Appendix F Using the QUESTT approach to assess the child
The ‘Q’ in QUESTT: Question the child and parent/caregiver.
- By 18 months, most children have a word to describe pain for example, a ‘hurt’ or an ‘eina’.
- Pain intensity can be described by children with a cognitive age of 4 years old.
- The gold standard for reporting pain is self-reporting as it is subjective and individual to the child.
- Parents understand and know their child therefore they will be able to recognise subtle behavioural changes.
- Parents may be more motivated to recognise pain in their child in order to help alleviate it.
Use the following acronym to ask questions about the pain:
P: Precipitating, palliating, provoking factors:
- What causes the pain?
- What makes the pain better?
- What makes the pain worse?
Q: Quality, quantity:
- What does the pain feel like?
- Is it sharp, stabbing, burning, and/or stinging?
R: Radiation, related factors:
- Where is the pain?
- Is it in one place or does the pain move? If so, where does it move to?
SS: Severity, site:
- How severe is the pain at the site?
- Score the intensity using pain rating scales (see appendix G).
TT: Time course, treatment:
- When did it start?
- Is it there all the time?
- Is it mainly at night or in the day?
- Is the pain worse when you move?
- How long does the pain last?
The ‘U’ in QUESTT: Use pain rating scales.
See appendix G for more information on age appropriate pain rating scales.
- Pain rating scales are useful for establishing a baseline and for measuring response to treatment.
- Different scales have been developed for different ages and levels of development in both non-verbal and verbal children.
- Use one that is appropriate to the child’s culture and developmental level. Consider ease and time taken to administer the scale.
- Find one or two that you are comfortable to use. There is no ideal rating scale.
- Remember that children may deny pain for fear of consequences.
The ‘E’ in QUESTT: Evaluate behaviour and physiological changes.
- Physiological responses to pain include increased pulse, raised BP, profuse (intense) sweating, pallor or flushing, decreased oxygen saturation, dilated pupils, increased tone, rapid shallow respiration and hyperglycaemia.
- Adaptation can occur with ongoing pain and physiological manifestations may be absent in chronic pain.
- Children’s response to pain depends on their developmental age and stage, therefore it is important to understand what these are. The following table indicates the typical responses to both acute and chronic pain according to the developmental stage.
| Age | Acute pain | Chronic pain |
|---|---|---|
| Newborns | Crying and moaning | Apathy |
| Muscle rigidity | Lack of interest in surrounding | |
| Flexion and flailing | Irritability | |
| Diaphoresis (perspiring a lot) | Changes in sleeping and eating patterns | |
| Irritability | ||
| Guarding | ||
| Reflex withdrawal to painful procedures | ||
| Toddlers and pre-schoolers | Crying, screaming and vocalizing hurt | Moody |
| Facial expression: eye squeeze, brow bulge, open mouth, taut tongue, chin quivering, grimacing | Unruly behaviour | |
| Thrashing of arms and legs | Decreased play | |
| Pushes away, withdraws limbs | Change in appetite | |
| Clings to parent/caregiver | Change in sleep pattern | |
| Restless and irritable | ||
| School-aged children | Crying | School refusal |
| Muscle rigidity, clenched fists, white knuckles, clenched teeth, closed eyes | Declining school performance | |
| Stalling techniques when anticipating a painful procedure | Decreased socialisation | |
| Anxiety and depression | ||
| Disturbed sleep | ||
| Adolescents | Verbalisation of pain | Depression and anxiety |
| Muscle tension | Low self-esteem | |
| Loss of appetite | Decreased socialisation | |
| Insomnia or hypersomnia | Drug and/or alcohol abuse | |
| Insomnia or hypersomnia |
The ‘S’ in QUESTT: Secure parent or caregiver’s involvement.
- Listen to mothers, fathers and caregivers as they know their child the best.
- Include them in the decision-making process.
- They are more tuned to subtle changes in their child’s behaviour.
- They know what works best to comfort their child.
The ‘T’ in QUESTT: Take the cause of the pain into account.
- Consider the pathophysiology of the underlying problem i.e., the cause of the pain.
- Identify whether the pain may be unrelated to the disease or condition, e.g. toothache.
- Descriptions of the type of pain help to determine its cause and management.
The ‘T’ in QUESTT: Take action and evaluate the results.
- Assess pain.
- Develop the treatment plan.
- Treat the identified pain according to its cause.
- Re-assess the pain by using the pain rating scales.
- Revise the treatment plan.
- Pain diaries are also helpful for constant re-evaluation in children with chronic pain.
