Neonatologists often feel helpless in the management of procedural pain. While we acknowledge that our patients are more frequently and chronically exposed to tissue damaging procedures than any other hospital population, and that they are more vulnerable both in the short and long term, it is not certain that we have any techniques that are proven to be effective. Although we have developed numerous guidelines1 2 they are not reliably applied in clinical practice.3

It is widely recognised that newborns undergoing intensive care are necessarily subjected to numerous painful procedures.4 Despite the availability of clinical guidelines the majority of painful procedures on neonatal intensive care units (NICUs) are still carried out without any form of analgesia. Even outside the NICU term neonates are subjected to multiple procedures such as blood tests and insertion of nasogastric tubes. Surgical procedures such as circumcision, tendonotomy and division of tongue tie are routinely carried out without analgesia because they are ‘quick’. The extra vulnerability of newborns to repeated noxious stimulation, arising from both their clinical instability and their developmental immaturity, makes this a situation that needs urgent solutions. This review will explore the options for managing procedural pain, and the limitations of the clinical evidence for their effectiveness.