Printer Friendly

Circumcision of neonates and children without appropriate anaesthesia is unacceptable practice.

Routine neonatal circumcision (RNC) of males is a non-therapeutic operation with no immediate medical indications (1-5). The practice however, continues, either for religious or cultural reasons, or in the expectation of future hygienic or prophylactic benefits (6). Although discouraged by the Royal Australasian College of Physicians (RACP) Paediatrics and Child Health Division, it has been estimated that 10 to 20% of Australian males still undergo circumcision, usually in their first year of life (5). Even if discussion is confined to the medical risks and benefits of neonatal circumcision, the procedure remains controversial. Routine neonatal circumcision has been promoted as a 'surgical vaccine' to protect against a variety of future ills including urinary tract infection, Human Immunodeficiency Virus Type 1 and cancer (7-8). Conversely, RNC has also been criticised as a criminal assault which seriously injures the penis, ablates structure and therefore future sexual function, and contravenes English Law and the United Nations Convention on the Rights of the Child (9-11).

Regardless of these debates, clinical and scientific evidence indicates that if performed, RNC is a painful surgical procedure requiring effective intraoperative anaesthesia and postoperative analgesia. The RACP acknowledge this, stating that infant circumcision without analgesia is unacceptable practice (5) and appropriate anaesthesia is required (12). Similarly, the state health departments of South Australia (13), New South Wales (14), Victoria (15) and Western Australia (16) all require appropriate anaesthesia for RNC. Disturbingly, however, anecdotal evidence exists that neonates continue to be circumcised in Australia without anaesthesia, with reports (authors' unpublished communications) of the practice ongoing in maternity units around Australia.

Even if anaesthesia is provided for RNC, published Medicare Australia data indicates that it is, at best, usually topical or local anaesthesia which is administered by the surgeon, and not local, regional or general anaesthesia provided by an anaesthetist. For example, over the years 2006 to 2010, less than 13,000 separate anaesthesia item numbers (Item 20920) were claimed while >95,000 for infants aged <6 months circumcision procedures were rebated (Item 30653) (17). This is concerning,

as evidence will be presented below that RNC is painful surgery, that topical and local anaesthesia techniques used for RNC can have significant failure rates, and that neonates may fail to display their distress. The absence of a skilled and dedicated anaesthetist to support the surgeon during RNC increases the risk of inadequate anaesthesia, and precludes the use of or progression to general anaesthesia if required.

NEONATAL CIRCUMCISION TECHNIQUES

Although often regarded as a minor intervention, RNC is an invasive surgical procedure on a specialised sensory organ. Between one-quarter and one-third of the penile skin is removed (18), producing significant intra- (19-25) and postoperative pain (26-29). Available techniques for neonatal circumcision include the Plastibell method and the Gomco and Mogen clamps (30). Plastibell circumcision is widespread in Australia, having been advocated as a low-risk, pain free outpatient method when combined with lignocaine-prilocaine (EMLA) cream (31), yet it remains an invasive surgical procedure with many steps in common with other circumcision techniques. These include the application of artery forceps to the foreskin, stretching of the preputial orifice, separation of the still fused glans and inner foreskin, dorsal incision and finally surgical amputation of the foreskin. The main difference to other circumcision techniques is the application of a bell shaped plastic shield, the 'Plastibell', over the glans penis and the tying of a tight ligature around the bell and foreskin prior to amputation. This limits bleeding and produces ischaemic necrosis of the residual foreskin stump, avoiding the need for sutures32. All techniques cause similar amounts of tissue destruction and pain (21,33-35).

CAN NEONATES FEEL OR REMEMBER CIRCUMCISION PAIN?

The earlier belief that the neonatal nervous system was not sufficiently developed to register or remember pain, or that the pain of neonatal circumcision was so minor or fleeting as to be inconsequential, has been comprehensively disproven (19-25). In fact, some authors have argued that neonates may be more sensitive to pain than older children or adults (36-38), yet lack mature coping strategies and therefore may be more likely to suffer permanent harm (25,39,40). Long-lasting alterations in behaviour have been attributed to circumcision without anaesthesia, including significantly greater distress during subsequent childhood vaccinations (25) and psychological changes akin to post traumatic stress disorder which, it is claimed, may persist into adulthood (28,41).

