Abstract
Circumcision is the most common surgical procedure performed in the neonatal period in North America. If untreated, the pain of circumcision causes both short and long term changes in infant behaviours. The most widely studied pharmacological intervention for pain management during circumcision is dorsal penile nerve block (DPNB) by injected lidocaine (lignocaine). Randomised controlled trials have demonstrated its efficacy; infants premedicated with lidocaine have significantly smaller changes in physiological and pain-related behaviours compared with infants who are not given analgesics. A meta-analysis of injection-related adverse effects (bruising/haematoma) yielded a risk of 6.7% (95% confidence interval, 0.5 to 12.9%). Systemic toxicity from injected local anaesthesia has not been reported.
Less effective modalities include topical anaesthesia with lidocaine-prilocaine cream [Eutectic Mixture of Local Anaesthetics (EMLA)], lidocaine cream and oral administration of sucrose. The good tolerability of lidocaine-prilocaine cream has been demonstrated by a lack of clinically significant methaemoglobinaemia when used appropriately. Nonpharmacological interventions (pacifier, specially designed restraint chair) reduce distress during the procedure, and paracetamol (acetaminophen) may provide postoperative analgesia.
No single agent has been demonstrated to ameliorate pain for all infants undergoing circumcision. A multimodal approach of pharmacotherapy is currently recommended. Studies evaluating the efficacy of combined analgesia have demonstrated significant benefits for combinations of 2 or more forms of treatment (such as DPNB and sucrose-dipped pacifier) compared with single interventions. The instrument used to perform the circumcision is also important. The Mogen clamp has been shown to be associated with a shorter procedure time and less pain compared with the Gomco clamp. If circumcision is to be performed on infants, it is, therefore, recommended that combined analgesia and the Mogen clamp technique are used, and nonpharmacological stress reducing interventions such as pacifiers and comfortable restraining chairs should also be employed.
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References
Marshall RE, Stratton WC, Moore J, et al. Circumcision I: effects upon newborn behaviour. Inf Behav Dev 1980; 3: 1–14
Brackbill Y. Continuous stimulation and arousal level in infancy: effects of stimulus intensity and stress. Child Dev 1975; 46: 364–9
Anders TF, Chalemian RJ. The effects of circumcision on sleep-wake states in human neonates. Psychosom Med 1974; 36: 174–9
Emde RN, Harmon RJ, Metcalf D, et al. Stress and neonatal sleep. Psychosom Med 1971; 33: 491–7
Dixon S, Snyder J, Holve R, et al. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984; 5: 246–50
Marshall RE, Porter FL, Rogers AG, et al. Circumcision II: effects upon mother-infant interaction. Early Hum Dev 1982; 7: 367–74
Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997; 349: 599–603
Taddio A, Goldbach M, Ipp M, et al. Effect of neonatal circumcision on pain response during vaccination in boys. Lancet 1995; 345: 291–2
Howard CR, Howard FM, Garfunkel LC, et al. Neonatal circumcision and pain relief: current training practices. Pediatrics 1998; 103(3): 423–8
American Academy of Pediatrics. Circumcision policy statement. Task Force on Circumcision. Pediatrics 1999; 103(3): 686–93
Maxwell LG, Yaster M. Analgesia for neonatal circumcision: no more studies, just do it. Arch Pediatr Adolesc Med 1999; 153: 444–5
Kurtis PS, DeSilva HN, Bernstein BA, et al. A comparison of the Mogen and Gomco clamps in combination with dorsal penile nerve block in minimizing the pain of neonatal circumcision. Pediatrics 1999; 103(2): E23
Holman JR, Lewis EL, Ringler RL. Neonatal circumcision techniques. Am Fam Phys 1995; 52(2): 511–8
Reynolds RD. Use of the Mogen clamp for neonatal circumcision. Am Fam Phys 1996; 54(1): 177–82
Kirya C, Werthmann MW. Neonatal circumcision and penile dorsal nerve block: a painless procedure. J Pediatr 1978; 92: 998–1000
Dalens B, Vanneuvile G, Dechelotte P. Penile block via the sub-pubic space in 100 children. Anesth Analg 1989; 69: 41–5
Fontaine P, Toffler WL. Dorsal penile nerve block for newborn circumcision. Am Fam Phys 1991; 43(4): 1327–33
Lander J, Brady-Fryer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA 1997; 278(24): 2157–62
Holliday MA, Pinckert TL, Kierman SC, et al. Dorsal penile nerve block vs topical placebo for circumcision in low-birthweight neonates. Arch Pediatr Adolesc Med 1999; 153: 476–80
Maxwell LG, Yaster M, Wetzel RC, et al. Penile nerve block for newborn circumcision. Obstet Gynecol 1987; 70(3): 415–9
Masciello AL. Anesthesia for neonatal circumcision: local anesthesia is better than dorsal penile nerve block. Obstet Gynecol 1990; 75(5): 834–8
Arnett RM, Jones JS, Horger EO. Effectiveness of 1% lidocaine dorsal penile nerve block in infant circumcision. Am J Obstet Gynecol 1990; 163(3): 1074–80
Holve RL, Bromberger PJ, Groveman HD, et al. Regional anesthesia during newborn circumcision: effect on infant pain response. Clin Pediatr 1983; 22(12): 813–8
