Pain reduction interventions during neonatal circumcision. Neonatal circumcision. Randomized trial of a sucrose pacifier for pain control. Effectiveness of 1% lidocaine dorsal penile nerve block in infant circumcision. Circumcision anesthesia: a study of nursing implications for dorsal penile nerve block. Analgesia for circumcision: effects on newborn behavior and mother/infant interaction. Analgesia for neonatal circumcision: a randomized controlled trial of EMLA cream versus dorsal penile nerve block. Topical anesthesia during circumcision in newborn infants. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. An evaluation of the effects of sucrose on neonatal pain with 2 commonly used circumcision methods. Anesthesia for neonatal circumcision: local anesthesia is better than dorsal penile nerve block. Pain reduction during neonatal circumcision. Ring block for neonatal circumcision. Oral glucose solution for analgesia in infant circumcision. Topical lidocaine-prilocaine versus lidocaine for neonatal circumcision: a randomized controlled trial. Penile nerve block for newborn circumcision. Plain and buffered lidocaine for neonatal circumcision. Local anesthesia for neonatal circumcision. Effects on distress and cortisol response. Behavioral effects of circumcision with and without anesthesia. Regional anesthesia during newborn circumcision. Effect on infant pain response. Neonatal cortisol response to circumcision with anesthesia. Safety and efficacy of a topical anesthetic for neonatal circumcision. Physiologic stress reduction by a local anesthetic during newborn circumcision. Dorsal penile nerve block in neonatal circumcision: chloroprocaine versus lidocaine. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. Beyond dorsal penile nerve block: a more humane circumcision. Sucrose as an analgesic for newborn infants. A randomized, controlled trial of a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) versus penile nerve block for pain relief during circumcision. A comparison of the Mogen and Gomco clamps in combination with dorsal penile nerve block in minimizing the pain of neonatal circumcision. Dorsal penile nerve block vs topical placebo for circumcision in low-birth-weight neonates. Evaluation of pain management interventions for neonatal circumcision pain. Comparison of analgesics in ameliorating the pain of circumcision. The effects of topical lidocaine on infant response to circumcision. Acetaminophen analgesia in neonatal circumcision: the effect on pain.
The purpose of this study was to determine the effect of some noninvasive pain reduction interventions on pain in 121 neonates undergoing unanesthetized circumcision. Subjects were randomly assigned to one of six groups: classical music, intrauterine sounds, pacifier, music and pacifier, intrauterine sounds and pacifier, or control (no nurses present and no pain reduction interventions used). Physiological variables that were monitored were heart rate, rhythm, dysrhythmias, blood pressure, transcutaneous oxygen (tcpO2), rate pressure product, and behavioral state, measured during 14 circumcision steps. Over the 14 steps, 42% of the heart rates, 78% of the systolic blood pressures (SBP), 30% of the diastolic blood pressures (DBP), and 81% of the tcpO2 pressures were abnormal. Few significant differences were found among any of the steps. SBP and DBP differed significantly between groups during two of the noninvasive steps; and tcpO2 differed significantly during six steps. To assess the effectiveness of oral sucrose via a nipple compared with no treatment and dorsal penile nerve block (DPNB) for alleviating pain in neonatal circumcision.
                Randomized control trial. Data analysis performed by investigators blinded to the 3 treatment groups.
                University teaching hospital, General Care Nursery.
                One hundred nineteen full-term male, normal birth weight neonates, 12 hours old or older.
                No treatment (our standard care), DPNB, or oral sucrose prior to circumcision.
                Differences between groups in heart rate and oxygen saturation changes from baseline during specified intervals of the circumcision procedure. Differences between groups in loss of data due to episodes of excessive motion.
                Sucrose gave significant (P < .001) pain relief compared with the no treatment control throughout most of the circumcision and particularly in the early stages of the procedure. Overall, the average difference in the elevation of heart rates during the circumcision operative procedure among the 3 groups and the 95% confidence intervals (CIs) were as follows: control vs DPNB, 27.1 beats/min (17.6, 36.6) and control vs sucrose, 9.7 beats/min (0.1, 19.3). Furthermore, newborns who received either DPNB or sucrose had less loss of oxygen saturation data due to excessive motion during the procedure than the no-treatment controls. The total percentages of lost data due to excessive motion in the 3 groups were 31% for control, 10% for DPNB, and 8% for sucrose. Relative risk and 95% CIs were: DPNB vs control, 0.32 (0.23, 0.43); sucrose vs control, 0.26 (0.18, 0.36). Differences in oxygen saturation among the 3 groups during the circumcision operative procedure were statistically (P < .001), but perhaps not clinically, significant. However, the analysis did not include missing data due to excessive motion, which occurred predominantly in the no-treatment control group.
