A Pictorial and Video Guide to Circumcision Without Pain

Nancy L. Kraft, RNC, MSN, NNP


Adv Neonatal Care. 2003;3(2) 

In This Article

Implications for Clinical Practice

Although great strides in the recognition and treatment of circumcision pain have been made, no single study to date has evaluated an approach to circumcision that integrates the multiple modalities that have been shown to be safe and effective when used individually. In the absence of these studies, clinicians who assist with or perform circumcision must use a combination of the existing science, along with experience and reason to guide their practice.

Using a multimodal approach to pain prevention during a newborn circumcision might lead to the following approach. The infant is premedicated with a 10- to 15-mg/kg dose of acetaminophen by mouth at least 30 minutes before the procedure. He is placed on a padded circumcision chair with his legs restrained in a comfortable, semiflexed position. His arms are secured with a swaddled blanket technique and placed in a flexed position with his hands placed near his face to allow for self-comforting measures. He is under a radiant warmer so his temperature is consistent and comfortable. His eyes are shielded from any bright light. A pacifier along with some 25% sucrose water is provided. His penis and groin are prepped with a warmed anti-septic solution, and 0.5% or 1% lidocaine is administered slowly in an SQRB (Fig 9). The circumcision is performed with a Mogen clamp. When the circumcision is complete, the infant is given to his parents, who will comfort and cuddle him, and he receives additional oral doses of acetaminophen every 6 to 8 hours, for 24 hours (Figs 10 and 11). View video clips 6, 7, and 8 for an example of an infant being circumcised using this multimodal approach.

Lidocaine infiltration for an SQRB.

Safely completing the circumcision is facilitated by a quiet and comfortable infant.

Wide-eyed interactive infant immediately after a circumcision providing adequate anesthesia and analgesia. Note the contrast with Fig 1.

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Video clip 6

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Video clip 7

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Video clip 8

The bedside nurse is a vital advocate for the infant undergoing a circumcision. Ensure that the infant is not hungry, position him comfortably, shield his eyes from bright light, and have a bulb syringe, pacifier, sucrose water, acetaminophen, and supplies for a penile block available at the bedside. While the neonatal nurse practitioner (NNP)/physician performs the circumcision, remain close by to monitor the infant's response to the procedure and provide assistance as needed.

Objectively assess pain with a pain assessment tool. This will help to identify and quantify pain and aid in evaluating the impact of measures taken to provide comfort and pain relief during circumcision. The Neonatal Infant Pain Scale (NIPS), a valid and reliable tool, was specifically designed for monitoring procedural pain. It is user-friendly and does not require cardiorespiratory equipment, making it ideal for use in the setting of newborn circumcision.[85] Pain, the fifth vital sign, should be anticipated and treated before the procedure, monitored throughout the procedure, and further assessed and treated after the procedure. Teach parents the signs and symptoms of pain and how to measure and administer acetaminophen in the home setting.

NNPs are performing circumcisions in some clinical settings. Proper education, training, and demonstrated competency to perform the procedure and to administer the appropriate anesthesia and analgesia must be prospectively established. Several pictorial guides and videos are available to assist in learning these techniques.[36,41,42,86] In addition to establishing that the scope of professional licensure covers this procedure, many hospitals require special medical or allied staff credentials and periodic proof of ongoing competency.

To ensure quality and consistency in the approach to circumcision, organizations are encouraged to develop a multidisciplinary evidence-based protocol, supporting the use of penile blocks and adjunctive comfort measures for this procedure. This protocol should provide mandated education and training and establish consistent guidelines for all practitioners who perform circumcisions.[12,87] Written parent information materials, such as brochures and consent forms, must address pain management strategies. The development of policies, procedures, and protocols are a positive step toward ensuring that comfort measures and a penile nerve block become the standard of care for every infant undergoing circumcision.


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