Anesthesia for Neonatal Circumcision: Who Benefits?
As the medical myths used to justify the practice of neonatal circumcision have each been disproven, the latest "myth" used by circumcisers to perpetuate the surgery is that the use of topical and local anesthetics "eliminates" the pain of neonatal circumcision. While some interventions have reduced the amount of crying during the surgery, it is not clear whether topical or local anesthetics reduce pain substantially. Their impact on the stress of the surgery appears to be minimal. If these attempts at pain relief are not very beneficial for the infant, are they employed to make the circumciser and the parents feel better about what they are doing to the newborn? If these methods are not effective, why is there currently a call for their routine use?
1. Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med 1987; 317: 1321-9
2. Garry T. Circumcision: a survey of fees and practices. OBG Management 1994 (October): 34-6.
3. Cold CJ. Neonatal circumcision. Lancet 1997; 349: 1257-8.
4. Porter FL, Forges SW, Marshall RE. Newborn pain cries and vagal tone: parallel changes in response to circumcision. Child Dev 1988; 59: 495-505.
5. Gunnar MR, Porter FL, Wolf CM, Rigatuso J, Larson MC. Neonatal stress reactivity: predictions to later emotional temperment. Child Dev 1995; 66: 1-13.
6. Gunnar MR, Fisch RO, Korsvik S, Donhowe JM. The effects of circumcision on serum cortisol and behavior. Psychoneuroendocrinology 1981; 6: 269-75.
7. Gunnar MR, Fisch RO, Malone S. The effects of a pacifying stimulus on behavioral and adrenocortical responses to circumcision in the newborn. J Am Acad Child Psychiatry 1984; 23: 34-8.
8. Gunnar MR, Malone S, Vance G, Fisch RO. Coping with aversive stimulation in the neonatal period: quiet sleep and plasma cortisol levels during recovery from circumcision. Child Dev 1985; 56: 824-34.
9. Rawlings DJ, Miller PA, Engel RR. The effect of circumcision on transcutaneous PO2 in term infants. Am J Dis Child 1980; 134: 676-8.
10. Talbert LM, Kraybill EN, Potter HD. Adrenal cortical response to circumcision in the neonate. Obstet Gynecol 1976; 48:208-10.
11. Porter FL, Miller RH, Marshall RE. Neonatal pain cries: effect of circumcision on acoustic features and perceived urgency. Child Dev 1986; 57: 790-802.
12. Goldman R. Circumcision The Hidden Trauma: How an American Cultural Practice Affects Infants and Ultimately Us All. Boston: Vanguard Publications, 1997.
13. Malone SM, Gunnar MR, Fisch RO. Adrenocortical and behavioral responses to limb restraint in human neonates. Dev Psychobiol 1985; 18: 435-46.
14. Emde RN, Harmon RJ, Metcalf D, Koenig KL, Wagonfeld S. Stress and neonatal sleep. Psychosom Med 1971; 33: 491-7.
15. Anders TF, Chalemian RJ. The effects of circumcision on sleep-wake states in human neonates. Psychosom Med 1974; 36: 174-9.
16. Marshall RE, Porter FL, Rogers AG, Moore J, Andersen B, Boxerman SB. Circumcision: II. Effects upon mother-infant interaction. Early Hum Dev 1982; 7: 367-74.
17. Dixon S. Snyder J. Holve R. Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Peds 1984; 5: 246-250.
18. Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93: 641-6.
19. Brackbill Y. Continuous stimulation and arousal level in infancy: effects of stimulus intensity and stress. Child Dev 1975; 46: 364-9.
20. Davis M, Emory E. Sex differences in neonatal stress reactivity. Child Dev 1995; 66: 14-27.
21. Ramsay DS, Lewis M. The effects of birth condition on infants' cortisol response to stress. Pediatrics 1995; 95: 546-9.
22. Taddio A, Goldbach M, Ipp M, Stevens B, Koren G Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 345: 291-2.
23. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997; 349: 599-603.
24. Schoen EJ, Fischell AA. Pain in neonatal circumcision. Clin Pediatr Phila 1991; 30: 429-32.
25. Marchette L, Main R, Redick E. Pain reduction during neonatal circumcision. Pediatr Nurs 1989; 15: 207-8, 210.
26. Marchette L, Main R, Redick E, Bagg A, Leatherland J. Pain reduction interventions during neonatal circumcision. Nurs Res 1991; 40: 241-4.
27. Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics 1991; 87: 215-8.
28. Gunnar MR, Connors J, Isensee J, Wall L. Adrenocortical activity and behavioral distress in human newborns. Dev Psychobiol 1988; 21: 297-310.
