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Guidelines For Pain Management During Newborn Circumcision

Pharmacologic Interventions

Use of topical anesthetic only
• One hour prior to the procedure administer acetaminophen (eg., Tylenol, 15 mg/kg) as ordered by the practitioner.
• Place a thick layer (1 gm) of EMLA cream around the penis where the prepuce (foreskin) attaches to the glans. Avoid placing cream on the tip of the penis where EMLA may come in contact with urethral opening.
• Cover the penis with a "finger cot" that is cut from a vinyl or latex glove, or a piece of plastic wrap and secure bottom of covering with tape. Avoid using Tegaderm or large amounts of tape on the skin because removing the adhesive causes pain and can irritate or remove the fragile skin.
• If the infant urinates during the time EMLA is applied (1 hour) and a significant amount of EMLA is removed, reapply the cream and covering. The total application of EMLA should not exceed a surface area of 10 cm² (1.25 by 1.25 inches).
• Remove cream with clean cloth or tissue. Blanching of skin is an expected reaction to EMLA's application under an occlusive dressing; erythema and some edema may occur also.
• During procedure, give the infant a sucrose solution: to make an approximate 24% sucrose solution, add 1 teaspoon of table sugar to 4 teaspoons of sterile water. Use this solution to coat the pacifier (recoat several times) or administer 2 ml to the tongue 2 minutes before the procedure.
• Following procedure, apply petrolatum or A&D ointment on a 4 x 4 dressing before diapering infant to prevent the wound from adhering to the dressing or diaper.
• Administer acetaminophen as ordered by the practitioner four hours after the initial dose; give additional doses as needed but not to exceed 5 doses in 24 hours or a maximum dose of 75mg/kg/day.

Use of dorsal penile nerve block (DPNB) or ring block
• One hour prior to the procedure administer acetaminophen as ordered by the practitioner.
• One hour prior to procedure apply EMLA. For the DPNB apply EMLA to the prepuce as described above, and at the penile base. For the ring block apply EMLA to the prepuce as described above and to the shaft of the penis. A topical anesthetic should be used in conjunction with the dorsal penile nerve block or ring block to avoid the pain of injecting the anesthetic.
• Use a 30-gauge needle to administer the lidocaine; inject the anesthetic slowly.* For the DPNB, 0.4 ml of the lidocaine is infiltrated at the 10:30 o'clock and at the 1:30 o'clock positions in Buck's fascia at the penile base. For the ring block, 0.4 ml of lidocaine is infiltrated subcutaneously on each side of the shaft of the penis below the prepuce.
• For maximum anesthesia, wait 5 minutes following the injection of lidocaine. An alternative anesthesia is chloroprocaine, which is as effective as lidocaine after 3 minutes.
• During the circumcision, allow infant to suck a pacifier coated with a slurry of sugar and water as described above; recoat pacifier several times during the procedure.
• Apply petrolatum or A&D ointment to a 4 x 4 gauze and cover the wound before diapering infant. This prevents wound from adhering to dressing or diaper. Administer acetaminophen as ordered by practitioner four hours after the initial dose; give additional doses as needed but not to exceed 5 doses in 24 hours or a maximum dose of 75mg/kg/day.

* In one study, the use of buffered lidocaine, which normally reduces the stinging sensation of lidocaine, did not provide effective anesthesia for DPNB (Stang and others, 1997). The study on slow injection of the anesthetics lidocaine and bupivacaine compared 40 vs 80 seconds in patients aged 15-53 years (Serour, Mandelberg & Mori, 1998).

Non-pharmacologic Interventions (to accompany pharmacologic interventions above)

• If Circumstraint board is used, pad with blankets or other thick, soft material, such as "Lambs wool." A more comfortable, padded and physiologic restraint that places the infant semi-reclining can also decrease distress (Stang and others, 1997).**
• Provide the parents, caregiver, or another staff member with the option to hold the infant during the procedure or to be present during the circumcision.
• Swaddle the upper body and legs to provide warmth and containment and to reduce movement.
• If the patient is not swaddled and is unclothed, use a radiant warmer to prevent hypothermia. Shield infant's eyes from overhead lights
• Pre-warm any topical solutions to be used in sterile preparation of the surgical site by placing in a warm blanket or towel.
• Play infant relaxation music*** before, during, and after procedure; allow parents or other caregiver the option to provide the music of their choice.
• Following the procedure, remove restraints and swaddle. Immediately have the parent, other caregiver, or nursing staff hold the infant. Continue to have the infant suck on pacifier or offer feeding.

