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Oral Glucose Solution for Analgesia in Infant Circumcision
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.
OUTCOME MEASURE: The primary outcome was the percentage of the procedure time neonates spent crying. Secondary outcomes were the percentage change in heart rate from baseline, the percentage of oxygen saturation, and the score from the modified behavioral pain scale.
RESULTS: There were no significant differences between the oral glucose and water groups among any of the pain-related measurements. The DPNB group had significantly lower pain-related measurements (P <.05).
CONCLUSIONS: Concentrated glucose administered orally does not provide significant analgesia for neonatal circumcision. The use of DPNB significantly reduced objective measurements of pain and physiologic stress in infants undergoing circumcision.
Neonatal circumcision is one of the most common surgical procedures performed in the United States.1,2 Neonates clearly perceive pain during this procedure;3 however, many physicians still do not offer analgesia or anesthesia. The pain of neonatal circumcision has measurable physiologic consequences (eg, pulse oximetry).4 Also, this early painful experience may have sustained effects on the neonate some detectable months into the future.5-9
Previous studies have demonstrated dorsal penile nerve block (DPNB), subcutaneous ring block, and some topical anesthetic formulations (eg, eutectic mixture of local anesthetics cream) to be effective.10-16 The barriers to offering analgesia or anesthesia are related to a variety of factors, such as new skill acquisition, fear of complications, or inconvenience of technique.17-19 The circumcision policy statement issued by the American Academy of Pediatrics in 1999 acknowledged that analgesia was safe and effective and that adequate pain relief should be provided.20
Other investigators have linked the use of concentrated sugar solutions with decreased pain activity in neonates undergoing mildly painful procedures, including circumcision. The administration of glucose for pain relief is thought to be because of the induction of endorphin production. Two mL of 12%, 25%, and 50% sugar solutions before heel stick blood collection caused a 50% decrease in the total crying time for infants, compared with those who received only sterile water.21,22 The improved pain tolerance is blocked by the administration of naloxone.21-23 However, none of this work has directly compared the use of an oral sugar solution with an established analgesic or anesthetic technique. We directly compared the analgesic properties of sterile water (placebo), concentrated oral glucose (50% dextrose solution [D50]), and DPNB.
Methods
We undertook a randomized double-blind placebo-controlled clinical trial to test the hypothesis that 2 mL of D50 would reduce the total crying time during the circumcision by 50%. One group received placebo (sterile water); a second group was given D50; and the third group received a DPNB. A power analysis with an a of 0.05 and a b of 0.80 revealed that 16 patients in each of the 3 arms would be adequate to detect a 50% difference in the percentage of the procedure time the infant was crying. After approval by the Human Subjects Review Committee, a total of 71 patients were enrolled from November 1, 1996, through March 13, 1997.
Subjects were chosen from all male live births at Naval Hospital Bremerton during the study period. Exclusion criteria included any high-risk characteristics as determined by the medical staff. Of 232 male children born during the study interval, 162 underwent circumcision, and 71 were included in our study after obtaining informed consent for the procedure and participation in the study. Fifty parents refused participation. Forty-one neonates were not included because of the unavailability of the investigators.
The primary outcome for this study was the percentage of the procedure time the infant spent crying. Secondary outcomes are the percentage change in heart rate from baseline, the percentage of oxygen saturation, and the modified behavioral pain scale (MBPS) score at 30-second intervals Table 1.
The infants were randomized (by computer modeling) to 1 of the 3 arms of the study: 24 received 2 mL of sterile water orally; 24 underwent DPNB; and 23 received 2 mL of D50 orally. The DPNB was carried out in the usual manner. The base of the penis in all patients was covered with a sterile 2 × 2 gauze pad secured with tape to obscure evidence of a DPNB. All circumcisions were performed using a Gomco clamp (Allied Healthcare Products, Inc; St. Louis, Mo) and begun between 2 and 6 minutes of the pain relief intervention.
We determined pulse oximetry and heart rate at baseline (after pain relief intervention but before beginning circumcision) and at 1-minute intervals during the procedure. Total procedure time and crying time were assessed later by viewing a videotape of the infant. Pain behavior scores were also independently determined at 30-second intervals by each investigator during videotape reviews using the MBPS.24
Continuous variables were compared using analysis of variance (ANOVA) and the Student t test. We compared pain behavior scale determinations at each 30-second mark with a 3-way ANOVA using time as repeated measures and a Scheffe test for pair-wise comparisons between groups.
