- Dorsal nerve block
A dorsal penile nerve block (DPNB) has been
shown to be the most effective type of anesthesia for circumcisions. This
procedure requires injecting 0.7ml of 1% xylocaine without epinephrine at
the base (dorsal end) of the penis at 2 and 10 o'clock.
A waiting period of at least 5 minutes
before performing the circumcision
is recommended to provide the optimal anesthesia effect.
The most common side effect of DPNB and the ring block are development of
hematomas at the injection sites.
A ring block may also be used as an effective form of anesthesia but requires 8 injections of lidocaine at the base of the penis prior to performing the circumcision. - Topical anesthetics EMLA (5% lidocaine-prilocaine) cream has been proven to be an effective anesthesia for circumcisions but does not penetrate deep enough to prevent pain during the adhesion removal stage of the circumcision. However, EMLA cream has not been approved in the United States for use on infants under 6 months of age due to the increased risk of methemoglobinemia caused by the immature methemoglobin reductase system of a newborn. For older children, it is possible to apply EMLA cream one hour before the circumcision, followed by a dorsal nerve block just prior to the procedure.
- Other possiblities Analgesics (pain relievers) like acetaminophen have also been used, but there is no conclusive proof yet that they are effective. During the circumcision, additional measures can also be used to promote comfort for the infant. Having an assistant hold the infant with legs flexed and not extended reduce pain during and after the circumcision. This will also produce a soothing effect because of human contact. The use of a pacifier that has been dipped in sugar water (see article below) has also been shown to help calm the infant.
Medical Articles and Abstracts
Relief of Pain: A Medical Discovery
It is a long-established custom among Muslim parents to put a piece of
well-chewed date (or other available sweet fruit) in the mouth of a
newborn baby. Muslims do this following the practice of the Prophet
Muhammad, upon him be peace, believing him to bee, as the Qur'an says,
sent as a healing and a mercy to mankind. We may infer from the way
this custom originated that there is a virtue in it. There is -
complimentary to the virtue and pleasure of following the Sunnah (the
practice of the Prophet) - placing a `sugary substance' inside the
mouth of a new-born baby dramatically reduces pain sensation and heart
rate.
An interesting scientific medical study, published in the British
Medical Journal (No 6993, 10 June 1995), proved beyond any doubt the
benefit of giving a new-born child sugar, in order to reduce the feeling
of any painful procedure like heel pricking for a blood sample or before
circumcision.
The study, entitled `The analgesic (pain killing) effect of sucrose in
full term infants: a randomised controlled trial', was done by Nora
Haouari, Christopher Wood, Gillian Griffiths and Malcolm Levene in the
post-natal ward in the Leeds General Infirmary in England.
60 healthy infants of gestational age 37-42 weeks and postnatal age of
1-6 days, were randomized to receive 2ml of one of the four solutions:
12.5% sucrose, 25% sucrose, 50% sucrose, and sterile water (control).
The first group of 30 babies received sugar syrup before a routine blood
test (heel pricking, which is usually painful) done to detect jaundice.
The other 30 babies were given only sterile water as a control group.
Placing 2ml of a 25% or 50% sucrose solution on the tongue before
pricking the heel significantly reduced the crying time, compared to
babies who got water. Also, their heart rate returned to normal more
quickly. The stronger sugar solution had the greater effect, crying
being reduced further with increasing concentration of sucrose. From
which we may conclude that sucrose (sugar) placed on the tongue may bee
a useful and safe form of analgesia for use with newborn infants.
Blass and Hoffmeyer also showed that 12% solution of inter-oral sucrose
significantly reduced the duration of crying in new-born babies subjected
to heel pricking or circumcision. This study was reported in The
Independent newspaper (Friday 9 June 1995) as well as in the
British Medical Journal article.
P.S. Kurtis, H.N. DeSilva, B.A. Bernstein, L. Malakh and N.L. Schechter,
Pediatrics 1999; 103(2) p e23.
Conclusions: This study has shown that the pain of circumcision
can be minimized or eliminated by the use of
anesthesia as well as by the choice of circumcision
instrument. The least painful circumcisions were
performed by using a Mogen clamp and DPNB, as more
than half of all infants circumcised with this method
did not cry at all. We hope that the performance of
circumcisions without anesthesia will no longer be
condoned or considered acceptable in either a
clinical or investigational setting.
It is likely that the popularity of circumcision will increase or decrease
every few years based on prevailing medical opinions as to its benefits or
lack thereof. It is also likely that despite changing trends it will
continue to be performed on a significant percentage of newborn infants. It
is therefore imperative that if it is going to be performed that it be
performed in a manner that causes the infant as little pain as possible. We
feel that unless another method is proven to be as effective, DPNB should be
used for all circumcisions. Other ancillary methods of circumcision pain
control continue to be investigated. As mentioned earlier, they include
dipping pacifiers in sucrose solution, various forms of swaddling, topical
anesthetics, and others. It is crucial to remember, however, that none of
these have been proven to be as effective as DPNB, and at the present time
should be considered for use in addition to, and not in place of, DPNB.
