General Health History
The examiner should determine whether the patient is an essentially well child with impairment or a sick child who has been hospitalized several times. In the latter case, one should explore in detail the frequency, reasons, tests, and treatments.
Even if one has access to records, the parents should be asked to tell the child's history in their own words. Their account provides an insight into their knowledge and participation in the child's care. One should ask how many visits they make to medical centers and therapists and how much time is spent in transit for the child's care.History of allergies to medications or other substances should be noted. An early history of allergies to different and often inconsistent formulas may indicate that the child in fact had feeding difficulties that were attributed to allergy. Multiple exposures to latex and any signs of allergy should be determined, particularly in spina bifida or after repeated surgeries. Any medications that the child takes regularly, including dietary supplements and homeopathic or alternative medications or aerosols, should be recorded with dosage and schedule.
The risk and incidence of seizures are higher in static and progressive diseases of the central nervous system. Overt or suspicious signs, type and frequency of seizures, anticonvulsants, and their effectiveness and possible side effects should be recorded.
Nutrition, with special consideration for the child's disability, should be reviewed. Feeding difficulties or behavior problems may lead to inadequate consumption of calories and essential nutrients. Dietary intake may be lower than required for the increased energy expenditure on physical activities in children with motor disability. In contrast, caloric intake may be excessive when physical activity level is restricted and lead to obesity, most often in wheelchair users with spina bifida (6) or muscular dystrophy.
Dietary information and guidance are fundamental for regulation of neurogenic bowel incontinence. Family eating patterns should be taken into consideration. Injuries, burns, fractures, and spinal cord and head trauma are followed by a catabolic state. Monitoring of weight, nutrition, and fluid intake is essential during inpatient rehabilitation for major injuries. Caloric requirements for children are calculated from age-appropriate standards, which take into consideration growth. In children with motor disability, upward or downward adjustment in height and weight may be needed, depending on their level of physical activity and individual growth trend. Specific recommendations are available for children with spina bifida to avoid obesity (7,8).History of respiratory complications, past or present, should be explored in certain disabilities. Central ventilatory dysfunction (CVD) is a complication of Arnold- Chiari malformation in spina bifida (9). Syringobulbia may cause similar symptoms. Nightmares, insomnia, and night sweating are complaints associated with hypercapnia, and may be reported in advanced stages of muscular dystrophy or atrophy. Hypercapnia and sleep apnea may occur in diseases of the central nervous system. Intercostal muscle paralysis in high thoracic paraplegia with spinal cord injury or spina bifida, spinal muscular atrophy, or advanced muscle diseases leads to inefficient pulmonary ventilation and handling of secretions. With severe spastic or dyski- netic cerebral palsy, the respiratory musculature may lack coordination. Such children are prone to recurrent bouts of pulmonary infections. Coexistent feeding difficulties with minor aspirations, or restrictive pulmonary disease due to spinal deformities are additional adverse factors.
Restricted mobility of the spine and thoracic cage may be present in ankylosing spondylitis or severe systemic-onset juvenile rheumatoid arthritis. Detailed information about home management and use and frequency of equipment must be included in the history.
Exercise dyspnea may be a sign of pulmonary compromise or deconditioning due to the high energy cost of physical activities in children with a motor disability. Cardiac decompensation with rightsided failure, a potential complication of pulmonary dysfunction, is more likely to occur in older children or young adults with the previously mentioned disabilities. Myopathic conduction defects and arrhythmias are often symptom-free in the absence of heart failure. Consultation with pulmonary and/or cardiology specialists should be arranged when history reveals suspicious symptoms.Visual and hearing impairments are more frequent in childhood disabilities. Inquiry about these aspects of function should not be overlooked in taking the history. The necessity of regular hearing assessment was mentioned earlier. The same applies to visual function. Prenatal infections, anoxic or infectious encephalopathy, metabolic diseases, meningitis, hydrocephalus, and head injury warrant exploration of visual and auditory function. With the development of new antibiotics, acquired hearing deficit due to antibiotic use is not a significant concern. Like all children, handicapped youngsters are prone to a variety of childhood illnesses. In some cases, however, acute symptoms and febrile illnesses may be directly related to complications of a specific disability. Vomiting, headache, irritability, or lethargy may be prodromal signs of decompensating hydrocephalus in spina bifida, cerebral palsy (2), or an intercurrent unrelated illness. Recurrent headaches are also a manifestation of autonomic dysreflexia in spinal cord injury, along with bowel or bladder distention. Fever may represent central hyperpyrexia in severe head injury or hyperthermia due to pseudomotor paralysis in high thoracic spinal cord injury. However, such conclusions can be reached only after other causes of fever have been excluded. In neurogenic bladder, urinary tract infection should always be investigated as a possible cause of febrile illness. A history of the usual pattern of the amount and frequency of voiding is essential in neurogenic bladder dysfunction. Systematic daily recording is a guide for bladder training. Fluid intake, in accordance with pediatric norms, needs to be monitored at home, and records of both bladder and bowel dysfunction should be available on the medical visit.
Immunization history is part of all pediatric visits. Often, a disabled child in good health has not received the recommended vaccinations because of excessive concern on the part of the family or pediatrician. But it also may mean that the child has always looked ill when scheduled for immunization.