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  • Review Article
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Neonatal Infant Pain Scale in assessing pain and pain relief for newborn male circumcision

Abstract

Circumcision—partial or total removal of the penile prepuce—requires cutting nerve-laden, sensitive genital tissue and is therefore liable to be painful. The aim of this review is to evaluate the evidence concerning pain felt by newborns during circumcision and to determine whether current analgesic methods can eliminate such pain. I performed a search in medical databases, selecting the trials published in the last 20 years that assessed pain in neonatal circumcision. Twenty-three trials have been retrieved. To get reliable findings, those trials that used validated pain scales were selected; then it was investigated which trials had comparable data for using the same pain scale. The only pain scale that was used in more than two trials was the modified Neonatal Infant Pain Scale (mNIPS) that ranges 0–6. The results of these trials show that none of the analgesic strategies used obtained the absence of pain. Some differences between circumcision techniques can be noticed, but most assessments exceed the score of 3, chosen as the clinically significant pain.

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Fig. 1: The PRISMA selection of trials.
Fig. 2: Pain level during circumcision with different analgesic methods.

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Data availability

Data of this review are available on demand.

References

  1. Malone P, Steinbrecher H. Medical aspects of male circumcision. BMJ. 2007;335:1206–90.

    Article  PubMed  PubMed Central  Google Scholar 

  2. World Health Organization. Newborn Health. https://www.who.int/westernpacific/health-topics/newborn-health.

  3. Jones L, Fabrizi L, Laudiano-Dray M, Whitehead K, Meek J, Verriotis M, et al. Nociceptive cortical activity is dissociated from nociceptive behavior in newborn human infants under stress. Curr Biol. 2017;27:3846–51.e3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Razmus IS, Dalton ME, Wilson D. Pain management for newborn circumcision. Pediatr Nurs. 2004;30:414–7. 427. PMID: 15587537.

    PubMed  Google Scholar 

  5. Bellieni CV. The limitations of pain scales. JAMA Pediatr. 2020;174:623. https://doi.org/10.1001/jamapediatrics.2020.0076. PMID: 32227135.

    Article  PubMed  Google Scholar 

  6. Cold CJ, Taylor J. The prepuce. BJU Int. 1999;83:34–44.

    Article  PubMed  Google Scholar 

  7. Earp BD. Against legalizing female ‘circumcision’ of minors. Global Discourse, 2022, online ahead of print at https://www.researchgate.net/publication/356002254.

  8. Gairdner D. Fate of the Foreskin. Br Med J. 1949;2:1433–7. 1949.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Sam P, LaGrange CA. Anatomy, abdomen and pelvis, penis. 2020. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 29489230.

  10. Amir M, Raja M, Niaz W. Neonatal circumcision with Gomco clamp—a hospital based retrospective study of 1000 cases. J Pak Med Assoc. 2000;50:224–7.

    CAS  PubMed  Google Scholar 

  11. Palit V, Menebhi D, Taylor I, Young M, Elmasry Y, Shah T. A unique service in UK delivering Plastibell (R) circumcision: review of 9-year results. Pediatr Surg Int. 2007;23:45–8.

    Article  PubMed  Google Scholar 

  12. Jayanthi VR, Burns JE, Koff SA. Postneonatal circumcision with local anesthesia: a cost-effective alternative. J Urol. 1999;161:1301–3.

    Article  CAS  PubMed  Google Scholar 

  13. Akyüz O, Ergün M. The effectiveness of jet (needle-free) injector to provide anesthesia in child circumcision under local anesthesia. J Invest Surg. 2022;35:44–8.

    Article  PubMed  Google Scholar 

  14. Al Qahtani R, Abu-Salem LY, Pal K. Effect of lidocaine-prilocaine eutectic mixture of local anaesthetic cream compared with oral sucrose or both in alleviating pain in neonatal circumcision procedure. Afr J Paediatr Surg. 2014;11:56–61.

    Article  PubMed  Google Scholar 

  15. Arunachalam P, King PA, Orford J. A prospective comparison of tissue glu versus sutures for circumcision. Pediatr Surg Int. 2003;19:18–9.

    Article  CAS  PubMed  Google Scholar 

  16. Banieghbal B. Optimal time for neonatal circumcision: an observation-based study. J Pediatr Urol. 2009;5:359–62. NIPS.

    Article  CAS  PubMed  Google Scholar 

  17. Bilgen S, Koner O, Menda F, Karacay S, Kaspar EC, Sozubir S. A comparison of two different doses of bupivacaine in caudal anesthesia for neonatal circumcision. A randomized clinical trial. Middle East J Anaesthesiol. 2013;22:93–8.

    PubMed  Google Scholar 

  18. Butler-O’Hara M, LeMoine C, Guillet R. Analgesia for neonatal circumcision: a randomized controlled trial of EMLA cream versus dorsal penile nerve block. Pediatrics. 1998;101:E5.

    Article  PubMed  Google Scholar 

  19. Garry DJ, Swoboda E, Elimian A, Figueroa R. A video study of pain relief during newborn male circumcision. J Perinatol. 2006;26:106–10.

    Article  CAS  PubMed  Google Scholar 

  20. Joyce BA, Keck JF, Gerkensmeyer J. Evaluation of pain management interventions for neonatal circumcision pain. J Pediatr Health Care. 2001;15:105–14.