                Sucrose on a pacifier is an inexpensive and effective method for pain relief in neonatal circumcision when DPNB is not desirable. A prospective, controlled, double-blinded investigation was conducted to evaluate whether infants undergoing circumcisions with 1% lidocaine dorsal penile nerve blocks experienced decreased stress as compared with those receiving saline solution injections or no injections. Stress was measured in terms of pulse rate and oxygen saturation on a pulse oximeter. A subjective grading scale was also developed to measure infant irritability. The total number in the study was 51 with 23 infants in the lidocaine group, 21 in the saline solution group, and 7 in the no injection group. The results of the study revealed an average increase of 28.8% in the pulse rate above baseline for the control infants (p less than 0.001) versus no significant change in the lidocaine group. The average oxygen saturation of the control groups decreased by 5.6% from baseline (p less than 0.001), and that of the lidocaine group decreased by 1.0%, which was not a significant change. The subjective data were gained by using a grading scale of 1 to 6 with 1 being the least irritable infant and 6 being the most irritable infant. The physician evaluation gave an average rating of 4.2 to the control group versus 2.4 for the lidocaine group (p less than 0.001). The nursing evaluation during the procedure gave an average rating of 4.2 to the control group versus 2.3 to the anesthetized group (p less than 0.001). The subjective evaluation of infants before and after the procedure was not significantly different. There were no major complications in any of the groups. To compare responses to circumcision between a group of unanesthetized newborn males and a group having dorsal penile nerve block (DPNB).
                Thirty newborn males who met the selection criteria were randomly assigned to the treatment (n = 20) or control group (n = 10). Oxygen perfusion, blood pressure, respiratory rate, heart rate, and cardiac rhythm were measured before, during, and after circumcision. In addition, observations were recorded during the procedure on crying duration and type, vomiting, gagging, breath holding, and jitteriness. Data were analyzed by t-test, Mann-Whitney analysis, and frequencies.
                There were no significant differences between groups except on physiologic and subjective stress reactions during circumcision.
                The unanesthetized subjects displayed stress reactions that have implications for nursing care. To test the effectiveness of acetaminophen for pain management during and after circumcision.
                A randomized, double-blind, placebo controlled, pretest-posttest design.
                Level III nursery at a Midwestern hospital.
                Sixty full-term newborns, whose mothers had uncomplicated pregnancies and vaginal deliveries.
                Administration of 10 mg/kg acetaminophen or placebo 1 hour before circumcision.
                Behaviors (clarity of cues and responsiveness) were observed in newborns during a feeding interaction, and pain distress (percentage of time crying and heart rate) was assessed during and after the circumcision.
                ANCOVA revealed significant group differences in subscales of the NCAFS (Nursing Child Assessment Feeding Scale) for newborns, whereas statistically significant differences for mothers were found in the sensitivity to cues and social-emotional growth-fostering scales. A significant increase in heart rate and crying time during the circumcision was noted; however, no significant difference was observed between groups. At the diaper change after the circumcision, the percentage of cry did suggest an effect from the analgesia.
                These findings reinforce the reciprocal, synchronous nature of mother-infant interactions during the early postpartum period and the need for pain control after circumcision to promote neonatal comfort and improve mother-infant interaction. To compare the efficacy of the dorsal penile nerve block (DPNB) with a less invasive form of local anesthesia, eutectic mixture of local anesthetic (EMLA) cream, for reduction of pain during neonatal circumcision.
                Prospective, blinded, randomized, controlled trial.
                Tertiary referral, neonatal intensive care nursery in a university teaching hospital.
                Fifty infants >/=341/2 weeks postmenstrual age and stable for discharge at time of circumcision; gestational age at birth 25 to 41 weeks; birth weight 600 to 4390 g; age at study 3 to 105 days. An additional cohort of term newborns (n = 20), who were not randomized, were circumcised without anesthesia.
                Administration of either EMLA cream (0.5 g topically 1 hour before circumcision) or 1% lidocaine (0.7-1.0 mL subcutaneously 3 minutes before circumcision).
                Primary: Neonatal Infant Pain Scale (NIPS) score; secondary: heart rate, respiratory rate. All outcome measures were assessed by an individual who was blinded to the group assignment and did not perform the circumcision.
                NIPS scores were significantly lower in the DPNB infants (2.3 +/- 1.8) compared with the EMLA infants (4.8 +/- 0.7). NIPS scores in patients circumcised without anesthesia indicated severe pain. There was a significantly greater increase in heart rate over the duration of the circumcision in the EMLA group than in the DPNB group (49 vs 9 beats per minute). Adverse effects included small hematomas at the site of injection in DPNB infants (10/23), mild erythema at 1 and/or 24 hours after circumcision in the EMLA infants (3/21), and penile edema noted 5 days after circumcision requiring removal of the circumcision bell in 1 DPNB infant.
                DPNB provides better pain reduction during neonatal circumcision than EMLA cream. EMLA cream may provide pain reduction compared with no anesthesia during neonatal circumcision. To determine the efficacy of topical anesthetic cream, eutectic mixture of local anesthetics (EMLA), in alleviating pain from neonatal circumcision.
