Retinopathy of Prematurity Pain Management ROP Conference; Birjand University of Medical science (BIUMS) Joobin Khadamy MD 11/March/2017

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.

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]

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]

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.

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.

Pain management strategies topical local anaesthetic sucrose breast milk glucose solution (25%/1ml / oral / 2 minutes before) but they have all been shown to be inadequate for reducing pain 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.

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.

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.

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.

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.

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

Thank you for attention