Assessment of pain in small children can be difficult, because preverbal children cannot articulate their pain and their behavioural responses, such as crying or resisting, may be muted or contradictory (42,43). Without the ability to resist or flee, small children may instead show signs of 'cognitive withdrawal', and retract into a trancelike state to limit incoming noxious stimuli, which might otherwise be overwhelming (20,44,45). Therefore, 'lack of responsiveness' may not reliably indicate absence of pain (33,42,43,46). The apparently 'restful sleep' of some neonates after circumcision may instead be a state of 'dissociative shock', rather than one of tranquility (21,44). As pain assessments that rely on infant behaviour and facial expressions may be unreliable, physiological and biochemical parameters are often used, including heart rate, blood pressure, oxygen saturation and serum levels of the stress hormone cortisol (21,47-50). Studies measuring these variables during RNC without anaesthesia have indicated that the procedure produces severe pain (19-25), with neonatal heart rates typically increasing from 120 beats per minute to 160 or more (19,49,51) and serum cortisol levels trebling (21,47,48,52).

ANAESTHETIC TECHNIQUES AVAILABLE FOR NEONATAL CIRCUMCISION

Anaesthesia techniques available for neonatal circumcision include the administration of general anaesthesia, local anaesthesia using subcutaneous ringblock of the penis or dorsal penile nerve block (DPNB) and topical anaesthesia with EMLA cream. A variety of lesser analgesic techniques including pacifiers, oral sucrose, music, paracetamol and intramuscular opioids have all been proven ineffective for the procedure (50). All of the topical and local anaesthesia techniques can have significant failure rates (27,50,53-56), which is concerning given the documented inability of neonates to reliably communicate pain with verbal or behavioural responses.

Subcutaneous ringblock of the penis involves the circumferential infiltration of local anaesthetic around the shaft of the penis, often at its midpoint. It has been shown to be the most effective method of all the local anaesthesia methods, but still involves pain with injection and infiltration, and distorts penile anatomy which impairs surgical conditions (53,54,57). Failure rates of 6 and 8% for subcutaneous ringblock were reported in two studies (53,54). The pre-emptive use of EMLA cream to reduce the pain of administration has been examined as a way to reduce the failure rate of subcutaneous ringblock, but it was concluded that EMLA was useful only for reducing needle insertion pain, and did not effectively cover the pain of infiltration, which was greater (54).

Dorsal penile nerve block involves the injection of local anaesthetic into the root of the penis either side of the fundiform ligament, at the 10 and 2 o'clock positions, aiming to block the dorsal penile nerves (58). In common with subcutaneous ringblock, DPNB involves a certain degree of pain during injection, but requires more operator skill. DPNB carries a small risk of serious complications, and has also had a failure rate of 8% reported (27). The use of ultrasound guidance to improve the reliability of DPNB as a postoperative analgesic technique has been discussed, and may offer improvements also for operative anaesthesia, by ensuring bilateral spread of local anaesthetic solution to both sides of the fundiform ligament (59). Those authors also highlighted the need to supplement the traditional bilateral '10 and 2 o'clock' injections with a 'peno-scrotal bleb' of local anaesthetic to block the sensory branches of the pudendal nerve, which supply the ventral penis. As for ringblock, pre-emptive use of EMLA cream might also be expected to reduce the pain of needle insertion in DPNB, although perhaps not the pain of infiltration. Lander reported that DPNB provided inferior surgical anaesthesia than subcutaneous ringblock, but produced less surgical field distortion (57). Both methods provide superior intraoperative anaesthesia than topical EMLA cream (34,50).

