ABSTRACT. Objective. To explore techniques that can be utilized in addition to the dorsal penile nerve block (DPNB) to further reduce the neonate's stress and pain from routine circumcision, and thus make the procedure more humane.Setting. Level 1 nursery at a community hospital. Subjects. Eighty healthy, term, newborn male infants scheduled for routine neonatal circumcision.Study Design. Prospective and randomized; double blind and placebo controlled for the study solutions.Methods. Four statistically similar groups of 20 were studied. The control group included infants circumcised using: a) a rigid plastic restraint board; b) standard DPNB; and c) a pacifier dipped in water to comfort the infant. Each study group differed from the controls in one variable including: 1) using a specially designed, physiologic circumcision restraint chair; 2) pH buffering of lidocaine hydrochloride used for DPNB; and 3) offering a pacifier dipped in a 24% sucrose solution during the DPNB and circumcision. Behavioral observations were recorded and compared for each group starting before the injection of lidocaine hydrochloride and continuing through the completion of the circumcision. Plasma for cortisol levels were collected 30 minutes after the circumcision.Results. Neonates circumcised on the new restraint chair showed a significant decrease in distress scores (>50%) compared with the control group on the rigid molded-plastic restraint. The pacifier dipped in sucrose had a distress-reducing effect during both the post-DPNB injection and circumcision periods. The infants who were injected with the buffered lidocaine showed no differences in distress from the controls. The plasma cortisol levels were not significantly affected by any additional technique and were comparable to the levels previously reported.Conclusions. When neonatal circumcisions are performed routinely, they should be done as humanely as possible. This study demonstrates that, when used in conjunction with DPNB, a pacifier dipped in 24% sucrose and a more comfortable, padded, and physiologic restraint can be useful in decreasing distress and pain. Pediatrics 1997;100(2). URL: http://www.pediatrics.org/ cgi/content/full/100/2/e3; dorsal penile nerve block, circumcision, neonatal pain.ABBREVIATIONS. DPNB, dorsal penile nerve block; EMLA, eutectic mixture of local anesthetics; GHI, Group Health, Inc.; ANOVA, analysis of variance. R outine neonatal circumcision, when performed without anesthesia, is a painful and stressful operation.

ABSTRACT. Objective. To determine 1) the performing of circumcision by medical specialty, gender, and years of practice; 2) the pattern of anesthetic use for this procedure; and 3) the reasons physicians cite for not using anesthesia.Design. A total of 3066 questionnaires were received from a mailing to a representative sampling of physicians stratified by specialty and geographic location.Results. Fifty-eight percent (1768) of the questionnaires were returned and interpretable from the following specialists: pediatricians (PEDs), 73% (n ‫؍‬ 691); family practitioners (FPs), 52% (n ‫؍‬ 464); and obstetricians (OBs), 51% (n ‫؍‬ 623).Of the respondents, 956 (54%) perform at least one circumcision per month (35% of PEDs; 60% of FPs; 70% of OBs). Of the physicians performing circumcisions, 45% use anesthesia (71% of PEDs; 56% of FPs; 25% of OBs). Of physicians using anesthesia, 85% use dorsal penile nerve block.A significantly higher percentage of male physicians (57%) are performing circumcisions than are females (45%), but there was no difference in the percent using anesthesia. Recently trained PEDs and FPs were more likely to use anesthetics than were their older colleagues, but OB use of pain relief was independent of their practice longevity. Physicians in the western states were significantly more likely to use anesthesia than were other physicians from the rest of the United States.Respondents who did not use anesthesia cited "concern over adverse drug effects" (54%) followed by "procedure does not warrant anesthesia" (44%) as the most common explanations.Conclusions. A substantial number of PEDs are performing circumcisions, and they are most likely to use anesthesia (71%), followed by FPs (56%), then OBs (25%). With recent recognition of the importance of pain reduction in neonatal procedures and the lack of substantiated contraindications to newborn anesthetic use, additional education of current practitioners, residents, and parents is required to increase the use of anesthesia for circumcision. Pediatrics 1998;101(6). URL: http://www. pediatrics.org/cgi/content/full/101/6/e5; circumcision, anesthesia for neonatal circumcision.ABBREVIATIONS. AAP, American Academy of Pediatrics; DPNB, dorsal penile nerve block; EMLA, eutectic mixture of local anesthetics; OB, obstetrician; FP, family practitioner; PED, pediatrician.

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Objective. To determine if it is appropriate to recommend that patients with group A β-hemolytic streptococcal pharyngitis, who are clinically well by the morning after starting antibiotic treatment, can return to school or day care, or if they should wait until they have completed 24 hours of antibiotics as recommended by the American Academy of Pediatrics Committee on Infectious Diseases. Methods. We examined the duration of positivity of the throat culture after antibiotics were begun as a means of assessing the potential risk of transmission to close school contacts. Forty-seven children (4 to 17 years of age) with pharyngitis and a positive throat culture for group A streptococci in an outpatient, staff model health maintenance organization clinic were enrolled and were randomly selected to receive therapy with either oral penicillin V, intramuscular benzathine penicillin G, or oral erythromycin estolate. Additional throat cultures were obtained and clinical findings were recorded for each child during three home visits in the 24 hours after their initial clinic visit. Acute and convalescent sera were obtained for determination of anti-streptolysin O and anti-DNase B titers. Results. Seventeen (36.2%) of the 47 patients had a positive culture the morning after initiating antibiotic therapy. However, thirty-nine (83%) of the patients became "culture negative" within the first 24 hours. Neither the time interval to the first negative culture nor the presence or absence of group A streptococcal organisms on any single convalescent culture could be predicted by clinical findings. Six of the eight children who failed to convert to a "negative" throat culture within 24 hours of initiating therapy were receiving erythromycin. We could detect no difference in either time to conversion to a negative culture or the presence of a positive culture 24 hours after starting antibiotics between those who demonstrated a significant antibody increase and those who did not. Conclusion. The data from this study strongly suggest that children with group A β-hemolytic streptococcal pharyngitis should complete a full 24 hours of antibiotics before returning to school or daycare.