Local Anesthesia for Infants Undergoing Circumcision

To the Editor.—Dr Lander and colleagues¹ have shown once again the value and safety of anesthesia for neonatal circumcision. In this study, local infiltration ring block or dorsal penile nerve block resulted in less heart rate elevation and less crying during the circumcision procedure. Outcome measures said to have been investigated included heart rate, respiratory rate, oxygen saturation, palmar sweat, sleep-wake states, crying, motor responses, and methemoglobin level. Only heart rate, crying, and methemoglobin levels were reported, and the reader assumes that no significant changes were found in the remaining parameters.

A larger prospective, controlled, double-blinded study of the effectiveness of penile nerve block by Arnett et al² showed not only significantly less heart rate elevation and less crying in the anesthetized infant, but also demonstrated significant decrease in oxygen saturation when circumcision was done without anesthesia. Although Lander et al followed the technique of Kirya and Werthmann³ for penile nerve block, using 0.4 mL of 1% lidocaine in each of 2 injection sites, the 14 nerve blocks under study were performed by 4 physicians and 3 assistants. In the study by Arnett et al,² 85% of the 44 injections and 51 circumcisions were performed by a single investigator, and only 0.2 mL per injection site provided effective anesthesia.

We applaud the efforts of Lander et al to encourage the use of anesthesia for neonatal circumcision. However, we have observed that many physicians resist using such anesthesia in their practices, likely related to the erroneous belief that it adds much time to the circumcision procedure. Nonetheless, as more parents become aware of its availability and effectiveness, more physicians become proponents of its value and expert in its use. All evidence indicates that such anesthesia does decrease the pain and stress on the infant.