    Article  CAS  PubMed  Google Scholar 

  21. Kass FC, Holman JR. Oral glucose solution for analgesia in infant circumcision. J Fam Pr. 2001;50:785–8.

    CAS  Google Scholar 

  22. Kaufman GE, Cimo S, Miller LW, Blass EM. An evaluation of the effects of sucrose on neonatal pain with 2 commonly used circumcision methods. Am J Obstet Gynecol. 2002;186:564–8.

    Article  CAS  PubMed  Google Scholar 

  23. Kozer E, Rosenbloom E, Goldman D, Lavy G, Rosenfeld N, Goldman M. Pain in infants who are younger than 2 months during suprapubic aspiration and transurethral bladder catheterization: a randomized, controlled study. Pediatrics 2006;118:e51–6.

    Article  PubMed  Google Scholar 

  24. Lehr VT, Cepeda E, Frattarelli DA, Thomas R, LaMothe J, Aranda JV. Lidocaine 4% cream compared with lidocaine 2.5% and prilocaine 2.5% or dorsal penile block for circumcision. Am J Perinatol. 2005;22:231–7.

    Article  PubMed  Google Scholar 

  25. Macke JK. Analgesia for circumcision: effects on newborn behavior and mother/infant interaction. J Obstet Gynecol Neonatal Nurs. 2001;30:507–14.

    Article  CAS  PubMed  Google Scholar 

  26. Malnory M, Johnson TS, Kirby RS. Newborn behavioral and physiological responses to circumcision. MCN Am J Matern Child Nurs. 2003;28:313–7.

    Article  PubMed  Google Scholar 

  27. Modekwe VI, Ugwu JO, Ekwunife OH, Osuigwe AN, Obiechina SO. Okpalike IV, et al. Comparison of the efficacy of eutectic mixture of local anesthetics (EMLA) and dorsal penile nerve block (DPNB) in neonatal circumcision. Niger J Clin Pr. 2019;22:1737–41.

    Article  CAS  Google Scholar 

  28. Mujeeb S, Akhtar J, Ahmed S. Comparison of eutectic mixture of local anesthetics cream with dorsal penile nerve block using lignocaine for circumcision in infants. Pak J Med Sci. 2013;29:27–30.

    PubMed  PubMed Central  Google Scholar 

  29. Olson TL, Downey VW. Infant physiological responses to noxious stimuli of circumcision with anesthesia and analgesia. Pediatr Nurs. 1998;24:385–9.

    CAS  PubMed  Google Scholar 

  30. Sharara-Chami R, Lakissian Z, Charafeddine L, Milad N, El-Hout Y. Combination analgesia for neonatal circumcision: a randomized controlled trial. Pediatrics. 2017;140:e20171935.

    Article  PubMed  Google Scholar 

  31. Sinkey RG, Eschenbacher MA, Walsh PM, Doerger RG, Lambers DS, Sibai BM, et al. The GoMo study: a randomized clinical trial assessing neonatal pain with Gomco vs Mogen clamp circumcision. Am J Obstet Gynecol. 2015;212:664.e1–8.

    Article  PubMed  Google Scholar 

  32. South MM, Strauss RA, South AP, Boggess JF, Thorp JM. The use of non-nutritive sucking to decrease the physiologic pain response during neonatal circumcision: a randomized controlled trial. Am J Obstet Gynecol. 2005;193:537–42.

    Article  PubMed  Google Scholar 

  33. Taddio A, Pollock N, Gilbert-MacLeod C, Ohlsson K, Koren G. Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med. 2000;154:620–3.

    Article  CAS  PubMed  Google Scholar 

  34. Taeusch HW, Martinez AM, Partridge JC, Sniderman S, Armstrong-Wells J, Fuentes-Afflick E. Pain during Mogen or PlastiBell circumcision. J Perinatol. 2002;22:214–8.

    Article  PubMed  Google Scholar 

  35. Lawrence J, Alcock D, Mc Grath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12:59–66.

    CAS  PubMed  Google Scholar 

  36. Ranger M, Grunau RE. How do babies feel pain? Elife 2015;4:e07552.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Grunau RE, Holsti, L, Peters JW. Long-term consequences of pain in human neonates. Semin Fetal Neonatal Med. 2006;11:268–75.

  38. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997;349:599–603.

    Article  CAS  PubMed  Google Scholar 

  39. Rossi S, Buonocore G, Bellieni CV. Management of pain in newborn circumcision: a systematic review. Eur J Pediatr. 2021;180:13–20.

    Article  PubMed  Google Scholar 

  40. Locatelli C, Bellieni CV. Sensorial saturation and neonatal pain: a review. J Matern Fetal Neonatal Med. 2018;31:3209–13.

    Article  PubMed  Google Scholar 

  41. Alkhenizan A, Elabd K. Non-therapeutic infant male circumcision. Evidence, ethics, and international law perspectives. Saudi Med J. 2016;37:941–7.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Brussels Collaboration on Bodily Integrity. Medically unnecessary genital cutting and the rights of the child: moving toward consensus. Am J Bioeth. 2019;19:17–28.

    Article  Google Scholar 

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Correspondence to Carlo V. Bellieni.

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Bellieni, C.V. Neonatal Infant Pain Scale in assessing pain and pain relief for newborn male circumcision. Int J Impot Res 35, 282–285 (2023). https://doi.org/10.1038/s41443-022-00551-x

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