Many children consider getting a needle to be one of their most feared and painful experiences. Differentiating between a child's experience of fear and pain is critical to appropriate intervention. There is no gold standard one-item self-report measure of fear for use with children. To conduct an initial investigation of the psychometric properties of the Children's Fear Scale (CFS; based on the adult Faces Anxiety Scale) with young school-age children. Children and their parents were filmed during venipuncture and completed pain and fear ratings immediately after the procedure (n = 100) and 2 weeks later (n = 48). Behavioral coding of the procedures was conducted. Support was found for interrater reliability (Time 1: rs = .51, p < .001) and test-retest reliability (rs = .76, p < .001) of the CFS for measuring children's fear during venipuncture. Assessment of construct validity revealed high concurrent convergent validity with another self-report measure of fear (Time 1: rs = .73, p < .001) and moderate discriminant validity (e.g., Time 1: rs = -.30, p < .005 with child coping behavior; rs = .41, p < .001 with child distress behavior). The CFS holds promise for measuring pain-related fear in children. In addition to further investigation into the psychometric properties of the CFS during acute pain with a wider age range, future research could validate this measure in other contexts. The utility of a one-item measure of fear extends beyond the field of pediatric pain to other contexts including intervention for anxiety disorders and children in hospital.

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. 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. 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. 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 current guideline expands on and updates the 2010 guideline with recommendations across the lifespan. This enhanced scope led to a revised team name of HELPinKids&Adults. The intended audience is all health care providers who administer vaccine injections. Recommendations for the management of fear in individuals with high levels of needle fear (i.e., individuals with persistent, intense apprehension of or fear in response to a needle procedure, who may endure needles with intense distress or avoidance) are reported separately, as they require knowledge and skills beyond those of practitioners who usually give vaccinations (C.M.M., unpublished data, 2015). Delayed pain (hours to days after injection) was not considered in this guideline.

The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them. Preparation of the child before the procedure seems to reduce anxiety and subsequent pain. The limited available data suggest that intramuscular administration of immunizations should occur in the vastus lateralis (anterolateral thigh) for children 36 months of age. Controversy exists in site selection for 18- to 36-month-old children. A number of studies suggest that the ventrogluteal area is the most appropriate for all age groups. Longer needles are usually associated with less pain and less local reaction. During the injection, parental demeanor clearly affects the child's pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, whereas humor and distraction tend to decrease distress. Distraction techniques vary with the age, temperament, and interests of the child, but their efficacy is well supported in the literature. Sucrose solution instilled directly into the mouth or administered on a pacifier reduces evidence of distress reliably in children <6 months of age and should be used routinely. Although there is no perfect topical anesthetic available at this time, selective use for children who are particularly fearful or who have had negative experiences in the past is highly endorsed. Pressure at the site, applied with either a device or a finger, clearly reduces pain. Finally, in the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.

Objectives To provide a concise and practical guide to the development, modification, and use of behavioral coding schemes for observational data in pediatric psychology. Methods This article provides a review of relevant literature and experience in developing and refining behavioral coding schemes. Results A step-by-step guide to developing and/or modifying behavioral coding schemes is provided. Major steps include refining a research question, developing or refining the coding manual, piloting and refining the coding manual, and implementing the coding scheme. Major tasks within each step are discussed, and pediatric psychology examples are provided throughout. Conclusions Behavioral coding can be a complex and time-intensive process, but the approach is invaluable in allowing researchers to address clinically relevant research questions in ways that would not otherwise be possible.