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J Pediatr Urol 2021 02 24;17(1):3-8. Epub 2020 Sep 24.

Division of General Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon. Electronic address:

Objective: Routine male infant circumcision (RMIC) is a common procedure that inadvertently causes significant but preventable pain. In this best evidence review, we examine the available pain management options and their effectiveness for RMIC.

Material And Methods: The Medline (OVID) and Cochrane library were searched for randomized controlled trials investigating pain control for RMIC. Read More

Pediatr Surg Int 2020 Apr 22;36(4):523-528. Epub 2020 Feb 22.

The Council of Forensic Medicine, Istanbul, Turkey.

Purpose: To perform a medical evaluation of penile necrosis causes and treatment approaches by examining patients who had penile necrosis after circumcision surgery.

Methods: A total of 24 patients with penile necrosis after circumcision surgery, who presented at various hospitals in Turkey between September 2003 and April 2013 and whose cases were being reviewed at the Institution of Forensic Medicine with regard to malpractice, were evaluated retrospectively.

Results: The mean age of the patients was 5 ± 3. Read More

Niger J Clin Pract 2019 Dec;22(12):1737-1741

Urology Unit, Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria.

Background: Neonates feel pain. There is a concern among practitioners that pain of injecting analgesics to neonates prior to circumcision could as well be the same as the pain of the procedure. This has made many reluctant to offer effective analgesia for circumcision. Read More

PLoS One 2018 6;13(9):e0203439. Epub 2018 Sep 6.

Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of GuangZhou Medical University, Guangzhou, Guangdong, China.

Objective: To compare dorsal penile nerve block (DPNB) and eutectic mixture of local anesthetics (EMLA) cream for pain relief in infants during circumcision.

Methods: We systematically searched Medline via PubMed, Embase, CNKI and the Cochrane Library Center Register to identify randomized controlled trials up to March 2018. Effect estimates were performed in random effect models. Read More

PLoS One 2018 14;13(2):e0191501. Epub 2018 Feb 14.

Nyanza Reproductive Health Society, Kisumu, Kenya.

Background: As countries scale up adult voluntary medical male circumcision (VMMC) for HIV prevention, they are looking ahead to long term sustainable strategies, including introduction of early infant male circumcision (EIMC). Although a number of devices for EIMC are prequalified by the World Health Organization, evaluation of additional devices can provide policy-makers and clinicians the information required to make informed decisions. We undertook a field evaluation of the safety and acceptability of the AccuCirc device in Kisumu County, Kenya. Read More

Pediatrics 2017 Dec 17;140(6). Epub 2017 Nov 17.

Surgery, American University of Beirut Medical Center, Beirut, Lebanon

Objectives: There is no consensus on the most effective pain management for neonatal circumcision. We sought to compare different modalities.

Methods: This is a double-blinded randomized controlled trial comparing 3 combination analgesics used during circumcision (EMLA + sucrose; EMLA + sucrose + dorsal penile nerve block [DPNB]; EMLA + sucrose + ring block [RB]) with the traditional topical analgesic cream EMLA alone. Read More

Anesthesiol Clin 2014 Jun 18;32(2):411-29. Epub 2014 Apr 18.

Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB-415, Boston, MA 02114, USA.

Pediatric patients often undergo anesthesia for ambulatory procedures. This article discusses several common preoperative dilemmas, including whether to postpone anesthesia when a child has an upper respiratory infection, whether to test young women for pregnancy, which children require overnight admission for apnea monitoring, and the effectiveness of nonpharmacological techniques for reducing anxiety. Medication issues covered include the risks of anesthetic agents in children with undiagnosed weakness, the use of remifentanil for tracheal intubation, and perioperative dosing of rectal acetaminophen. Read More

Pak J Med Sci 2013 Jan;29(1):27-30

Soofia Ahmed, Dept. of Paediatric Surgery, National Institute of Child Health, Rafiquee Shaheed Road, Karachi-75510, Pakistan.

Objective: Circumcision is a commonly performed surgical procedure but choice of anesthesia remained an issue of research and debate. This study was conducted to find out the effectiveness of the eutectic mixture of local anesthetic (EMLA) cream with dorsal penile nerve block (DPNB) using lignocaine, for reduction of pain during circumcision.

Methodology: This was comparative study carried out in Surgical Unit B of National Institute of Child Health Karachi, from May 2008 to October 2008. Read More

Am Fam Physician 2012 Aug;86(3):222

J Pak Med Assoc 2011 Aug;61(8):782-6

Boztepe State Hospital of Ordu, Department of Anaesthesia and Reanimation, Pain, Ordu, Turkey.

Objectives: To evaluate paediatric regional anaesthesia applications in 2200 children at Diyarbakir Children's Hosptial, Turkey.

Methods: This is a cross-sectional study done from January 2005 and October 2009. Paediatric regional anaesthesia applications in 2200 children were retrospectively analysed and included in this study. Read More

Pain Res Manag 2008 Sep-Oct;13(5):413-20

The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.

Background: Hospitalized infants undergo multiple, repeated painful procedures. Despite continued efforts to prevent procedural pain and improve pain management, clinical guidelines and standards frequently do not reflect the highest quality evidence from systematic reviews.

Objective: To critically appraise all systematic reviews on the effectiveness of procedural pain interventions in hospitalized infants. Read More

J Perinatol 2006 Feb;26(2):106-10

Department of Obstetrics, Gynecology and Reproductive Medicine, Stony Brook University, Stony Brook, NY, USA.

Objective: The purpose of this investigation was to compare the effectiveness of dorsal penile nerve block and topical lidocaine-prilocaine anesthesia techniques for pain relief during circumcision.

Methods: In total, 18 healthy term newborn males were divided based on anesthesia. The topical lidocaine-prilocaine group had six males undergoing circumcision and three males undergoing a sham procedure. Read More

Am J Obstet Gynecol 2005 Aug;193(2):537-42; discussion 542-3

Department of Obstetrics and Gynecology, University of North Carolina Hospitals, Chapel Hill, NC 27514, USA.

Objective: The purpose of this research was to study the effects on the physiologic pain response of the neonate during circumcision with the use of a gloved human finger.

Study Design: This was a randomized controlled trial analyzing the effect of non-nutritive sucking (NNS) on pain response during circumcision. Term neonates were randomized to 2 groups. Read More

Am J Perinatol 2005 Jul;22(5):231-7

Department of Pharmacy Practice, The Eugene Applebaum College of Pharmacy & Health Sciences, Pediatric Pharmacology Research Unit, Children's Hospital of Michigan, Detroit, Michigan 48201, USA.

This study evaluated the efficacy and safety of lidocaine 4% cream (LMX4), compared with lidocaine 2.5% and prilocaine 2.5% (EMLA) or dorsal penile block (DPNB) for analgesia during circumcision. Read More

BMC Pediatr 2005 May 22;5(1):12. Epub 2005 May 22.

Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Israel.

Background: Analgesia for neonatal circumcision was recently advocated for every male infant, and its use is considered essential by the American Academy of Pediatrics. We compared the post-operative analgesic quality of bupivacaine to that of lidocaine for achieving dorsal penile nerve block (DPNB) when performing neonatal circumcision.

Methods: Data were obtained from 38 neonates following neonatal circumcision. Read More

Cochrane Database Syst Rev 2004 Oct 18(4):CD004217. Epub 2004 Oct 18.

Child Health - Critical Care, Capital Health, Royal Alexandra Hospital, 10240 Kingsway, Room 5027-10 DTC, Edmonton, Alberta, Canada, T5H 3V9.

Background: Circumcision is a painful procedure that many newborn males undergo in the first few days after birth. Interventions are available to reduce pain at circumcision; however, many newborns are circumcised without pain management.

Objectives: The objective of this review was to assess the effectiveness and safety of interventions for reducing pain at neonatal circumcision. Read More

Am Fam Physician 2004 Feb;69(4):896-900

North Shore University Hospital at Manhasset, Manhasset, New York, USA.

The hand can be anesthetized effectively with blocks of the median, ulnar, or radial nerve. Each digit is supplied by four digital nerves, which can be blocked with injections on each side of the digit. Anterior or posterior ankle blocks can be used for regional anesthesia for the foot. Read More

J Obstet Gynecol Neonatal Nurs 2002 Jul-Aug;31(4):403-10

Children's Hospital of Iowa, University of Iowa Hospitals and Clinics, Iowa City 52242-1009, USA.

Pain experienced in infancy may have effects later in life. Neonatal circumcision is a common painful procedure. In addition to dorsal penile nerve block, interventions that may have a role in minimizing pain and distress in neonatal circumcision include use of a sucrose pacifier, buffered lidocaine, small needles, acetaminophen, swaddling, and environmental modification. Read More

J Fam Pract 2001 Sep;50(9):785-8

Headquarters Battalion, BAS, Camp Lejeune, CA, USA.

Objectives: Our objectives were to determine if a 50% dextrose solution would reduce the percentage of circumcision procedure time a neonate spent crying by 50% compared with water and whether it would be similar to a dorsal penile nerve block (DPNB).

Study Design: This was a randomized placebo-controlled blinded clinical trial.

Population: We included 71 patients who were recruited from the inpatient nursery of a military community hospital over a 5-month period. Read More

J Pediatr Surg 2001 Jul;36(7):1047-9

State University of New York HSC at Brooklyn, Brooklyn, NY, USA.

Background/purpose: The Gomco clamp is used most commonly for neonatal circumcisions in the United States with reported rates of complication as low as 0.2%. Often, however, circumcision is delayed beyond the neonatal period because of illness, parental concerns, or physician bias with patients presenting for elective circumcision in the first few years of life. Read More

Paediatr Drugs 2001 ;3(2):101-11

Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada.

Circumcision is the most common surgical procedure performed in the neonatal period in North America. If untreated, the pain of circumcision causes both short and long term changes in infant behaviours. The most widely studied pharmacological intervention for pain management during circumcision is dorsal penile nerve block (DPNB) by injected lidocaine (lignocaine). Read More

Arch Pediatr Adolesc Med 2000 Jun;154(6):620-3

Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada.

Background: Pain of circumcision is only partially relieved by single modalities, such as penile nerve block, lidocaine-prilocaine cream, and sucrose pacifiers.

Objective: To assess the effectiveness of a combination of interventions on the pain response of infants undergoing circumcision.

Methods: Cohort study. Read More

Prim Care Update Ob Gyns 1998 Jul;5(4):196

Rochester General Hospital, University of Rochester School of Medicine and Dentistry, New York, Rochester, USA

Objective: To evaluate the relative efficacies of eutetic mixture of local anesthetics (EMLA()) cream and dorsal penile nerve block (DPNB) for pain relief during neonatal circumcision.Methods: After parental informed consent, appropriate-for-gestational age, term, healthy newborns were randomized to receive either EMLA cream and placebo saline DPNB or placebo cream and 1% lidocaine DPNB. Placebo and EMLA cream were prepared by the pharmacy and applied by study nurses. Read More

Cochrane Database Syst Rev 2000 (2):CD000496

Paediatrics, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario, Canada. or

Background: Neonates routinely undergo tissue-damaging interventions as part of medical treatment. The skin is the site of noxious stimulation for many procedures, including circumcision. EMLA (eutectic mixture of local anesthetics) penetrates intact skin and has the potential to reduce pain associated with circumcision. Read More

Am J Obstet Gynecol 1999 Dec;181(6):1506-11

Department of Pediatrics, Rochester General Hospital, The University of Rochester School of Medicine and Dentistry, NY 14621, USA.

Objective: We set out to compare a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) to dorsal penile nerve block with lidocaine for anesthesia during circumcision.

Study Design: In a double-blind study, term newborns were randomized to local anesthetic cream and sodium chloride solution dorsal penile nerve block (n = 31) or to placebo cream and lidocaine dorsal penile nerve block (n = 29). Pain was assessed by determination of heart rate, respiratory rate, and behavioral distress scoring. Read More

Arch Pediatr Adolesc Med 1999 May;153(5):476-80

Department of Pediatrics, Georgetown University Medical Center, Washington, DC, USA.

Objective: To investigate the efficacy and safety of dorsal penile nerve block (DPNB) and eutectic mixture of lidocaine (EMLA) for palliation of pain associated with circumcision in low-birth-weight infants.

Design: Randomized, blinded, controlled trial.

Setting: Intensive care nursery (step down unit) at Georgetown University Medical Center, Washington, DC. Read More

Obstet Gynecol 1999 Mar;93(3):350-2

Blodgett Memorial Medical Center, Grand Rapids, Michigan 49506, USA.

Objective: To determine if buffered lidocaine provided a more effective nerve block in a short time than plain lidocaine for neonatal circumcision.

Methods: One hundred ninety-four newborn males were studied in a randomized trial using two dorsal penile nerve block preparations for circumcision. Ninety-two received plain lidocaine, and 102 received buffered lidocaine. Read More

Pediatrics 1999 Feb;103(2):E23

Department of Pediatrics, St Francis Hospital and Medical Center, Hartford, CT 06105, USA.

Objectives: 1) To compare the Mogen and Gomco clamps with regard to pain experienced during neonatal circumcision, and 2) to assess neonatal circumcision pain with and without dorsal penile nerve block (DPNB).

Design/methods: A randomized, controlled, nonblinded clinical trial; 48 healthy, full-term infants were randomized into one of the following four groups: Gomco vs Mogen with (+) or without (-) DPNB. DPNB+ infants were injected with 0. Read More

Pediatr Nurs 1998 Jul-Aug;24(4):385-9

Anesthesia Associates, Fargo, ND, USA.

Purpose: To compare the efficacy of dorsal penile nerve block (DPNB) and eutectic mixture of local anesthetic (EMLA) for attenuation of neonatal pain during circumcision.

Method: A total of 20 infants born at a United States upper Midwestern hospital were involved in the study. Measurements of blood pressure, heart rate, respiratory rate, and oxygen saturation were obtained along with a Neonatal Infant Pain Scale (NIPS) grading at five separate intervals (baseline, restraint, incision, Gomco clamp application, and post circumcision) throughout the circumcision procedure. Read More

Pediatrics 1998 Jun;101(6):E5

Department of Pediatrics and Adolescent Medicine, HealthPartners Medical Group, Minneapolis-St Paul, Minnesota, USA.

Objective: To determine 1) the performing of circumcision by medical specialty, gender, and years of practice; 2) the pattern of anesthetic use for this procedure; and 3) the reasons physicians cite for not using anesthesia.

Design: A total of 3066 questionnaires were received from a mailing to a representative sampling of physicians stratified by specialty and geographic location.

Results: Fifty-eight percent (1768) of the questionnaires were returned and interpretable from the following specialists: pediatricians (PEDs), 73% (n = 691); family practitioners (FPs), 52% (n = 464); and obstetricians (OBs), 51% (n = 623). Read More