Results
The baseline values are shown in Table 2. The DPNB group differed at baseline with respect to the D50 group in time since last fed and heart rate. No other significant differences were noted.
Table 3 shows the data obtained from the circumcision procedures. Mean heart rate differed significantly among the 3 groups, with the D50 group having the highest mean heart rate. However, the percentage increase in heart rate did not differ between the D50 group and the placebo group. No other differences were noted between the D50 group and the placebo group. Mean pulse oximetry measurements and percentage of crying time also differed significantly between the DPNB group and the other 2 groups.
The data from the modified behavioral pain scale confirmed the findings from the crying time, heart rate, and pulse oximetry measurements. The 3-way ANOVA test showed that the MBPS score varied significantly by patient group and by the time when it was measured (P <.001). The Scheffe test for pair-wise comparisons showed that the DPNB group exhibited significantly less pain behavior than either the placebo or dextrose groups (P <.001).
Discussion
Administration of concentrated dextrose solution before circumcision does not offer adequate analgesia. For all pain-related measures (heart rate, pulse oximetry, crying time, and MBPS), there were no statistically significant differences detected between the placebo group and the D50 group.
The baseline differences between the 3 groups studied include the time since last feeding and heart rate. The time since last feeding does not seem to be clinically significant. The higher heart rate in the D50 group may be a result of the high glucose load. The findings of the experiment should not be affected by these differences.
The DPNB group showed significant differences in heart rate, pulse oximetry, crying time, and pain scale scores compared with the other 2 groups during circumcision. This fact reinforces that the study size was adequately powered to detect differences in these parameters and that DPNB provides pain relief for neonatal circumcision. No comparison was done using a topical agent or the circumferential ring block, although previous research has shown these methods to be similar, or in some cases superior, to DPNB.14
Our results differ from those of Herschel and colleagues,23 who found a benefit from sucrose administered through a pacifier. Their study compared changes in heart rate, oxygen saturation, and pain-related behavior among 3 study groups: no treatment, DPNB, and delivery of a 50% sucrose solution through a nipple held in place during the procedure. They found significant improvement in pain measures with the sucrose pacifier group. A potential flaw in this study is use of a nipple to deliver the sucrose. The suckling action of the infant on the pacifier alone may have produced analgesia. Our study eliminates the potential effects of suckling on pain-related behavior and physiologic responses.
Limitations
One drawback to our study concerns the use of D50 versus a concentrated sucrose solution. We chose D50 because of its ready availability, compared with a nonstandard solution like sucrose, and because in animal studies the specific type of oral solution used (eg, milk, various sugars, fats) did not alter the measured analgesic effect.25 Further study using a concentrated sucrose solution should be considered before dismissing this form of analgesia entirely.
Conclusions
Future study comparing concentrated sucrose, DPNB, or superficial ring block, and topical local anesthetics would further clarify the issues brought up by our study. Also, the antinociceptive properties of suckling during circumcision should be evaluated. For now, the readily available concentrated glucose solutions, such as 50% dextrose, do not offer any advantage over placebo in relieving the pain associated with neonatal circumcision, and are inferior to a DPNB.
1. Holman JR, Lewis EL, Ringler RL. Neonatal circumcision techniques. Am Fam Physician 1995;52:511-18.
2. Niku SD, Stock JA, Kaplan GW. Neonatal circumcision. Urol Clin North Am 1995;22:57-65.
3. Schoen EJ, Fischell AA. Pain in neonatal circumcision. Clin Pediatr 1991;30:429-32.
4. Rawlings DJ, Miller PA, Engel RR. The effect of circumcision on transcutaneous PO2 in term infants. Am J Dis Child 1980;134:4676-78.
5. Marshall RE, Stratton WC, Moore J, Boxerman SB. Circumcision I: effects upon newborn behavior. Infant Behav Dev 1980;3:1-14.
6. Marshall RE, Porter FJ, Rogers AG, Moore J, Anderson B, Boxerman SB. Circumcision II: effects upon mother-infant interaction. Early Hum Dev 1982;7:367-74.
7. Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984;5:246-50.
8. Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995;345:291-92.
9. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349:599-603.
10. Weatherstone KB, Rasmussen LB, Erenberg A, Jackson EM, Claflin KS, Leff RD. Safety and efficacy of a topical anesthetic for neonatal circumcision. Pediatrics 1993;92:710-14.
