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Meta-Analysis
. 2004 Oct 18;2004(4):CD004217.
doi: 10.1002/14651858.CD004217.pub2.

Pain relief for neonatal circumcision

B Brady-Fryer  1 , N Wiebe, J A Lander
Affiliations
Meta-Analysis

Pain relief for neonatal circumcision

B Brady-Fryer et al. Cochrane Database Syst Rev. .

Abstract

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.

Search strategy: We searched Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004), MEDLINE (1966 - April 2004), EMBASE (1988 - 2004 week 19), CINAHL (1982 - May week 1 2004), Dissertation Abstracts (1986 - May 2004), Proceedings of the World Congress on Pain (1993 - 1999), and reference lists of articles. Language restrictions were not imposed.

Selection criteria: Randomised controlled trials comparing pain interventions with placebo or no treatment or comparing two active pain interventions in male term or preterm infants undergoing circumcision.

Data collection and analysis: Two independent reviewers assessed trial quality and extracted data. Ten authors were contacted for additional information. Adverse effects information was obtained from the trial reports. For meta-analysis, data on a continuous scale were reported as weighted mean difference (WMD) or, when the units were not compatible, as standardized mean difference.

Main results: Thirty-five trials involving 1,984 newborns were included. Thirty-three trials enrolled healthy, full term neonates, and two enrolled infants born preterm. Fourteen trials involving 592 newborns compared dorsal penile nerve block (DPNB) with placebo or no treatment. Compared to placebo/no treatment, DPNB demonstrated significantly lower heart rate [WMD -35 bpm, 95% CI -41 to -30], decreased time crying [WMD -54 %, 95% CI -64 to -44], and increased oxygen saturation [WMD 3.2 %, 95% CI 2.7 to 3.7]. Six trials involving 190 newborns compared eutectic mixture of analgesics (EMLA) with placebo. EMLA demonstrated significantly lower facial action scores [WMD -46.5, 95% CI -80.4 to -12.6], decreased time crying [WMD - 15.8 %, 95% CI -20.8 to -6.8] and lower heart rate [WMD -15 bpm, 95% CI -19 to -10]. DPNB, compared with EMLA in four trials involving 164 newborns, demonstrated significantly lower heart rate [WMD -17 bpm, 95% CI -23 to -11] and pain scores. When compared with sucrose in two trials involving 126 newborns, DPNB demonstrated less time crying [MD -166 s, 95% CI -211 to -121], and lower heart rate [WMD -27 bpm, 95% CI -33 to -20]. Results obtained for trials comparing oral sucrose and oral analgesics to placebo, and trials of environmental modification were either inconsistent or were not significantly different. Adverse effects included gagging, choking, and emesis in placebo/untreated groups. Minor bleeding, swelling and hematoma were reported with DPNB. Erythema and mild skin pallor were observed with the use of EMLA. Methaemoglobin levels were evaluated in two trials of EMLA, and results were within normal limits.

Reviewers' conclusions: DPNB was the most frequently studied intervention and was the most effective for circumcision pain. Compared to placebo, EMLA was also effective, but was not as effective as DPNB. Both interventions appear to be safe for use in newborns. None of the studied interventions completely eliminated the pain response to circumcision.

PubMed Disclaimer

Conflict of interest statement

Two of the reviewers, Brady‐Fryer and Lander, were authors of a trial, Lander 1997, included in this review.