EMLA cream is a topical anaesthetic agent used to provide cutaneous anaesthesia for minor procedures such as venepuncture, and is also widely used in Australia for circumcision of neonates and infants (31,60). The technique involves the application of EMLA cream to the prepuce under an occlusive dressing for at least 60 minutes before surgery. While an apparently simple and attractive option, five randomised controlled trials and one systematic review showed that topical EMLA cream was substantially inferior to DPNB and provides insufficient anaesthesia for neonatal circumcision (Table 1). Disturbingly, given the neonatal prepuce is normally fused to the glans, requiring its forcible separation during circumcision (32,64,65), one author reported that 25% of older boys given topical EMLA for release of preputial adhesions could not tolerate even the pain of this (66), reinforcing concerns that EMLA cream provides insufficient anaesthesia for circumcision proper.

POSTOPERATIVE ANALGESIA

Regardless of the success of the intraoperative anaesthetic technique, as with any surgery, a certain degree of postoperative pain is to be expected after circumcision. In neonates, not only is there the skin incision to consider, but there is also the raw surface of the glans that is inevitably left after its forceful separation from the inner foreskin. This will be exposed to both mechanical irritation from the nappy and chemical assault from urine and faeces until the newly exposed surface of the glans keratinises. It is thus likely that the pain of neonatal or infant circumcision is more severe and of longer duration than that of older children or adults (4,29,64,67-69). As circumcision is a painful surgical operation, the usual range of multimodal analgesics should be available postoperatively, including paracetamol, oral and parenteral opioids and nonsteroidal anti-inflammatory drugs. These, however, provide demonstrably less effective immediate postoperative analgesia than local anaesthetic techniques (55,70-73) and thus there is a postoperative role for such techniques as DPNB, ringblock and caudal block, even if they may be inferior to general anaesthesia intraoperatively. The most effective postoperative analgesic techniques in two studies were DPNB and caudal block, each providing around four hours of postoperative analgesia (55,74), although disturbingly, a 2008 Cochrane Review found that 30 to 50% of patients still needed rescue analgesia in the recovery unit after either of these techniques (75). EMLA cream provided inferior postoperative analgesia than either DPNB, caudal block or ringblock, with a typical duration of less than one hour (74). As pain after circumcision has been described as severe and long lasting (26-28), none of the above techniques are likely to provide complete postoperative analgesia after circumcision.

INCONSISTENCY OF CURRENT HEALTH DEPARTMENT AND MEDICAL COLLEGE POLICY

While the medical practitioners performing RNC in Australia may include surgeons, obstetricians and general practitioners, none of their Professional Colleges have policies regarding anaesthesia for RNC. Neither the Royal Australasian College of Surgeons, nor the Australian and New Zealand Association of Paediatric Surgeons have a current policy statement on neonatal circumcision. Both appear to have discarded their joint 1996 position, which stated that RNC was an inappropriate, traumatic and unnecessary procedure with no medical indications, which, if performed at all, should be done after six months of age with an experienced surgeon and a paediatric anaesthetist (65). Only the RACP has a policy, stating since 1996 that appropriate anaesthesia must be used (12), and ranking DPNB above EMLA, and EMLA above sucrose in order of effectiveness for neonates (5). Paediatricians who refer neonates to surgeons performing RNC without appropriate anaesthesia would appear to be disregarding their own College guidelines. In the authors' opinion, the RACP should ensure that its members are aware of their College policy, and the Royal Australasian College of Surgeons, Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the Royal Australian College of General Practitioners should urgently review their positions regarding anaesthesia for RNC.