Williamson PS, Evans ND. Neonatal cortisol response to circumcision with anesthesia. Clin Pediatr 1986; 25(8): 412–5
Williamson ML. Circumcision anesthesia: a study of nursing implications for dorsal penile nerve block. Pediatr Nurs 1997; 23(1): 59–63
Williamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 1983; 71(1): 36–40
Stang HJ, Gunnar MR, Snellman L, et al. Local anesthesia for neonatal circumcision: effects on distress and cortisol response. JAMA 1988; 259(10): 1507–11
Spencer DM, Miller KA, O’Quin M, et al. Dorsal penile nerve block in neonatal circumcision: chloroprocaine versus lidocaine. Am J Perinatal 1992; 9(3): 214–8
Herschel M, Khoshnood B, Ellman C, et al. Neonatal circumcision: randomized trial of a sucrose pacifier for pain control. Arch Pediatr Adolesc Med 1998; 152: 279–84
Stang HJ, Snellman LW, Condon LM, et al. Beyond dorsal penile nerve block: a more humane circumcision. Pediatrics 1997; 100(2): E3
Newton CW, Mulnix N, Baer L, et al. Plain and buffered lidocaine for neonatal circumcision. Obstet Gynecol 1999; 93: 350–2
Lenhart JG, Lenhart NM, Reid A, et al. Local anesthesia for circumcision: which technique is most effective? J Am Board Fam Pract 1997; 10: 13–9
Olson TL, Downey VW. Infant physiological responses to noxious stimuli of circumcision with anesthesia and analgesia. Pediatr Nurs 1998; 24(4): 385–9
Butler-O’Hara M, LeMoine C, Guillet R. Analgesia for neonatal circumcision: a randomized controlled trial of EMLA cream versus dorsal penile nerve block. Pediatrics 1998; 101(4): E5
Howard CR, Howard FM, Fortune K, et al. A randomized, controlled trial of an eutectic mixture of local anesthetic cream (lidocaine and prilocaine) versus penile nerve block for pain relief during circumcision. Am J Obstet Gynecol 1999; 181(6): 1506–11
Taddio A, Pollock N, Gilbert-MacLeod C, et al. Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med 2000; 154(6): 620–3
Serour P, Mandelberg A, Zabeeda D, et al. Efficacy of EMLA cream prior to dorsal penile nerve block for circumcision in children. Acta Anaesth Scand 1998; 42: 260–3
Hardwick-Smith S, Mastrobattista JM, Wallace PA, et al. Ring block for neonatal circumcision. Obstet Gynecol 1998; 91(6): 930–4
Snellman LW, Stang HJ. Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision. Pediatrics 1995; 95(5): 705–8
Mintz MR, Grillo R. Dorsal penile nerve block for circumcision. Clin Pediatr 1989; 28(12): 590–1
Fontaine P, Dittberner D, Scheltema KE. The safety of dorsal penile nerve block for neonatal circumcision. J Fam Pract 1994; 39(3): 243–8
Taddio A, Stevens B, Craig K, et al. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. New Engl J Med 1997; 336: 1197–201
Benini F, Johnston C, Faucher D, et al. Topical anesthesia during circumcision in newborn infants. JAMA 1993; 270: 280–3
Taddio A, Ohlsson K, Ohlsson A. Lidocaine-prilocaine cream for analgesia during circumcision of newborn boys (Cochrane Review) In: The Cochrane Library, Issue 4. Oxford: Update Software, 2000
Russell CT, Chaseling J. Topical anaesthesia in neonatal circumcision: a study of 208 consecutive cases. Aust Fam Physician 1996; 25(1): S30–4
Mohan CG, Risucci DA, Casimir M, et al. Comparison of analgesics in ameliorating the pain of circumcision. J Perinatol 1998; 18(1): 13–9
Law RMT, Halpern S, Martins RF, et al. Measurement of methaemoglobin after EMLA analgesia for newborn circumcision. Biol Neonate 1996; 70: 213–7
Taddio A, Ohlsson A, Einarson TR, et al. A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics 1998; 101(2): E1
Kumar AR, Dunn N, Naqvi M. Methemoglobinemia associated with aprilocaine-lidocaine cream. Clin Pediatr 1997; 36: 239–40
Mudge D, Younger JB. The effects of topical lidocaine on infant response to circumcision. J Nurs Midwifery 1989; 34(6): 335–40
Weatherstone KB, Rasmussen LB, Erenberg A, et al. Safety and efficacy of a topical anesthetic for neonatal circumcision. Pediatrics 1993; 92(5): 710–4
Lawson RA, Morton NS. Amethocaine gel for percutaneous local anaesthesia. Hospital Med 1998; 59(7): 564–6
Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics 1991; 87(2): 215–8
Zahorodny W, David ES, Estrada P, et al. Efficacy of a sucrose pacifier for newborn pain [abstract 93]. Pediatr Res 1999; 45(4 Pt 2): 17A
Naqvi M, Biskinis EK, Khattak A. Effect of 50% sucrose on pain response in full term male infants during circumcision [abstract 397]. Pediatrics 1999; 103(4 Suppl. Pt 2): 937
Howard CR, Howard FM, Weitman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93: 641–6
Marchette L, Main R, Redick E, et al. Pain reduction interventions during neonatal circumcision. Nurs Res 1991; 40(4): 241–4
Marchette L, Main R, Redick E. Pain reduction during neonatal circumcision. Pediatr Nurs 1989; 15(2): 207–10
Gunnar MR, Fisch RO, Malone S. The effects of a pacifying stimulus on behavioral and adrenocortical responses to circumcision in the newborn. J Am Acad Child Psychiatry 1984; 23(1): 34–8
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Taddio, A. Pain Management for Neonatal Circumcision. Paediatr Drugs 3, 101–111 (2001). https://doi.org/10.2165/00128072-200103020-00003
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DOI: https://doi.org/10.2165/00128072-200103020-00003