Figures

1
1
1.1
1.1. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 1 Pain score.
1.2
1.2. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 2 Cry time (by unit).
1.3
1.3. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 3 Heart rate (by unit).
1.4
1.4. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 4 Heart rate (by wait time).
1.5
1.5. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 5 Heart rate (by clamp).
1.6
1.6. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 6 Oxygen saturation (by unit).
1.7
1.7. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 7 Transcutaneous oxygen saturation ‐ change from baseline.
1.8
1.8. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 8 Respiratory rate (by unit).
1.9
1.9. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 9 Systolic blood pressure (by unit).
1.10
1.10. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 10 Serum cortisol (nmol/dL) 30 min post.
1.11
1.11. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 11 Salivary cortisol increase (ug/dL) from baseline to 30 min post.
1.12
1.12. Analysis
Comparison 1 DPNB versus no treatment or sham, Outcome 12 B‐endorphin (pmol/L).
2.1
2.1. Analysis
Comparison 2 Ring block versus no treatment, Outcome 1 Cry time (by unit).
2.2
2.2. Analysis
Comparison 2 Ring block versus no treatment, Outcome 2 Heart rate (bpm) change‐from‐baseline.
2.3
2.3. Analysis
Comparison 2 Ring block versus no treatment, Outcome 3 Oxygen saturation (%) change‐from‐baseline.
2.4
2.4. Analysis
Comparison 2 Ring block versus no treatment, Outcome 4 Respiratory rate (rpm) change‐from‐baseline.
3.1
3.1. Analysis
Comparison 3 EMLA versus placebo or no treatment, Outcome 1 Pain score.
3.2
3.2. Analysis
Comparison 3 EMLA versus placebo or no treatment, Outcome 2 Cry time (by unit).
3.3
3.3. Analysis
Comparison 3 EMLA versus placebo or no treatment, Outcome 3 Heart rate (by unit).
3.4
3.4. Analysis
Comparison 3 EMLA versus placebo or no treatment, Outcome 4 Oxygen saturation (%).
3.5
3.5. Analysis
Comparison 3 EMLA versus placebo or no treatment, Outcome 5 Respiratory rate (rpm).
3.6
3.6. Analysis
Comparison 3 EMLA versus placebo or no treatment, Outcome 6 Systolic blood pressure (mmHg) change‐from‐baseline.
3.7
3.7. Analysis
Comparison 3 EMLA versus placebo or no treatment, Outcome 7 Diastolic blood pressure (mmHg) change‐from‐baseline.
4.1
4.1. Analysis
Comparison 4 Topical lidocaine versus placebo, Outcome 1 Pain score.
4.2
4.2. Analysis
Comparison 4 Topical lidocaine versus placebo, Outcome 2 Cry time (s).
4.3
4.3. Analysis
Comparison 4 Topical lidocaine versus placebo, Outcome 3 Heart rate (bpm).
4.4
4.4. Analysis
Comparison 4 Topical lidocaine versus placebo, Outcome 4 Oxygen saturation (%).
4.5
4.5. Analysis
Comparison 4 Topical lidocaine versus placebo, Outcome 5 Respiratory rate (rpm).
4.6
4.6. Analysis
Comparison 4 Topical lidocaine versus placebo, Outcome 6 B‐endorphin (pg/mL).
5.1
5.1. Analysis
Comparison 5 Sucrose versus water or no treatment, Outcome 1 Pain score.
5.2
5.2. Analysis
Comparison 5 Sucrose versus water or no treatment, Outcome 2 Cry time (by unit).
5.3
5.3. Analysis
Comparison 5 Sucrose versus water or no treatment, Outcome 3 Heart rate (by unit).
5.4
5.4. Analysis
Comparison 5 Sucrose versus water or no treatment, Outcome 4 Oxygen saturation (by unit).
5.5
5.5. Analysis
Comparison 5 Sucrose versus water or no treatment, Outcome 5 Serum cortisol (nmol/dL) 30 min post.
6.1
6.1. Analysis
Comparison 6 Acetaminophen versus placebo, Outcome 1 Pain / behavior score.
6.2
6.2. Analysis