11. Howard CR, Howard FM, Garfunkel LC, de Blieck EA, Weitzman M. Neonatal circumcision and pain relief: current training practices. Pediatrics 1998;101:423-28.
12. Williamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 1983;71:36-40.
13. Holve RL, Bromberger PJ, Groveman HD, Lauber MR, Dixon SD, Snyder JM. Regional anesthesia during neonatal circumcision: effect on infant pain response. Clin Pediatr 1983;22:813-18.
14. Masciello AL. Anesthesia for neonatal circumcision: local anesthesia is better than dorsal penile nerve block. Obstet Gynecol 1990;75:834-38.
15. Serour F, Reuben S, Exra S. Circumcision in children with penile block alone. J Urol 1995;153:474-76.
16. Williamson PS, Evans ND. Neonatal cortisol response to circumcision with anesthesia. Clin Pediatr 1986;25:412-15.
17. Wellington N, Rieder MJ. Attitudes and practices regarding anesthesia for newborn circumcision. Pediatrics 1993;92:541-43.
18. Ryan CA, Finer NN. Changing attitudes and practices regarding local anesthesia for newborn circumcision. Pediatrics 1994;94:230-33.
19. Weiss GN. Local anesthesia for neonatal circumcision. JAMA 1988;260:637.-
20. American Academy of Pediatrics. Circumcision policy statement: American Academy of Pediatrics Task Force on Circumcision. Pediatrics 1999;103:686-93.
21. Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics 1991;87:215-18.
22. Ramenghi LA, Wood CM, Griffith GC, Levene MI. Reduction of pain in prematures using oral sucrose. Arch Dis Childh 1996;78:126-28.
23. Herschel M, Khoshnood B, Ellman C, Maydew N, Mittendorf R. Neonatal circumcision: randomized trial of a sucrose pacifier for pain control. Arch Pediatr Adolesc Med 1998;152:279-84.
24. Taddio A, Nulman I, Koren B, Stevens B, Koren G. A revised measure of acute pain in infants. J Pain Symptom Manage 1995;10:456-63.
25. Shide DJ, Blass EM. Opioid-like effects of intraoral infusions of corn oil and polycose on stress reactions in 10-day-old rats. Behav Neurosci 1989;103:1168-75.
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.
OUTCOME MEASURE: The primary outcome was the percentage of the procedure time neonates spent crying. Secondary outcomes were the percentage change in heart rate from baseline, the percentage of oxygen saturation, and the score from the modified behavioral pain scale.
RESULTS: There were no significant differences between the oral glucose and water groups among any of the pain-related measurements. The DPNB group had significantly lower pain-related measurements (P <.05).
CONCLUSIONS: Concentrated glucose administered orally does not provide significant analgesia for neonatal circumcision. The use of DPNB significantly reduced objective measurements of pain and physiologic stress in infants undergoing circumcision.
Neonatal circumcision is one of the most common surgical procedures performed in the United States.1,2 Neonates clearly perceive pain during this procedure;3 however, many physicians still do not offer analgesia or anesthesia. The pain of neonatal circumcision has measurable physiologic consequences (eg, pulse oximetry).4 Also, this early painful experience may have sustained effects on the neonate some detectable months into the future.5-9
Previous studies have demonstrated dorsal penile nerve block (DPNB), subcutaneous ring block, and some topical anesthetic formulations (eg, eutectic mixture of local anesthetics cream) to be effective.10-16 The barriers to offering analgesia or anesthesia are related to a variety of factors, such as new skill acquisition, fear of complications, or inconvenience of technique.17-19 The circumcision policy statement issued by the American Academy of Pediatrics in 1999 acknowledged that analgesia was safe and effective and that adequate pain relief should be provided.20
Other investigators have linked the use of concentrated sugar solutions with decreased pain activity in neonates undergoing mildly painful procedures, including circumcision. The administration of glucose for pain relief is thought to be because of the induction of endorphin production. Two mL of 12%, 25%, and 50% sugar solutions before heel stick blood collection caused a 50% decrease in the total crying time for infants, compared with those who received only sterile water.21,22 The improved pain tolerance is blocked by the administration of naloxone.21-23 However, none of this work has directly compared the use of an oral sugar solution with an established analgesic or anesthetic technique. We directly compared the analgesic properties of sterile water (placebo), concentrated oral glucose (50% dextrose solution [D50]), and DPNB.
Methods
We undertook a randomized double-blind placebo-controlled clinical trial to test the hypothesis that 2 mL of D50 would reduce the total crying time during the circumcision by 50%. One group received placebo (sterile water); a second group was given D50; and the third group received a DPNB. A power analysis with an a of 0.05 and a b of 0.80 revealed that 16 patients in each of the 3 arms would be adequate to detect a 50% difference in the percentage of the procedure time the infant was crying. After approval by the Human Subjects Review Committee, a total of 71 patients were enrolled from November 1, 1996, through March 13, 1997.
Subjects were chosen from all male live births at Naval Hospital Bremerton during the study period. Exclusion criteria included any high-risk characteristics as determined by the medical staff. Of 232 male children born during the study interval, 162 underwent circumcision, and 71 were included in our study after obtaining informed consent for the procedure and participation in the study. Fifty parents refused participation. Forty-one neonates were not included because of the unavailability of the investigators.
The primary outcome for this study was the percentage of the procedure time the infant spent crying. Secondary outcomes are the percentage change in heart rate from baseline, the percentage of oxygen saturation, and the modified behavioral pain scale (MBPS) score at 30-second intervals Table 1.
The infants were randomized (by computer modeling) to 1 of the 3 arms of the study: 24 received 2 mL of sterile water orally; 24 underwent DPNB; and 23 received 2 mL of D50 orally. The DPNB was carried out in the usual manner. The base of the penis in all patients was covered with a sterile 2 × 2 gauze pad secured with tape to obscure evidence of a DPNB. All circumcisions were performed using a Gomco clamp (Allied Healthcare Products, Inc; St. Louis, Mo) and begun between 2 and 6 minutes of the pain relief intervention.
We determined pulse oximetry and heart rate at baseline (after pain relief intervention but before beginning circumcision) and at 1-minute intervals during the procedure. Total procedure time and crying time were assessed later by viewing a videotape of the infant. Pain behavior scores were also independently determined at 30-second intervals by each investigator during videotape reviews using the MBPS.24
Continuous variables were compared using analysis of variance (ANOVA) and the Student t test. We compared pain behavior scale determinations at each 30-second mark with a 3-way ANOVA using time as repeated measures and a Scheffe test for pair-wise comparisons between groups.
Results
The baseline values are shown in Table 2. The DPNB group differed at baseline with respect to the D50 group in time since last fed and heart rate. No other significant differences were noted.
Table 3 shows the data obtained from the circumcision procedures. Mean heart rate differed significantly among the 3 groups, with the D50 group having the highest mean heart rate. However, the percentage increase in heart rate did not differ between the D50 group and the placebo group. No other differences were noted between the D50 group and the placebo group. Mean pulse oximetry measurements and percentage of crying time also differed significantly between the DPNB group and the other 2 groups.
The data from the modified behavioral pain scale confirmed the findings from the crying time, heart rate, and pulse oximetry measurements. The 3-way ANOVA test showed that the MBPS score varied significantly by patient group and by the time when it was measured (P <.001). The Scheffe test for pair-wise comparisons showed that the DPNB group exhibited significantly less pain behavior than either the placebo or dextrose groups (P <.001).
Discussion
Administration of concentrated dextrose solution before circumcision does not offer adequate analgesia. For all pain-related measures (heart rate, pulse oximetry, crying time, and MBPS), there were no statistically significant differences detected between the placebo group and the D50 group.
The baseline differences between the 3 groups studied include the time since last feeding and heart rate. The time since last feeding does not seem to be clinically significant. The higher heart rate in the D50 group may be a result of the high glucose load. The findings of the experiment should not be affected by these differences.
The DPNB group showed significant differences in heart rate, pulse oximetry, crying time, and pain scale scores compared with the other 2 groups during circumcision. This fact reinforces that the study size was adequately powered to detect differences in these parameters and that DPNB provides pain relief for neonatal circumcision. No comparison was done using a topical agent or the circumferential ring block, although previous research has shown these methods to be similar, or in some cases superior, to DPNB.14
Our results differ from those of Herschel and colleagues,23 who found a benefit from sucrose administered through a pacifier. Their study compared changes in heart rate, oxygen saturation, and pain-related behavior among 3 study groups: no treatment, DPNB, and delivery of a 50% sucrose solution through a nipple held in place during the procedure. They found significant improvement in pain measures with the sucrose pacifier group. A potential flaw in this study is use of a nipple to deliver the sucrose. The suckling action of the infant on the pacifier alone may have produced analgesia. Our study eliminates the potential effects of suckling on pain-related behavior and physiologic responses.
Limitations
One drawback to our study concerns the use of D50 versus a concentrated sucrose solution. We chose D50 because of its ready availability, compared with a nonstandard solution like sucrose, and because in animal studies the specific type of oral solution used (eg, milk, various sugars, fats) did not alter the measured analgesic effect.25 Further study using a concentrated sucrose solution should be considered before dismissing this form of analgesia entirely.
Conclusions
Future study comparing concentrated sucrose, DPNB, or superficial ring block, and topical local anesthetics would further clarify the issues brought up by our study. Also, the antinociceptive properties of suckling during circumcision should be evaluated. For now, the readily available concentrated glucose solutions, such as 50% dextrose, do not offer any advantage over placebo in relieving the pain associated with neonatal circumcision, and are inferior to a 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.
OUTCOME MEASURE: The primary outcome was the percentage of the procedure time neonates spent crying. Secondary outcomes were the percentage change in heart rate from baseline, the percentage of oxygen saturation, and the score from the modified behavioral pain scale.
RESULTS: There were no significant differences between the oral glucose and water groups among any of the pain-related measurements. The DPNB group had significantly lower pain-related measurements (P <.05).
CONCLUSIONS: Concentrated glucose administered orally does not provide significant analgesia for neonatal circumcision. The use of DPNB significantly reduced objective measurements of pain and physiologic stress in infants undergoing circumcision.
Neonatal circumcision is one of the most common surgical procedures performed in the United States.1,2 Neonates clearly perceive pain during this procedure;3 however, many physicians still do not offer analgesia or anesthesia. The pain of neonatal circumcision has measurable physiologic consequences (eg, pulse oximetry).4 Also, this early painful experience may have sustained effects on the neonate some detectable months into the future.5-9
Previous studies have demonstrated dorsal penile nerve block (DPNB), subcutaneous ring block, and some topical anesthetic formulations (eg, eutectic mixture of local anesthetics cream) to be effective.10-16 The barriers to offering analgesia or anesthesia are related to a variety of factors, such as new skill acquisition, fear of complications, or inconvenience of technique.17-19 The circumcision policy statement issued by the American Academy of Pediatrics in 1999 acknowledged that analgesia was safe and effective and that adequate pain relief should be provided.20
Other investigators have linked the use of concentrated sugar solutions with decreased pain activity in neonates undergoing mildly painful procedures, including circumcision. The administration of glucose for pain relief is thought to be because of the induction of endorphin production. Two mL of 12%, 25%, and 50% sugar solutions before heel stick blood collection caused a 50% decrease in the total crying time for infants, compared with those who received only sterile water.21,22 The improved pain tolerance is blocked by the administration of naloxone.21-23 However, none of this work has directly compared the use of an oral sugar solution with an established analgesic or anesthetic technique. We directly compared the analgesic properties of sterile water (placebo), concentrated oral glucose (50% dextrose solution [D50]), and DPNB.
Methods
We undertook a randomized double-blind placebo-controlled clinical trial to test the hypothesis that 2 mL of D50 would reduce the total crying time during the circumcision by 50%. One group received placebo (sterile water); a second group was given D50; and the third group received a DPNB. A power analysis with an a of 0.05 and a b of 0.80 revealed that 16 patients in each of the 3 arms would be adequate to detect a 50% difference in the percentage of the procedure time the infant was crying. After approval by the Human Subjects Review Committee, a total of 71 patients were enrolled from November 1, 1996, through March 13, 1997.
Subjects were chosen from all male live births at Naval Hospital Bremerton during the study period. Exclusion criteria included any high-risk characteristics as determined by the medical staff. Of 232 male children born during the study interval, 162 underwent circumcision, and 71 were included in our study after obtaining informed consent for the procedure and participation in the study. Fifty parents refused participation. Forty-one neonates were not included because of the unavailability of the investigators.
The primary outcome for this study was the percentage of the procedure time the infant spent crying. Secondary outcomes are the percentage change in heart rate from baseline, the percentage of oxygen saturation, and the modified behavioral pain scale (MBPS) score at 30-second intervals Table 1.
