Retinopathy of Prematurity, Pain Management, BIUMS, Dr Joobin Khadamy, 1st feb 2018 It review current approach in management of pain during retinopathy of prematurity screening.

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
1/Feb/2018

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!
• But most painful part is related to eyelids speculum!
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
1) Nonpharmacological interventions
2) Topical eye anesthetics
3) Eye examination techniques
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. NON-PHARMACOLOGICAL
INTERVENTIONS
a) Use of sucrose or oral glucose (effective)
b) With swaddle (effective)
c) Nonnutritive sucking (effective)
d) Human milk (comparable to sucrose)
e) Use of the Newborn Individualized Developmental Care and
Assessment Program (NIDCAP)
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.

9. PHARMACOLOGICAL
INTERVENTIONS
• Topical/local anesthetics (in consistent effect)
• Paracetamol (ineffective)
• Morphine?
• Fentanyl infusion safer than morphine in laser therapy
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.

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 but
longer examination time).
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. 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.

12. FUTURE STUDIES
• The efficacy and use of techniques is not adequate!
• Further investigation of pain management techniques may
relief parents and infant stress.
• Investigating the clinical feasibility of an eye examination
without speculum use may be beneficial for this population.

13. IMPORTANT NOTES
• Use multiple strategies
• Protocols should address:
• timing of mydriatic eye drops
• feeding times
• Examination times at schedules
10.1097/ANC.0000000000000267 :What Is Best Practice for Providing Pain Relief During Retinopathy of Prematurity Eye Examinations?

14. THANK YOU FOR ATTENTION