Comparison 6 Acetaminophen versus placebo, Outcome 2 Cry time (%).
6.3
6.3. Analysis
Comparison 6 Acetaminophen versus placebo, Outcome 3 Heart rate (bpm).
6.4
6.4. Analysis
Comparison 6 Acetaminophen versus placebo, Outcome 4 Respiratory rate (rpm).
7.1
7.1. Analysis
Comparison 7 DPNB versus EMLA, Outcome 1 Pain score.
7.2
7.2. Analysis
Comparison 7 DPNB versus EMLA, Outcome 2 Cry time (%).
7.3
7.3. Analysis
Comparison 7 DPNB versus EMLA, Outcome 3 Heart rate (by unit).
7.4
7.4. Analysis
Comparison 7 DPNB versus EMLA, Outcome 4 Heart rate by wait time.
7.5
7.5. Analysis
Comparison 7 DPNB versus EMLA, Outcome 5 Respiratory rate (rpm).
8.1
8.1. Analysis
Comparison 8 DPNB versus sucrose, Outcome 1 Pain score.
8.2
8.2. Analysis
Comparison 8 DPNB versus sucrose, Outcome 2 Cry time (s).
8.3
8.3. Analysis
Comparison 8 DPNB versus sucrose, Outcome 3 Heart rate (by unit).
8.4
8.4. Analysis
Comparison 8 DPNB versus sucrose, Outcome 4 Oxygen saturation (by unit).
9.1
9.1. Analysis
Comparison 9 DPNB versus ring block, Outcome 1 Cry time (%).
9.2
9.2. Analysis
Comparison 9 DPNB versus ring block, Outcome 2 Heart rate (bpm) change‐from‐baseline.
10.1
10.1. Analysis
Comparison 10 DPNB versus local block, Outcome 1 Serum cortisol (nmol/dL) 30 min post.
11.1
11.1. Analysis
Comparison 11 Ring block versus EMLA, Outcome 1 Heart rate (bpm) change‐from‐baseline.
11.2
11.2. Analysis
Comparison 11 Ring block versus EMLA, Outcome 2 Cry time (%).
12.1
12.1. Analysis
Comparison 12 Buffered lidocaine DPNB versus plain lidocaine DPNB, Outcome 1 Pain score.
12.2
12.2. Analysis
Comparison 12 Buffered lidocaine DPNB versus plain lidocaine DPNB, Outcome 2 Cry time (%).
12.3
12.3. Analysis
Comparison 12 Buffered lidocaine DPNB versus plain lidocaine DPNB, Outcome 3 Heart rate (bpm).
12.4
12.4. Analysis
Comparison 12 Buffered lidocaine DPNB versus plain lidocaine DPNB, Outcome 4 Oxygen saturation (%).
12.5
12.5. Analysis
Comparison 12 Buffered lidocaine DPNB versus plain lidocaine DPNB, Outcome 5 Serum cortisol (nmol/dL) 30 min post.
13.1
13.1. Analysis
Comparison 13 EMLA versus 30% topical lidocaine, Outcome 1 Cry time (s).
13.2
13.2. Analysis
Comparison 13 EMLA versus 30% topical lidocaine, Outcome 2 Heart rate (bpm).
13.3
13.3. Analysis
Comparison 13 EMLA versus 30% topical lidocaine, Outcome 3 Oxygen saturation (%).
14.1
14.1. Analysis
Comparison 14 EMLA versus sucrose, Outcome 1 Cry time (%).
14.2
14.2. Analysis
Comparison 14 EMLA versus sucrose, Outcome 2 Heart rate (bpm).
14.3
14.3. Analysis
Comparison 14 EMLA versus sucrose, Outcome 3 Oxygen saturation (%).
14.4
14.4. Analysis
Comparison 14 EMLA versus sucrose, Outcome 4 Systolic blood pressure (mmHg).
14.5
14.5. Analysis
Comparison 14 EMLA versus sucrose, Outcome 5 Diastolic blood pressure (mmHg).
15.1
15.1. Analysis
Comparison 15 EMLA versus music, Outcome 1 Cry time (min).
15.2
15.2. Analysis
Comparison 15 EMLA versus music, Outcome 2 Heart rate (bpm).
15.3
15.3. Analysis
Comparison 15 EMLA versus music, Outcome 3 Oxygen saturation (%).
15.4
15.4. Analysis
Comparison 15 EMLA versus music, Outcome 4 Respiratory rate (rpm).
16.1
16.1. Analysis
Comparison 16 Music versus no treatment, Outcome 1 Cry time (min).
16.2
16.2. Analysis
Comparison 16 Music versus no treatment, Outcome 2 Heart rate (bpm).
16.3
16.3. Analysis
Comparison 16 Music versus no treatment, Outcome 3 Oxygen saturation (%).
16.4
16.4. Analysis
Comparison 16 Music versus no treatment, Outcome 4 Respiratory rate (rpm).
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References

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