In summary, we have shown that using the Mogen clamp after a DPNB will
minimize or even eliminate the pain of neonatal circumcision. We believe
that it is incumbent upon those performing circumcisions as well as on those
who establish national policies and guidelines to acknowledge the pain and
distress associated with this procedure. It is therefore imperative that
methods of pain control with proven safety and efficacy become the standard
of care for all neonatal circumcisions.
For the complete article,
see here
Mimimizing Circumcision Pain
Alison Birkey RN
The controversy continues in the medical profession about the use of
anesthesia when performing a circumcision. But since everyone in the medical
profession has the ethical responsibility to minimize pain in all patients,
a universal approach toward the use of anesthesia during circumcisions needs
to be adopted. Even though most doctors believe that newborns experience
minimal or no pain during and after circumcisions, scientific research
explores a different theory and new ways of dealing with the pain related to
the circumcision.
Newborns can show response to painful stimuli both physiologically and
behaviorally. Physiological responses include change in heart rate and
transcutaneous partial oxygen pressure, along with altered levels of serum
cortisol, catacholimines, growth hormones, glucagon, insulin, and
aldosterone. Behavioral responses include facial grimancing, varying crying
responses, and disturbances in normal behavior. Research has also shown
that babies have more problems with routine immunizations when they have had
circumcisions without anesthesia.
There are several techniques that can be implemented for pain control before
a circumcision is performed. EMLA (5% lidocaine-prilocaine) cream has been
proven to be an effective anesthesia for circumcisions but does not
penetrate deep enough to prevent pain during the adhesion removal stage of
the circumcision. However, EMLA cream has not been approved in the United
States for use on infants under 6 months of age due to the increased risk of
methemoglobinemia caused by the immature methemoglobin reductase system of a
newborn. A ring block may also be used as an effective form of anesthesia
but requires 8 injections of lidocaine at the base of the penis prior to
performing the circumcision. A dorsal penile nerve block (DPNB) has been
shown to be the most effective type of anesthesia for circumcisions. This
procedure requires injecting 0.7ml of 1% xylocaine without epinephrine at
the dorsal end of the penis at 2 and 10 o'clock. Waiting at least 5 minutes
before performing the circumcision will promote optimal anesthesia effects.
The most common side effect of DPNB and the ring block are development of
hematomas at the injection sites.
During the circumcision, ancillary measures also need to be used to promote
comfort for the infant. Having an assistant hold the infant with legs flexed
and not extended reduce pain during and after the circumcision. This will
also produce a soothing effect because of human contact. Calming the infant
with a sugared pacifier may also be helpful.
After the circumcision, acetaminophen (Tylenol) should be administered.
Proper dosage is 10-15mg/kg every 6 hours. An infant should need analgesic
for approximately 24 hours after the circumcision has been performed.
To encourage the adoption of humane practices when performing circumcisions,
nurses and parents need to become advocates for the infants and discuss
these procedures with the doctors performing the circumcisions. Doctors that
are using these techniques need to encourage and train their fellow
colleagues to use these procedures.
References:
Veltman, Dr. Larry, Contemporary OB/GYN, June 1998, Vol.43, No. 6, Pg.
135,Medical Economics, Montvale, NJ.
Wiswell, Dr. Thomas E., New England Journal of Medicine, April 1997, Vol.
336, No. 17, Pg.1224, Massachusetts Medical Society.
Linder, J., Brady-Fryer, B., Metcalfe, J., Muttett, Dr. S., JAMA, Dec. 24,
1997, Vol.278,No. 24, Pg. 2157. American Medical Association Chicago, ILL.
Thomas A. McCalden, Ph.D. (contribution to
Healthcarenewscenter website, July 7, 1997)
Many university animal care and use committees require use of postsurgical analgesics before an experimental rat emerges from surgical anesthetic, and dosages of analgesics are continued for the next 24 hours. Yet recent literature has documented that in many instances male newborns receive no relief from pain and discomfort during and after circumcision of the penile foreskin.
While some have described the circumcision procedure as "a senseless and barbaric sexual mutilation of innocent children" (Fleis, 1995), and an "unnecessary, intrusive, mutilating and painful operation"(Warren, 1995), others have contended that the procedure offers "substantial evidence of benefits," including decreased incidence of inflammation, infection, cancers and sexually transmitted diseases (Wisell, 1997).
This article focuses on some evidence showing that analgesia should be an essential part of circumcisions and attempts to answer three questions:
Neonatal pain
There is little doubt that the surgical procedure of circumcision is a painful experience for older boys who are able to effectively communicate their feelings. A detailed study of circumcision in 45 boys aged 1 to 13 years showed that the patients required significant postoperative fentanyl for relief of pain, even when the procedure was performed under general anesthesia (Chambers et al, 1994). Even the use of postoperative penile nerve block or topical lidocaine did not preclude the need for the more powerful fentanyl analgesic.
