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Objective: Pain is common for children with intellectual and developmental disabilities. It is critical that caregivers have adequate pain assessment and management knowledge. The Let's Talk About Pain program has shown promise to provide pain-related knowledge and skills to respite workers; however, more systematic evaluation of the program is needed. This study aims to support Let's Talk About Pain's RCT development by using stakeholder input to help determine a feasible approach for collecting behaviorally based outcomes. A secondary aim is to discuss relevant considerations and implications for others in the disability field conducting similar work. Methods/Design: Four employees in children's respite organizations completed telephone interviews lasting approximately fifteen minutes and a questionnaire about feasible data collection approaches. Results: The use of questionnaire and focus group methodology was determined to be the most feasible method to evaluate participants' pain-related approaches in practice. Conclusions: Special consideration should be made when making methodological-related choices during study development to help ensure study feasibility. The iterative approach described in this paper may also be helpful in clinical settings when designing program evaluations to enhance feasibility and suitability; it is particularly important for multifaceted organizations supporting individuals with complex needs including those with intellectual and developmental disabilities. Canadian Institutes of Health Research Doctoral Research Award, Society of Pediatric Psychology's Marion, Donald Routh Student Research Grant, Annual Dr. Benjamin Goldberg Research

Objective: Pain is common and complex for children with intellectual and developmental disabilities (I/DD). Secondary caregivers such as respite workers are lacking important pain-related information which can impact care. Here, we outline a randomized controlled trial (RCT) protocol testing the effectiveness of a pain training for respite workers supporting children with I/DD. Methods/design: Organizations enrolled in the RCT were randomly assigned to receive a 3-3.5 hours pain or family-centered care training. Data were collected immediately before, after, and 4-6 weeks following completion of the training. Outcomes are as follows: pain knowledge (primary), pain assessment and management perceptions (secondary), training evaluations (secondary), and use of pain assessment and management skills (tertiary). Both quantitative and qualitative methodologies are being used including questionnaires, rating scales, a standardized vignette, and focus groups. Conclusions: Results from this trial will be used to further understand the impact of the pain training and inform next steps related to implementation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03421795. Canadian Institutes of Health Research - Doctoral Research Award, Marion and Donald Routh Student Research Award, Annual Dr. Benjamin Goldberg Research Award

As part of a larger research program targeting the knowledge-to-action gap in pain in children with intellectual and developmental disabilities (IDD), we developed Let's Talk About Pain. This program introduces evidence-based pain assessment and management approaches that can be used by respite workers when caring for children with IDD. It has been successfully piloted and evaluated using a randomized controlled trial with promising outcomes. This commentary: 1) outlines our reflections while planning, conducting, and publishing this work, 2) provides recommendations to other researchers in the field when conducting knowledge-translation based work; and 3) serves as a call to action for further research and knowledge translation in this area.

Increasing the comfort of vaccine delivery at school is needed to improve the immunization experience for students. We created the \(CARD^{TM}\) (C-Comfort, A-Ask, R-Relax and D-Distract) system to address this clinical care gap. Originally designed for grade 7 students, this study examined the perceptions of grade 9 students of \(CARD^{TM}\). Grade 9 students who had experience with school-based immunizations, either as recipients or onlookers (n = 7; 100% females 14 years old) participated. Students answered pre-post surveys, reviewed \(CARD^{TM}\) educational materials and participated in a semi-structured focus group discussion. The Consolidated Framework for Implementation Research (CFIR) was used as the framework for analysis of qualitative data. Participants reported positive perceptions of \(CARD^{TM}\) educational materials and that \(CARD^{TM}\) could fit into the school immunization process. \(CARD^{TM}\) improved knowledge about effective coping interventions and was recommended for education of both nurses and students. The results provide preliminary evidence that \(CARD^{TM}\) is acceptable and appropriate for implementation in grade 9 school-based immunizations. Canadian Institute of Health Research

The aim of our paper is to provide succinct and explicit guidance for professionals who are less familiar with heart rate variability (HRV) methodology. Specifically, we provide a brief overview of the methodological considerations when examining caregiver high frequency HRV in the pediatric pain context, with regard to: (1) study design, (2) selecting an HRV parameter, (3) apparatus and subject preparation, and (4) data cleaning and analysis.

