Baby R, a 34-day-old term male (4.3 kg), presented to a tertiary paediatric hospital with irritability and central cyanosis. Three days prior, he underwent a circumcision via primary care. Baby R was reviewed in emergency department (ED) 1 day post-procedure for irritability and urinary retention. A pain management plan was implemented with good effect, including regular paracetamol (weight-based dosing to a maximum of four doses) and one drop of 2% lignocaine gel four-hourly for 24 h. Clear instructions to discard residual gel and safety net ED representation criteria were provided. The parents were requested to present to their general practitioner the next day. The following day, his parents were unable to access their general practitioner. Baby R was reviewed by the practice nurse. At 2 pm, an initial application of approximately 10 g of Numit 5% cream (2.5% lidocaine/2.5% prilocaine) was administered around the penile wound site and covered with the nappy. The parents were instructed to apply 10 g of cream 4-hourly as analgesia. The application at 4 h was performed, after which baby R developed perioral cyanosis and irritability. A second application was performed at 8 h but wiped off as Baby R clinically worsened, with increasing cyanosis and irritability, resulting in ED representation. No other relevant medical history or medication use was noted. On ED presentation, baby R was mottled, cyanotic, afebrile, with intermittent tachycardia to >200 bpm and oxygen saturations of

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