Listen to the heart and estimate the heart rate, then listen to the lungs and palpate the abdomen. Measure the head circumference and examine the skull and scalp, then the eyes, ears, nose and mouth. Examine the neck, including the clavicles, and the arms, hands, legs and feet. Feel the femoral pulses, examine the genitalia and anus, and examine the back and spine. Evaluate the central nervous system and the hips.

Throughout the examination, note the skin texture and colour, any rashes and naevi, nutritional state, the respiratory pattern and cry, posture, muscle tone, neurological and behavioural state, gestational age, and any dysmorphic features or minor abnormalities. Repeated examination matters, because physical findings change quickly in normal infants as well as in infants who are unwell.

Gestational age is assessed by the Ballard score, which has two parts. The neuromuscular maturity score looks at posture, the square window at the wrist, arm recoil, the popliteal angle, the scarf sign and the heel-to-ear manoeuvre. The physical maturity score looks at skin, lanugo, the plantar surface, the breast, the eye and ear, and the genitalia. The total is converted to weeks of gestation with the rating table in the figure. A total of minus 10 corresponds to 20 weeks, and a total of 50 corresponds to 44 weeks.

The Apgar score is recorded at 1 and 5 minutes after birth. Each of five signs is scored 0, 1 or 2, giving a total out of 10. Low scores at 1 and 5 minutes are a sign of perinatal asphyxia, and the score guides the need for resuscitation.

The skin should be firm and smooth. Peeling and dryness are seen in post-term babies. A loose skin suggests intrauterine growth restriction or dehydration, and oedema is common in preterm babies because of hypoalbuminaemia. Rashes and naevi are noted and described.

A varying degree of acrocyanosis, a blue discoloration of the hands and feet, is normal in the newborn. Perioral cyanosis in the first 48 hours is also common and harmless. Traumatic cyanosis, with bruising and sometimes petechiae over the presenting part, is different. Central cyanosis, shown by a blue tongue, must be taken seriously. If there is any doubt, check the oxygen saturation with a pulse oximeter. Babies with confirmed central cyanosis should be admitted to the neonatal unit for blood gas estimation, an X-ray and an echocardiogram, unless there is lung pathology.

Jaundice needs an immediate check in the first 24 hours, including the blood group and rhesus type of the baby and the mother, signs of congenital infection, and antibodies. Jaundice between 2 and 4 days after birth is extremely common. About 65% of term babies have a serum bilirubin above 80 µmol/L in this period. In a preterm baby, signs of neonatal infection may be subtle, and they include lethargy, poor feeding, temperature instability, vomiting and apnoeas.

Pallor and capillary filling time are also checked.

The occipito-frontal head circumference of a term baby normally lies between 33 and 37 cm. A small head suggests dysmorphic syndromes, congenital infection or isolated microcephaly. A large head suggests megacephaly or hydrocephalus. The anterior fontanelle is variable in size. A full fontanelle may indicate raised intracranial pressure, as in hydrocephalus, meningitis or severe hypoxic-ischaemic encephalopathy. Ridging at the suture lines suggests craniosynostosis.

The skull bones are separated by sutures and by the fontanelles, which are the anterior, posterior and, if present, third fontanelles. Moulding of the skull bones is common in a vaginal delivery.

Caput succedaneum is a soft, diffuse swelling of the scalp that crosses the suture lines, and it is common after delivery. A cephalhaematoma is a collection of blood between the skull bone and the periosteum. It is felt as a softish swelling over the affected bone, usually a parietal bone, and it does not cross the suture lines. Skull fractures can also occur.

Eyes need examination for the red reflex, which tests the lens and retina. Mucoid discharge is usually harmless, but purulent discharge with redness and oedema of the lids needs bacteriological investigation and treatment. Subconjunctival haemorrhage is harmless. Nystagmus, strabismus and cataract should be noted, and the cornea should be about 10 mm across.

The nose is checked for the width of the bridge, measured as the distance between the inner canthi, which is about 2.5 cm. The size and symmetry of the corners of the mouth and the nasolabial folds are noted. In the mouth, Epstein pearls on the palate or gums and small natal teeth are normal findings, but a short frenulum and bluish swellings (ranulae) on the floor of the mouth should be recorded. A webbed neck suggests Turner syndrome. Redundant skin at the nape of the neck suggests Down syndrome. A cystic hygroma is a soft fluctuant swelling in the neck. Fractures of the clavicle are sometimes found after a difficult birth, and forceps marks or lacerations from scalp electrodes may also be seen.

Minor anomalies in the newborn include an accessory auricle, white pimples, capillary naevi, Mongolian spots, sacral dimples, a single palmar crease and an accessory digit. They are usually harmless, but dysmorphic features should be looked for alongside them.

The normal respiratory rate of a newborn is 40 to 60 breaths a minute. Breathing pauses of 5 to 10 seconds, interspersed with normal breathing, are normal. True apnoeas of 15 to 20 seconds, often with heart rate decelerations, are seen only in preterm babies. Tachypnoea of more than 60 breaths a minute, with or without retraction, is abnormal, and it may indicate pulmonary disease or heart failure. Signs of dyspnoea include flaring of the alae nasi, grunting and retraction. The Silverman score grades the severity of respiratory distress from the movements of the chest and abdomen, the xiphoid retraction, the expiratory grunt, nasal flaring and the chin position.

The chest is inspected for breast swelling, which is normal and often produces a few drops of milk, sometimes called witch's milk. The breath sounds are auscultated, and the lungs are listened to for crackles or wheezes.

The heart rate of the newborn is usually around 100 beats a minute, with a normal range of 70 to 180, and it is generally faster than in older children. The right ventricle is relatively dominant, so the apex beat lies at the lower left sternal border rather than at the apex. The second heart sound may be single in the first days of life. An ejection click may be heard in the first hours. Peripheral pulses should be palpable in all four limbs, including the feet. They appear bounding in preterm babies because of the thin subcutaneous tissue.

An innocent murmur is common, with grade 1 or 2 out of 6 intensity at the left sternal edge, no click, normal pulses and an otherwise normal examination. A murmur that is loud, pansystolic or harsh, that is grade 3 or more out of 6, or that comes with an abnormal second heart sound needs review by a cardiologist. The usual cause of an innocent murmur is the acute angle at the bifurcation of the pulmonary artery, or transitory tricuspid regurgitation. Weak or absent femoral pulses need explanation.

At birth the circulation changes in a set order. The rise in left atrial pressure, when the lungs first expand, closes the foramen ovale. The fall in pulmonary vascular resistance and the rise in oxygen tension close the ductus arteriosus. Interruption of the placental flow closes the ductus venosus.

Umbilical discharge and reddening of the skin around the cord need attention, and abdominal distension should be noted. A single umbilical artery warrants investigation of the kidneys. On palpation, the liver may be felt up to 2 cm below the right costal edge in a normal newborn, but a spleen more than 1 cm below the left costal edge is abnormal, and so are large renal masses. Diastasis of the recti may be found.

In a male newborn the penis is about 3 cm long, the scrotum and testes are examined, and hydroceles and inguinal hernias are noted. In a female newborn, the clitoris and labia are prominent in preterm babies, and a white mucoid vaginal discharge is normal.

Birth injuries include fractures of the clavicle, humerus and ribs, nervous tissue damage such as a brain bleed from a tentorial tear, spinal cord injury and upper brachial plexus injury, and dislocations of the shoulder and hip.

Perinatal asphyxia is suspected from the history, from cardiotocographic signs of decompensated fetal distress, from low Apgar scores at 1 and 5 minutes, from early neurological abnormalities, and from clinical and laboratory evidence of multisystem dysfunction. About 10% of newborns need some help to start breathing. The steps are to watch the clock, clear the airway of mucus and vernix by suction, stimulate a gasp, and intubate the trachea and give oxygen if the baby needs it. Personnel able to resuscitate must attend every delivery. The aim is a vigorous cry or regular breathing, a heart rate above 100 a minute, and good colour and tone. When meconium is present in the liquor, the head is delivered and the meconium is suctioned from the hypopharynx. A depressed baby, with absent or weak breathing, poor tone and a heart rate below 100 a minute, needs direct tracheal suction. Ventilation is the first priority, with a bag and mask, tracheal intubation or assisted ventilation. Chest compressions are given if the heart rate stays below 60 a minute after 30 seconds of effective ventilation, with compressions and ventilation coordinated at a ratio of 3 to 1. Adrenaline is given if the heart rate stays below 60 a minute despite effective ventilation and compressions.

A paediatric history is taken from the parents, and from the child when old enough. Use the parents' own words, and put the complaints in chronological order. The history is the approach to the child at each age, and in a newborn, a child with a genetic problem or a child with a developmental problem, the birth and family history are especially important.

Record the child's name, age and date of birth, sex, the address of the parents and the date of admission. The presenting complaints are written in the parents' own words, in the order in which they happened.

Start by asking when the child was last entirely well. For each presenting complaint, record its time (onset, duration, frequency and course), its place (site), its quality (character of pain, and the composition of vomit), its quantity (severity of pain, and amount of vomit), any provoking or relieving factors, and any diurnal or seasonal variation. Record the associated symptoms and any treatment already given.

Then ask a systematic enquiry by system. For the general state, ask about weight loss and appetite. For the cardiovascular system, ask about breathlessness on exertion, breathlessness and sweating on feeding, cyanotic spells, squatting, fainting, cyanosis, oedema, and chest pain or palpitations. For the respiratory system, ask about sore throat, earache, cough, wheeze, frequent chest infections, aspiration and haemoptysis. For the gastrointestinal system, ask about abdominal pain, vomiting, jaundice, diarrhoea or constipation, and blood in the stools. For the central nervous system, ask about fits, syncope or dizziness, headache, visual problems, numbness, weakness, falls and incontinence. For the genitourinary system, ask about the stream, dysuria, frequency, nocturia or enuresis, incontinence and haematuria. For the rheumatological system, ask about limp, joint swelling, hair loss, rash, dry mouth or mouth ulcers, dry or sore eyes and cold extremities.

The antenatal history covers the mother's health and nutrition during pregnancy, and any illness in pregnancy, such as hypertension, diabetes, pre-eclampsia or antepartum haemorrhage. It asks about infections in pregnancy, including rubella, urinary infections, syphilis and tuberculosis. It asks about drugs taken, including iron, multivitamins and any other drug, with dose, duration and the stage of gestation, and about any radiation exposure in the first trimester. It notes the mother's tetanus immunisation and the past obstetric history, including problems with earlier pregnancies, stillbirths, miscarriages, the birth weights of earlier children, prematurity and blood transfusions.

Teratogenic exposures matter. Infections such as rubella, cytomegalovirus, herpesvirus and coxsackievirus B can affect the fetus, as can maternal use of amphetamines, anticonvulsants, lithium, retinoic acid and valproic acid, and heavy smoking or alcohol intake. A baby who is small for gestational age may have had an intrauterine infection or been exposed to drugs or chemicals. Rubella syndrome and fetal alcohol syndrome are typical examples. Babies of diabetic mothers are often large for gestational age, and maternal lupus or mixed connective tissue disease is also recorded.

The natal history records the place of delivery (hospital or home), who conducted the delivery, the sterilisation technique for the instruments, the length of gestation, the time of rupture of membranes, the duration of labour, the presentation and type of delivery (spontaneous vaginal delivery, forceps, vacuum extraction or caesarean section), any sedation or analgesia in labour, and any complications such as abnormal bleeding.

The postnatal history records the first cry (immediate, cyanosed or apnoeic), any need for resuscitation, problems with breathing or with sucking and swallowing, the birth weight, any birth injury, convulsions, cyanosis, jaundice, fever or rash, and any procedures such as exchange transfusion, umbilical artery catheterisation or drugs given.

The feeding history is important in any child under 2 years, and in an anaemic or malnourished child. Record the time of the first feed after birth. For breastfed babies, record the duration of breastfeeding. For bottle-fed babies, record the age at which bottle feeding started, the composition of the formula, the amount, the frequency and any dilution. Record any supplements, such as vitamins or iron, the age at which weaning started, what was given, the amount and the frequency, and the current diet, including any change during illness.

Check the vaccination card. Record the vaccines given, the age at which they were started and by whom, and the doses and any adverse effects.

Record the age at which the child achieved each milestone: smiling, holding the neck up, sitting, crawling, standing, walking, talking, and control of bladder and bowel. Compare each with the normal for the child's age.

Record any significant illness in the past, especially diarrhoea, respiratory infections, fevers, fits and jaundice, and any history of similar complaints before.

Record the particular habits of the child, the class and school, the child's interest in studies, any missed school attendance, and the child's behaviour at school and relationships with other children.

Record any medication used, with its frequency, dose and adverse effects, and any drug allergy. Ask about maternal drug use if the child is a neonate or breastfed, because drugs pass into breast milk.

Family history is important in chromosomal, hereditary and infectious disease. Record the ages of the mother and father and how long they have been married, and ask specifically about consanguinity. Record the parents' present and past health, and the siblings: their number, age and sex, illnesses, any deaths and their causes, and any stillbirths or miscarriages. Ask about the grandparents' health, particularly if they live with the family, and about the health of uncles, aunts and their children if an inherited disorder is suspected. Draw a family tree.

Record the parents' education and occupation, the family income, and the house, including the materials it is made of, the number of people living in it and its size. Note the cleanliness and general hygiene, the household's drinking water supply and any pets at home.