Background: Low levels of agreement between caregiver and child reports of acute pain are well documented. Aims: This study builds on prior research through exploring factors that may contribute to low caregiver-child concordance. Specifically, the study examined the influence of adult and child sex on adult judgments of children's pain and fear during venipuncture and examined whether trait parental pain catastrophizing, empathy, and anxiety predicted judgment accuracy. Methods: Using a judgment study paradigm, 160 participants (82 women) viewed 20 10-s video clips of children (10 boys, 10 girls) undergoing venipuncture and rated each child's pain and fear. Adults' ratings were compared to the children's own ratings. Adults completed measures of trait parental pain catastrophizing, dispositional empathy, and trait anxiety. Results: Adults accurately judged boys' pain and fear significantly more often than that of girls. Further, adults underestimated and overestimated girls' pain and overestimated girls' fear significantly more frequently than that of boys. No effects of adult sex or adult by child sex interactions emerged. Parental pain catastrophizing significantly predicted underestimation of girls' pain, with adults who engaged in more catastrophizing being less likely to underestimate girls' pain. The variables did not predict adult judgment of child pain for women and men separately and did not predict adult judgment of child fear when examined by adult sex, child sex, or both combined. Conclusions: Child sex influences adult pain and fear judgments, with girls being more vulnerable to inaccurate assessment than boys. Higher levels of parental pain catastrophizing may buffer against adults' propensities to underestimate girls' pain.

This commentary examines the resilience mechanism of pain self-efficacy and aims to (1) define the construct, (2) briefly review relevant literature, and (3) discuss clinical implications and future research directions.

Background. Pediatric medical information provision literature focuses on hospitalization and surgical procedures, but children would also benefit from an educational program regarding more commonly experienced medical procedures (e.g., needles, general check-up). Objective. To determine whether an evidence-based educational program reduced children’s ratings of fear of and expected pain from medical stimuli and increased their knowledge of procedural coping strategies. Methods. An educational, interactive, developmentally appropriate Teddy Bear Clinic Tour was developed and delivered at a veterinary clinic. During this tour, 71 5–10-year-old children (\(M_{age}\)= 6.62 years, SD = 1.19) were taught about medical equipment, procedures, and coping strategies through modelling and rehearsal. In a single-group, pretest posttest design, participants reported their fear of and expected pain from medical and nonmedical stimuli. Children were also asked to report strategies they would use to cope with procedural fear. Results. Children’s ratings for expected pain during a needle procedure were reduced following the intervention. No significant change occurred in children’s fear of needles. Children reported more intervention-taught coping strategies at Time 2. Conclusions. The results of this study suggest that an evidence-based, interactive educational program can reduce young children’s expectations of needle pain and may help teach them procedural coping strategies.

The objectives of this commentary are to: 1) define the construct of optimism, 2) briefly review the literature supporting the importance of optimism in pain contexts, and 3) outline areas for future research and clinical implications.

Background: This systematic review evaluated the effectiveness of process interventions (education for clinicians, parent presence, education of parents [before and on day of vaccination], and education of patients on day of vaccination) on reducing vaccination pain, fear, and distress and increasing the use of interventions during vaccination. Design/Methods: Databases were searched using a broad search strategy to identify relevant randomized and quasi-randomized controlled trials. Critical outcomes were pain, fear, distress (when applicable), and use of pain management interventions. Data were extracted according to procedure phase (preprocedure, acute, recovery, combinations of these) and pooled using established methods. Analyses were conducted using standardized mean differences (SMD) and risk ratios (RR). Results: Thirteen studies were included. Results were generally mixed. On the basis of low to very low-quality evidence, the following specific critical outcomes showed significant effects suggesting: (1) clinicians should be educated about vaccine injection pain management (use of interventions: SMD 0.66; 95% confidence interval [CI]: 0.47, 0.85); (2) parents should be present (distress preprocedure: SMD -0.85; 95% CI: -1.35, -0.35); (3) parents should be educated before the vaccination day (use of intervention preprocedure: SMD 0.83; 95% CI: 0.25, 1.41 and RR, 2.08; 95% CI: 1.51, 2.86; distress acute: SMD, -0.35; 95% CI: -0.57, -0.13); (4) parents should be educated on the vaccination day (use of interventions: SMD 1.02; 95% CI: 0.22, 1.83 and RR, 2.42; 95% CI: 1.47, 3.99; distress preprocedure+acute+recovery: SMD -0.48; 95% CI: -0.82, -0.15); and (5) individuals 3 years of age and above should be educated on the day of vaccination (fear preprocedure: SMD -0.67; 95% CI: -1.28, -0.07). Conclusions: Educating individuals involved in the vaccination procedure (clinicians, parents of children being vaccinated; individuals above 3 y of age) is beneficial to increase use of pain management strategies, reduce distress surrounding with vaccination, and to reduce fear. When possible, parent presence is also recommended for children undergoing vaccination.

