Pain relief for neonatal circumcision

Brady‐Fryer, Barbara; Blankston, G; Lander, Janice

doi:10.1002/14651858.cd004217

Cited by 35 publications

(73 citation statements)

References 38 publications

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“…[139][140][141][142][143][144][145] Therefore, adequate analgesia should be provided when newborn circumcision is performed. Topical 4% lidocaine, DPNB, and a subcutaneous ring block are all effective options, although the latter may provide the most effective analgesia.…”

Section: Nonpharmacologic Techniquesmentioning

confidence: 99%

“…141,142,144 There is good evidence that a more physiologic positioning of the infant in a padded environment may decrease distress during the procedure. 146 There is fair evidence that sucrose on a pacifier has been demonstrated to be more effective than water alone for decreasing crying during circumcision.…”

Section: Nonpharmacologic Techniquesmentioning

confidence: 99%

“…159 There is good evidence that DPNB is effective in reducing the behavioral and physiologic indicators of pain caused by circumcision, regardless of the device used. 144 There is good evidence that DPNB is superior to lidocaine-prilocaine in relieving pain during and after circumcision in newborns. 142,[160][161][162] One good-quality prospective cohort study of 491 newborn circumcisions measured complications of DPNB analgesia; it reported an 11% incidence of bruising and a 0.2% incidence of hematoma, none of which required any change in management.…”

Section: Dpnbmentioning

confidence: 99%

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Male Circumcision

Blank¹,

Brady²,

Buerk³

et al. 2012

Pediatrics

298

149

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Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP’s 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association’s template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners’ competency in discussing circumcision’s benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.Elective circumcision should be performed only if the infant’s condition is stable and healthy.Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management.Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision.If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns.Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing;Teach the procedure and analgesic techniques during postgraduate training programs;Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents;Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises.The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.

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Section: Nonpharmacologic Techniquesmentioning

confidence: 99%

Section: Nonpharmacologic Techniquesmentioning

confidence: 99%

Section: Dpnbmentioning

confidence: 99%

See 1 more Smart Citation

Male Circumcision

Blank¹,

Brady²,

Buerk³

et al. 2012

Pediatrics

298

149

View full text Add to dashboard Cite

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“…A total sample size of 90 pain reviewers was required to achieve a power of 0.90 to detect a mean difference in Neonatal Infant Pain Scale scores of À2.5 with an alpha of 0.05 between medical and nonmedical cohorts. 7,8,10 Results The dorsal penile nerve block and topical lidocaine-prilocaine anesthesia groups were similar with respect to gestational age (39. 3±1.0 versus 39.2±0.89 week; P ¼ 0.31), maternal age (31.6±4.1 versus 28.1±3.8 year; P ¼ 0.09), and birth weight (3452±372 versus 3449±287 g; P ¼ 0.30).…”

Section: Methodsmentioning

confidence: 94%

“…These behavioral components have been videotaped for the investigators to complete analysis. [7][8][9][10][11][12][13][14] Video studies have only been reviewed by the study investigators and never reviewed by noninvestigators or by nonmedical persons. In addition, no studies have used sham procedures in comparing anesthesia techniques or evaluate baseline levels of pain.…”

Section: Introductionmentioning

confidence: 99%

A video study of pain relief during newborn male circumcision

et al. 2005

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Objective: The purpose of this investigation was to compare the effectiveness of dorsal penile nerve block and topical lidocaine-prilocaine anesthesia techniques for pain relief during circumcision.Methods: In total, 18 healthy term newborn males were divided based on anesthesia. The topical lidocaine-prilocaine group had six males undergoing circumcision and three males undergoing a sham procedure. The dorsal penile nerve block group had six males undergoing circumcision and three males undergoing a sham procedure. The procedures were videotaped and viewed by 90 noninvestigator reviewers who scored the infants' pain using the Neonatal Infant Pain Scale and a numeric pain scale. Statistical analysis utilized a P-value of <0.05 as significant.Results: The median Neonatal Infant Pain Scale and numeric pain scores were significantly lower in the dorsal penile nerve block group than in the topical lidocaine-prilocaine group or the sham group (Neonatal Infant Pain Scale: 1.0 (range 0-6) versus 6.0 (range 2-6) versus 4.0 (range 0-6), P<0.001, respectively; numeric pain scale: 2.0 (range 0-10) versus 8.0 (range 1-10) versus 4.0 (range 0-10), P<0.001, respectively). In the sham group, procedures with the dorsal penile nerve block had significantly lower pain scores than those with topical lidocaine-prilocaine (Neonatal Infant Pain Scale: 1.0 (range 0-6) versus 5.0 (range 2-6), P<0.001; numeric pain scale: 1.0 (0-8) versus 6.0 (range 0-10), P<0.001). When reviewers were divided by medical background, gender or parental status, no differences in pain scores were observed. Conclusion:The dorsal penile nerve block anesthesia technique for newborn male circumcision was significantly more effective for pain relief than topical lidocaine-prilocaine.

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Revisiting established medicines: An overview of systematic reviews about ibuprofen and paracetamol for treating pain in children

Radman

Babić

Runjić

et al. 2019

European Journal of Pain

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Background and objective We explored how systematic reviews evaluated paracetamol and ibuprofen for treating pain in children, as these two non‐opioid analgesics are well‐established medicines included in most national essential medicines lists. Databases and data treatment We carried out an overview of systematic reviews (SRs) of randomized controlled trials (RCTs) of interventions (PROSPERO registration: 42016045367). We searched MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR) and Database of Reviews of Effects (DARE) up to 23 August 2017. We used AMSTAR checklist to analyse methodological quality of included SRs. Results We found 17 SRs with 72 unique RCTs; the majority of those trials included under 100 children. Positive conclusive evidence was found in only one SR, regarding safety of paracetamol. Conclusions of other SRs for efficacy and safety of ibuprofen and paracetamol were inconclusive, unclear, or there was no opinion. Only one SR analysed efficacy of ibuprofen and other non‐steroidal anti‐inflammatory drugs (NSAIDs) in chronic pain and the conclusion was that there was no evidence from RCTs that NSAIDs were effective for chronic non‐cancer pain in children and adolescents. Most of the SRs addressed very narrow questions, included few trials, with few children and were of low or medium methodological quality. Conclusions Most SRs on two relevant medicines have inconsistent conclusions and doubt upon their effectiveness. Instead of focusing on very narrow questions, SRs should examine more comprehensive research topics to obtain a general sense of consistency, particularly when analysing established medicines. Significance Evidence behind two analgesics—ibuprofen and paracetamol—that are well‐established medicines for children in most countries appears limited, judging by the systematic reviews. The discrepancy between clinical use and the extensive evidence we reviewed may be a result of the selective criteria in the reviews examined. We need new, and better evidence syntheses supporting the use of these two medicines in wide indications regarding pain in children.

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Pain relief for neonatal circumcision

Cited by 35 publications

References 38 publications

Male Circumcision

Male Circumcision

A video study of pain relief during newborn male circumcision

Revisiting established medicines: An overview of systematic reviews about ibuprofen and paracetamol for treating pain in children

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