The infants were randomized (by computer modeling) to 1 of the 3 arms of the study: 24 received 2 mL of sterile water orally; 24 underwent DPNB; and 23 received 2 mL of D50 orally. The DPNB was carried out in the usual manner. The base of the penis in all patients was covered with a sterile 2 × 2 gauze pad secured with tape to obscure evidence of a DPNB. All circumcisions were performed using a Gomco clamp (Allied Healthcare Products, Inc; St. Louis, Mo) and begun between 2 and 6 minutes of the pain relief intervention.
We determined pulse oximetry and heart rate at baseline (after pain relief intervention but before beginning circumcision) and at 1-minute intervals during the procedure. Total procedure time and crying time were assessed later by viewing a videotape of the infant. Pain behavior scores were also independently determined at 30-second intervals by each investigator during videotape reviews using the MBPS.24
Continuous variables were compared using analysis of variance (ANOVA) and the Student t test. We compared pain behavior scale determinations at each 30-second mark with a 3-way ANOVA using time as repeated measures and a Scheffe test for pair-wise comparisons between groups.
Results
The baseline values are shown in Table 2. The DPNB group differed at baseline with respect to the D50 group in time since last fed and heart rate. No other significant differences were noted.
Table 3 shows the data obtained from the circumcision procedures. Mean heart rate differed significantly among the 3 groups, with the D50 group having the highest mean heart rate. However, the percentage increase in heart rate did not differ between the D50 group and the placebo group. No other differences were noted between the D50 group and the placebo group. Mean pulse oximetry measurements and percentage of crying time also differed significantly between the DPNB group and the other 2 groups.
The data from the modified behavioral pain scale confirmed the findings from the crying time, heart rate, and pulse oximetry measurements. The 3-way ANOVA test showed that the MBPS score varied significantly by patient group and by the time when it was measured (P <.001). The Scheffe test for pair-wise comparisons showed that the DPNB group exhibited significantly less pain behavior than either the placebo or dextrose groups (P <.001).
Discussion
Administration of concentrated dextrose solution before circumcision does not offer adequate analgesia. For all pain-related measures (heart rate, pulse oximetry, crying time, and MBPS), there were no statistically significant differences detected between the placebo group and the D50 group.
The baseline differences between the 3 groups studied include the time since last feeding and heart rate. The time since last feeding does not seem to be clinically significant. The higher heart rate in the D50 group may be a result of the high glucose load. The findings of the experiment should not be affected by these differences.
The DPNB group showed significant differences in heart rate, pulse oximetry, crying time, and pain scale scores compared with the other 2 groups during circumcision. This fact reinforces that the study size was adequately powered to detect differences in these parameters and that DPNB provides pain relief for neonatal circumcision. No comparison was done using a topical agent or the circumferential ring block, although previous research has shown these methods to be similar, or in some cases superior, to DPNB.14
Our results differ from those of Herschel and colleagues,23 who found a benefit from sucrose administered through a pacifier. Their study compared changes in heart rate, oxygen saturation, and pain-related behavior among 3 study groups: no treatment, DPNB, and delivery of a 50% sucrose solution through a nipple held in place during the procedure. They found significant improvement in pain measures with the sucrose pacifier group. A potential flaw in this study is use of a nipple to deliver the sucrose. The suckling action of the infant on the pacifier alone may have produced analgesia. Our study eliminates the potential effects of suckling on pain-related behavior and physiologic responses.
Limitations
One drawback to our study concerns the use of D50 versus a concentrated sucrose solution. We chose D50 because of its ready availability, compared with a nonstandard solution like sucrose, and because in animal studies the specific type of oral solution used (eg, milk, various sugars, fats) did not alter the measured analgesic effect.25 Further study using a concentrated sucrose solution should be considered before dismissing this form of analgesia entirely.
Conclusions
Future study comparing concentrated sucrose, DPNB, or superficial ring block, and topical local anesthetics would further clarify the issues brought up by our study. Also, the antinociceptive properties of suckling during circumcision should be evaluated. For now, the readily available concentrated glucose solutions, such as 50% dextrose, do not offer any advantage over placebo in relieving the pain associated with neonatal circumcision, and are inferior to a DPNB.
