Less invasive surfactant administration spares preterm infants intubation and mechanical ventilation, but it is still an awake laryngoscopy in a sick baby, and how much pain it causes has been an open question. This Indian randomised trial asked whether a video laryngoscope, by giving a better view with less manipulation, would hurt less than a conventional one.
Forty-two preterm neonates under 35 weeks, requiring more than 30% oxygen on CPAP of at least 6 cm H2O, were randomised to surfactant by LISA using either device. Pain was scored on the Faceless Acute Neonatal Pain Scale before the procedure, immediately after, and at 5 and 10 minutes. Median score immediately after was 2 (IQR 2 to 4) with the video laryngoscope and 2 (1 to 4) with the conventional one, p=0.79. Procedure time, number of attempts, intraventricular haemorrhage and adverse events did not differ either.
Two things follow. First, if you already have a video laryngoscope, this gives no reason to stop using it, and no reason to buy one for pain reasons alone — the operators here were neonatologists experienced with conventional laryngoscopes, and for a trainee learning the technique the calculation may well differ. Second, and more useful, the trial characterises the pain itself: moderate in degree and short in duration, on both devices.
That characterisation is what should shape practice. Moderate, brief procedural pain in a preterm infant is exactly the situation that non-pharmacological measures were designed for — sucrose, non-nutritive sucking, facilitated tucking, containment. Reaching for sedation or analgesia instead carries real costs in a baby whose whole point of avoiding intubation was to keep breathing spontaneously. The trial is small, at 42 infants, so it cannot exclude a modest difference between devices; it can, and does, describe what the procedure feels like.
- Do not buy a video laryngoscope on the argument that it reduces LISA pain; it did not.
- Expect moderate, short-lived pain during LISA whichever device is used.
- Use non-pharmacological measures — sucrose, non-nutritive sucking, facilitated tucking — as the default.
- Avoid sedation for LISA where possible; suppressing respiratory drive defeats the purpose of the technique.
- With 42 infants the trial cannot exclude a small difference, and it says nothing about operators still learning.
The statistics, in plain English
Forty-two infants is a very small trial, and a p value of 0.79 on the primary outcome means the two groups looked essentially identical — but with numbers this small, a genuine moderate difference could easily have been missed. Read this as 'no difference was detected' rather than 'no difference exists'. The outcome is a behavioural pain score, which depends on an observer interpreting an infant's responses; the Faceless scale is validated for this, but scores from a small unblinded trial should be read as approximate. The descriptive finding — median 2 on both arms, settling within 10 minutes — is more robust than the comparison.
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