Beyond Dorsal Penile Nerve Block: A More Humane Circumcision

Abstract

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.

Pain During Mogen or PlastiBell Circumcision

“…Better restraint devices have been proposed. 19 Another source of discontent is infant hunger, because it is traditional to carry out the procedure when the infants have not recently been fed to prevent vomiting and possible aspiration. However, we know of no evidence for this approach and no rationale other than the time-honored practice of doing elective surgery on patients who have an empty stomach.…”

Circumcision Practice Patterns in the United States

“…30 Oral sucrose is an effective adjunct for pain relief 15 and should be considered safe, although no published study has examined this issue. Concerns about methemoglobinemia and prilocaine sensitivity and 28 its inferiority to DPNB 31 and long application time for effectiveness have limited the use of EMLA.…”

“…23 When used in conjunction with DPNB, a more comfortable restraint chair and oral sucrose was found recently to decrease the distress of the circumcision. 15 Nearly 10% cited "adding too much time" for not using anesthesia. In practice, DPNB adds only 1 to 2 minutes, and the waiting time of 3 to 5 minutes for the anesthetic effect can be well used for preparing the instruments and surgical field or performing a discharge examination.…”

“…The 1989 AAP Task Force on Circumcision 8 recommended additional study on local anesthesia and, in the subsequent 8 years, numerous studies have documented the efficacy and safety of dorsal penile nerve block (DPNB) with lidocaine, 5,9,10 eutectic mixture of local anesthetics (EMLA), [11][12][13] oral sucrose, 14,15 and topical lidocaine. 16 Despite this evidence of anesthesia's benefits and safety, there has been to date little published data on the prevalence of its use.…”

A Comparison of the Mogen and Gomco Clamps in Combination With Dorsal Penile Nerve Block in Minimizing the Pain of Neonatal Circumcision

“…A recent comparison between EMLA and DPNB has shown DPNB to be a significantly more effective means of pain control for circumcision. 19 In addition to local anesthetic techniques, others have reported on the use of a more comfortable circumcision restraint, 20 the administration of a pacifier dipped in sucrose, 20 -22 postoperative local anesthesia, 23,24 and postoperative systemic analgesia. 25 Although there is a great deal of literature supporting anesthetic and analgesic practices, the American Academy of Pediatrics Task Force on Circumcision did not endorse the use of local anesthesia in its most recent position statement, citing the inadequacy of available data.…”