CONCLUSION AND RECOMMENDATIONS

Neonatal circumcision is an elective surgical procedure which causes significant pain. Neonatal circumcision without anaesthesia is unacceptable practice. Neonatal circumcision with inadequate anaesthesia is also unacceptable practice. Oral sucrose does not provide anaesthesia for RNC. Topical anaesthesia with EMLA cream is inferior to other local anaesthetic techniques and has been reported to be inadequate for RNC. Local anaesthesia techniques including ringblock and DPNB may be acceptable, but can have significant failure rates and may provide inadequate pain relief. Ideally, local or regional techniques should be performed by a separate skilled anaesthetist, who can monitor the patient and intervene if anaesthesia is inadequate. Using ultrasound to guide DPNB, and supplementing the traditional paired dorsal injections with a peno-scrotal bleb, may improve the reliability of DPNB. Overall, general anaesthesia may arguably be more reliable than either ringblock or DPNB in ensuring adequate anaesthesia for neonatal circumcision, but involves its own risks and may mean deferment of the procedure until after six months of age. Appropriate anaesthesia for RNC is the policy of the majority of State Health Departments. However, several relevant Australian Medical Colleges do not have or do not enforce policies guiding their members towards appropriate anaesthesia for RNC. All should urgently address this deficiency.

REFERENCES

(1.) Grimes DA. Routine circumcision of the newborn infant: a reappraisal. Am J Obstet Gynecol 1978; 130: 125-129.

(2.) The British Association of Paediatric Surgeons, The Royal College of Nursing, The Royal College of Paediatrics and Child Health, The Royal College of Surgeons of England and The Royal College of Anaesthetists. Male Circumcision Guidance for Healthcare practitioners. The Royal College of Surgeons of England, London May 2000.

(3.) Alanis MC, Lucidi RS. Neonatal circumcision: a review of the world's oldest and most controversial operation. Obstet Gynecol Surv 2004; 59: 379-395.

(4.) Hill G. The case against circumcision. J Mens Health Gend 2007; 4: 318-323.

(5.) Royal Australian College of Physicians. Circumcision of infant males. Paediatrics & Child Health Division, The Royal Australasian College of Physicians, 145 Macquarie Street, Sydney, New South Wales 2000, Australia, 2010.

(6.) Perera CL, Bridgewater FHG, Thavaneswaran P, Maddern GJ. Nontherapeutic male circumcision: tackling the difficult issues. J Sex Med 2009; 6: 2237-2243.

(7.) Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays 2007; 29: 1147-1158.

(8.) Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV [editorial]. Med J Aust 2010; 193: 318-319.

(9.) Van Howe RS, Svoboda JS, Dwyer JG, Price CP. Involuntary circumcision: the legal issues. BJU Int 1999; 83: 63-73.

(10.) Boyle GJ, Svoboda JS, Price CP, Turner JN. Circumcision of healthy boys: criminal assault? J Law Med 2000; 7: 301-310.

(11.) Office of the United Nations High Commissioner for human rights. Convention on the rights of the child. From http://www2. ohchr.org/english/law/crc.htm Accessed April 2011.

(12.) Australian College of Paediatrics. Position Statement, Routine Circumcision of Normal Male Infants and Boys. Australian College of Paediatrics. Parkville, Victoria, 1996.

(13.) Government of South Australia. Department of Health. Guidelines for Male Circumcision in South Australian Public Hospitals. From http://www.health.sa.gov.au/ ELECTIVESURGERY/Portals/0/Exclusion%20-%20 Health%20Care%20Professionals%20Fact%20Sheet.pdf Accessed April 2011.

(14.) Government of New South Wales. Department of Health. Circumcision of Normal Male Infants: Policy. From http:// www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_330.pdf Accessed September 2011.

(15.) Government of Victoria. Department of Human services. Guidelines for male circumcision in the Victorian Public Health System. From www.health.vic.gov.au/.../circumcision/ circumcision-guidelines-healthprof.pdf Accessed September 2011.

(16.) Government of Western Australia, Minister for Health. Letter. Government of Western Australia, Minister for Health, Governor Stirling Tower, 197 St Georges Tce, Perth, Western Australia. 11 July 2011.