Background: This systematic review evaluated the effectiveness of simple psychological interventions for managing pain and fear in adults undergoing vaccination or related common needle procedures (ie, venipuncture/venous cannulation). Design/Methods: Databases were searched to identify relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear were prioritized as critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk (RR) with 95% confidence intervals (CI). Results: No studies involving vaccination met inclusion criteria; evidence was drawn from 8 studies of other common needle procedures (eg, venous cannulation, venipuncture) in adults. Two trials evaluating the impact of neutral signaling of the impending procedure (eg, "ready?") as compared with signaling of impending pain (eg, "sharp scratch") demonstrated lower pain when signaled about the procedure (n=199): SMD=-0.97 (95% CI, -1.26, -0.68), after removal of 1 trial where self-reported pain was significantly lower than the other 2 included trials. Two trials evaluated music distraction (n=156) and demonstrated no difference in pain: SMD=0.10 (95% CI, -0.48, 0.27), or fear: SMD=-0.25 (95% CI, -0.61, 0.10). Two trials evaluated visual distraction and demonstrated no difference in pain (n=177): SMD=-0.57 (95% CI, -1.82, 0.68), or fear (n=81): SMD=-0.05 (95% CI, -0.50, 0.40). Two trials evaluating breathing interventions found less pain in intervention groups (n=138): SMD=-0.82 (95% CI, -1.21, -0.43). The quality of evidence across all trials was very low. Conclusions: There are no published studies of simple psychological interventions for vaccination pain in adults. There is some evidence of a benefit from other needle procedures for breathing strategies and neutral signaling of the start of the procedure. There is no evidence for use of music or visual distraction.

Background: This systematic review assessed the effectiveness and safety of pharmacotherapy and combined interventions for reducing vaccine injection pain in individuals across the lifespan. Design/Methods: Electronic databases were searched for relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear as well as observer-rated distress were critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk with 95% confidence intervals (CI). Results: Fifty-five studies that examined breastfeeding (which combines sweet-tasting solution, holding, and sucking), topical anesthetics, sweet-tasting solutions (sucrose, glucose), vapocoolants, oral analgesics, and combination of 2 versus 1 intervention were included. The following results report findings of analyses of critical outcomes with the largest number of participants. Compared with control, acute distress was lower for infants breastfed: 1) during vaccination (n= 792): SMD 1.78 (CI, 2.35, 1.22) and (2) before vaccination (n = 100): SMD 1.43 (CI, 2.14, 0.72). Compared with control/placebo, topical anesthetics showed benefit on acute distress in children (n= 1424): SMD 0.91 (CI, 1.36, 0.47) and self-reported pain in adults (n = 60): SMD 0.85 (CI, 1.38, 0.32). Acute and recovery distress was lower for children who received sucrose (n= 2071): SMD 0.76 (CI, 1.19, 0.34) or glucose (n = 818): SMD 0.69 (CI, 1.03, 0.35) compared with placebo/no treatment. Vapocoolants reduced acute pain in adults [(n = 185), SMD 0.78 (CI, 1.08, 0.48)] but not children. Evidence from other needle procedures showed no benefit of acetaminophen or ibuprofen. The administration of topical anesthetics before and breastfeeding during vaccine injections showed mixed results when compared with topical anesthetics alone. There were no additive benefits of combining glucose and non-nutritive sucking (pacifier) compared with glucose or non-nutritive sucking (pacifier) alone or breastfeeding and sucrose compared with breastfeeding or sucrose alone. Conclusions: Breastfeeding, topical anesthetics, sweet-tasting solutions, and combination of topical anesthetics and breastfeeding demonstrated evidence of benefit for reducing vaccine injection pain in infants and children. In adults, limited data demonstrate some benefit of topical anesthetics and vapocoolants.