29. Allen KD, White DD, Walburn JN. Sucrose as an analgesic agent for infants during immunization injections. Arch Pediatr Adolesc Med 1996; 150: 270-4.
30. Wiswell TE. "Circumcision: Foreskin Fact, Foreskin Fiction" Presented at Advances and Controversies in Clinical Pediatrics, San Francisco, California, May 17, 1997.
31. Wiswell TE. Circumcision circumspection. N Engl J Med 1997; 336: 1244-5.
32. Kirya C, Werthmann MW Jr. Neonatal circumcision and penile dorsal nerve blocka painless procedure. J Pediatr 1978; 92: 998-1000.
33. Poma PA. Painless neonatal circumcision. Int J Gynaecol Obstet 1980; 18: 308-9.
34. Maxwell LG, Vaster M, Wetzel RC, Niebyl JR. Penile nerve block for newborn circumcision. Obstet Gynecol 1987; 70: 415-9.
35. Holve RL, Bromberger PJ, Groveman HD, Klauber MR, Dixon SD, Snyder JM. Regional anesthesia during newborn circumcision. Effect on infant pain response. Clin Pediatr Phila 1983; 22: 813-8.
36. Williamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 1983; 71: 36-40.
37. Spencer DM, Miller KA, O'Quin M, Tomsovic JP, Anderson B, Wong D, Williams WE. Dorsal penile nerve block in neonatal circumcision: chloroprocaine versus lidocaine. Am J Perinatal 1992; 9: 214-8.
38. Arnett RM, Jones JS, Horger EO 3d Effectiveness of 1% lidocaine dorsal penile nerve block in infant circumcision. Am J Obstet Gynecol 1990; 163: 1074-80.
39. Holton ME. Comparison of newborn circumcision pain to calcaneal heel puncture pain: is newborn circumcision pain control clinically warranted? JAOA 1996; 96: 31-3.
40. Williamson PS, Evans ND. Neonatal cortisol response to circumcision with anesthesia. Clin Pediatr Phila 1986; 25: 412-5.
41. Masciello AL. Anesthesia for neonatal circumcision: local anesthesia is better than dorsal penile nerve block. Obstet Gynecol 1990; 75: 834-8.
42. Stang HJ, Gunnar MR, Snellman L, Condon LM, Kestenbaum R. Local anesthesia for neonatal circumcision. Effects on distress and cortisol response. JAMA 1988; 259: 1507-11.
43. Fontaine P, Dittberner D, Scheltema KE. The safety of dorsal penile nerve block for neonatal circumcision. J Fam Pract 1994; 39: 243-8.
44. Snellman LW, Stang HJ. Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision. Pediatrics 1995; 95: 705-708.
45. Sara CA, Lowry CJ. A complication of circumcision and dorsal nerve block of the penis. Anaesth Intensive Care 1985; 13: 79-82.
46. Berens R, Pontus SP Jr A complication associated with dorsal penile nerve block. Keg Anesth 1990; 15: 309-10.
47. Mandel S. Methemoglobinemia following neonatal circumcision. JAMA 1989; 261: 702.
48. Toffler WL, Sinclair AE, White KA. Dorsal penile nerve block during newborn circumcision: underutilization of a proven technique? J Am Board Fam Pract 1990; 3: 171-4.
49. Kaneko S, Bradley WE. Penile electrodiagnosis: penile peripheral innervation. Urology 1987; 30: 210-2.
50. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77: 291-95.
51. Mudge D, Younger JB. The effects of topical lidocaine on infant response to circumcision. J Nurse Midwifery 1989; 34: 335-40.
52. Weatherstone KB, Rasmussen LB, Erenberg A, Jackson EM, Claflin KS, Leff RD. Safety and efficacy of a topical anesthetic for neonatal circumcision. Pediatrics 1993; 92: 710-4.
53. Benini F, Johnston CC, Faucher D, Aranda JV. Topical anesthesia during circumcision in newborn infants. JAMA 1993; 270: 850-3.
54. Puthoff TD, Visconti JA, Tschampel MM. Use of EMLA prior to circumcision. Ann Pharmacotherapy 1996; 30: 1327-30.
55. Taddio A, Stevens B, Craig K, Rastogi P, Ben-David S, Shennan A, Mulligan P, Koren G. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med 1997336: 1197-1201.
56. Barreto J, Caballero C, Cubilla A. Penis. In: Sternberg SS, editor. Histology for Pathologists. New York: Raven Press, Ltd., 1992: 721-30.