                Randomized, controlled trial.
                Normal newborn nursery in a university teaching hospital.
                Twenty-seven newborn, full-term male neonates, aged 1 to 3 days.
                Heart rate, transcutaneous oxygen saturation, facial activity, and crying.
                Compared with baseline, all newborns experienced pain as evidenced by increased heart rate of an average of 40 beats per minute (F [8, 25] = 14.12; P < .0001), decreased oxygen saturation of 3% (F [8, 25] = 15.02; P < .0001), and more facial actions indicative of pain (F [8, 25] = 5.25; P < .002) during all phases of the procedure. Compared with placebo, EMLA significantly attenuated the pain response as shown by lower heart rate of an average of 25 beats per minute (F [1, 25] = 14.92; P < .001), higher oxygen saturation of 5%, particularly during the clamping and lysis phases (F [1, 25] = 19.83; P < .0001), 20% less facial activity (F [1, 25] = 12.01; P < .002), and 15% less crying during the clamping, Gomco clamp application, and incision of the foreskin. There were no differences between groups in the spectral crying parameters.
                Circumcision procedure produces pain responses that EMLA diminishes. Thus, EMLA may be a useful agent for pain management in neonatal circumcision. Beliefs about the safety and effectiveness of current anesthetics have resulted in many newborns being circumcised without the benefit of anesthesia.
                To compare ring block, dorsal penile nerve block, a topical eutectic mixture of local anesthetics (EMLA), and topical placebo when used for neonatal circumcision. The placebo represented current practice, with no anesthetic for neonatal circumcision.
                A randomized controlled trial.
                Antenatal units in 2 tertiary care hospitals in Edmonton, Alberta.
                A consecutive sample of 52 healthy, full-term, male newborns, aged 1 to 3 days.
                Physiological and behavioral monitoring occurred in a series of trials: baseline, drug application, preparation, circumcision, and postcircumcision. Surgical procedures defined the following 4 stages of the circumcision: cleansing, separation, clamp on, and clamp off. Methemoglobin level was assessed 6 hours after surgery.
                Heart rate, cry, and methemoglobin level.
                Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high-pitched cry throughout the circumcision and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). The 3 treatment groups all had significantly less crying and lower heart rates during and following circumcision compared with the untreated group. The ring block was equally effective through all stages of the circumcision, whereas the dorsal penile nerve block and EMLA were not effective during foreskin separation and incision. Methemoglobin levels were highest in the EMLA group, although no newborn required treatment.
                The most effective anesthetic is the ring block; EMLA is the least effective. It is our recommendation that an anesthetic should be administered to newborns prior to undergoing circumcision. The purpose of this study was to identify the least painful circumcision method.
                The infants were circumcised with either the Mogen or the Gomco procedure and were given a sweetened pacifier or a pacifier dipped in water. All infants had a eutectic mixture of local anesthetic cream applied before circumcision. The duration of the crying and grimacing were measured.
                The Gomco procedure took 1.9 times longer to complete. Infants who were circumcised with the Mogen procedure cried and grimaced far less than infants who were circumcised with the Gomco procedure (P =.0001). Sucrose on a pacifier was far more analgesic than water on a pacifier for infants in the Gomco group.
                On the basis of these and other findings on pain prevention and amelioration, we recommend that a local anesthetic be administered in advance of circumcision and that the Mogen procedure be used, unless contraindicated. We also recommend that infants be given a sweetened pacifier before, during, and after circumcision if the Gomco method is used. Several studies document the benefit of dorsal penile nerve block for neonatal circumcision, but the literature does not address the use of local anesthesia. A randomized, controlled, prospective study was conducted to compare the efficacy of dorsal penile nerve block versus local anesthesia. Thirty infants were randomly divided into three equal groups (N = 10): an unanesthetized control group, a group given dorsal penile nerve block, and a group given local anesthesia. Heart rate, transcutaneous oxygen saturation, and crying were monitored continuously before, during, and after circumcision. During circumcision, both the dorsal penile nerve block group and the local-anesthesia group demonstrated smaller increases in heart rate, smaller drops in oxygen saturation, and less crying compared with unanesthetized controls (P less than .05). Both techniques worked well in anesthetizing the dorsal aspect of the penis; however, during those steps of circumcision involving trauma to the ventral aspect of the penis, the local-anesthesia group demonstrated smaller increases in heart rate and less crying compared with infants given dorsal penile nerve block (P less than .05). Cortisol levels measured 30 minutes postoperatively were lower in the local-anesthesia group than in either the controls or the dorsal penile nerve block group (P less than .05). Dorsal penile nerve block had no effect on postoperative cortisol levels. No complications occurred. Although both types of anesthesia attenuated the physiologic responses to circumcision, local anesthesia demonstrated greater efficacy than dorsal penile nerve block while being simpler to perform. To determine the effect of two comfort interventions during unanesthesized circumcision on neonatal pain.
                Fifty-eight neonates were randomly assigned to one of three intervention groups. Eighteen control infants received routine care, 15 infants had music played, and 15 infants had a tape of intrauterine sounds played. During circumcision, monitors measured cardiac rate, rhythm, blood pressure, and transcutaneous oxygen. Pain was measured by analysis of videotaped facial expressions using Izard's Maximally Discriminative Facial Movement Coding System (1983).
                Mean heart rate was above normal limits during all steps of the circumcision for the control group and during some of the steps for the other two groups. Facial expressions analyzed showed all three groups had pain much more than any other emotion during the procedure.
                The two interventions were unable to offset the effects of circumcision pain. To determine whether a difference in the behavioral and physiologic response to circumcision can be demonstrated between neonates undergoing the procedure with ring block and those receiving no anesthesia.
                Forty healthy male newborns were assigned randomly to receive either ring block or no anesthesia. Indices of perceived pain including crying time, behavioral state, oxygen saturation, and heart and respiratory rates were recorded at baseline and at intervals during the circumcision. Infants were reassessed 2 minutes and 2 hours postoperatively.
                Infants receiving ring block cried less than did controls (P < .001). Anesthetized infants had smaller increases in heart rate (P < .005) and demonstrated less arousal (P < .005) during each operative interval. For all operative intervals combined, anesthetized infants had a smaller decrease in oxygen saturation (P < .001) and a smaller increase in respiratory rate (P = .005) than did controls. Two minutes postoperatively, anesthetized infants had returned to their baseline behavioral state, whereas controls remained significantly more aroused (P < .005). Two hours postoperatively, there were no significant differences in any variables between the groups, nor between each group and its baseline. There were no complications related to anesthesia administration.
                Neonatal circumcision causes behavioral and physiologic changes consistent with the perception of pain. Ring block is an effective method of anesthesia for this procedure. Our objectives were to determine if a 50% dextrose solution would reduce the percentage of circumcision procedure time a neonate spent crying by 50% compared with water and whether it would be similar to a dorsal penile nerve block (DPNB).
                This was a randomized placebo-controlled blinded clinical trial.
                We included 71 patients who were recruited from the inpatient nursery of a military community hospital over a 5-month period.
                The primary outcome was the percentage of the procedure time neonates spent crying. Secondary outcomes were the percentage change in heart rate from baseline, the percentage of oxygen saturation, and the score from the modified behavioral pain scale.
                There were no significant differences between the oral glucose and water groups among any of the pain-related measurements. The DPNB group had significantly lower pain-related measurements (P &lt.05).
                Concentrated glucose administered orally does not provide significant analgesia in neonatal circumcision. The use of DPNB significantly reduced objective measurements of pain and physiologic stress in infants undergoing circumcision. To evaluate epicutaneous application of 5% lidocaine-prilocaine and 30% lidocaine cream anesthetics for neonatal circumcision.
                The efficacy of 5% lidocaine-prilocaine and 30% lidocaine creams was compared in a randomized, double-blind, placebo-controlled trial. Sixty-one neonates were randomly assigned to one of three groups: 5% prilocaine-lidocaine (n = 20), 30% lidocaine (n = 20), and a control group that received an acid-mantle cream (n = 21). Heart rate, oxygen saturation, and crying time were monitored before, during, and after circumcision. Blood pressure was measured before and after circumcision.
                Mean peak heart rates for the 5% lidocaine-prilocaine, 30% lidocaine, and control groups (+/- standard deviation) were 146 +/- 16, 157 +/- 10, and 164 +/- 16 beats per minute, respectively. During four of six active phases of circumcision, the 5% lidocaine-prilocaine group suppressed significant increases in heart rate better than 30% lidocaine, which was more effective than control (dorsal clamp, P < .001; bell clamp on, P = .001; tightening, P = .001; bell clamp off, P < .001). During tightening of the bell clamp, significantly less crying was seen in the 5% lidocaine-prilocaine group (13 +/- 12 seconds) compared with 30% lidocaine (24 +/- 14 seconds) and controls (38 +/- 27 seconds) (P < .001). The group that received 5% lidocaine-prilocaine also had no significant increase in systolic (t = 1.6, P = .12) or diastolic (t = 1.9, P = .067, respectively) blood pressure, unlike the group receiving 30% lidocaine (t = 4.8, P = .001 and t = 2.9, P = .009, respectively) and the placebo group (t = 2.5, P = .023 and t = 2.3, P = .032). There were no significant differences in oxygen saturation (alpha = .05, power 0.79).
                Epicutaneous 5% lidocaine-prilocaine was more effective than 30% lidocaine for neonatal circumcision, better reducing neonatal stress indicators. Lidocaine-prilocaine significantly shortened crying time during one of the most painful phases of circumcision. Both topical anesthetics were more effective than placebo in attenuating the behavioral and physiologic indicators of neonatal pain. Circumcision in neonates is performed, almost universally, without anesthesia or analgesia. It is associated with pain, crying, agitation, and physiologic stress. Twenty infants receiving penile nerve block for circumcision were compared with ten infants having circumcision without anesthesia. Heart rate and blood pressure rose 34 and 15%, respectively, in unblocked infants, and were unchanged in infants receiving local anesthesia. Oxygen saturation declined 16% in unanesthetized infants compared with 6% in blocked infants (P less than .03). Anesthetized infants were less agitated and cried less. Peak plasma concentrations of the local anesthetic lidocaine averaged 0.51 +/- 0.17 microgram/mL (range 0.1-1.6), well below accepted toxic levels. There were no local or systemic complications. To determine if buffered lidocaine provided a more effective nerve block in a short time than plain lidocaine for neonatal circumcision.
                One hundred ninety-four newborn males were studied in a randomized trial using two dorsal penile nerve block preparations for circumcision. Ninety-two received plain lidocaine, and 102 received buffered lidocaine. The infants were evaluated at timed intervals before the procedure, during anesthetic injection, and during circumcision. Objective measurements of heart rate and oxygen saturation, and subjective determinations of behavioral state were recorded. Using heart rate as the major outcome variable, it was determined that 65 subjects per group would be needed to achieve a power of .08. Complications also were noted.
                Heart rates and oxygen saturations were similar in the two groups at each timed interval. The behavioral characteristics and amount of crying also were comparable in both groups. The only complication was minor bleeding, seen in each group.
                Adding a buffering agent to lidocaine did not provide a more effective level of anesthesia in a short time. A controlled, double-blind investigation was conducted to determine whether the dorsal penile nerve block using lidocaine hydrochloride without epinephrine would effectively reduce behavioral distress and adrenocortical responses to routine neonatal circumcision. The subjects were healthy male newborns whose parents had requested circumcision. Equal numbers (n = 20) were randomly assigned to circumcision with lidocaine, saline, or no injection. Dorsal penile nerve block was found to be a safe and easy technique that was effective in reducing behavioral distress and modifying the adrenocortical stress response. The injection itself did not increase stress reactions and did not offset the beneficial effects of anesthesia. If circumcisions are to be performed, they should be done as humanely as possible. The behavior of full-term neonates undergoing circumcision with and without local anesthesia was examined using the Brazelton Neonatal Assessment Scale (BNAS). Evaluations were done blindly pre-and postcircumcision and on the day following the procedure. Infants receiving lidocaine in a dorsal penile nerve block (DPNB) remained more attentive to animate and inanimate stimuli following circumcision and demonstrated a greater ability to quiet themselves when disturbed. The smoothness and maturity of motor behaviors showed the expected rate of improvement or recovery curve in the anesthetized group, while the control group's behavior did not. Behavioral differences were still evident on the day following the procedure. This report adds to the growing body of data that indicate that circumcision is a painful procedure that disrupts the course of behavioral recovery following birth. These disruptions can be lessened by the use of local anesthesia to relieve pain and stress during the procedure without any additional morbidity. These data support the use of DPNB during anesthesia for routine neonatal circumcisions still requested by the majority of parents in the country. A controlled, double-blind investigation was undertaken to determine whether regional anesthesia by dorsal penile nerve block (DPNB) could effectively minimize the pain and behavioral disruptions usually associated with newborn circumcision. Fifteen infants had DPNB with lidocaine, eight control infants had DPNB with saline, and eight additional control infants were circumcised without undergoing DPNB. Newborn distress was gauged by subjective observation, measurement of heart rate, and the percent of time spent crying in six sequential timed intervals during circumcision. Ninety-three percent of subjects who received lidocaine were observed to have a decrease in agitation after anesthetic administration. The mean increase in heart rate during circumcision was at least 50 percent less in the lidocaine injected group than in either control group (p less than 0.01). Infants who had DPNB with lidocaine cried 50 percent less during circumcision compared to combined controls (p less than 0.01). DPNB was easily administered, and there were no significant complications. Physicians who circumcise newborns have good reason to employ the technique of dorsal penile nerve block with lidocaine to minimize infant pain and distress. Eleven male newborns were circumcised with a local dorsal penile nerve block, and 13 controls were circumcised without anesthetic. Matched pairs of pre- and postcircumcision cortisol levels in the two groups were compared. The adrenal cortisol response to surgery was not significantly reduced by the administration of lidocaine. Blood sampling and anesthetic injection of venipuncture alone did not evoke the adrenal response in uncircumcised control infants. Cortical input or secondary epinephrine elevation may be producing the cortisol elevation in infants despite regional blockage of the afferent nerve pathways. Circumcision is a common neonatal surgical procedure routinely performed without the use of anesthesia. The purpose of this study was to evaluate the safety and efficacy of topical lidocaine cream as an anesthetic for circumcision.
