dear editor,

Many procedural interventions remain a burden as they result in pain or discomfort in neonates. Adequate management of pain necessitates an integrated approach. Such an approach should also include the use of the most effective methods to perform a given procedure. [1] We therefore appreciate the paper on the randomized comparison between binocular indirect ophthalmoscopy (BIO) and wide-field digital retinal imaging (WFDRI) recently published by Dhaliwal et al. in this journal. [2] Based on observations collected in 76 infants, the authors concluded that both techniques resulted in a similar pain response and speculated that the pain during screening for retinopathy of prematurity was mainly due to the introduction of the speculum. We recently also reported on the clinical pain response during BIO and compared these observations with the outcome variables as described by Belda et al. [3,4] However, instead of the classic scleral indentation technique as used by Belda et al. and by Dhaliwal et al., the eyelid was kept open with a 20 diopter lens (Fabrilens). [5] A blunted clinical stress response was observed with a faster return to baseline in neonates in whom the Fabrilens was used since CRIES score returned to pre- intervention values within 5 minutes while changes in cardiovascular indicators were less prominent. We therefore confirm the hypothesis formulated by Dhaliwal et al. that indeed the introduction of the eyelid speculum results in the pain response. In addition to the prospective validation of various (non)pharmacological interventions for procedural pain relief, there is extensive field of prospective evaluation of various procedural techniques waiting for neonatal caregivers, nurses and doctors, to generate the data urgently needed reduce the pain and stress associated with the medical and nursing care in neonates.

References 1.Allegaert K, Veyckemans F, Tibboel D. Clinical practice: analgesia in neonates. Eur J Pediatr 2009;168:765-770. 2.Dhaliwal CA, Wright E, McIntosh N, Dhalial K, Fleck BW. Pain in neonates during screening for retinopathy of prematurity using binocular indirect ophthalmoscopy and wide-filed digital retinal imaging: a randomised comparison. Arch Dis Child Fetal Neonatal Ed 2009 (online available) DOI:10.1136/adc.2009.168971 3.Belda S, Pallas CR, De la Cruz J, Tejada P. Screening for retinopathy of prematurity: is it painful? Biol Neonate 2004;86:195-200. 4.Allegaert K, Tibboel D. Shouldn’t we reconsider procedural techniques to prevent neonatal pain? Eur J Pain 2007;11:910-912. 5.Missotten L, Afschrift L. Contact lenses for ophthalmoscopy in children and premature. Bull Soc Belge Ophthalmol 1975;172:802-804.