These studies beg the question if similar painful experience is found in the 1.2 million to 1.8 million newborn boys who undergo circumcision each year in the U.S. Many reports suggest that this is the case. "During circumcision boys are agitated, cry intensely, and have changes in facial expression. Their heart rates and blood pressure increase. Their serum cortisol, beta-endorphin, and catecholamine concentrations rise. Clearly circumcision is painful" (Wisell, 1977).
One recent study (Taddio et al, 1997) of 30 infants showed that without post-surgical analgesia, there was a significant increase in pain perception by the neonates (as measured by videotape analysis of their facial expressions). This increase in pain perception began with restraint of the infant and continued through all of 12 defined procedures to apply the clamps, manipulations and cutting. There was no information in this study about the speed with which the infants returned to normal. These new data merely confirm previous studies showing that circumcision is associated with alterations in behavior, sleep patterns, feeding, crying, fussiness, and heart rate (Taddio et al, 1995, Dixon et al, 1984).
Pain of circumcision and altered perceptions
Some physicians surveyed in a 1993 study (Wellington and Rieder, 1993) reported that they believed neonatal pain exposure was quickly forgotten and had no effects on later life. There is some evidence, however, that this is incorrect. In a study of the pain response during vaccination of infants aged four to six months, some observers have found that infants who were circumcised show greater sensitivity to the painful injection than other similar non-circumcised individuals (Taddio et al, 1995). The facial responses/pain perceptions of these four- to six-month-old children were scored by an observer using a videotape of the vaccination. The results show that circumcised infants displayed a pain score almost twice that of the noncircumcised group, and in addition, cried for a significantly longer time. While these experiments involving only 30 circumcised infants are preliminary, they nevertheless point to the possibility that the pain perception of early circumcision has a lasting effect on the infant. Clearly further study is needed in this area.
Reducing pain during circumcision
The question is whether a penile nerve block should be used, or topical analgesia, or both. The injection of an analgesic into the region of the penile nerves is clearly the most effective method for reducing postoperative pain associated with circumcision. Studies in older children show that the need for postoperative fentanyl and the pain perception score is less when babies have received a dorsal nerve block than when they have received an application of topical lidocaine (Chambers et al, 1994).
Post-Op Number of children
Pain Score needing fentanyl
Topical Lidocaine 3.7 10 out of 15
Dorsal Nerve Block 1.5 2 out of 15
Thus, nerve block by injection of anesthetic around the base of the penis is more effective than the use of topical analgesic. These data are generally supported in the literature (Dixon et al, 1984). Dorsal penile nerve block improved the recovery from circumcision during the 24 hours after the procedure (Toffler et al, 1990). Multiple studies have shown that dorsal penile nerve block can also relieve pain and stress during circumcision.
Topical analgesic
The topical application of an analgesic to penile skin has less intrinsic effect on the pain process than does a dorsal penile nerve block, simply because the drug cannot penetrate to the nerve endings in a timely fashion (Andersen, 1995). However, one recent study (Taddio et al, 1997) seems to have made some advances in solving this problem. A lidocaine-prilocaine (L-P) cream was developed that allowed the use of a high concentration of anesthetic bases without concern about local irritation. The cream was applied to the neonatal penis for 60 to 80 minutes before surgery. The results show some improvement in the infant pain response, as measured by facial expressions, heart rates and time of crying. During 4 of the 12 periods of the circumcision, the facial pain responses were reduced by between 12% and 49%. This was coupled with a significant reduction in the time the infants spent crying and in the overall increase in their heart rates during the procedure.
All of this seems promising. However, the infants' pain responses were only reduced during 4 of 12 processes involved in the circumcision. Thus, during the majority of the procedure, the treated group showed just as much pain response as the placebo group. Thus, at this time there is little doubt that injection of anesthetic around the penile nerves is the most effective way of preventing undue postsurgical pain with circumcision.
Physician attitudes
Many physicians remain skeptical about the need for analgesia during and after circumcision. In a typical study of attitudes, of 74 physicians who reported performing the procedure (Wellington and Rieder, 1993), 76% used no analgesia. The reasons most often cited were that the physicians had no experience with analgesia in neonates, no experience with the dorsal penile block, and they were concerned about the side effects of analgesics in newborns. A similar survey in 1990 showed similar results (Toffler et al, 1990).
The conclusion here would appear to be that physicians need further education about the need for and uses of analgesia in neonates, especially those undergoing circumcision. Increased awareness of the problem will lead physicians to decide either:
Prof. McCalden is associate professor of pharmacology in the College of Veterinary Medicine and Biomedical Science at Colorado State University. He has been active in academic and industrial biomedical research for 25 years.
References
Links to further Medical Research Papers (some off-site)
A comparison of the Mogen and Gomgo clamps in combination
with dorsal penile nerve block in minimizing the pain of
neonatal circumcision
Circumcision pain relief
L-P cream Placebo
% increase
over baseline 21 46
in crying time
Increased
heart rate 7 17
(beats/min)
on-site text.
