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

Evaluating the Effectiveness of Nonpharmacologic Interventions

Multiple studies evaluating the effectiveness of nonpharmacologic interventions for the reduction of circumcision pain have been performed. In general, these measures have been found to be ineffective when used alone, but have shown effectiveness as adjunctive measures.

There has been extensive testing of sweet-tasting oral solutions administered during painful procedures in the neonatal period. Of these, sucrose has been the most widely studied and seems to provide the most consistent analgesia. It is theorized that sucrose and sweet-tasting solutions produce analgesia through both endogenous opioid and nonopioid pathways because of their sweet taste.[69,70,71,72] The analgesic effect of sucrose has been reversed with naloxone (Narcan; Endo Laboratories, Inc, Chadds Ford, PA) in studies with rat pups.[73] Although not as effective as a penile nerve block, oral sucrose water, generally at a 24% to 25% concentration, seems to provide significant adjunctive pain relief to infants undergoing circumcision.[44,55,57,69,74]

The use of pacifiers to calm newborn infants is universal; their soothing effect seems to be mediated by nonopioid systems.[75,76] Several studies have shown a synergistic effect with the combined use of a pacifier and sucrose to reduce circumcision pain.[74,75,76] The method of sucrose administration varies; pacifiers were dipped in sucrose or alternatively up to 2 mL of sucrose was administered to the anterior portion of the tongue, with or without the addition of a pacifier.[71] In practice, sucrose solution often is given in small amounts throughout a procedure. See Sidebar 1 for practical tips on sucrose preparation and administration. Video clip 3 shows a demonstration of this technique.

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Video clip 3

Circumcision boards are commonly used to immobilize infants for circumcision or other procedures. Infants may cry and exhibit significant distress when they are unwrapped and placed on this device. A circumcision board takes an infant, whose natural state is one of flexion, and forces the infant into an unnatural state of immobilized extension.

A specially designed, padded, physiologically supportive chair has been evaluated for infant circumcisions (Pedicraft, Jacksonville, FL). This chair enables the infants to sit in a flexed, comfortable position (Fig 6). The infants circumcised on this device (n 80) showed a 50% reduction in behavioral distress compared with those circumcised on the more common circumcision board.[45] However, in the absence of this chair, simple padding of the usual restraining board and swaddling of the upper part of the body are measures that are easily accomplished and will add to an infant's comfort (Fig 7). Swaddling of an infant's arms with hands positioned near the mouth, instead of restraining them in the usual extended position, facilitates self-regulation and self-consoling behavior.[77] View video clips 4 and 5 for a demonstration of comfortable and developmentally appropriate restraining techniques for newborn circumcision.

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Video clip 4

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Video clip 5

The Stang circumcision chair, providing physiologic positioning for newborn circumcision. Photograph courtesy of PEDICRAFT. Reprinted with permission.

Swaddling is an effective means to provide restraint and comfort in a developmental manner to newborns.

In 1989, the effect of sound on circumcision pain was investigated in a randomized controlled study of term infants (n = 58) undergoing unanesthetized circumcision. Infants were assigned to 1 of 3 intervention groups: routine care, classical music, or intrauterine sounds. Neither the music nor the intrauterine sounds effectively offset circumcision-related pain.[78] A second study, reported by the same research team in 1991, was a controlled trial of term infants (n = 121) also examining the impact of sound on circumcision pain. Infants were randomized to 6 different groups: classical music, intrauterine sounds, pacifier, music and pacifier, intrauterine sounds and pacifier, and a control group with no nurse present and no pacifier or sound interventions used. Analysis of the infants' behavioral and physiologic parameters showed that classical music and intrauterine sounds did not reduce the pain of circumcision.[79] In contrast, a more recent small, randomized, double-blind, experimental study of term infants (n = 23) concluded that music may have a positive effect on diminishing pain during circumcision.[58] None of these studies evaluated the effect of sound in combination with an effective penile block. Although sound has the potential to provide additional comfort, it is unlikely to stand alone as an effective intervention for an invasive surgical procedure.

Infants are routinely fasted for varying periods of time before circumcision.[41,52] It is likely that this practice originated from the theoretic risk of vomiting, which may be seen, in response to pain, during an unanesthetized circumcision.[5] The safety of discontinuing this practice, now that adequate analgesia and anesthesia are available, has been prospectively evaluated in a study of 80 infants. There was "no forced fasting period preoperatively," the mean time since last feeding being 1.19 hours, and no negative sequelae were reported.[45]

Infants cry when they are hungry. Withholding food adds to an infant's discomfort during circumcision. Neurologically intact infants have numerous innate reflexive mechanisms to protect their airway during vomiting, and in this population, vomiting rarely leads to aspiration.[80,81] For these reasons, it may be safe to discontinue the practice of withholding food before circumcision. Further study is required to evaluate this practice. Infants should be observed closely during the procedure for vomiting. If it occurs, the procedure should be interrupted and the infant's mouth and nose cleared with a bulb suction device; the procedure can likely be resumed.

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