Note: On March 11, 1999, the FDA approved the use of EMLA in infants age 37 weeks of gestation. Although the package insert lists under "Warnings" that patients taking drugs associated with drug-induced methemoglobinemia, such as acetaminophen, are at greater risk for developing methemoglobinemia, there have been no reported cases of this complication occurring in children taking acetaminophen and using EMLA. In fact, there is no evidence that acetaminophen is a methemoglobin-inducing drug in humans. (Prescott LF: Paracetamol (acetaminophen): a critical bibliographic review, Taylor & Francis, Bristol, PA, 1996.) The only reported cases of methemoglobinemia from acetaminophen have been in cats and dogs. (Hjelle JJ, Grauer GF: Acetaminophen-induced toxicosis in dogs and cats, J Am Vet Med Assoc 188(7):742-749, 1986.)

** For information on the Stang Circ Chair, contact Pedicraft, 4134 Augustine Rd., Jacksonville, FL 32207; 1-800-223-7649; Email info@pedicraft.com; www.pedicraft.com

*** Suggested infant relaxation music: "Heartbeat Lullabies" by Terry Woodford. Available from, Baby-Go-To-Sleep Center, Audio Therapy Innovations, Inc., P.O. Box 550, Colorado Springs, CO 80901; 1-800-537-7748; www.babygotosleep.com.

References

American Academy of Pediatrics, Task Force on Circumcision (1999). Circumcision policy statement. Pediatrics, 103(3), 686-693.
Abstract

"Circumcision: Information for Parents" is available from American Academy of Pediatrics, Division of Pediatrics, 141 Northwest Point Blvd., PO Box 747, Elk Grove Village, IL 60009-0747; Phone: 800-433-9016; Fax: 847-228-1281; www.aap.org.

Broadman, L.M., Hannallah, R.S., Belman, A.B., Elder, P.T., Ruttimann, U., & Epstein, B.S. (1987). Post-circumcision analgesia - a prospective evaluation of subcutaneous ring block of the penis. Anesthesiology, 67, 399-402.

Gourrier, E., and others (1996): Use of EMLA cream in a department of neonatology, Pain 68, 431-434.

Howard, C.R., Howard, F.M., & Weitzman, M.L. (1994). Acetaminophen analgesia in neonatal circumcision: the effect on pain, Pediatrics 93(4):641-646.

Lander, J., Brady-Fryer, B., Metcalfe, J.B., Nazarali, S., & Muttitt, S. (1997). Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA, 278, 2157-2162.

Mintz, M.R. & Grillo, R. (1989). Dorsal penile nerve block for circumcision. Clinical Pediatrics, 28, 590-591.

Myron, A.V. & Maguire, D.P. (1991). Pain perception in the neonate: implications for circumcision. Journal of Professional Nursing, 7, 188-195.

Sermour F, Mandelberg A, & Mori J (1998). Slow injection of local anesthetic will decrease pain during dorsal penile nerve block. Acta Anesthesiologica Scandinavica, 42, 926-928.

Spencer, D.M., Miller, K.A., O'Quin, M., Tomsovic, J.P., Anderson, B., Wong, D., & Williams, W.E. (1992). Dorsal penile nerve block in neonatal circumcision: chloroprocaine versus lidocaine. American Journal of Perinatology, 9,(3), 214-218.

Stang, H. et al. (1997). Beyond dorsal penile nerve block: a more humane circumcision, Pediatrics 100(2): E3. (www.pediatrics.org/cgi/content/full/100/2/e3)

Stevens, B., Taddio,A., Olsson, A., Einarson, T. (1997). The efficacy of sucrose for relieving procedural pain in neonates — a systematic review and meta-analysis. Acta Pediatrics, 86, 837-842.

Taddio A, Stevens, B., et al. (1997). Efficacy and safety of lidocaine-prilocaine cream (EMLA) for pain during circumcision, NEJM, 336(17):1197-1201.

Williamson, M.L. (1997). Circumcision anesthesia: a study of nursing implications for dorsal penile nerve block. Pediatric Nursing, 23, 59-63.

Wong DL, Pasero CL: Using local anesthetics to control procedural pain, Am J Nurs 97(1):17, 1997.

Wong DL, Pasero CL: Reducing the pain of lidocaine, Am J Nurs 97(1):17-18, 1997.

Yaster, M., Krane, E.J., Kaplan, R.F., Cote, C.J., & Lappe, D.G. (1997). Pediatric Pain Management and Sedation Handbook. Mosby, St. Louis.

Additional Information

Guidelines for Using EMLA

American Academy of Pediatrics Revised Circumcision Policy Statement

Effect of Neonatal Circumcision on Pain Response During Subsequent Routine Vaccination

EMLA Approved For Newborns, Available In Disc, and Relieves Pain of Chest Tube Removal and a note about acetaminophen

March 15, 2002

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