Anesthesia for Neonatal Circumcision: Who Benefits? (1997)

ABSTRACT: As the medical myths used to justify the practice of neonatal circumcision have each been disproven, the latest used by circumcisers to perpetuate the surgery is that the use of topical and local anesthetics eliminates the pain of neonatal circumcision. While some interventions have reduced the amount of crying during the surgery, it is not clear whether topical or local anesthetics reduce pain substantially. Their impact on the stress of the surgery appears to be minimal. If these attempts at pain relief are not very beneficial for the infant, are they employed to make the circumciser and the parents feel better about what they are doing to the newborn? If these methods are not effective, why is there currently a call for their routine use? INTRODUCTION For most of this century, physicians have been performing procedures and surgeries on newborns without anesthesia with the mistaken notion that newborns were not neurologically complex enough to experience pain. Although this myth has been dispelled[1] the most common surgery in the newborn period, circumcision, continues to be performed, in the majority of cases, without any attempt at pain relief. In 1994, only 4% of obstetricians under 34 years of age used anesthetic for circumcisions. Overall the rate of anesthetic use was 14% among obstetricians with 20% of the female obstetricians using anesthetic.[2] As routine circumcision comes under attack, the most recent backlash against the anti-circumcision crusade is advocating local and topical anesthesia. Like most information used to perpetuate neonatal circumcision, it is a mixture of well-collected data and hyperbole. This article will review the medical research regarding topical and local anesthesia for neonatal circumcision and what information should be given regarding its effectiveness. CIRCUMCISION HURTS-A LOT! If there is a bright side to this topic, performing this extremely painful procedure without anesthetic has allowed researchers to study the parameters of extreme pain in experiments that would not have been allowed on laboratory animals.[3] The most evident expression of pain and stress in the newborn is crying. The amount of crying and pitch of the cry can give an indication of the degree of pain and stress.[4] Facial expressions have also been found to be a reliable measure of distress. Electrophysiological measurement of cardiac activity assesses the reactivity and regulation of the autonomic nervous system. This direct measure of vagal tone is a very sensitive measure of stress.[5] Vital signs, such as heart rate, blood pressure, and oxygenation levels all change with pain and stress and are easily measured. Cortisol levels assess the hypothalamic-pituitary-adrenocortical response to pain and stress. A recent development has been measuring salivary cortisol levels, so the stress and pain of drawing blood are no longer confounding factors.[5] Omitting any of these parameters will give a less than complete picture of neonatal stress reactivity.[5] Cortisol may be the consistently studied parameter. A positive correlation has been demonstrated between the average behavioral state and crying during circumcision and increase in serum cortisol levels.[6-7] Cortisol may also effect the type of sleep babies experience. Quiet sleep, which investigators call a shallow, restless sleep, was negatively correlated with cortisol levels prior to circumcision. Quiet sleep increased significantly following circumcision, with the greatest increase in quiet sleep corresponding to the period of the most rapid drops in cortisol levels.[8] Vagal tone is significantly reduced during the severe stress of circumcision. These reductions were paralleled by significant increases in the pitch of the infant's cries. In addition, individual differences in vagal tone measured prior to circumcision surgery are predictive of the physiological and acoustic reactivity to subsequent stress. …