The history is the most important component of the evaluation of a child with a suspected neurologic problem. The history should carefully document in chronological order the onset of symptoms and a thorough description of their frequency, duration, and associated characteristics.
Most children beyond the age of 3–4 yr are capable of contributing to their history, particularly about facts relating to the present illness.
A detailed history might suggest that the child’s vomiting is due to increased intracranial pressure (ICP), that the pain behind the eye may be caused by migraine headaches or multiple sclerosis, and that the constipation and urinary dribbling may be due to a spinal cord tumor.
It is important to start with a concise description of the chief complaint within its developmental context. Parents may be concerned that their child cannot talk. The seriousness of this problem depends on many factors, including the age of the patient, the normal range of language development for age, the parent-child interaction, functioning of the auditory system, and the intellectual level of the child. A comprehensive understanding of developmental milestones is essential in order to ascertain the relative importance of the parents’ observations.
After the chief complaint and history of present illness are elicited, a review of the pregnancy, labor, and delivery is indicated, particularly if a congenital disorder is suspected.
Was the mother exposed to a viral illness during the pregnancy, and what is the mother’s rubella, HIV, and syphilis immune status? HIV Prevention is extremely important during pregnancy, as this condition could be passed on to the child, and the mother could suffer from pregnancy complications do to it as well.
Were there additional concerns such as pregnancy-induced hypertension or gestational diabetes? The history should determine the number and results of ultrasound or amniocentesis studies. The review should also include information about the quantity of cigarette and alcohol consumption, toxin exposure, and the use of drugs (legal, illicit, and herbal) known to have adverse effects on fetal development. Decreased or absent fetal activity may be associated with a congenital myopathy and other neuromuscular disorders.
The history of the birthweight, length, and head circumference is particularly important. It may be necessary to obtain the infant’s hospital records to determine the head circumference, particularly if congenital microcephaly is a consideration, and the Apgar score for suspected asphyxia. Several indicators of neurologic dysfunction during the newborn period can reliably be obtained from the history.
The fact that a full-term infant was unable to breathe spontaneously and required ventilatory assistance may suggest a CNS abnormality.
Additional important information in the newborn period includes the presence of jaundice, its degree, and management.
The most important component of a neurologic history is a child’s developmental assessment. Careful evaluation of a child’s language, social skills, and motor skills (fine and gross motor) is required to distinguish global developmental delay versus delay in a particular subset of development (isolated motor delay). An abnormality in development from birth suggests an intrauterine or perinatal cause. Slowing of the rate of acquisition of skills later in infancy or childhood may imply an acquired abnormality of the nervous system.
Family history is extremely important in the neurologic evaluation of a child. Parents may be unwilling to discuss family members with debilitating neurologic disorders or may be unaware of them, particularly if they are institutionalized. Most parents are extremely cooperative in securing medical information about family members, particularly if it may have relevance for their child. The history should document the ages and well-being of all close relatives and the presence of neurologic disease, including epilepsy, migraine, cerebrovascular accidents, developmental delay, and inherited disorders. The sex and age at death of miscarriages or liveborn siblings, including the results of postmortem examinations, should be obtained because this information may have a direct bearing on the patient’s condition.
An attempt should be made to learn about the patient as a person. The child’s performance in school, both academically and socially, may shed light on the diagnosis, particularly if there has been an abrupt change. A good way to get at this from the school-aged child’s perspective is to have the child name his or her “best friends.” Any child that is unable to name at least two or three playmates may have abnormal social development. This is especially problematic when there has been a significant change in academic performance.