(17.) Government of Australia. Medicare Australia Statistics. From https://www.medicareaustralia.gov.au/cgi-bin/broker. exe?_PROGRAM=sas.mbs_item_standard_report.sas&_ SERVICE=default&DRILL=ag&_DEBUG=0&group=30 653%2C30656%2C+30659%2C+30660&VAR=services&ST AT=count&RPT_FMT=by+state&PTYPE=calyear&STAR T_DT=200601&END_DT=201012 Accessed April 2011.

(18.) Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77: 291-295.

(19.) Williamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 1983; 71: 36-40.

(20.) Dixon S, Snyder J, Holve R. Behavioural effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984; 5: 246-250.

(21.) Gunnar MR, Malone S, Vance G, Fisch RO. Quiet sleep and levels of plasma cortisol during recovery from circumcision in newborns. Child Dev 1985; 56: 824-834.

(22.) American Academy of Pediatrics, Committee on the Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery. Neonatal anesthesia. Pediatrics 1987; 80: 446.

(23.) Anand KJS, Hickey PR. Pain and its effects in the human neo nate and fetus. N Engl J Med 1987; 317: 1321-1329.

(24.) Chamberlain DB. Babies remember pain. Pre- Perinatal Psychol 1989; 3: 297-310.

(25.) Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 345: 291-292.

(26.) Bramwell RGB, Bullen C, Radford P. Caudal block for postoperative analgesia in children. Anaesthesia 1982; 37: 1024-1028.

(27.) McGowan PR, May H, Molnar Z, Cunliffe M. A comparison of three methods of analgesia in children having day case circumcision. Paediatr Anaesth 1998; 8: 403-407.

(28.) Goldman R. The psychological impact of circumcision. BJU Int 1999; 83: 93-103.

(29.) Warren J. Circumcison. Lancet 1995; 345: 927.

(30.) Morris BJ, Bailis SA, Castellsague X, Wiswell TE, Halperin DT. RACPs policy statement on infant male circumcision is ill-conceived. Aust N Z J Public Health 2006; 30: 16-22.

(31.) Russell CT. Circumcision: another view. MedicineToday 2002; 3: 124-125.

(32.) al-Samarrai AY. Plastibell circumcision. J R Coll Surg Edinb 1991; 36: 411.

(33.) Stang HJ, Snellman LW, Condon LM, Conroy MM, Liebo R, Brodersen L et al. Beyond dorsal penile nerve block: a more humane circumcision. Pediatrics 1997; 100: 1-6.

(34.) Taddio A, Stevens B, Craig K, Rastogi P, Ben-David S, Shennan A et al. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med 1997; 336: 1197-1201.

(35.) American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999; 103: 686-693.

(36.) Fitzgerald M. The birth of pain. Medical Research Council News 1998; Summer: 20-23.

(37.) Simons SH, van Dijk M, Anand KS, Roofthooft D, van Lingen RA, Tibboel D. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med 2003; 157: 1058-1064.

(38.) Coleman M, Kolawole S, Smith C. Assessment and management of pain and distress in the neonate. Adv Neonatal Care 2002; 2: 123-139.

(39.) Anand KJS, Scalzo F. Can adverse neonatal experiences alter brain development and subsequent behaviour? Biol Neonate 2000; 77: 69-82.

(40.) Hermann C, Hohmeister J, Demirakga S, Zohsel K, Flor H. Long term alteration of pain sensitivity in school aged children with early pain experiences. Pain 2006; 125: 278-285.

(41.) Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal 1999; 29: 215-221.

(42.) Bouwmeester NJ, Anand KJ, van Dijk M, Hop WC, Boomsma F, Tibboel D. Hormonal and metabolic stress responses after major surgery in children aged 0-3 years: a double blind, randomised trial comparing the effects of continuous versus intermittent morphine. Br J Anaesth 2001; 87: 390-399.

(43.) Clifford PA, Stringer M, Christensen H, Mountain D. Pain assessment and intervention for term newborns. J Midwifery Womens Health 2004; 49: 514-519.

(44.) Emde RN, Harmon RJ, Metcalf D, Koenig KL, Wagonfeld S. Stress and neonatal sleep. Psychosom Med 1971; 33: 491-497.

