0
December 24, 1997, Vol 278, No. 24 >
ARTICLE | December 24, 1997

Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision: Title and subTitle BreakA Randomized Controlled Trial FREE

Janice Lander, PhD; Barbara Brady-Fryer, MN; James B. Metcalfe, MD, FRCSC; Shemin Nazarali, MPharm; Sarah Muttitt, MD, FRCPC
[+] Author Affiliations

Reprints: Janice Lander, PhD, Clinical Sciences, University of Alberta, Edmonton, Alberta, Canada T6G 2G3 (e-mail: janice.lander@ualberta.ca).


JAMA. 1997;278(24):2157-2162. doi:10.1001/jama.1997.03550240047032
Text Size: A A A
Published online
Article
References

Context.  —Beliefs about the safety and effectiveness of current anesthetics have resulted in many newborns being circumcised without the benefit of anesthesia.

Objective.  —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.

Design.  —A randomized controlled trial.

Setting.  —Antenatal units in 2 tertiary care hospitals in Edmonton, Alberta.

Participants.  —A consecutive sample of 52 healthy, full-term, male newborns, aged 1 to 3 days.

Interventions.  —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.

Main Outcome Measures.  —Heart rate, cry, and methemoglobin level.

Results.  —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.

Conclusions.  —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.

REFERENCES

1 +
Wiswell T, Roscelli J.  Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants . Pediatrics . 1986;;78:96-99.
2 +
Moses S, Bradley J, Nagelkerke N, Ronald A, Ndinya-Achola J, Plummer F.  Geographical patterns of male circumcision practices in Africa: association with HIV seroprevalence . Int J Epidemiol . 1990;;19:693-697.
3 +
Maden C, Sherman K, Beckmann A, et al.  History of circumcision, medical conditions, and sexual activity and risk of penile cancer . J Natl Cancer Inst . 1993;;85:19-24.
4 +
Poland R.  The question of routine neonatal circumcision . N Engl J Med . 1990;;322:1312-1315.
5 +
Wallerstein E.  Circumcision: the uniquely American medical enigma . Urol Clin North Am . 1985;;12:123-132.
6 +
Rabinowitz R, Hulbert W.  Newborn circumcision should not be performed without anesthesia . Birth . 1995;;22:45-46.
7 +
Wellington N, Rieder M.  Attitudes and practices regarding analgesia for newborn circumcision . Pediatrics . 1993;;92:541-543.
8 +
Toffler W, Sinclair A, White K.  Dorsal penile nerve block during newborn circumcision: underutilization of a proven technique? J Am Board Fam Pract . 1990;;3:171-174.
9 +
Kirya C, Werthmann M.  Neonatal circumcision and penile dorsal nerve block: a painless procedure . J Pediatr . 1978;;92:998-1000.
10 +
Holve RL, Bromberger PJ, Groveman HD, Klauber MR, Dixon SD, Snyder JM.  Regional anesthesia during newborn circumcision . Clin Pediatr . 1983;;22:813-818.
11 +
Stang H, Gunnar M, Snellman L, Condon L, Kestenbaum R.  Local anesthesia for neonatal circumcision: effects on distress and cortisol response . JAMA . 1988;;259:1507-1511.
12 +
Fontaine P, Dittberner D, Scheltema K.  The safety of dorsal penile nerve block for neonatal circumcision . J Fam Pract . 1994;;39:243-248.
13 +
Snellman L, Stang H.  Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision . Pediatrics . 1995;;95:705-708.
14 +
Benini F, Johnston C, Faucher D, Aranda J.  Topical anesthesia during circumcision in newborn infants . JAMA . 1993;;270:850-853.
15 +
Taddio A, Stevens B, Craig K, et al.  Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision . N Engl J Med . 1997;;336:1197-1201.
16 +
Broadman L, Hannallah R, Belman B, Elder P, Ruttimann U, Epstein B.  Post-circumcision analgesia: a prospective evaluation of subcutaneous ring block of the penis . Aesthesiology . 1987;;67:399-402.
17 +
Harper V, Rutter N.  Development of emotional sweating in the newborn infant . Arch Dis Child . 1982;;57:691-695.
18 +
Owens M, Todt E.  Pain in infancy: neonatal reaction to heel lance . Pain . 1984;;20:77-86.
19 +
Rawlings D, Miller P, Engel R.  The effect of circumcision on transcutaneous Po2 in term infants . AJDC . 1980;;134:676-678.
20 +
Grunau R, Johnston C, Craig K.  Neonatal facial and cry responses to invasive and non-invasive procedures . Pain . 1990;;42:295-305.
21 +
Gunnar M, Malone S, Vance G, Fisch R.  Coping with aversive stimulation in the neonatal period: quiet sleep and plasma cortisol levels during recovery from circumcision . Child Dev . 1985;;56:824-834.
22 +
Lander J, Hodgins M, Nazarali S, McTavish J, Ouellette J, Friesen E.  Determinants of success and failure of EMLA . Pain . 1996;;64:89-97.
23 +
Streiner D, Norman G. Health Measurement Scales . 2nd ed. Oxford, England: Oxford University Press; 1995;.