Background: A knowledge synthesis was undertaken to inform the development of a revised and expanded clinical practice guideline about managing vaccination pain in children to include the management of pain across the lifespan and the management of fear in individuals with high levels of needle fear. This manuscript describes the methodological details of the knowledge synthesis and presents the list of included clinical questions, critical and important outcomes, search strategy, and search strategy results. Methods: The Grading of Assessments, Recommendations, Development and Evaluation (GRADE) and Cochrane methodologies provided the general framework. The project team voted on clinical questions for inclusion and critically important and important outcomes. A broad search strategy was used to identify relevant randomized-controlled trials and quasi-randomized-controlled trials. Quality of research evidence was assessed using the Cochrane risk of bias tool and quality across studies was assessed using GRADE. Multiple measures of the same construct within studies (eg, observer-rated and parent-rated infant distress) were combined before pooling. The standardized mean difference and 95% confidence intervals (CI) or relative risk and 95% CI was used to express the effects of an intervention. Results: Altogether, 55 clinical questions were selected for inclusion in the knowledge synthesis; 49 pertained to pain management during vaccine injections and 6 pertained to fear management in individuals with high levels of needle fear. Pain, fear, and distress were typically prioritized as critically important outcomes across clinical questions. The search strategy identified 136 relevant studies. Conclusions: This manuscript describes the methodological details of a knowledge synthesis about pain management during vaccination and fear management in individuals with high levels of needle fear. Subsequent manuscripts in this series will present the results for the included questions.

Background: This systematic review evaluated the effectiveness of distraction for reducing infant distress during vaccinations in young children aged 0 to 3 years. Design/Methods: Database searches identified relevant randomized and quasi-randomized controlled trials. Three separate clinical questions related to variants of the psychological strategy of distraction (directed video; directed toy; nondirected toy) were pursued. Distress was identified as the critical outcome to assess the benefits of distraction and extracted from relevant trials. Distress was analyzed by phase of procedure (distress preprocedure; distress acute; distress recovery; idiosyncratic phases based on some or all of the 3 aforementioned phases). Results: Ten studies were included in the review. Significant results are presented herein. For directed video distraction, moderate quality evidence suggested that distress was lowered in the treatment group standardized mean difference (SMD -0.68 lower [95% confidence interval (CI), -1.04 to -0.32]) for the acute+recovery phase as well as the preprocedure phase (SMD -0.49 lower [95% CI, -7.6 to -0.22]). For directed toy distraction, the analysis of low-quality evidence for a combined preprocedure+acute+recovery phase of distress (analysis n=81), suggested that distress was lowered in the treatment group (SMD -0.47 lower [95% CI, -0.91 to -0.02]). An effect for nondirected toy distraction was also seen, analyzing very-low-quality evidence, for the acute distress phase (n=290; SMD -0.93 lower [95% CI, -1.86 to 0.00]). Conclusion: Generally low-quality to very-low-quality evidence suggests that there may be an effect of directed (toy and video) and nondirected toy distraction for children aged 0 to 3 years, for certain phases of the vaccination.

Background: This systematic review evaluated the effectiveness of psychological interventions for reducing vaccination pain and related outcomes in children and adolescents. Design/Methods: Database searches identified relevant randomized and quasi-randomized controlled trials. Data were extracted and pooled using established methods. Pain, fear, and distress were considered critically important outcomes. Results: Twenty-two studies were included; 2 included adolescents. Findings showed no benefit of false suggestion (n=240) for pain (standardized mean difference [SMD] -0.21 [-0.47, 0.05]) or distress (SMD -0.28 [-0.59, 0.11]), or for use of repeated reassurance (n=82) for pain (SMD -0.18 [-0.92, 0.56]), fear (SMD -0.18 [-0.71, 0.36]), or distress (SMD 0.10 [-0.33, 0.54]). Verbal distraction (n=46) showed reduced distress (SMD -1.22 [-1.87, -0.58]), but not reduced pain (SMD -0.27 [-1.02, 0.47]). Similarly, video distraction (n=328) showed reduced distress (SMD -0.58 [-0.82, -0.34]), but not reduced pain (SMD -0.88 [-1.78, 0.02]) or fear (SMD 0.08 [-0.25, 0.41]). Music distraction demonstrated reduced pain when used with children (n=417) (SMD -0.45 [-0.71, -0.18]), but not with adolescents (n=118) (SMD -0.04 [-0.42, 0.34]). Breathing with a toy (n=368) showed benefit for pain (SMD -0.49 [-0.85, -0.13]), but not fear (SMD -0.60 [-1.22, 0.02]); whereas breathing without a toy (n=136) showed no benefit for pain (SMD -0.27 [-0.61, 0.07]) or fear (SMD -0.36 [-0.86, 0.15]). There was no benefit for a breathing intervention (cough) in children and adolescents (n=136) for pain (SMD -0.17 [-0.41, 0.07]). Conclusions: Psychological interventions with some evidence of benefit in children include: verbal distraction, video distraction, music distraction, and breathing with a toy.

Background: This systematic review evaluated the effectiveness of exposure-based psychological and physical interventions for the management of high levels of needle fear and/or phobia and fainting in children and adults. Design/Methods: A systematic review identified relevant randomized and quasi-randomized controlled trials of children, adults, or both with high levels of needle fear, including phobia (if not available, then populations with other specific phobias were included). Critically important outcomes were self-reported fear specific to the feared situation and stimulus (psychological interventions) or fainting (applied muscle tension). Data were pooled using standardized mean difference (SMD) or relative risk with 95% confidence intervals. Results: The systematic review included 11 trials. In vivo exposure based therapy for children 7 years and above showed benefit on specific fear (n= 234; SMD: 1.71 [95% CI: 2.72, 0.7]). In vivo exposure-based therapy with adults reduced fear of needles posttreatment (n= 20; SMD: 1.09 [2.04, 0.14]) but not at 1-year follow-up (n= 20; SMD: 0.28 [1.16, 0.6]). Compared with single session, a benefit was observed for multiple sessions of exposure-based therapy posttreatment (n = 93; SMD: 0.66 [1.08, 0.24]) but not after 1 year (n= 83; SMD: 0.37 [0.87, 0.13]). Non in vivo e.g., imaginal exposure-based therapy in children reduced specific fear posttreatment (n= 41; SMD: 0.88 [1.7, 0.05]) and at 3 months (n= 24; SMD: 0.89 [1.73, 0.04]). Non in vivo exposure-based therapy for adults showed benefit on specific fear (n = 68; SMD: 0.62 [1.11, 0.14]) but not procedural fear (n= 17; SMD: 0.18 [0.87, 1.23]). Applied tension showed benefit on fainting posttreatment (n = 20; SMD: 1.16 [2.12, 0.19]) and after 1 year (n= 20; SMD: 0.97 [1.91, 0.03]) compared with exposure alone. Conclusions: Exposure-based psychological interventions and applied muscle tension show evidence of benefit in the reduction of fear in pediatric and adult populations.

Background: This systematic review evaluated the effectiveness of physical and procedural interventions for reducing pain and related outcomes during vaccination. Design/Methods: Databases were searched using a broad search strategy to identify relevant randomized and quasi-randomized controlled trials. Data were extracted according to procedure phase (preprocedure, acute, recovery, and combinations of these) and pooled using established methods. Results: A total of 31 studies were included. Acute infant distress was diminished during intramuscular injection without aspiration (n=313): standardized mean difference (SMD) -0.82 (95% confidence interval [CI]: -1.18, -0.46). Injecting the most painful vaccine last during vaccinations reduced acute infant distress (n=196): SMD -0.69 (95% CI: -0.98, -0.4). Simultaneous injections reduced acute infant distress compared with sequential injections (n=172): SMD -0.56 (95% CI: -0.87, -0.25). There was no benefit of simultaneous injections in children. Less infant distress during the acute and recovery phases combined occurred with vastus lateralis (vs. deltoid) injections (n=185): SMD -0.70 (95% CI: -1.00, -0.41). Skin-to-skin contact in neonates (n=736) reduced acute distress: SMD -0.65 (95% CI: -1.05, -0.25). Holding infants reduced acute distress after removal of the data from 1 methodologically diverse study (n=107): SMD -1.25 (95% CI: -2.05, -0.46). Holding after vaccination (n=417) reduced infant distress during the acute and recovery phases combined: SMD -0.65 (95% CI: -1.08, -0.22). Self-reported fear was reduced for children positioned upright (n=107): SMD -0.39 (95% CI: -0.77, -0.01). Non-nutritive sucking (n=186) reduced acute distress in infants: SMD -1.88 (95% CI: -2.57, -1.18). Manual tactile stimulation did not reduce pain across the lifespan. An external vibrating device and cold reduced pain in children (n=145): SMD -1.23 (95% CI: -1.58, -0.87). There was no benefit of warming the vaccine in adults. Muscle tension was beneficial in selected indices of fainting in adolescents and adults. Conclusions: Interventions with evidence of benefit in select populations include: no aspiration, injecting most painful vaccine last, simultaneous injections, vastus lateralis injection, positioning interventions, non-nutritive sucking, external vibrating device with cold, and muscle tension.

