Neonatal Cortisol Response to Circumcision with Anesthesia

Williamson, Paul; Evans, N.

doi:10.1177/000992288602500807

Cited by 45 publications

(17 citation statements)

References 10 publications

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“…To date, 12 randomised or quasi-randomised controlled trials assessing the efficacy of DPNB, compared with placebo or no treatment, have been published. [12,[18][19][20][21][22][23][24][25][26][27][28][29] DPNB has been demonstrated to significantly reduce infant pain during circumcision. The effectiveness of DPNB has also been demonstrated in other studies, including randomised studies with an active control group.…”

Section: Local Anaesthetic Infiltration Techniquesmentioning

confidence: 99%

“…[12,29] However, in 3 studies measuring plasma cortisol levels 30 to 40 minutes postprocedure, no differences were observed between groups (weighted mean difference, -16.7 μg/L; 95% CI, -4.3 μg/L to 9.7 μg/L). [21,24,27] It is possible that either plasma cortisol was not measured at the optimal time or that plasma cortisol is not a sensitive measure of pain. Two randomised controlled trials investigated the effects of a buffered lidocaine solution in an attempt to decrease DPNB injection pain.…”

Section: Local Anaesthetic Infiltration Techniquesmentioning

confidence: 99%

“…[17] In an infant weighing as little as 2.5kg, the single dose of lidocaine which would be used (up to 1ml of 1% lidocaine) would result in an exposure of 4 mg/kg, which is considered nontoxic. In studies which have measured lidocaine concentrations, mean peak values of 0.3 to 0.5 mg/L [20,24] have been reported after 40 to 60 minutes. These concentrations are below 'toxic' concentrations (>5 mg/L).…”

Section: Local Anaesthetic Infiltration Techniquesmentioning

confidence: 99%

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Pain Management for Neonatal Circumcision

Taddio

2001

Paediatric Drugs

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Circumcision is the most common surgical procedure performed in the neonatal period in North America. If untreated, the pain of circumcision causes both short and long term changes in infant behaviours. The most widely studied pharmacological intervention for pain management during circumcision is dorsal penile nerve block (DPNB) by injected lidocaine (lignocaine). Randomised controlled trials have demonstrated its efficacy; infants premedicated with lidocaine have significantly smaller changes in physiological and pain-related behaviours compared with infants who are not given analgesics. A meta-analysis of injection-related adverse effects (bruising/haematoma) yielded a risk of 6.7% (95% confidence interval, 0.5 to 12.9%). Systemic toxicity from injected local anaesthesia has not been reported. Less effective modalities include topical anaesthesia with lidocaine-prilocaine cream [Eutectic Mixture of Local Anaesthetics (EMLA)], lidocaine cream and oral administration of sucrose. The good tolerability of lidocaine-prilocaine cream has been demonstrated by a lack of clinically significant methaemoglobinaemia when used appropriately. Nonpharmacological interventions (pacifier, specially designed restraint chair) reduce distress during the procedure, and paracetamol (acetaminophen) may provide postoperative analgesia. No single agent has been demonstrated to ameliorate pain for all infants undergoing circumcision. A multimodal approach of pharmacotherapy is currently recommended. Studies evaluating the efficacy of combined analgesia have demonstrated significant benefits for combinations of 2 or more forms of treatment (such as DPNB and sucrose-dipped pacifier) compared with single interventions. The instrument used to perform the circumcision is also important. The Mogen clamp has been shown to be associated with a shorter procedure time and less pain compared with the Gomco clamp. If circumcision is to be performed on infants, it is, therefore, recommended that combined analgesia and the Mogen clamp technique are used, and nonpharmacological stress reducing interventions such as pacifiers and comfortable restraining chairs should also be employed.

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Section: Local Anaesthetic Infiltration Techniquesmentioning

confidence: 99%

Section: Local Anaesthetic Infiltration Techniquesmentioning

confidence: 99%

Section: Local Anaesthetic Infiltration Techniquesmentioning

confidence: 99%

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Pain Management for Neonatal Circumcision

Taddio

2001

Paediatric Drugs

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“…Thus the infant undergoing circumcision shows responses, behavioural [23,42,54,55,70], humeral [23,63,65,70,71] and physiological [11,31,44,53,55,72], that indicate severe and acute distress. In the absence of their ability to describe their feelings are we unable to say that this is pain?…”

Section: Pain Definition and The Newbornmentioning

confidence: 99%

“…renin [12], vasopressin [36], and beta-endorphins [18,32,37,59]. It is now accepted that newborn infants have the same neurohumeral responses when subjected to such painful stimuli as venepunctures [12] and circumcision [23,63,65,70,71] as adults. 3.…”

Section: Acutementioning

confidence: 99%

Pain in the newborn, a possible new starting point

McIntosh

1997

Eur J Pediatr

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Pain is not a subjective experience, it is, particularly in children, an emotional issue. The formation of the International Association for the Study of Pain (IASP) in 1973 injected some standards and objectivity into the subject which allowed investigators around the world to probe both the underlying scientific basis of pain and nociception (nociception being the noxious sensation per se with no regard to the emotional experience). At the same time therapeutic strategies for different clinical problems have been evaluated, putting pain management on a scientifically secure and more individually effective basis. Self report has been the 'gold standard' of pain measurement but even in co-operative adults this has inherent weaknesses/biases related to the person and their situation (both the feelings and the reporting of pain are context sensitive). In some clinical areas, subject report is clearly impossible e.g. the psychogeriatric population, the mentally retarded and in preverbal children. However, even in these groups, there are usually behavioural responses to acute pain that are reasonably interpretable by their caregivers.

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Local Anesthesia for Neonatal Circumcision

Stang

Gunnar²,

Snellman

et al. 1988

JAMA

100

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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.

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Neonatal Cortisol Response to Circumcision with Anesthesia

Cited by 45 publications

References 10 publications

Pain Management for Neonatal Circumcision

Pain Management for Neonatal Circumcision

Pain in the newborn, a possible new starting point

Local Anesthesia for Neonatal Circumcision

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