24 +
Williamson P, Williamson M.  Physiologic stress reduction by a local anesthetic during newborn circumcision . Pediatrics . 1983;;71:36-40.
25 +
NeterJ, Wasserman W, Kutner M. Applied Linear Regression Models . 3rd ed. Homewood, Ill: Irwin Inc; 1983;.
26 +
Freedman B.  Equipoise and the ethics of clinical research . N Engl J Med . 1987;;317:141-145.
27 +
Stav A, Gur L, Gorelik U, Ovadia L, Isaakovich B, Sternberg A.  Modification of the penile block . World J Urol . 1995;;13:251-253.
28 +
Schoen E, Fischell A.  Pain in neonatal circumcision . Clin Pediatr . 1991;;30:429-432.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Wiswell T, Roscelli J.  Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants . Pediatrics . 1986;;78:96-99.
2 +
Moses S, Bradley J, Nagelkerke N, Ronald A, Ndinya-Achola J, Plummer F.  Geographical patterns of male circumcision practices in Africa: association with HIV seroprevalence . Int J Epidemiol . 1990;;19:693-697.
3 +
Maden C, Sherman K, Beckmann A, et al.  History of circumcision, medical conditions, and sexual activity and risk of penile cancer . J Natl Cancer Inst . 1993;;85:19-24.
4 +
Poland R.  The question of routine neonatal circumcision . N Engl J Med . 1990;;322:1312-1315.
5 +
Wallerstein E.  Circumcision: the uniquely American medical enigma . Urol Clin North Am . 1985;;12:123-132.
6 +
Rabinowitz R, Hulbert W.  Newborn circumcision should not be performed without anesthesia . Birth . 1995;;22:45-46.
7 +
Wellington N, Rieder M.  Attitudes and practices regarding analgesia for newborn circumcision . Pediatrics . 1993;;92:541-543.
8 +
Toffler W, Sinclair A, White K.  Dorsal penile nerve block during newborn circumcision: underutilization of a proven technique? J Am Board Fam Pract . 1990;;3:171-174.
9 +
Kirya C, Werthmann M.  Neonatal circumcision and penile dorsal nerve block: a painless procedure . J Pediatr . 1978;;92:998-1000.
10 +
Holve RL, Bromberger PJ, Groveman HD, Klauber MR, Dixon SD, Snyder JM.  Regional anesthesia during newborn circumcision . Clin Pediatr . 1983;;22:813-818.
11 +
Stang H, Gunnar M, Snellman L, Condon L, Kestenbaum R.  Local anesthesia for neonatal circumcision: effects on distress and cortisol response . JAMA . 1988;;259:1507-1511.
12 +
Fontaine P, Dittberner D, Scheltema K.  The safety of dorsal penile nerve block for neonatal circumcision . J Fam Pract . 1994;;39:243-248.
13 +
Snellman L, Stang H.  Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision . Pediatrics . 1995;;95:705-708.
14 +
Benini F, Johnston C, Faucher D, Aranda J.  Topical anesthesia during circumcision in newborn infants . JAMA . 1993;;270:850-853.
15 +
Taddio A, Stevens B, Craig K, et al.  Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision . N Engl J Med . 1997;;336:1197-1201.
16 +
Broadman L, Hannallah R, Belman B, Elder P, Ruttimann U, Epstein B.  Post-circumcision analgesia: a prospective evaluation of subcutaneous ring block of the penis . Aesthesiology . 1987;;67:399-402.
17 +
Harper V, Rutter N.  Development of emotional sweating in the newborn infant . Arch Dis Child . 1982;;57:691-695.
18 +
Owens M, Todt E.  Pain in infancy: neonatal reaction to heel lance . Pain . 1984;;20:77-86.
19 +
Rawlings D, Miller P, Engel R.  The effect of circumcision on transcutaneous Po2 in term infants . AJDC . 1980;;134:676-678.
20 +
Grunau R, Johnston C, Craig K.  Neonatal facial and cry responses to invasive and non-invasive procedures . Pain . 1990;;42:295-305.
21 +
Gunnar M, Malone S, Vance G, Fisch R.  Coping with aversive stimulation in the neonatal period: quiet sleep and plasma cortisol levels during recovery from circumcision . Child Dev . 1985;;56:824-834.
22 +
Lander J, Hodgins M, Nazarali S, McTavish J, Ouellette J, Friesen E.  Determinants of success and failure of EMLA . Pain . 1996;;64:89-97.
23 +
Streiner D, Norman G. Health Measurement Scales . 2nd ed. Oxford, England: Oxford University Press; 1995;.
24 +
Williamson P, Williamson M.  Physiologic stress reduction by a local anesthetic during newborn circumcision . Pediatrics . 1983;;71:36-40.
25 +
NeterJ, Wasserman W, Kutner M. Applied Linear Regression Models . 3rd ed. Homewood, Ill: Irwin Inc; 1983;.
26 +
Freedman B.  Equipoise and the ethics of clinical research . N Engl J Med . 1987;;317:141-145.
27 +
Stav A, Gur L, Gorelik U, Ovadia L, Isaakovich B, Sternberg A.  Modification of the penile block . World J Urol . 1995;;13:251-253.
28 +
Schoen E, Fischell A.  Pain in neonatal circumcision . Clin Pediatr . 1991;;30:429-432.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems