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Pain control in neonatal male circumcision: A best evidence review
Muhieddine Labban1, Zahraa Menhem2, Tarek Bandali2
1Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
Insights
Routine male infant circumcision causes pain. Nerve blocks are more effective than topical anesthetics or oral sucrose alone. Multimodal pain control is the most effective approach for managing circumcision pain.
Area of Science:
- Pediatric Surgery
- Pain Management
- Neonatal Care
Background:
- Routine male infant circumcision (RMIC) is a common procedure associated with significant, preventable pain.
- Effective pain management strategies are crucial for minimizing infant distress during RMIC.
Purpose of the Study:
- To review the evidence on pain management options for RMIC.
- To evaluate the effectiveness of various interventions for pain control during infant circumcision.
Main Methods:
- A systematic search of Medline (OVID) and Cochrane Library for randomized controlled trials (RCTs) on pain control for RMIC in newborns under 45 days.
- Independent screening of articles by two authors, with a third reviewer resolving discrepancies.
- Categorization of trials based on intervention type: topical anesthetics, oral sucrose, nerve blocks, caudal blocks, devices, non-pharmacological adjuncts, and combinations.
Main Results:
- Twenty-nine RCTs were analyzed, evaluating pain prevention measures for RMIC.
- Nerve blocks demonstrated superior pain control compared to topical anesthetics and oral sucrose as single agents.
- Oral sucrose combined with non-pharmacological methods (swaddling, music) and perioperative oral acetaminophen were found to be beneficial.
Conclusions:
- RMIC is a painful procedure requiring effective pain management.
- Multimodal pain control, combining anesthetics, analgesics, and kinesthetic methods, is the most effective strategy for optimal outcomes.
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. Only trials that included newborns younger than 45 days of age were included. The articles generated in the initial search were screened independently by two of the authors. A third reviewer settled any discrepancies about the inclusion. Then, trials were categorized based on the type of intervention: topical anesthetics, oral sucrose, oral acetaminophen, nerve blocks, caudal blocks, circumcision device, non-pharmacological adjuncts, and multiple combinations.
Results:
Twenty-nine randomized clinical trials (RCTs) were found to address pain preventative measures in RMIC. As single agent, nerve blocks outperformed topical anesthetics and oral sucrose, as the latter two proved to be insufficient for proper pain control. Additionally, dorsal penile nerve block and ring blocks have a reasonable safety profile. The use of caudal blocks in RMIC was uncommon. Oral sucrose in association with swaddling or music are helpful and can be easily combined with other methods of pain management. Moreover, oral acetaminophen given perioperatively helps the patient recover. Ultimately, pain control should rely on a combination of anesthetics, analgesics, and kinesthetic methods to be administered before, during, and after the procedure for optimal outcome.
Conclusion:
RMIC is a painful procedure in need of proper pain control. Different interventions and agents have various abilities in controlling pain; however, developing a protocol centered around multimodal pain control proves to be the most effective.