(45.) Anders TF, Chalemian RJ. The effects of circumcision on sleep-wake states in human neonates. Psychosom Med 1974; 36: 174-179.

(46.) Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychol 2002; 7: 329-343.

(47.) Talbert LM, Kraybill EN, Potter HD. Adrenal cortical response to circumcision in the neonate. Obstet Gynecol 1976; 48: 208-210.

(48.) Gunnar MR, Fisch RO, Korsvik S, Donhowe JM. The effects of circumcision on serum cortisol and behaviour. Psychoneuroendocrinology 1981; 6: 269-275.

(49.) Rawlings DJ, Miller PA, Engel RR. The effect of circumcision on transcutaneous PO2 in term infants. Am J Dis Child 1980; 134: 676-678.

(50.) Brady-Fryer B, Wiebe N, Lander JA. Pain relief for neonatal circumcision. Cochrane Database Syst Rev 2004; 18:CD004217.

(51.) Marchette I, Main R, Redick E. Pain reduction during neonatal circumcision. Pediatr Nurs 1989; 15: 207-210.

(52.) Willamson PS, Evans ND. Neonatal cortisol response to circumcision with anesthesia. Clin Pediatr (Phila) 1986; 25: 412-425.

(53.) Irwin MG, Cheng W. Comparison of subcutaneous ring block of the penis with caudal epidural block for post-circumcision analgesia in children. Anaesth Intensive Care 1996; 24: 365-367.

(54.) Ng WT, Ng TK, Tse S, Keung Wong C, Wing Lau H. The use of topical lidocaine/prilocaine cream prior to childhood circumcision under local anesthesia. Ambul Surg 2001; 9: 9-12.

(55.) Choi WY, Irwin MG, Hui TW, Lim HH, Chan KL. EMLA cream versus dorsal penile nerve block for postcircumcision analgesia in children. Anesth Analg 2003; 96: 396-399.

(56.) Taddio A, Pollock N, Gilbert-MacLeod C, Ohlsson K, Koren G. Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med 2000; 154: 620-623.

(57.) Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA 1997; 278: 2157-2162.

(58.) Kirya C, Werthmann MW. Neonatal circumcision and dorsal penile nerve block - a painless procedure. J Pediatr 1978; 92: 998-1000.

(59.) Sandeman DJ, Dilley AV. Ultrasound guided dorsal penile nerve block in children. Anaesth Intensive Care 2007; 35: 266-269.

(60.) Russell CT, Chaseling J. Topical anaesthesia in neonatal circumcision: a study of 208 consecutive cases. Aust Fam Physician 1996; Suppl 1: S30-34.

(61.) Benini F, Johnson CC, Faucher D, Aranda JV. Topical anesthesia during circumcision in newborn infants. JAMA 1993; 270: 850-853.

(62.) Butler-O'Hara M, LeMoine C, Guillet R. Analgesia for neonatal circumcision: a randomized controlled trial of EMLA cream versus dorsal penile nerve block. Pediatrics 1998; 101: E5.

(63.) Howard CR, Howard FM, Fortune K, Generelli P, Zolnoun D, tenHoopen C et al. A randomized, controlled trial of a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) versus penile nerve block for pain relief during circumcision. Am J Obstet Gynecol 1999; 181: 1506-1511.

(64.) Cold CJ, Taylor JR. The prepuce. BJU Int 1999; 83 (Suppl 1): 34-44.

(65.) Leditshke JF. Guidelines for Circumcision. Australasian Association of Paediatric Surgeons. Herston, Queensland, 1996.

(66.) Lim A, Saw Y, Wake PN, Croton RS. Use of a eutectic mixture of local anaesthetics (EMLA) in the release of preputial adhesions: is it a worthwhile alternative? Br J Urol 1994; 73: 428-430.

(67.) Preston EN. Whither the foreskin? A consideration for routine neonatal circumcision. JAMA 1970; 213: 1853-1858.

(68.) Williams N, Kapila L. Complications of circumcision. Br J Surg 1993; 80: 1231-1236.

(69.) Goodman J. Jewish circumcision: an alternative perspective. BJU International 1999; 83: 22-27.

(70.) Mak MY, Philip AE, Cho SC, Chan JT. Postoperative analgesia in children day surgery circumcision: comparison of 3 methods. Ann Coll Surg HK 2001; 5: 146-150.

(71.) Lunn JN. Postoperative analgesia after circumcision: a randomised comparison between caudal analgesia and intramuscular morphine in boys. Anaesthesia 1979; 34: 552-554.

(72.) Tree-Trakarn T, Pirayavaraporn S. Postoperative pain relief for circumcision in children: comparison among morphine, nerve block, and topical analgesia. Anesthesiology 1985; 62: 519-522.

(73.) Howard CR, Howard FM and Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93: 641-646.

(74.) Lee JJ, Forrester P. EMLA for postoperative analgesia for day case circumcision in children: a comparison with dorsal nerve of penis block. Anaesthesia 1992; 47: 1081-1083.

(75.) Cyna AM, Middleton P. Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys. Cochrane Database Syst Rev 2008; 8: CD003005.

B. R. PAIX *, S. E. PETERSON ([dagger])

Department of Anaesthesia, Flinders Medical Centre, Adelaide, South Australia and Faculty of Health Sciences, School of Veterinary and Biomedical Sciences, Murdoch University, Perth, Western Australia, Australia

* MB, BS, BMedSc (Hons), FANZCA, Senior Staff Anaesthetist, Department of Anaesthesia, Flinders Medical Centre, Adelaide, South Australia.

([dagger]) BS. (Biotechnology), Hons (Bioinformatics), PhD Candidate, Faculty of Health Sciences, School of Veterinary and Biomedical Sciences, Murdoch University, Perth, Western Australia.

Address for correspondence: Dr B. R. Paix, Senior Staff Anaesthetist, Flinders Medical Centre, South Road, Bedford Park, SA 5042. Email: flyingdoc@bigpond.com

Accepted for publication on January 10, 2012.
Table 1
A comparison of the effectiveness of DPNB, Ringblock and
EMLA cream for pain relief during routine neonatal
circumcision

 Number of
First author Year subjects Study design

Benini (61) 1993 28 RCT of EMLA vs placebo

Taddio (34) 1997 59 RCT of EMLA vs placebo

Lander (57) 1997 52 RCT of Ringblock vs DPNB vs
 EMLA vs placebo

Butler-O'Hara (62) 1998 64 RCT of DPNB vs EMLA vs placebo

Howard (63) 1999 60 RCT of DPNB vs EMLA

Brady-Fryer (50) 2004 35 trials Cochrane systematic review
 of anesthesia for RNC

First author Conclusion

Benini (61) EMLA better than placebo but both
 groups clearly distressed

Taddio (34) EMLA better than placebo but did
 not eliminate pain

Lander (57) Ringblock better than DPNB, DPNB better
 than EMLA, EMLA better than placebo,
 but with the EMLA group clearly distressed

Butler-O'Hara (62) DPNB better than EMLA, EMLA better than placebo

Howard (63) DPNB better than EMLA

Brady-Fryer (50) DPNB substantially better than EMLA but
 neither fully eliminated circumcision pain

DPNB=dorsal penile nerve block, EMLA=eutectic mixture
of local anaesthetic (lignocaine prilocaine cream),
RCT=randomised controlled trial.
COPYRIGHT 2012 Australian Society of Anaesthetists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2012 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:Point of View
Author:Paix, B.R.; Peterson, S.E.
Publication:Anaesthesia and Intensive Care
Article Type:Report
Geographic Code:8AUST
Date:May 1, 2012
Words:4277
Previous Article:Dreaming during sevoflurane or propofol short-term sedation: a randomised controlled trial.
Next Article:Donation after cardiac death in Queensland: review of the pilot project.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters