Beyond Dorsal Penile Nerve Block: A More Humane Circumcision

Abstract

Objective. To explore techniques that can be utilized in addition to the dorsal penile nerve block (DPNB) to further reduce the neonate's stress and pain from routine circumcision, and thus make the procedure more humane. Setting. Level 1 nursery at a community hospital. Subjects. Eighty healthy, term, newborn male infants scheduled for routine neonatal circumcision. Study Design. Prospective and randomized; double blind and placebo controlled for the study solutions. Methods. Four statistically similar groups of 20 were studied. The control group included infants circumcised using: a) a rigid plastic restraint board; b) standard DPNB; and c) a pacifier dipped in water to comfort the infant. Each study group differed from the controls in one variable including: 1) using a specially designed, physiologic circumcision restraint chair; 2) pH buffering of lidocaine hydrochloride used for DPNB; and 3) offering a pacifier dipped in a 24% sucrose solution during the DPNB and circumcision. Behavioral observations were recorded and compared for each group starting before the injection of lidocaine hydrochloride and continuing through the completion of the circumcision. Plasma for cortisol levels were collected 30 minutes after the circumcision. Results. Neonates circumcised on the new restraint chair showed a significant decrease in distress scores (>50%) compared with the control group on the rigid molded-plastic restraint. The pacifier dipped in sucrose had a distress-reducing effect during both the post-DPNB injection and circumcision periods. The infants who were injected with the buffered lidocaine showed no differences in distress from the controls. The plasma cortisol levels were not significantly affected by any additional technique and were comparable to the levels previously reported. Conclusions. When neonatal circumcisions are performed routinely, they should be done as humanely as possible. This study demonstrates that, when used in conjunction with DPNB, a pacifier dipped in 24% sucrose and a more comfortable, padded, and physiologic restraint can be useful in decreasing distress and pain.