Acetaminophen
Analgesia
in Neonatal
Circumcision:
The
Effect
on
Pain
Cynthia R. Howard, MD*; Fred M. Howard, MDX; and Michael L. Weitzman, MD*
ABSTRACT. Objective. Recognizing the concerns
about the use of local anesthesia in neonatal circumcision, a painful procedure usually performed without analgesia
or anesthesia, we undertook a study of acetaminophen for
pain management of this procedure.
Design. A prospective, randomized, double-blind, placebo-controlled, clinical trial of acetaminophen
anal-gesia in 44 healthy full-term neonates undergoing
circum-cision was conducted. Beginning 2 hours before Gomco
circumcision, neonates received either acetaminophen (15
mg/kg per dose, 0.15 mL/kg per dose) or placebo (0.15
mL/kg per dose) every 6 hours for 24 hours. Neonates were
monitored intraoperatively for changes in heart rate,
res-piratory rate, and crying time. Postoperative pain was
as-sessed at 30, 60, 90, 120, 360 minutes, and 24 hours using
a standardized postoperative comfort scoring system.
Feeding behavior was also assessed before and after
cir-cumcision by nursing observation.
Results. Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences
ob-served between the groups. Postoperative comfort scores
showed no significant differences between the groups
un-til the 360-minute postoperative assessment, at which
time the acetaminophen group had significantly
im-proved scores (P < .05). Feeding behavior deteriorated in breast- and bottle-fed neonates in both groups, and acet-aminophen did not seem to influence this deterioration.
Conclusions. This study confirms that circumcision of
the newborn causes severe and persistent pain.
Acet-aminophen was not found to ameliorate either the
intra-operative or the immediate postoperative pain of
circum-cision, although it seems that it may provide some benefit
after the immediate postoperative period. Pediatrics
1994;93:641-646; neonatal circumcision, acetaminophen.
Neonatal circumcision is the most common surgical
procedure performed on males in the United States.1’2
As many as 86% of male neonates undergo this
op-eration.3 It is unlikely that the frequency of this
pro-cedure will decrease in the near future as the
Amen-can Academy of Pediatrics has acknowledged that it
has possible medical benefits.4 Although there is clear
neurophysiologic and clinical evidence that neonates
are capable of mature pain perception, even at
rela-tively immature gestational ages,5 neonatal
circum-cision is usually performed without analgesia or
anesthesia.1 Dorsal penile nerve block has been
The Departments of *pediatrics and $Qbstetrics and Gynecology, Rochester
General Hospital, The University of Rochester School of Medicine and
Dentistry, Rochester, NY.
Received for publication Aug 4, 1993; accepted Oct 8, 1993.
Reprint requests to (C.R.H.) Dept of Pediatrics, Rochester General Hospital,
1425 Portland Aye, Rochester, NY 14621.
PEDIATRICS (ISSN 0031 4005). Copyright © 1994 by the American
Acad-emy of Pediatrics.
shown to provide anesthesia and analgesia,9”12 but it
is not widely used due to concerns of sufficient
safety,4’1#{176}the additional time required to perform the
block, and the continued belief that the pain of
neo-natal circumcision is insignificant. The American
Academy of Pediatrics supports the use of anesthetics
and analgesics in neonates and in its statement on
neonatal anesthesia recommends that “the decision to
withhold such medication should be based on the
same medical criteria used for older patients.”3
Recognizing the concerns about the use of local
an-esthesia in neonatal circumcision, we undertook a
study of acetaminophen for pain management of this
procedure. Acetaminophen is used extensively for
re-lief of mild to moderate pain after minor surgery, has
a broad margin of safety in infancy,’4 and is
metabo-lized and excreted efficiently by newborns.’5-17 To test
the hypothesis that acetaminophen alleviates
intra-operative and postoperative pain in neonatal
circum-cision, a prospective, randomized, double-blind,
placebo-controlled, clinical trial of acetaminophen
an-algesia in healthy full-term neonates undergoing
cir-cumcision was conducted.
MATERIALS AND METHODS
Patient Population
All male neonates who met the study criteria defined below
and who were delivered by the staff obstetrical service of
Roch-ester Ceneral Hospital from July 1992 to April 1993 were
poten-tially eligible to participate in the study. Rochester Ceneral
Hos-pital is a 526-bed community hospital affiliated with the
University of Rochester School of Medicine and Dentistry with
approximately 2500 deliveries per year. Parents requesting
cir-cumcision of healthy, appropriate for gestational age, full-term
male newborns were asked to participate, and informed consent
was obtained for study participation. Full-term was defined as 37
to 42 weeks gestation. Further eligibility criteria were: (1) Apgar
scores >7 at I and 5 minutes; (2) absence of any chronic or
infec-tious disease process; (3) no history of maternal illicit drug or
alcohol use; (4) absence of any other contraindication to
circum-cision, such as hypospadias, epispadias, or cordee of the penis;
and (5) no family history of a bleeding disorder. The study pro-tocol and consent form were approved by the hospital’s Clinical
Investigation Committee.
