Local Anesthesia for Infants Undergoing Circumcision

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Letters

Local Anesthesia For Infants Undergoing Circumcision

To the Editor.

Dr. Lander and colleagues¹ have shown once again the value and safety of anesthesia for neonatal circumcision. In this study, local infiltration ring block or dorsal penile nerve block resulted in less heart rate elevation and less crying during the circumcision procedure. Outcome measures said to have been investigated included heart rate, respiratory rate, oxygen saturation, palmar sweat, sleep-wake state, crying, motor responses, and methemoglobin level. Only heart rate, crying, and methemoglobin levels were reported, and the reader assumes that no significant changes were found in the remaining parameters.

A larger prospective, controlled study of the effectiveness of penile nerve block by Arnett et al.² showed not only significantly less heart rate elevation and less crying in the anesthetized infant, but also demonstrated significant decrease in oxygen saturation when circumcision was done without anesthesia. Although Lander et al followed the procedure of Kirya and Werthman³ for penile nerve block, using 0.4 mL of 1% lidocaine in each of two injection sites, the 14 nerve blocks under study were performed by 4 physicians and 3 assistants. In the study by Arnett et al,² 85% of the 44 injections and 51 circumcisions were performed by a single investigator, andonly 0.2 mL per injection site provided effective anesthesia.

We applaud the efforts of Lander et al to encourage the use of anesthesia for neonatal circumcision. However, we have observed that many physicians resist using such anesthesia in their practices, likely related to the erroneous belief that it adds much time to the circumcision procedure. Nontheless, as more parents become aware of its availability and effectiveness, more physicians become proponents of its value and expert in its use. All evidence indicates that such anesthesia does decrease the pain and stress on the infant.

E. O. Horger III, MD
Columbia, SC

Robert M. Arnett, MD
Spartanburg, SC

J. Stephen Jones, MD
Greenville, SC

To the Editor.

Dr. Lander and colleagues have corroborated earlier work documenting that significant pain is experienced during neonatal circumcision, especially when performed without anesthetic, and they are to be commended for recognizing that this pain should be considered.¹ In recommending that anesthetic should be administered during the neonatal period, the authors have failed, however, to note that the pain of circumcision would be more effectively addressed if the operation were postponed to a later age.

Historically, the neonatal period has been preferred for elective circumcisions in large part because of the perceived danger of administering anesthetic at a later age.² This logic was based on the unfortunate presumption that neonatal pain should be ignored. In view of the ongoing improvements in local anesthetics and the authors' argument that the pain of neonatal circumcision should be addressed, a more complete analysis of the available options is indicated. Two relevant medical concerns are mentioned: sexually transmitted diseases (STDs) and urinary tract infections. The objective of reducing urinary tract infection may represent a rationale for performing the procedure on neonates, but the cited authors do not recommend neonatal circumcision as a medically necessary procedure to address this risk. Methodological problems involve, for example, the reported counsel to retract the foreskin in the uncircumcised cohort. Other, less drastic strategies have been suggested.³

On the other hand, the prevention of STDs represents a far more important issue, and in this case, the need for more information argues for postponing the procedure. Although the cited studies have favored circumcision as a means of reducing the tranmission of STDs, more recent work has found a negligible association in most cases as well as evidence indicating that chlamydia infections occurs more often in men with circumcisions.⁴ But it is not the prevalence or transmission of STDs today that is primarily at issue. Rather of relevance to the neonate is the possible role of the foreskin in the transmission or prevention of future STDs decades hence, and this is both unknown and unknowable at birth.

Therefore, postponement of circumcision preserves options and allows for the decision to be informed by future developments. Postponement also has other advantages. For example, performing the operation at a later age increases the likelihood that the foreskin will have separated from the glans, and, as noted elsewhere, the risk of complications may be substantially reduced.⁵

The authors refer to the controversy surrounding the decision to circumcise, but the question at issue is more narrowly whether to circumcise at birth. Urgency in the choice of the neonatal period should be argued in the context of a presumption of preference that the decision to circumcise be informed by the patient's own advice.⁶It is not enough for the authors to claim that their method represents an improvement over current practice. In light of their pointed appreciation of the problems of both pain and pain management during the neonatal period, it should be noted that postponement is an alternative worth considering.

