Analgesia is poised to become a standard part of neonatal circumcision now that the American Academy of Pediatrics has recommended that pain relief be routinely provided during the procedure.

In a position statement issued earlier this month, the AAP declared that there is now enough evidence to support the routine use of analgesia during neonatal circumcision, reversing a 1989 conclusion that there were to few safety and efficacy studies to back routine analgesic use.

The AAP position statement, issued by its Task Force on Circumcision, maintains its 1989 position that although there is some evidence that neonatal circumcision lowers a child’s risk of urinary tract infection, penile cancer, and HIV infection, the reduction in risk isn’t meaningful enough to recommend circumcision as a routine procedure.

There is some indication that the American College of Obstetricians and Gynecologists may follow suit regarding the use of anesthesia.

“I personally agree with the [AAP] position on anesthesia and intend to encourage ACOG to take a stronger stand in favor of proper anesthesia for the procedure,” said Dr. Michael F. Green, chair of the division of maternal-fetal medicine at Massachusetts General Hospital in Boston and ACOG’s liaison to the AAP.

In its 1992 statement, ACOG did not address whether circumcision anesthesia or analgesia should be used routinely but noted that more studies were needed to assess the short- and long-term side effects of its use.

Dr. Greene told Ob.Gyn.News that he is now in the early stages of drafting a statement on circumcision, which will recommend routine analgesia use during the procedure. The statement will be submitted to the ACOG for further consideration.

The American Academy of Family Physicians acknowledged in a 1991 fact sheet that dorsal penile nerve block (DPNB) poses little risk to the infant and “may reduce the pain and stress of newborn circumcision.”

But the academy’s 1996 policy statement on circumcision stopped short of recommending routine use of the technique.

Although the AAP statement did not endorse routine use of circumcision on medical grounds, it encouraged parents to weigh their cultural, religious, and ethnic traditions, as well as medical factors, when deciding whether their son should be circumcised.

If parents opt to have their child circumcised, analgesia in the form of either topical EMLA cream, DPNB, or a subcutaneous ring block should be used, according to the statement.

Recent survey data indicate that 70% of U.S. ob.gyns. routinely perform circumcisions in male infants, but only a quarter of them provide any sort of anesthesia or analgesia for their patients.

It’s a statistic the profession should be ashamed of, said Dr. Fred Howard, chair of the department of ob.gyn. at Rochester (N.Y.) General Hospital.

Dr. Howard points to a robust body of literature documenting that neonates keenly sense pain. A growing number of studies also suggest that infants circumcised without anesthesia show a stronger response to immunization pain up to 5 years after the procedure.

“With respect to anesthetic techniques, DPNB or ring block are clearly the procedures of choice,” said Dr. Larry Veltman, chair of the department of ob.gyn. at Providence St. Vincent Medical Center in Portland, Ore.

Several studies, including one led by Dr. Howard, found that infants anesthetized using DPNB cried less and had less-elevated heart rates and higher average blood oxygen saturation percentages than infant anesthetized with EMLA cream.

Eighty-three percent of 1,778 U.S. doctors who provide anesthesia during circumcision use DPNB with 1% lidocaine, according to a 1997 national survey (Pediatrics 101[6]:E5, 1998).

Sixteen percent reported using acetaminophen, and 9% said they use EMLA cream.

The AAP document stated that the subcutaneous ring block “may provide the most effective analgesia” (Pediatrics 103[3]:686-93, 1999).

“For an ob.gyn. accustomed to performing subcutaneous injections, the ring block takes very little time to learn,” said Dr. Joan M. Mastrobattista of the division of maternal-fetal medicine at the University of Texas in Houston.

Dr. Mastrobattista and her colleagues recently published a randomized study on their experience with ring block using 0.5% lidocaine in 40 healthy neonates. Infants who received the ring block cried significantly less, had smaller increases in their heart and respiratory rates, and had a smaller decrease in oxygen saturation than unanesthetized infants undergoing the procedure (Obstet. Gynecol. 91[6]:930-34, 1999).

But Dr. Myron Yaster, who directs the multidisciplinary pain service at the Children’s Center at Johns Hopkins Hospital in Baltimore, contends that DPNB is just as effective and easier to learn.

“It’s a matter of what you feel comfortable with,” Dr. Yaster said. “DPNB uses only two injections whereas a ring block can require up to eight.”

As adjunctive analgesics, pacifiers dipped in sugar water, postoperative acetaminophen, and warm confining blankets can help calm babies. None are adequate as the sole source of pain relief, according to the AAP position statement.