Circumcision of neonates and children without appropriate anaesthesia is unacceptable practice.
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evidence exists that neonates continue to be circumcised in Australia without anaesthesia, with reports (authors' unpublished communications) of the practice ongoing in maternity units around Australia.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.
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.
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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: email@example.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.
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|Title Annotation:||Point of View|
|Author:||Paix, B.R.; Peterson, S.E.|
|Publication:||Anaesthesia and Intensive Care|
|Date:||May 1, 2012|
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