Carl Anderson, Ph.D.
University of Wisconsin

To the Editor.

Dr. Lander and colleagues¹ studied pain relief options for neonatal circumcision that differ greatly from those offered to adults for the same surgery. If these methods are ineffective in adults, why would they be considered efficacious in newborn who have a lower pain threshold? The Australian Association of Paediatric Surgeons recommends deferring circumcision until adequate anesthesia can be administered.²

To anyone familiar with the anatomy of the penis, these findings should not be surprising. In a study by Taddio et al, the eutectic mixture of local anesthetics cream (EMLA) was more effective than placebo during only 31% of the stages of neonatal circumcision.³ To be effective, the EMLA cream would have to penetrate the outer epidermis, dermis, dartos muscle, mucosal lamina propria, the fused inner prepuce mucosa/glans penis mucosa, and the glans lamina propria to anesthetize the free nerve endings of the glans penis. Clearly it does not. With higher doses, however, life-threatening consequences have been reported.⁴

Dorsal penile nerve block is inadequate because the ventral surface of the penis is also innervated by the perineal branch of the pudendal nerve.⁵ The frenulum, which has the highest concentration of nerve endings in the penis,⁶ is the prominent ventral structure and may not be affected by blocking the dorsal penile nerve.

There is currently little experience with ring block in neonates. Since Lander had 50% bruising with the ring block and little patient follow-up, it is impossible to predict its safety in newborns. While ring block was superior to no treatment, heart rates increased significantly above baseline, suggesting that the surgery was still painful with anesthetic use.

The apnea and choking noted in 18% of controls meet the criteria for apparent life threatening events. Reporting this as a new finding reflects how little study the most commonly performed surgery has received and howe the complications following circumcision have been ignored. While non-treatment of pain is clearly unethical in a research setting, we may have to debunk the pain is good for boys myth before anesthetized circumcisions are abandoned in clinical practice.

Although some men may prefer a scar on their penis, and some men may prefer to have an unanesthetized circumcision for personal reasons, ultimately, the decision is theirs, not their parents'. Instead of searching for the optimal anesthetic, the most prudent course may be to abandon ritual newborn circumcision.

Robert S. Van Howe, MD
Marshfield Clinic, Lakeland Center, Minocqua, Wis

Christopher Cold, MD
Marshfield Clinic, Marshfield, Wis

To the Editor.

Despite the several interesting points raised by Dr. Lander and colleagues,¹ some issues remain unresolved. As noted in previous studies,^2,3 EMLA cream has the risk of methemoglibinemia and only partly minimizes pain.

The main outcome measure is the analysis of variance of heartrate and the cry of babies undergoing the procedure contrasted with relaxed babies. To have a better perspective, the analysis of variance between babies crying for a diaper change or crying to be fed should be studied incontrast to that for relaxed babies, also.

The average length of time reported for a dorsal penile nerve block is 25 seconds and for a ring block is 48 seconds. Add 92 seconds (1.53 minutes), the average time the newborns cried after the block, and the total distress time becomes 117 seconds (1.95 minutes) for dorsal penile nerve block and 140 seconds (2.33 minutes) for ring block. Add 210 seconds (3.5 minutes), the listed average circumcision time (the newborns were not completely relaxed during their circumcisions), and the total distress time becomes 327 seconds (5.45 minutes) for dorsal penile nerve block and 350 seconds (5.83 minutes) for ring block.

Holman et al.⁴ recommend that [t]he clamp should remain secure for a total of five minutes to allow the crush effect to be complete ... to reduce the incidence of bleeding after the clamp is removed. Add this 300 seconds (5 minutes) so the total distress time is really 627 seconds (10.45 minutes) for dorsal penile nerve block and 650seconds (10.83 minutes) for ring block.

Furthermore, the Gomco and Mogen clamps precrush the proposed excision site.⁴ The inventor of the Mogen clamp stated: You get the same results by using a greater crushing pressure for a shorter period of time as by using a lesser crushing pressure for a longer period of time (Rabbi H. Bronstein, oral communication, August 6, 1962).

The Gomco clamp crushes the excision site with 1.35 kg (3 lb) of pressure and requires 8 to 10 minutes to complete the procedure.⁴ The Mogen clamp crushes the excision site with 5.4 kg (12 lb) of pressure and needs 1 to 2 minutes for the procedure to be completed.⁴ For crushing techniques, local anesthesia might be indicated.

