Journal of Developmental and Behavioral Pediatrics, Volume 5, Issue 5, Pages 246-250. October 1984.
Department of Pediatrics and Department of Community Medicine, University of California, San Diego School of Medicine
Journal of Developmental and Behavioral Pediatrics, Volume 5, Issue 5, Pages 246-250. October 1984.
Department of Pediatrics and Department of Community Medicine, University of California, San Diego School of Medicine
Note:
Address for reprints: Suzanne Dixon, M.D.,
Division of General Pediatrics
(H-664), UCSD Medical Center,
225 Dickinson St.
San Diego, California 92103.
Dr Holve is currently at the Department of Family Medicine, Bucksport Regional Medical Center, Bucksport, Maine.
Dr. Bromherger is currently at the Division of Neonatology/Perinatology, Kaiser Permanente Medical Center, San Diego, California.
The behavior of full-term neonates undergoing circumcision with and without local anesthesia was examined using the Brazelton Neonatal Assessment Scale (BNAS). Evaluations were done blindly pre- and post- circumcision and on the day following the procedure. Infants receiving lidocaine in a dorsal penile nerve block (DPNB) remained more attentive to animate and inanimate stimuli following circumcision and demonstrated a greater ability to quiet themselves when disturbed. The smoothness and maturity of motor behaviors showed the expected rate of improvement or recovery curve in the anesthetized group, while the control group's behavior did not. Behavioral differences were still evident on the day following the procedure. This report adds to the growing body of data that indicate that circumcision is a painful procedure that disrupts the course of behavioral recovery following birth. These disruptions can be lessened by the use of local anesthesia to relieve pain and stress during the procedure without any additional morbidity. These data support the use of DPNB during anesthesia for routine neonatal circumcisions still requested by the majority of parents in the country.
Neonatal circumcision has remained a common practice in spite of efforts by the American Academy of Pediatrics and others to halt its use as a routine medical procedure.1-6 The few studies that have explored the effects of this procedure on the neonate's behavior have indicated that this is a stressful and painful event.7-11 Changes in heart rate, respiratory rate, transcutaneous pO2, adrenal cortical hormone secretion, sleep patterns, and behavioral patterns have been shown to be altered during and/or following circumcision of the full-term neonate. Indeed, circumcision has been recommended as a model for studying pain in the neonate,12 and its effects are suggested to be long lasting.13 Kirya and Werthmann14 described a simple technique for the use of local anesthesia during neonatal circumcision to minimize pain during this procedure. Williamson and Williamson12 reported a reduction in the infant's circumcision stress as indicated by several physiologic measures when a similar technique was used. It has also been demonstrated that a dorsal penile block with lidocaine reduced intraprocedure indicators of distress: crying and heart rate changes.15 The present study expands those observations to include an assessment of behavior pre- and post-circumcision in a group of infants receiving a dorsal penile block, in contrast to that of a group circumcised without the local anesthetic. The study was designed to determine whether the alterations in behavior following circumcision could be reduced through the use of a local anesthetic during the procedure.
The study population included 31 male infants who were born during a two-month period at UCSD Medical Center, San Diego, Calif. Parent(s) requested circumcision with informed consent for study participation. All were full-term appropriate for gestational age (AGA) infants of two to five days of age with an uncomplicated perinatal course. Subjects were randomly assigned to one of three groups: group 1 infants were restrained and circumcised with a Gomco clamp in the standard manner after dorsal penile nerve block (DPNB) with lidocaine (lidocaine group); eight were circumcised in a similar manner after DPNB with saline (group 2, saline control group) to control for the stress of an injection and possible effects of fluid volume compression on penile sensation. Eight were circumcised under identical circumstances without any injection (group 2, control group). The procedures were performed by a single physician who was blind to the injection content in groups 1 and 2. Heart rate and crying patterns were monitored continuously from the time of the initial restraint until completion of the procedure. The entire procedure has been described in detail elsewhere.15 Two physicians, were blind to the child's group