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Preterm birth, defined as childbirth occurring at less than 37 completed weeks or 259 days of gestation, is a major cause of neonatal mortality and morbidity and has long-term adverse consequences for health [1–4]. The World Health Organization estimates that there are more than 12 million preterm births per year, and the numbers are increasing [3]. A significant proportion of these babies will develop retinopathy of prematurity (ROP) [5, 6]. In many countries, ROP is a leading cause of blindness in childhood [2, 7]. Retinopathy of prematurity can cause blindness if not diagnosed and treated early. The current joint policy statement on ROP screening produced by the American Academy of Pediatrics (AAP), American Academy of Ophthalmology, and the American Association for Pediatric Ophthalmology and Strabismus recommends that babies with a birth weight of less than 1,500 g or gestational age (GA) of 32 weeks or less and high-risk infants undergo retinal examination to detect ROP [8].

Y. Kandasamy

Department of Neonatology, The Townsville Hospital, P.O. Box 670, Townsville, QLD 4810, Australia

e-mail: yogavijayan.kandasamy@studentmail.newcastle. edu.au

Currently available evidence shows that ROP examination is a painful and distressing procedure for a premature baby [9–12]. The neonatal pain management policy produced by AAP recognises that ROP examination is a painful and uncomfortable procedure but cautions that the currently available methods of pain relief with topical anaesthetic agents or oral sucrose may be insufficient [13].There are various methods which can be used to assess pain in babies [13]. One of the more commonly used and established scoring methods developed to assess acute pain in preterm and term neonates is the Premature Infant Pain Profile (PIPP) score. This is a 7-indi- cator composite measure that includes behavioural, physiologic, and contextual indicators [14–16]. Possible scores range from 1 to 21. PIPP scores <7 are indicative of no pain, PIPP scores 7–12 are indeterminate and >12 are indicative of significant pain. First introduced approximately 14 years ago, this tool has been validated in numerous reviews and continues to be a reliable method of assessing pain in neonates [14]. The AAP recommends that whatever pain assessment tools are used, continual multidisciplinary training of staff in the recognition of neonatal pain and in the use of the chosen pain assessment tools should be provided [13]. It is important that a standardised method of pain and stress scoring system be used when comparing one technique to the other.

18.3ROP Screening Technique

Indirect ophthalmoscopy with dilated pupils has been the mainstay of assessment. Examinations require specialised training and are typically performed by retinal specialists or paediatric ophthalmologists, who may not be readily available in regional and rural areas. Premature babies receive multiple examinations at regular intervals, requiring coordination of care between ophthalmologists and neonatal intensive care unit (NICU) staff. Documentation of findings requires

hand-drawn pictures with annotation of zone, stage, extent, and presence of plus disease, which can be subjective and could potentially be a source of medicolegal liability. In the recent years, wide-angle retinal camera, such as RetCam (Clarity Medicals, USA), is increasingly being recognised as a reliable option. This device has the ability to acquire images of the retina which can be electronically stored and transferred from a regional centre to a tertiary ophthalmology centre which has the expertise of a paediatric ophthalmologist (Figs. 18.1 and 18.2).