57. Tse S, Barrington K, Byrne P. Methemoglobinemia associated with prilocaine use in neonatal circumcision. Am J Perinatology 1995; 12: 331-2.
58. Ozbek N, Sarikayalar F. Toxic methaemoglobinemia after circumcision. Eur J Pediatr 1993; 152: 80.
59. Gazarian M, Taddio A, Klein J, Kent G, Koren G. Penile absorption of EMLA cream in piglets: implications for use of EMLA in neonatal circumcision. Biol Neonate 1995; 68: 334-41.
60. Nilsson A, et al. Inverse relationship between age dependent erythrocyte activity of methemoglobin reductase and prolocaine-induced methemoglobinemia during infancy. Br J Anaesth 1990; 64: 72-6.
61. Kumar AR, Dunn N, Naqvi M. Methemoglobinemia associated with prilocaine-lidocaine cream. Clin Pediatr Phila 1997; 36: 239-40.
62. Lenhart JG, Lenhart NM, Reid A, Chong BK. Local anesthesia for circumcision: which technique is most effective. J Am Board Fam Pract 1997: 10: 13-9.
63. Pinkham EW, Stevenson AW. Unusual reactions to local anesthesia: gangrene of the prepuce. U S Armed Forces Med J 1958; 9: 120-2.
64. Stinson JM. Impotence and adult circumcision. J Natl Med Assoc. 1973; 65: 161.
65. Heitsch G. Swaddling eases circumcision. AAP News 1997; 13(7): 3.
66. Stang HJ, Snellman LW, Condon LM, Conroy MM, Liebo R, Brodersen, Gunnar MR. Beyond dorsal penile nerve block: a more humane circumcision [abstract] Pediatrics 1997; 100: 256-7.
67. Shechet J, Fried SM. Use of the Mogen clamp for neonatal circumcision, [letter] Am Fam Physician 1997; 55: 46.
68. Shechet J, Fried SM. Ritual circumcision and natural healing. [letter] Contemporary Pediatrics 1997; 14(4): 188.
69. "The Clinically Proven Mogen Circumcision Instruments," Mogen Circumcision Instruments Ltd. Brooklyn, New York.
70. DeSilva H. Pediatric Academic Societies, cited in Childs ND. Physician's choice of clamp may cause more pain. Pediatric News 1997; 31(8): 40.
71. Holly EA, Palefsky JM. Factors related to risk of penile cancer: new evidence from a study in the Pacific Northwest. J Natl Cancer Inst 1993; 85: 2-4.
72. Maden C, Sherman KJ, Beckmann AM, Hislop TG, Teh CZ, Ashley RL, Daling JR. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993; 85: 19-24.
73. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practices, and sexual practice. JAMA 1997; 277: 1052-7.
74. Price C. Male circumcision: an ethical and legal affront. Bull Med Ethics 1997; 128: 13-19.
75. Van Howe RS. Variations in penile appearance and findings: a prospective study. Br J Urol. In press.
76. Cold CJ, Van Howe RS, Storms MR. Anesthesia for neonatal circumcision. J Am Board Fam Pract 1997; 10: 310-1.
77. Van Howe RS. Neonatal circumcision. Lancet 1997; 349: 1257.
78. Warren J. Circumcision [letter] Lancet. 1995; 345: 927.
79. Fleiss PM. Circumcision [letter] Lancet. 1995; 345: 927.
80. Weiss GN. Local anesthesia for neonatal circumcision [letter] JAMA 1988; 260: 638.
81. Weiss GN, Weiss EB. A perspective on controversies over neonatal circumcision. Clin Pediatr Phila 1994; 33: 726-730.
82. Wellington N, Rieder MJ. Attitudes and practices regarding analgesia for newborn circumcision. Pediatrics 1993; 92: 541-3.
83. Australasian Association of Paediatric Surgeons. Guidelines for circumcision. April 1996.
84. Lenhart JG. Anesthesia for neonatal circumcision. J Am Board Fam Pract 1997; 10: 311.
83. Moses Maimonides (1135-1204), The Guide for the Perplexed, New York: Dover Publications, 1956.
Robert S. Van Howe, M.D. FAAP
Robert S. Van Howe, M.D. is a Clinical Instructor, Medical College of Wisconsin Department of Pediatrics, Marshfield Clinic - Lakeland Center, Minocqua, Wisconsin. Correspondence directed to: P.O. Box 1390, 9601, Townline Road, Minocqua, Wisconsin 54548-1390, Phone: 715-358-1191
Fax: 715-358-1156, email: firstname.lastname@example.org