Protocol and Data Collection
Using a computer-generated random number list, neonates
were randomized to either an acetaminophen or placebo group.
Twenty-one infants were randomized to the placebo group, and 23
to the acetaminophen group. The acetaminophen group received
acetaminophen infant drops (Tylenol infant drops, McNeil
Con-sumer Products), 15 mg/kg per dose (0.15 mL/kg per dose) every
6 hours for 24 hours (or until the neonate was discharged if this
occurred before 24 hours), starting 2 hours preoperatively.
Neo-nates in the placebo group were treated by an identical protocol,
but received 0.15 mL/kg per dose of a placebo solution, colored
and saccharin-sweetened to resemble the acetaminophen drops.
Five single doses of either placebo or acetaminophen were
dis-pensed to the hospital’s mother-baby unit for each infant.
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Assessment 0 None Strong, rhythmic pacifying effect Normal Normal Absent
Normal for age
cations were dispensed in nursing bottles containing individual,
prediluted doses ready for administration to the infant. Study
medications for both groups were prediluted by pharmacy
per-sonnel with 4 mL of sterile water. After administration of the
acetaminophen or placebo, 4 mL of sterile water were placed into
the nursing bottle, swirled to dissolve any residual medication,
and given to the neonate. All nurses and physicians involved in
the study were blinded to the group assignments.
All circumcisions were performed in a quiet room specifically
designated for circumcision procedures. All neonates were treated
identically to the fullest possible extent. Circumcisions were
per-formed between 6:30 AM and 8:00 AM to allow one investigator to
do all postoperative assessments and to guarantee relatively
uni-form routine care experiences for the neonates before evaluation.
Neonates had received nothing by mouth for a minimum of 2
hours before circumcision, and no neonates went longer than 3 hours without feeding before the procedure. All neonates had
uneventful newborn nursery courses and were at least 24 hours
old at the time of circumcision.
Intraoperatively, pain was assessed using crying time, heart
rate changes, and respiratory rate changes. Heart rate was counted
by a nurse via cardiac auscultation. Respiratory rate was
deter-mined by visual observation by a second nurse. Heart rates and
respiratory rates were assessed every 30 seconds beginning with
the 3-minute preoperative observation and extending through the
3-minute postoperative observation. Crying time was assessed by
the same investigator (C.R.H.) for all neonates and was
deter-mined using stopwatch measurement of crying vocalizations
dur-mg each stage of the procedure. Pacifiers were offered to all
neo-nates during the procedures.
Neonates were restrained on a circumcision board for 3
mm-utes before the surgical procedure to assess baseline
measure-ments of crying times, heart rate, and respiratory rate. All
circum-cisions were performed by the same physician (F.M.H.) using the
same Comco clamp technique in all neonates. For purposes of data
interpretation, the operation was divided into the following
stages: (1) 3 minutes baseline with limbs restrained; (2) cleansing
of genital area; (3) dissection and lysis of adhesions; (4) Comco
clamp placement; (5) foreskin excision; (6) Comco clamp removal
and dressing placement; and (7) 3-minute postoperative period on
circumcision board without restraint. Mean heart rates and
respi-ratory rates were calculated for each of these stages, as were
percents of time spent in crying.
The Postoperative Comfort Score described by Attia et al’8
(Table 1), which has previously been used in the assessment of
postoperative pain in infancy,’9 was utilized to assess
postopera-tive pain. This score assesses 10 infant behaviors, each of which is
scored 0, 1, or 2, resulting in possible scores from 0 to 20. The lower
the score, the more uncomfortable the infant. Each neonate was
scored in the immediate preoperative period, and postoperatively
TABLE 1. Postoperative Comfort Score
at 30, 60, 90, 120, and 360 minutes. Those neonates who were
hospitalized long enough to allow for additional postoperative
scoring at 24 and 48 hours were also assessed at these times. All
comfort scores were obtained by the same physician (C.R.H.).
Before scoring, the state of the neonate (quiet/awake, fussy, or
sleeping) was recorded. The amount of time since the neonate was
last fed and any blood drawing or other painful procedure (eg,
immunization) that had occurred within the last 30 minutes were
also recorded.
