A Pictorial and Video Guide to Circumcision Without Pain

Nancy L. Kraft, RNC, MSN, NNP

Disclosures

Adv Neonatal Care. 2003;3(2) 

In This Article

Abstract and Introduction

Despite the 1999 American Academy of Pediatrics (AAP) policy statement indicating that routine neonatal circumcision is not medically necessary, circumcision continues to be the most frequently performed surgical procedure in the newborn period in the United States. Further, many health care practitioners routinely perform this procedure without the use of any or with inadequate or ineffective analgesia and anesthesia.

Multiple studies have evaluated the safety and efficacy of specific pharmacologic and nonpharmacologic interventions to relieve circumcision pain and discomfort. Penile nerve blocks, local anesthetics, various operative instruments, acetaminophen, sweet oral solutions, pacifiers, a physiologic restraining device, intrauterine sounds, and music all have been evaluated. This article synthesizes these studies and highlights their significance for current clinical practice. The article provides a detailed pictorial and video guide to circumcision with an emphasis on the use of multimodal strategies to ensure adequate anesthesia, analgesia, and infant comfort before, during, and after the procedure.

Although United States law prohibits the performance of even minor surgical procedures on animals without adequate anesthesia, there is no federal or state legislation to prevent the performance of unanesthetized circumcision on the human infant.[1] Caregivers who have witnessed or performed unanesthetized circumcisions probably are familiar with the following phrases. "He doesn't like being tied down." "He's just hungry." "He will never remember it." One only needs to witness the procedure to recognize the reality of circumcision pain (Fig 1).

Unanesthetized circumcision. Note the classic face of pain with prominent brow bulge, facial grimace, and gaping mouth. Reprinted with permission from The Saturday Evening Post Society, copyright 1982 BFL&MS, Inc.

Pain during circumcision results in physiologic instability, affecting heart and respiratory rates, transcutaneous oxygen saturations, and cortisol levels.[2,3,4,5,6] Infants who experience painful circumcisions exhibit behavioral changes, including increased crying and irritability and poorer feeding and responsiveness to their mothers in the postoperative period.[7,8] Infants who were circumcised without analgesia have a stronger response to pain during a subsequent routine vaccination than uncircumcised infants or those who received analgesia for the procedure.[9] There is no longer any doubt that newborn infants are fully capable of nociception and that circumcision is extremely painful.

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