1. Holman JR, Lewis EL, Ringler RL. Neonatal circumcision techniques. Am Fam Physician 1995;52:511-18.
2. Niku SD, Stock JA, Kaplan GW. Neonatal circumcision. Urol Clin North Am 1995;22:57-65.
3. Schoen EJ, Fischell AA. Pain in neonatal circumcision. Clin Pediatr 1991;30:429-32.
4. Rawlings DJ, Miller PA, Engel RR. The effect of circumcision on transcutaneous PO2 in term infants. Am J Dis Child 1980;134:4676-78.
5. Marshall RE, Stratton WC, Moore J, Boxerman SB. Circumcision I: effects upon newborn behavior. Infant Behav Dev 1980;3:1-14.
6. Marshall RE, Porter FJ, Rogers AG, Moore J, Anderson B, Boxerman SB. Circumcision II: effects upon mother-infant interaction. Early Hum Dev 1982;7:367-74.
7. Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984;5:246-50.
8. Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995;345:291-92.
9. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997;349:599-603.
10. Weatherstone KB, Rasmussen LB, Erenberg A, Jackson EM, Claflin KS, Leff RD. Safety and efficacy of a topical anesthetic for neonatal circumcision. Pediatrics 1993;92:710-14.
11. Howard CR, Howard FM, Garfunkel LC, de Blieck EA, Weitzman M. Neonatal circumcision and pain relief: current training practices. Pediatrics 1998;101:423-28.
12. Williamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 1983;71:36-40.
13. Holve RL, Bromberger PJ, Groveman HD, Lauber MR, Dixon SD, Snyder JM. Regional anesthesia during neonatal circumcision: effect on infant pain response. Clin Pediatr 1983;22:813-18.
14. Masciello AL. Anesthesia for neonatal circumcision: local anesthesia is better than dorsal penile nerve block. Obstet Gynecol 1990;75:834-38.
15. Serour F, Reuben S, Exra S. Circumcision in children with penile block alone. J Urol 1995;153:474-76.
16. Williamson PS, Evans ND. Neonatal cortisol response to circumcision with anesthesia. Clin Pediatr 1986;25:412-15.
17. Wellington N, Rieder MJ. Attitudes and practices regarding anesthesia for newborn circumcision. Pediatrics 1993;92:541-43.
18. Ryan CA, Finer NN. Changing attitudes and practices regarding local anesthesia for newborn circumcision. Pediatrics 1994;94:230-33.
19. Weiss GN. Local anesthesia for neonatal circumcision. JAMA 1988;260:637.-
20. American Academy of Pediatrics. Circumcision policy statement: American Academy of Pediatrics Task Force on Circumcision. Pediatrics 1999;103:686-93.
21. Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics 1991;87:215-18.
22. Ramenghi LA, Wood CM, Griffith GC, Levene MI. Reduction of pain in prematures using oral sucrose. Arch Dis Childh 1996;78:126-28.
23. Herschel M, Khoshnood B, Ellman C, Maydew N, Mittendorf R. Neonatal circumcision: randomized trial of a sucrose pacifier for pain control. Arch Pediatr Adolesc Med 1998;152:279-84.
24. Taddio A, Nulman I, Koren B, Stevens B, Koren G. A revised measure of acute pain in infants. J Pain Symptom Manage 1995;10:456-63.
25. Shide DJ, Blass EM. Opioid-like effects of intraoral infusions of corn oil and polycose on stress reactions in 10-day-old rats. Behav Neurosci 1989;103:1168-75.
1. Holman JR, Lewis EL, Ringler RL. Neonatal circumcision techniques. Am Fam Physician 1995;52:511-18.
2. Niku SD, Stock JA, Kaplan GW. Neonatal circumcision. Urol Clin North Am 1995;22:57-65.
3. Schoen EJ, Fischell AA. Pain in neonatal circumcision. Clin Pediatr 1991;30:429-32.
4. Rawlings DJ, Miller PA, Engel RR. The effect of circumcision on transcutaneous PO2 in term infants. Am J Dis Child 1980;134:4676-78.
5. Marshall RE, Stratton WC, Moore J, Boxerman SB. Circumcision I: effects upon newborn behavior. Infant Behav Dev 1980;3:1-14.
6. Marshall RE, Porter FJ, Rogers AG, Moore J, Anderson B, Boxerman SB. Circumcision II: effects upon mother-infant interaction. Early Hum Dev 1982;7:367-74.
7. Dixon S, Snyder J, Holve R, Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984;5:246-50.
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