Two of the authors (C.R.H. and F.M.H.), both blinded to
in-fants’ circumcision status, performed a pilot test of the
Postopera-tive Comfort Score in a group of 55 well, full-term newborns, 15 of
whom were postcircumcision. lntraobserver reliability for this
in-strument was r = .90, and interobserver reliability was r = .85. A
comfort score of <16 from <1 hour to 70 hours postcircumcision
identified neonates who had undergone circumcision with a
posi-tive predictive value of 85%, a sensitivity of 73%, and specificity of
96%. In the subgroup of circumcised neonates, a score of <16
predicted with 85% sensitivity and 100% specificity those neonates
who were <24 hours postcircumcision. Interobserver reliability
was reverified (r > .90) in the later half of the current study in a
subgroup of 13 neonates.
Feeding behavior was evaluated before and after circumcision.
In accord with standard nursing protocol at this hospital, nurses
record breast-feeding behavior or formula intake each time an
neonate feeds. For the purposes of this study, preoperative feeding
behavior was defined as follows for breast-fed neonates: (1)
breast-feeding satisfactory, if by nursing observation the neonate was
judged to have breast-fed well for the two feedings before
circum-cision; and (2) breast-feeding unsatisfactory, if by nursing
obser-vation the neonate was judged to have fed poorly on either of two
breast-feedings before circumcision.
All neonates were taken to their mothers for feeding
immedi-ately after circumcision. If, in postoperative feedings, a neonate
who was in the satisfactory category was judged to have fed
poorly in two breast-feeding attempts or if the neonate refused to
be breast-fed on two attempts, then breast-feeding behavior was
judged to have deteriorated postoperatively. If after two attempts
at breast-feeding the neonate required formula supplementation
(eg, the neonate was symptomatic with a blood glucose <50) or the
mother chose to feed the infant formula, breast-feeding was also
judged to have deteriorated. If a neonate who had breast-fed
poorly preoperatively fed well in postoperative feedings,
breast-feeding behavior was judged to have improved.
Formula intakes of bottle-fed neonates for the two feedings
before circumcision were averaged. This average was recorded
as the baseline formula intake for the neonate. If on the first
post-operative feeding the neonate consumed <50% of the
preopera-tive volume of formula, feeding behavior was judged to have
worsened.
Sleep during preceding hour
Facial expression of pain
Quality of cry
Consolability
Sociability, eye contact,
response to voice, smile, real interest in face
Sucking
Spontaneous excitability
and responsiveness to ambient stimulation Spontaneous motor
activity
Constant and excessive
flexion of fingers and toes
Clobal evaluation of tone
Marked, constant
Screaming, painful, high
pitched
None after 2 mm
Absent
Absence or disorganized suck
Tremulous, clonic
move-ments, spontaneous moro
reflexes
Thrashing around, incessant
agitation
Very pronounced, marked,
and constant
Strong hypertonicity
Score
Short naps between 5 and
10 mm each
Less marked, intermittent
Modulated, can be
dis-tracted by normal sound
Quiet after I mm of effort
Difficult to obtain
Intermittent suck (3 or 4)
and stops with crying
Excessive reactivity (to any
stimulation)
Moderate agitation
Less marked, intermittent
Moderate hypertonicity
2
Longer naps, >10 mm
each
Calm, relaxed
No cry
Calm before I mm of
effort
TABLE 2. Intraoperative Heart Rates, Respiratory Rates, and Crying Times DuringNeonatal Circumcision
Baseline Sterile Dissection Clamp On Excision Clamp Off Recovery
Heart rate (beats/mm)
Preparation
Acetarninophen 132.4 ± 14.5 138.3 ± 14.4 155.3 ± 20.5 162.0 ± 21.8 141.8 ± 15.7 149.4 ± 19.6 141.0 ± 20.2
Placebo 138.9 ± 21.0 141.0 ± 23.0 156.8 ± 20.0 161.1 ± 21.9 139.9 ± 17.4 140.0 ± 22.1 135.7 ± 17.6
Respiratory rate (breaths/mm)
Acetaminophen 48.9 ± 10.4 43.1 ± 13.4 48.5 ± 12.5 55.1 ± 10.5 59.9 ± 13.3 53.6 ± 16.9 61.6 ± 12.8
Placebo 55.2 ± 14.2 51.0 ± 22.5 53.4 ± 14.8 57.5 ± 15.7 67.8 ± 19.3 53.3 ± 19.4 67.6 ± 16.9
Crying time (% time)
Acetaminophen 0.15 ± 0.27 0.56 ± 0.30 0.83 ± 0.15 0.79 ± 0.27 0.16 ± 0.20* 0.63 ± 0.21 0.32 ± 0.27
Placebo 0.32 ± 0.35 0.66 ± 0.27 0.85 ± 0.12 0.80 ± 0.24 0.35 ± 0.29* 0.68 ± 0.30 0.39 ± 0.34
*P value <.05.
