Retinopathy of prematurity (ROP) screening is a painful medical procedure performed on premature infants that can cause stress and physiological instability. While considered the gold standard for pain assessment, current pain management strategies for ROP screening such as local anesthetics and sucrose have proven ineffective. Further investigation is still needed to develop pain relief techniques that can reduce the pain and stress experienced by infants and parents during this repetitive screening process.

1. PA I N M A N A G E M E N T
RETINOPATHY OF
PREMATURITY
ROP Conference; Birjand University of Medical science (BIUMS)
Joobin Khadamy MD
11/March/2017

2. INTRODUCTION
• The most vulnerable infants, with the highest burden of
pain, are those born prematurely who require intensive
neonatal care.
• Retinopathy of Prematurity (ROP) screening is an
example of a highly invasive medical procedure that is
repeatedly performed on premature infants.
• Stress or pain caused during Exam may contribute to
apnea(up to 41%) and bradycardia events during and
after the exam.
Wade KC, Pistilli M, Baumritter A, et al. Safety of ROP Examination and imaging in Premature Infants. The Journal of
pediatrics. 2015;167(5):994-1000.e2. doi:10.1016/j.jpeds.2015.07.050.

3. INTRODUCTION
• Unfortunately, ROP screening is considered to be painful
and stressful for both infants and parents!
• CRIES pain score was significantly higher 5 min after
and 24 h after the screening procedure than before.
screening for retinopathy of prematurity: is it painful? [Biol Neonate. 2006]

4. INTRODUCTION
• Unfortunately, ROP screening is considered to be painful
and stressful for both infants and parents!
• CRIES pain score was significantly higher 5 min after
and 24 h after the screening procedure than before.
screening for retinopathy of prematurity: is it painful? [Biol Neonate. 2006]

5. INTRODUCTION
• EVEN MYDRIATIC DROP REPORTED TO BE
PAINFUL!
Cohen, Amy M. et al. “The Pain Response to Mydriatic Eye Drops in Preterm Infants.” Journal of perinatology : official
journal of the California Perinatal Association 33.6 (2013): 462–465. PMC. Web. 11 Mar. 2017.

6. PAIN ASSESSMENT
• Behavioural > GOLD STANDARD
• Premature Infant Pain Profile (PIPP)
• electrophysiological techniques
• nociceptive-specific brain activity and reflex withdrawal
activity
Slater R, Hartley C, Moultrie F, et al. A blinded randomised placebo-controlled trial investigating the efficacy of morphine
analgesia for procedural pain in infants: Trial protocol. Wellcome open research. 2016;1:7.
doi:10.12688/wellcomeopenres.10005.1.

7. PAIN MANAGEMENT STRATEGIES
• topical local anaesthetic
• sucrose
• breast milk
• glucose solution (25%/1ml / oral / 2 minutes before)
Da Costa, Marlene Coelho et al. “Oral Glucose for Pain Relief during Examination for Retinopathy of Prematurity: A Masked
Randomized Clinical Trial.” Clinics 68.2 (2013): 199–203. PMC. Web. 11 Mar. 2017.

8. PAIN MANAGEMENT STRATEGIES
• a recent Cochrane review examining the use of local
anaesthetic concluded that
• “screening remains a painful procedure and the role of
non-pharmacological and pharmacological intervention
including different local anaesthetic agents should be
ascertained in future randomised trials”.
• effective pain relief may reduce physiological instability
Local anaesthetic eye drops for prevention of pain in preterm infants undergoing screening for retinopathy of
prematurity.Dempsey E, McCreery K Cochrane Database Syst Rev. 2011 Sep 7; (9):CD007645.

9. PAIN MANAGEMENT STRATEGIES
• Morphine?
Slater R, Hartley C, Moultrie F, et al. A blinded randomised placebo-controlled trial investigating the efficacy of morphine
analgesia for procedural pain in infants: Trial protocol. Wellcome open research. 2016;1:7.
doi:10.12688/wellcomeopenres.10005.1.

10. IMAGING VS. INDIRECT
OPHTHALMOSCOPE
• A transient short-term pain and stress response occurs
with both
• Digital retinal imaging ( less pain and stress at
30 seconds).
Moral-Pumarega MT, Caserío-Carbonero S, De-La-Cruz-Bértolo J, Tejada-Palacios P, Lora-Pablos D, Pallás-Alonso CR.
Pain and stress assessment after retinopathy of prematurity screening examination: Indirect ophthalmoscopy versus digital
retinal imaging. BMC Pediatrics. 2012;12:132. doi:10.1186/1471-2431-12-132.

11. BEHAVIORAL TECHNIQUES
• Non-nutritive sucking
• Breast feeding
• Swaddling
• Kangaroo care
Krishnan, Lalitha. “Pain Relief in Neonates.” Journal of Neonatal Surgery 2.2 (2013): 19. Print.

12. PAIN MANAGEMENT
• The efficacy and use of techniques is not adequate!
• Further investigation of pain management
techniques may relief parents and infant stress.

13. THANK YOU FOR ATTENTION