The goal of this clinical trial is to learn whether intranasal fentanyl (a pain medicine given as a nasal spray) can reduce pain and is safe to use during routine eye examinations for retinopathy of prematurity (ROP) in preterm infants. ROP is an eye condition that can affect babies born too early and requires regular eye examinations. The main questions this study aims to answer are: Does intranasal fentanyl lower pain during ROP screening? Is intranasal fentanyl safe for preterm infants? Researchers will compare intranasal fentanyl with a placebo (a saltwater spray that contains no medicine) to determine whether the medicine lowers pain during ROP screening.

Participants will receive either intranasal fentanyl or placebo before their routine ROP eye examination, in addition to the standard comfort measures normally used during the procedure. Researchers will measure participants' pain and monitor their heart rate, oxygen levels, and any side effects during and after the examination.

Retinopathy of prematurity (ROP) screening is an essential part of the care of preterm infants. Despite the routine use of standard comfort measures, the examination remains associated with moderate-to-high pain intensity scores in many infants. Repeated exposure to untreated or undertreated procedural pain in preterm infants has been associated with adverse short- and long-term effects, highlighting the need for additional evidence-based pain management strategies.

Intranasal fentanyl has several characteristics that make it a promising option for procedural pain management. It has a rapid onset of action, is easy to administer, avoids the need for intravenous access, and has been shown to be effective and well tolerated for procedural pain in older infants and children. Emerging neonatal evidence, including randomized controlled trials, suggests that intranasal fentanyl may reduce pain during ROP screening, but additional high-quality evidence is needed to establish its effectiveness and safety in preterm infants.

This randomized, double-blind, placebo-controlled clinical trial will evaluate whether intranasal fentanyl, when used in addition to standard comfort measures, reduces pain during routine ROP screening while maintaining an acceptable safety profile. The study is designed to provide high-quality evidence to help determine whether intranasal fentanyl should be considered as an additional option for pain management during this necessary neonatal procedure.

The findings from this study may help improve pain management for preterm infants undergoing ROP screening and contribute to future evidence-based clinical practice guidelines for neonatal procedural pain management.

Inclusion Criteria

• Preterm infants born ≤31 weeks gestational age and/or with birth weight <1250 g
• Scheduled to undergo routine retinopathy of prematurity (ROP) screening as part of standard NICU care
• Clinically stable at the time of screening, defined as not requiring acute resuscitative support (no bag-mask ventilation, intubation, or chest compressions within the preceding 24 hours) and maintaining stable cardiorespiratory parameters on baseline respiratory support
• Written informed consent obtained from a parent or legally authorized representative

Exclusion Criteria

• Congenital anomalies or conditions affecting the nasal passages that would interfere with intranasal drug administration
• Receipt of systemic opioids, benzodiazepines, barbiturates, or other sedative/analgesic medications within 24 hours prior to the ROP examination
• Known hypersensitivity or prior adverse reaction to fentanyl

The plan to share individual participant data (IPD) is currently undecided. IPD sharing may be considered in the future depending on institutional policies, ethics approval, and participant consent. If data sharing is pursued, it will involve de-identified data underlying published results, and appropriate data use agreements and secure access mechanisms will be established. No final decision has been made at this stage.

This is a quadruple-masked (participant/family, care provider, investigator, and outcome assessor) randomized controlled trial. Blinding is maintained through pharmacy-controlled randomization and preparation of identical syringes containing either intranasal fentanyl or intranasal 0.9% normal saline placebo. Study drug and placebo are matched for volume, appearance, labeling, and administration method using a mucosal atomization device. Clinical staff administering the intervention, investigators, outcome assessors scoring PIPP-R from video recordings, and families remain unaware of treatment allocation throughout the trial. Allocation concealment is ensured by the institutional pharmacy, which maintains the randomization sequence and dispenses study medication according to assignment.