The HELPinKidsandAdults knowledge synthesis for the management of vaccination-related pain and high levels of needle fear updated and expanded upon the 2010 HELPinKIDS knowledge synthesis and clinical practice guideline for pain mitigation during vaccine injections in childhood. Interventions for vaccine pain management in adults and treatment of individuals with high levels of needle fear, phobias, or both were included, thereby broadening the reach of this work. The present paper outlines the overarching limitations of this diverse evidence base and provides recommendations for future research. Consistent with the framing of clinical questions in the systematic reviews, the Participants, Intervention, Comparison, Outcome, Study design (PICOAS) framework was used to organize these predominant issues and research directions. The major limitations we identified across systematic reviews were an overall dearth of trials on vaccination, lack of methodological rigor, failure to incorporate important outcomes, poor study reporting, and various sources of heterogeneity. Future research directions in terms of conducting additional trials in the vaccination context, improving methodological quality and rigor, assessment of global acceptability and feasibility of interventions, and inclusion of outcomes that stakeholders consider to be important (eg, compliance) are recommended. Given concerns about pain and fear are known contributors to vaccine hesitancy, improving and expanding this evidence base will be integral to broader efforts to improve vaccine compliance and public health worldwide.

Background: Vaccine injections are the most common painful needle procedure experienced throughout the lifespan. Many strategies are available to mitigate this pain; however, they are uncommonly utilized, leading to unnecessary pain and suffering. Some individuals develop a high level of fear and subsequent needle procedures are associated with significant distress. Objective: The present work is part of an update and expansion of a 2009 knowledge synthesis to include the management of vaccine-related pain across the lifespan and the treatment of individuals with high levels of needle fear. This article will provide a conceptual foundation for understanding: (a) painful procedures and their role in the development and maintenance of high levels of fear; (b) treatment strategies for preventing or reducing the experience of pain and the development of fear; and (c) interventions for mitigating high levels of fear once they are established. Results: First, the general definitions, lifespan development and functionality, needle procedure-related considerations, and assessment of the following constructs are provided: pain, fear, anxiety, phobia, distress, and vasovagal syncope. Second, the importance of unmitigated pain from needle procedures is highlighted from a developmental perspective. Third, the prevalence, course, etiology, and consequences of high levels of needle fear are described. Finally, the management of needle-related pain and fear are outlined to provide an introduction to the series of systematic reviews in this issue. Discussion: Through the body of work in this supplement, the authors aim to provide guidance in how to treat vaccination-related pain and its sequelae, including high levels of needle fear.

The objectives of this commentary are to examine: (a) pain expression and experience in Autism Spectrum Disorder, (b) challenges in pain assessment, (c) and the role of socio-communicative deficits and pain context.

This commentary will introduce massage therapy as a potentially useful intervention for pain in pediatric palliative care and encourage research on its efficacy for this population.

BACKGROUND: Although children experience pain during their daily life, research has generally focused on medical pain. Sport-related pain has not been widely studied in children and research has not examined the occurrence of painful incidents in gymnastics. The prevalence of painful incidents among children in recreational gymnastics classes and accompanying coach responses were recorded.METHODS: Sixty-one children between five and 10 years of age were observed at a gymnastics club. A checklist was used to record painful incidents as well as coach and child responses.RESULTS: The rate of painful incidents was 0.17 per child per hour observed. The floor apparatus was the most common site of incidents, while bumping into equipment was the most common incident. Based on observer ratings, most incidents were mild to moderate in severity and, on average, the child’s reaction to these mild to moderate incidents lasted for 8.5 s. Forty per cent of the children had a mild to moderate painful experience. Coaches reacted to more than 60% of the painful incidents, usually asking how the child was and what had happened. A significant difference was found between the mean severity ratings of painful incidents that were followed by coach response and incidents followed by no response.CONCLUSION: Most children who attend recreational gymnastics classes will likely experience at least one mild to moderate painful experience for every 6 h of class. Coaches are more inclined to react to a painful incident than not. Moreover, a difference was found that suggests coaches responded to more painful incidents.

The objectives of this commentary are: (1) to highlight challenges in the health research pipeline (i.e. recruiting, training, and retaining researchers); (2) to describe an innovative training program addressing the problem in pediatric pain (Pain in Child Health; PICH); and (3) to encourage researchers to build training networks in their own area of expertise. Since some of the challenges faced by clinical researchers are also experienced by scientists in general, both difficulties unique to health researchers as well as more general issues will be discussed.