                Thirty newborns were studied in a randomized, double-blind, placebo-controlled study; 15 received a topical 30% lidocaine cream and 15 received the cream base alone. Vital signs were recorded, and preoperative and postoperative serum beta-endorphin and lidocaine concentrations were measured. A videotape of the newborn was used to score behavioral changes.
                Comparisons of the vital signs precircumcision and postcircumcision showed no differences between the placebo and treatment groups, with the exception of mean systolic blood pressure, which significantly increased in the placebo-treated newborns (P < .05). Serum beta-endorphin concentrations increased postoperatively in 11 of 15 subjects receiving placebo, but decreased or remained unchanged in 10 of 15 subjects receiving lidocaine (P = .03, Fisher's exact test). When stress-related behaviors in the precircumcision and post-circumcision periods were compared, the mean increase in their occurrence was greater in the placebo than in the treatment group. There was no significant absorption of lidocaine as measured in the serum.
                Topical application of a 30% lidocaine cream as used in this study may be a safe and efficacious anesthetic for circumcision. To evaluate the effectiveness of the dorsal penile nerve block in reducing the stress of circumcision upon newborns, physiologic measurements in 30 healthy full-term infants (including transcutaneous oxygen levels, crying time, heart rate, and respiratory rate) were monitored continuously before, during, and after the operation. Infants receiving the dorsal penile nerve block with lidocaine (1% Xylocaine) (N = 20) experienced significantly less stress, as evidenced by smaller decreases in transcutaneous oxygen pressure levels, less time spent crying, and smaller increases in heart rate, than infants circumcised in an identical manner without anesthetic (N = 10). No complications resulted from injection of the local anesthetic or from the circumcision procedure itself. Inasmuch as dorsal penile nerve block has a low complication rate, is simple to learn, and adds little time or expense to the overall procedure, and if it proves to be as effective clinically as the physiologic data indicate, the dorsal penile nerve block should be considered for every infant undergoing circumcision. Dorsal penile nerve blocking (DPNB) has been used with success in decreasing neonatal stress during circumcision. This study was designed to confirm the effectiveness of lidocaine in DPNB and to demonstrate that chloroprocaine, a shorter acting anesthetic, is as effective in blocking circumcision stress as lidocaine, but, because of its shorter plasma elimination half-life and time of onset of action, is safer. Five groups of 15 neonates were matched for weight, age, and Apgar scores and randomly assigned to a control group, one lidocaine group and three chloroprocaine groups with 2-, 3- and 5-minute postinjection waiting periods. Each neonate was subjected to six events during circumcision for which heart rate, tissue oxygenation, and cry duration were recorded. We found that, as in previous investigations, DPNB with lidocaine was effective in reducing neonatal stress, as was evident from decreased excursion from baseline heart rate, tissue oxygenation, and cry duration when compared with the control group (nonblocked). Furthermore, chloroprocaine DPNB approximates the effectiveness of lidocaine, as was evident from decreased change from baseline cry duration, tissue oxygenation, and heart rate during the most stressful events, particularly in the 3-minute wait chloroprocaine group. This more rapid onset of regional anesthesia decreases DPNB circumcision time and benefits patients, parents, and physicians. Neonatal circumcision is a painful surgical procedure often performed without analgesia. We assessed the efficacy and safety of 5 percent lidocaine-prilocaine cream (Emla) in neonates undergoing circumcision.
                We carried out a double-blind, randomized, controlled trial in 68 full-term male neonates: 38 were assigned to receive lidocaine-prilocaine cream, and 30 to receive placebo. One gram of lidocaine-prilocaine or placebo cream was applied to the penis under an occlusive dressing for 60 to 80 minutes before circumcision. Behavioral (facial activity and time spent crying) and physiologic (heart rate and blood pressure) responses were recorded during the procedure. Blood samples were obtained at various times after drug application for measurements of methemoglobin and plasma lidocaine, prilocaine, and o-toluidine (a metabolite of prilocaine).
                A total of 68 and 59 neonates were included in the safety and efficacy analyses, respectively. Demographic characteristics such as gestational age and birth weight did not differ between the lidocaine-prilocaine and placebo groups. During circumcision, the neonates in the lidocaine-prilocaine group had less facial activity (P= 0.01), spent less time crying (P<0.001), and had smaller increases in heart rate (P=0.007) than the neonates in the placebo group. Facial-activity scores were 12 to 49 percent lower during various steps of the procedure in the lidocaine-prilocaine group. As compared with neonates in the placebo group, infants in the lidocaine-prilocaine group cried less than half as much and had heart-rate increases of 10 beats per minute less. Blood methemoglobin concentrations (expressed as a percentage of the hemoglobin concentration) were similar (1.3 percent) in both groups. Lidocaine and prilocaine were detected in plasma in 23 (61 percent) and 21 (55 percent) of the infants treated with lidocaine-prilocaine cream, respectively.
