Indicators of persistent pain in preterm neonates are poorly defined. In the setting of a double blind, placebo-controlled trial investigating morphine use in ventilated preterm infants (NEOPAIN Trial) we aimed to identify factors that may be useful in assessing persistent pain. Twenty-two babies (morphine 12; placebo 10) were assessed for comfort, pain or distress and clinical staff described the factors they had considered. This assessment was performed during the first period of duty with the baby. Based on this, they stated which study drug they believed the infant was receiving. Eighty-nine assessments were made in total (1-14 per baby). The drug was correctly identified on 71% of occasions. Staff considered one or more of the following factors: infant activity; response to routine care; known pain-related behaviours; posture/quality of movements; respiratory effort; synchrony with ventilator; blood pressure and heart rate. Four factors most frequently identified babies receiving placebo: facial expressions of pain, high activity levels, poor response to handling and poor synchrony with ventilation. Absence of pain-related behaviour was less discriminating. Observation of a good response to handling, good synchrony with ventilation, a "settled" baby, normal blood pressure and heart rate were poor discriminators. Hypotension and poor respiratory drive were noted exclusively in babies receiving morphine infusions. Facial expressions of pain, high activity levels, poor response to routine care, and poor ventilator synchrony were associated with placebo versus morphine therapy, and may be considered useful markers for persistent pain in preterm infants.

Objective: Despite evidence that excessive screen use may contribute to negative health, developmental, emotional, and behavioral outcomes, more children are engaging in increasing amounts of screen-related activities. For children with neurodevelopmental conditions, increased screen use could exacerbate emotional/behavioral difficulties (EBDs) by interfering with sleep quantity and quality. Aims: This study examined the possible mediating role of sleep in the relationship between screen use and EBDs in preschool children with neurodevelopmental disorders (NDDs) clinically referred to a child development center in Singapore. Methods: A screen use questionnaire developed for the purposes of the present study, the Children's Sleep Habits Questionnaire, and the Strengths and Difficulties Questionnaire were completed by 367 caregivers of 2- to 5-year-old children with NDDs (39.5% autism spectrum disorder; 36.8% speech-language disorders; 23.7% others). Results: Average daily screen use duration was 3.98 hours, with 93.9% exceeding 1 hour of screen time daily. 57.7% of children had screen devices in their bedrooms, while 52% commenced screen use at the age of 18 months or earlier. Sleep problems fully mediated the relationship between the number of bedroom screen devices and children's EBDs, as well as between the age of first screen use and EBDs, but not between hours of screen use and EBDs. Controlling for age, developmental level, and family income, children who started using screens earlier than 18 months and who had screen devices in their bedrooms had significantly more sleep problems and EBDs than those without. Conclusion: Children with neurodevelopmental conditions may have more difficulties disengaging from screen devices in their bedrooms, and an earlier age of screen exposure may contribute to more chronic disruption of sleep.

Further revisions to the checklists can include simplifying the words and sentences and providing relevant pictures to aid understanding. If the checklists are to be used for screening, standardization of how the checklists are to be completed and how children at risk of developmental delays can be identified on the checklists need to be provided. Parents' awareness of the importance of evaluating their child's development at 9 months, 18 months, and particularly at 2.5 years, needs to be raised. Developmental screening for children at these critical ages can be made mandatory. An electronic version of the health booklet is likely to facilitate implementation of developmental screening in the health care system.

WHAT IS AUTISM SPECTRUM DISORDER? 'Autism', derived from the Greek word 'autos', or 'self', refers to someone who 'lives in a world of his own'. Hence, autism spectrum disorder (ASD) is a neurodevelopmental condition that affects a person's ability to make sense of the world and relate to other people. It is characterised by persistent deficits in social communication and interaction, as well as restricted, repetitive patterns of behaviour and interests. These manifest during the early developmental period and cause clinically significant impairment of social and occupational function (Box 1). (1) The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, refers to ASD as a single condition with different levels of severity, collectively representing four subtypes that were previously defined in DSM-IV (autistic disorder, Asperger's syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified). (1) ASD is also associated with psychiatric comorbidities such as anxiety, aggression, attention deficit hyperactivity disorder and obsessivecompulsive disorder. (2) The exact aetiology of ASD is unknown; it is thought to have strong and complex genetic underpinnings with modulation of phenotypic expression by environmental factors. (3) Normal childhood vaccines have been falsely implicated in the causation of ASD, and extensive research has now proven no link between vaccination and ASD. (4) Factors associated with increased risk of ASD include: (5) male gender; family history of sibling or parent with ASD; advanced paternal and maternal age; prematurity (gestational age < 35 weeks) or antenatal infections; antenatal exposure to medications (e.g. valproate and antidepressants); and genetic syndromes such as fragile X syndrome, tuberous sclerosis, Rett syndrome, Down syndrome, muscular dystrophy and neurofibromatosis. ASD is not uncommon. Based on local data from KK Women's and Children's Hospital and National University Hospital, the prevalence of ASD in Singapore is estimated to be one in 100 individuals, and most children are formally diagnosed at approximately three years of age. (6)