However, the authentic traditional Jewish technique of newborn bris⁵ does not crush any tissue. Circumcision clamps and dorsal hemostats are not allowed. Excising time is about 1 second, the entire procedure takes approximately 10 seconds. Healing is by secondary intention (natural healing), and complications are rare. Most babies who are properly fed stop crying within a half a minute to a minute after the bris (without sedation or intoxication). Add 10 seconds of procedure and 60 seconds of postoperative crying for a total of seventy seconds. Furthermore, since there is no crushing of tissue, the pain is not as severe as with the other techniques. Therefore, with the authentic traditional Jewish technique, it is actually more humane to not subject the infant to local anesthesia.

Jewish patients interested in this technique should be referred to a mohel (ritual circumciser) who is adept at doing authentic traditional bris.

Rabbi Jacob Shechet
Los Angeles, Calif

Stanley M. Fried, MD
Kaiser Permanente, Downer, Calif

Barton Tanenbaum, MD
Beverly Hills, Calif.

Rabbi Shechet practices as a mohel.

In Reply.

Our study compared 3 anesthetic inventions to detect their relative effectiveness for neonatal circumcision, thus providing evidence to address a recently identified question.^1,2 We evaluated the authenticity of several beliefs about circumcision, neonates, and pain. We had the opportunity to observe and record apparent lifethreatening events by neonates who did or did not have an anesthetic. THe opportunity for systematic observation is not often available in clinical practice, and life-threatening events have often gone un-reported.

Many agree that clinicians should provide anesthetics for neonates having circumcision. Dr. Horger and colleagues thank that physicians may not use anesthetic because of the belief that it lengthens the procedure. We have faith that few physicians would consider the 5 to 10 minutes needed to provide an anesthetic as more important than a duty to protect the infant from preventable harm associated with pain.

Dr. Anderson has suggested that delaying circumcision presumably until adulthood, would eliminate several problems associated with neonatal circumcision. He did not elaborate on the risks that he thinks are related to neonatal circumcision. Anderson also suggested that we ought not to assume that all males will have a lifestyle that ncreases risks for STDs. He stopped short of suggesting that there is no medical indication for circumcision. This was the position of Drs Van Howe and Cold and one that is supported by the Fetus and Newborn Committee of the Canadian Pediatric (sic) Society.¹

In our study, we followed the procedure first described by Kirya and Werthmann.³ Horger et al may be correct that a smaller dose than 0.4 mL of 1% lidocaine in each injection site is effective but we know of no studies comparing dosages.

Rabbi Shechet and colleagues described an unusual approach to compare various circumcision techniques. They seemed to view overall time for the circumcision procedure as the important factor. This is not unlike the argument for performing circumcision without a block⁴--that a quick and efficient circumcision negates the need for a block. Our results show that pain from the infiltration is short lived and significantly less than the pain from unanesthetized circumcision. We know of no studies that have compared neonatal distress associated with the various circumcision clamps or techniques described by Shechet et al. We have heard others suggest that the traditional bris is less traumatic than common institutional approaches. This is a matter that is worthy of investigation.

Horger et al asked about our analysis of other physiological measures. Oxygen saturation data duplicate the results obtained with heart rate. Respiration is a poor measure of neonatal distress since it both rose and fell with invasive events in our study.

Van Howe and Cold suggest that neonates in our study who had ring blocks also experienced pain because their heart rates increased from baseline. In fact, this increase in heart rate reflects an alerting response to the activity around them. Neonates in all groups had similar increases in heart rates as the draping and cleansing stage of the circumcision commenced. When the invasive part of the circumcision began, heart rates of infants in all groups, except ring block, increased significantly.

Whether or not to circumcise a newborn is an emotional issue. We advocate listening to the parents. If they wish to proceed with the circumcision, we believe that our study documents the benefits of local anesthetics. Like Van Howe and Cold, we also hope that our study leads to a change in clinical practice. It is a change that is long past due.

Janice Lander, Ph.D.
James B. Metcalfe, MD, FRCSC
Sarah Muttit, MD, FRCSC
University of Alberta

Barbara Brady-Fryer, MN
University of Alberta Hospitals, Edmonton, Alberta

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