                Lidocaine-prilocaine cream is efficacious and safe for the prevention of pain from circumcision in neonates. 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.
                Level 1 nursery at a community hospital.
                Eighty healthy, term, newborn male infants scheduled for routine neonatal circumcision.
                Prospective and randomized; double blind and placebo controlled for the study solutions.
                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.
                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.
                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. The effectiveness of sucrose as an analgesic agent for newborn infants was assessed during two standard painful hospital procedures: blood collection via heel lance and circumcision. Infants who drank 2 mL of a 12% sucrose solution prior to blood collection cried 50% less during the blood collection procedure than did control infants who had received 2 mL of sterile water. Crying of infants who ingested sucrose returned to baseline levels within 30 to 60 seconds after blood collection whereas control infants required 2.5 to 3.0 minutes to return to baseline. Like findings were obtained for infants who received sucrose on a pacifier prior to and during circumcision. Specifically, control infants who underwent a standard circumcision procedure without intervention cried 67% of the time. A water-moistened pacifier reduced crying to 49% (P less than .01). Crying was reduced further to 31% (P less than .05) by providing infants with a sucrose-flavored pacifier to suck. These findings, which parallel results obtained in studies of pain in infant rats, provide a potent yet simple, benign intervention to help alleviate stress and pain routinely experienced by human infants. We set out to compare a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) to dorsal penile nerve block with lidocaine for anesthesia during circumcision.
                In a double-blind study, term newborns were randomized to local anesthetic cream and sodium chloride solution dorsal penile nerve block (n = 31) or to placebo cream and lidocaine dorsal penile nerve block (n = 29). Pain was assessed by determination of heart rate, respiratory rate, and behavioral distress scoring. Group differences were evaluated with repeat-measures analyses of variance.
                Distress scores and heart rates were significantly higher in the eutectic mixture group than in the lidocaine group. Respiratory rates were higher in the eutectic mixture group but did not reach statistical significance.
                Distress scores and heart rates were significantly higher in infants treated with the anesthetic mixture than in infants treated with lidocaine. Dorsal penile nerve block with lidocaine is a more efficacious means of providing anesthesia for neonatal circumcision than the mixture of local anesthetics. 1) To compare the Mogen and Gomco clamps with regard to pain experienced during neonatal circumcision, and 2) to assess neonatal circumcision pain with and without dorsal penile nerve block (DPNB).
                A randomized, controlled, nonblinded clinical trial; 48 healthy, full-term infants were randomized into one of the following four groups: Gomco vs Mogen with (+) or without (-) DPNB. DPNB+ infants were injected with 0.8 mL of 1% lidocaine before circumcision. DPNB- infants received no placebo injection. Heart rate, respiratory rate, and oxygen saturation (SaO2) during the procedure were monitored and data transferred to computer files by using the Datalab software system. Crying was recorded on videotape. Pre- and postcircumcision saliva samples for cortisol analysis were collected. Heart rate, respiratory rate, SaO2, cortisol changes, and duration of crying were evaluated statistically with two-way analyses of variance and t tests.
                The type of clamp but not the use of anesthesia was significantly associated with the length of the procedure (mean Mogen time, 81 seconds; mean Gomco time, 209 seconds) and percentage of respiratory rate change. The use of anesthesia but not the type of clamp was significantly associated with percentage of crying time and percentage of SaO2 change during the procedure. Heart rate changes and total crying time were significantly associated with both the type of clamp and the use of anesthesia. Neither clamp type nor anesthesia status was significantly associated with salivary cortisol changes, although the mean increase for the DPNB- group was approximately twice that for the DPNB+ group. Fifty-six percent of infants circumcised with the Mogen clamp and DPNB did not cry at all during the procedure.
                DPNB is effective in reducing neonatal circumcision pain with either the Mogen or the Gomco clamp. For a given anesthesia condition, the Mogen clamp is associated with a less painful procedure than the Gomco. The Mogen clamp with DPNB causes the least discomfort during neonatal circumcision. To investigate the efficacy and safety of dorsal penile nerve block (DPNB) and eutectic mixture of lidocaine (EMLA) for palliation of pain associated with circumcision in low-birth-weight infants.
                Randomized, blinded, controlled trial.
                Intensive care nursery (step down unit) at Georgetown University Medical Center, Washington, DC.
                Fifty neonates with weights of 1600 to 2500 g at the time of circumcision who were discharged from the hospital between May 1994 and June 1995 were randomly assigned to the DPNB, EMLA, or control group. Twenty-five infants who were otherwise eligible were excluded because of parental refusal of consent to participate.
