Ring Block Improves Analgesia for Newborn Circumcision

Ricki Lewis, PhD

November 17, 2017

Adding ring block to a local anesthetic cream and sucrose improves pain relief for newborns being circumcised, according to a study published online today in Pediatrics.

Newborn circumcision is one of the most widely performed surgical procedures in the world, yet the degree to which patients feel pain and how best to address associated pain remain open to debate.

"Despite our findings and those in the extensive literature about the effectiveness and safety of different analgesic approaches for circumcision and pain management,

this procedure continues to be performed without a proper, standardized pain management strategy," the researchers write.

Rana Sharara-Chami, MD, and colleagues in the departments of pediatrics and adolescent medicine and surgery at American University of Beirut Medical Center, Lebanon, conducted a prospective, double-blinded, randomized controlled trial that compared three combination analgesic regimens with EMLA cream (which contains lidocaine and prilocaine) alone. The analgesic combinations consisted of EMLA cream and sucrose; EMLA cream, sucrose, and dorsal penile nerve block (DPNB); and EMLA, sucrose, and ring block (RB). Nurses applied the cream an hour before the procedure.

The investigators randomly assigned 70 healthy newborns in the nursery of a teaching hospital to intervention or the control EMLA cream alone in a 2:1 ratio. They assessed behavioral and physiologic aspects of pain.

Video images of each infant's face and torso during the procedure provided information on facial expression, crying time and intensity, breathing patterns, arm movements, and state of arousal, which are all part of the Neonatal Infant Pain Scale (NIPS). Nurses blinded to treatment group observed the patients hourly for the first 4 hours after the procedure and used the NIPS. 

NIPS findings range from 0 to 7, with values above 3 indicating pain. Secondary outcomes in the study included heart rate, respiratory rate, and oxygen saturation.

The extent of pain according to the scale differed significantly among the groups: for EMLA and sucrose, 3.1 (standard deviation [SD], 1.33); for EMLA, sucrose, and DPNB, 3 (SD, 1.33); for EMLA, sucrose, and RB, 2.45 (SD, 1.27); and EMLA alone, 5.50 (SD, 0.53). Breakdown of the procedure into four time intervals also revealed the group with ring block to experience the least pain, particularly during the most painful stage, lysis of adhesions between the foreskin and the glans. The 10 infants in the control group who received only EMLA cream experienced the most intense pain, ranging from 3.80 to 5.90 on the scale.

Heart rate and crying time were also significantly less in the intervention group than in the control group, with heart rate ranging from 139 to 163 beats/min and crying time from 5.78 to 45.37 seconds. However, oxygen saturation during the procedure and postoperative NIPS did not differ.

"During neonatal circumcision in boys, the most effective analgesia is RB combined with oral sucrose and EMLA cream. Our data revealed that during newborn circumcision, all interventions provided better pain relief than EMLA alone," the researchers conclude. They add that RB "must be performed by trained and experienced practitioners."

In an accompanying Commentary, David A. Rosen, MD, and Lynn M. Broadman, MD, from the Department of Anesthesia at the School of Medicine of West Virginia University, Morgantown, write that the level of expertise in the study — procedures performed by a "skilled pediatric urologist" — are not necessary. Ring block "can be readily mastered by most pediatric and obstetric practitioners with little training, and thus, it provides a safe,

nonnarcotic approach to providing both surgical anesthesia and postoperative analgesia to neonatal boys undergoing circumcision," they write, adding that they've taught the procedure to more than a thousand anesthesia residents, fellows, and nurses, with no complications.

The researchers and commentators have disclosed no relevant financial relationships.

Pediatrics. Published online November 17, 2017. Abstract, Commentary

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