until the end of the study. They performed behavioral assessments on 16 infants selected blindly and at random from the three subgroups. They utilized the Brazelton Neonatal Assessment Scale (BNAS),16 a widely used instrument that consists of 27 behavioral items, each scored on a scale of 1 to 9, and 20 reflexes, scored on a 3-point scale. The scale examines the organization and integration of behavior while the infant is being presented with a series of graded positive and adversive situations. Those behaviors that are most salient in specifying the infants' internal neurobehavioral organization and social interaction are particularly highlighted in this behavioral assessment. Both examiners were trained to reliability of greater than 0.85 on all items and demonstrated interscorer reliability at that level, at the inception and conclusion of the study. All assessments were performed in a quiet darkened room, and every effort was made to bring out the best performance of the infant over the 30-minute examination, in line with the established protocol. The examinations were conducted during interfeeding periods, prior to the circumcision (exam 1), following the circumcision (exam 2), and on the day following the procedure (exam 3). Half of the infants were breastfed, and these were distributed proportionately across the groups. The infants were all circumcised two to five days after birth. Clusters of assessment items normalized so that 9 was the optimal score and were then combined in an a priori, nonweighted fashion. This approach has been used in previous reports.17,18
Circumcision was completed in a satisfactory manner in all infants. One infant developed a small unilateral hematoma after the puncture of the superficial dorsal penile vein following regional anesthesia. There were no untoward effects from this. As reported previously, infants who received the DPNB with lidocaine showed less distress during the circumcision procedure. Heart rate changes were less, and percent of time that the baby cried was decreased in the anesthetized group.15
The mean scores on the Brazelton Neonatal Assessment Scale for the three groups at three examination periods are shown in Table I. These group means are broadly within the norm of behavior expected for American samples reported elsewhere.17-19 Individual variation in the item scores precluded demonstration of any statistically significant differences between the group means. However, the changes in behavior pre- and post-circumcision at the individual level within each of the groups was tested (alpha at 0.05 level) using the Mann-Whitney and Kniskal-Wallis one-way analysis of variance. nonparametric techniques appropriate for the small sample size.20
Changes from Pre- to Post-circumcision, Exam 1 and Exam 2 The orientation response to an inanimate auditory stimulus (i.e., rattle) showed significant differences between the groups in change of behavior from exam 1 and exam 2 (Kruskal-Wallis H = 6.84,p 1.
TABLE 1. Mean Scores of Brazelton
Neonatal Assessment Scale Scores At Three Exam Times in
Three Study Groups.
Lidocaine Group Saline Group Control Group
1 2 3 1 2 3 1 2 3
Habituation Light 1 5.33 6.44 5.25 4.50 3.75 5.50 5.75 5.00 5.50
Rattle 2 5.83 6.83 6.25 6.50 6.67 7.00 5.75 8.25 5.50
Bell 3 6.00 6.83 6.00 6.50 6.00 9.00 6.00 5.75 4.00
Pin 4 2.75 3.75 4.00 4.00 3.33 2.50 2.00 2.00 3.50
Orientation Ball 5 5.33 4.79 6.50 6.75 4.25 5.00 6.50 5.75 5.00
Rattle 6 6.44 5.78 6.00 6.75 5.50 6.33 7.00 7.00 7.00
Face 7 5.78 4.78 6.50 6.50 3.75 5.00 6.00 5.25 4.50
Voice 8 6.00 5.36 6.00 7.00 6.00 6.33 6.25 6.00 6.50
Face and voice 9 6.00 5.00 6.00 6.50 3.50 5.00 6.25 5.25 4.00
Alertness 10 5.56 4.11 5.20 6.50 4.75 5.00 6.00 6.25 5.00
Tone 11 5.44 5.00 4.80 5.25 4.75 5.33 4.50 4.75 4.50
Motor maturity 12 7.00 6.67 6.40 5.50 5.25 5.67 5.00 5.75 3.00
Pull-to-sit 13 7.00 6.56 6.00 5.00 4.25 5.33 4.75 4.50 4.50
Cuddliness 14 6.11 5.56 6.40 5.75 5.50 4.67 3.25 5.50 4.50
Defensive 15 5.56 3.56 5.40 3.25 3.25 2.33 5.00 5.25 4.00
Consolability 16 6.14 5.67 6.20 8.00 7.50 5.50 7.25 7.33 6.00
Peak excitement 17 6.00 6.00 5.80 5.25 6.25 6.00 5.00 4.75 6.00
Rapidity 18 5.25 6.00 6.20 4.50 4.25 6.00 5.25 4.00 3.50
Irritability 19 5.67 5.56 5.80 4.75 6.50 5.00 6.00 4.75 5.00
Activity 20 4.67 4.44 5.00 3.75 3.75 5.00 4.25 3.50 3.50
Tremulousness 21 2.89 4.44 5.40 3.75 5.33 4.67 5.25 5.50 4.00
Startle 22 3.00 3.56 3.75 3.50 4.25 4.33 2.75 4.00 4.50
Lability of state 23 5.11 6.22 6.60 4.50 5.25 5.00 5.50 5.75 5.50
Lability of color 24 3.22 4.00 3.80 2.00 3.50 3.67 2.75 3.00 4.00
Self-quieting 25 6.71 6.88 6.20 7.25 5.50 4.00 7.00 7.25 6.00
Hand to mouth 26 4.67 4.44 6.00 4.25 4.25 4.67 4.00 6.00 5.00
Smile 1.0
* Numbers refer to first, second. and third examinations.
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