                Infants in the DPNB and EMLA groups received anesthesia with subcutaneous injection of 1% lidocaine hydrochloride or topical EMLA, respectively. The control group received sham anesthesia with topical placebo (acid mantle cream).
                Changes in physiologic variables (heart rate, blood pressure, oxygen saturation, and respiratory rate) and behavioral score 20 minutes before, during, and 5 and 20 minutes after circumcision between DPNB and control groups. Surgical complications and adverse effects were also monitored.
                Fifty infants were enrolled in the study: 19 randomized to the DPNB group, 19 to the control group, and 12 to the EMLA group. Enrollment into the EMLA group was suspended early because of redness and blistering of the foreskin in 2 infants, and this entire group was excluded from further analysis. The clinical course was similar in all groups of infants. All circumcisions were performed without complication or technical difficulty. Statistically significant differences were noted in heart rate, respiratory rate, and behavioral score when comparing the DPNB group with controls during and after circumcision.
                Dorsal penile nerve block is safe and effective in controlling pain associated with circumcision in low-birth-weight infants. The purpose of the study was to determine the efficacy of music and eutectic mixture of local anesthetics (EMLA) on pain responses of neonates undergoing circumcision.
                A randomized, double-blind experimental design was used with 23 neonates. Pain response was measured using an observational pain intensity rating scale and the physiologic parameters of heart rate, respiratory rate, oxygen saturation levels, salivary cortisol levels, and length of cry. Each infant's state was examined for a potential contribution to the pain response.
                Infant state, salivary cortisol levels, and respiratory rates were not significant. Pain ratings had considerable variability for all treatment conditions, but both single treatment groups had less pain by the end of the procedure. The heart rate was significantly lower for the EMLA group and remained stable for the music group. Oxygen saturation differences were statistically significant for the music group (P =.02) and approached significance for the EMLA group.
                Preliminary support was provided for the efficacy of EMLA and music to contribute to the pain relief of neonates undergoing circumcision. Further study is warranted. Neonates deserve interventions that will provide them with a less painful start in life. Our objective was to compare two methods of pain control during neonatal circumcision: a sucrose-dipped pacifier and an analgesic cream (EMLA).
                This study was conducted in our well-baby nursery where 80 male infants were placed into one of four groups: control (water-dipped pacifier only), sucrose alone, EMLA alone, or sucrose and EMLA. Heart rate, oxygen saturation, systolic and diastolic blood pressure, and crying time were measured as indicators of pain. The primary data analysis was a 2 x 2 factorial analysis of variance with repeated measures.
                Physiologic and behavioral parameters indicated significantly (p < 0.05) decreased pain response in all treatment groups compared with that in the control group. The combination of sucrose and EMLA was most effective in reducing pain responses; sucrose alone was significantly less effective. There were no side effects of treatment.
                Pain during neonatal circumcision can be optimally ameliorated by combined use of a sucrose-dipped pacifier and a local analgesic cream. The effects of a topical anesthetic used prior to newborn circumcision on the parameters of heart rate, respiratory rate, oxygen saturation levels, seconds of crying time, and overt generalized reaction to the procedure were investigated. In the double-blind design, an experimental group (n = 20) received 4% lidocaine cream mixed with 500 mg acid mantle cream two hours before circumcision, and a control group (n = 24) received 500 mg acid mantle cream two hours before circumcision. The circumcision was divided into five events with parameters recorded 30 seconds into each event. The results showed a significant difference in the heart rate between the treated and untreated group, but the respiratory rate and oxygen saturation levels did not differ significantly. Seconds of crying time also differed significantly between groups, as did overt generalized response. There were no untoward reactions. Results showed that topical lidocaine, simple and safe to use, reduced parameters associated with pain and stress. Recognizing the concerns about the use of local anesthesia in neonatal circumcision, a painful procedure usually performed without analgesia or anesthesia, we undertook a study of acetaminophen for pain management of this procedure.
                A prospective, randomized, double-blind, placebo-controlled, clinical trial of acetaminophen analgesia in 44 healthy full-term neonates undergoing circumcision was conducted. Beginning 2 hours before Gomco circumcision, neonates received either acetaminophen (15 mg/kg per dose, 0.15 mL/kg per dose) or placebo (0.15 mL/kg per dose) every 6 hours for 24 hours. Neonates were monitored intraoperatively for changes in heart rate, respiratory rate, and crying time. Postoperative pain was assessed at 30, 60, 90, 120, 360 minutes, and 24 hours using a standardized postoperative comfort scoring system. Feeding behavior was also assessed before and after circumcision by nursing observation.
                Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences observed between the groups. Postoperative comfort scores showed no significant differences between the groups until the 360-minute postoperative assessment, at which time the acetaminophen group had significantly improved scores (P < .05). Feeding behavior deteriorated in breast- and bottle-fed neonates in both groups, and acetaminophen did not seem to influence this deterioration.
                This study confirms that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate either the intraoperative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the immediate postoperative period.