Power calculations based on the results of the pilot test of the
Postoperative Comfort Score indicated that a group size of 18
neonates in each of the two test groups would allow detection of
a 50% improvement in Postoperative Comfort Scores with 80%
power and an a of .05 in a one-tailed analysis.
Data Analysis
Data analysis was performed using EPI Info, Version 5 (Centers
for Disease Control Shareware) and SPSS-PC statistical programs.
Statistical comparisons were performed using the Student’s t-test
for normally distributed continuous data, and the Wilcoxon
two-sample test for nonnormally distributed data. Categorical
van-ables were tested for differences by x statistics, and 95%
confi-dence intervals for proportions were calculated to examine the
variance of the point estimates. Fisher’s exact tests were used
whenever a cell size was <5. Differences between groups for
Post-operative Comfort Scores were analyzed using the Student’s t-test
and analysis of variance techniques. Analysis of variance
tech-niques tested for differences between the groups with the
preced-ing comfort scores treated as a covaniate.
Comparisons between groups were also performed for all
out-come measures accounting for rates obtained in preoperative
ob-servations. Preoperative values were subtracted from subsequent
measures of a particular pain measure to produce adjusted values.
Appropriate statistical analysis was then performed on these
ad-justed values.
RESULTS
There were no significant differences between the
study groups for birth weight, race, maternal age,
ges-tational age, maternal smoking during pregnancy,
method of delivery, maternal use of intravenous or
intramuscular analgesics during labor, maternal use
of local or epidural anesthesia during labor, Apgar
scores at I and 5 minutes, method of infant feeding,
age at circumcision, or time required for the
proce-dure. Only the incidence of obstetric complications
differed between the groups. Two neonates in the
ac-etaminophen group were born to mothers with
ges-tational diabetes (non-insulin-dependent), and one
was born to a mother with pregnancy-induced
hy-pertension, whereas there were no obstetric
compli-cations in the group receiving placebo. In all cases,
neonates were asymptomatic at birth with normal
growth parameters and uneventful newborn courses.
There were no statistically significant differences in
unadjusted heart rate or respiratory rate (Table 2)
be-tween the acetaminophen and placebo groups at any
stage of the circumcision procedure. Neonates in the
placebo group cried significantly more than those in
the acetaminophen group during foreskin removal
(Table 2, P < .05). These differences, however, were
not evident when crying times were adjusted for
base-line crying time (Table 3). The analysis of adjusted
mean heart rates showed that the acetaminophen
group had significantly greater changes in heart rate
during the clamp removal and recovery periods of the
procedure (P < .05 for each of these stages).
There were no significant differences between the
groups at any designated postoperative pain
assess-ment for the behavioral state of the neonates before
scoring, time since last feeding, or for the numbers of
painful procedures (eg, blood drawing or
immuni-zation) which occurred within 30 minutes of a
com-fort score. Significant differences occurred between
preoperative scores and the 30-, 60-, 90-, 120-minute,
and 6-hour postoperative comfort scores in both
groups. When preoperative and postoperative
corn-fort scores were compared, significant changes
oc-curred in 9 of 10 and 8 of 10 components of the
comfort score in the acetaminophen and placebo
groups, respectively.
The t-test comparisons of comfort scores, adjusted
and unadjusted for preoperative values, revealed no
significant differences between the groups at any of
TABLE 3. Changes in Intraoperative Heart Rates, Respiratory Rates, and Crying Times During Neonatal Circumcision Adjusted for
Baseline Values
Sterile Dissection Clamp On Excision Clamp Off Recovery
Preparation
Heart rate (beats/mm)
Acetaminophen 5,9 ± 13.9 22.9 ± 18.5 29.6 ± 21.8 9.4 ± 18.8 17.0 ± 21,4* 8.6 ± 20,4*
Placebo 2.0 ± 14.4 17.8 ± 14.9 22.3 ± 19.4 1.0 ± 17.9 1.2 ± 23,2* -3.2 ± 18.5*
Respiratory rate (breaths/mm)
Acetaminophen -5.8 ± 14.0 -0.4 ± 13.1 6.2 ± 10.3 11.0 ± 8.2 4.7 ± 13.8 12.7 ± 10.2
Placebo -4.2 ± 18.4 -1.7 ± 13.0 2.0 ± 10.3 12.5 ± 16.1 -2.0 ± 15.2 12.7 ± 10.2
Crying time (% time)
Acetaminophen 0.42 ± 0.30 0.68 ± 0.27 0.64 ± 0.34 0.03 ± 0.26 0.49 ± 0.29 0.18 ± 0.25
Placebo 0.34 ± 0.26 0.52 ± 0.33 0.49 ± 0.46 0.03 ± 0.28 0.35 ± 0.31 0.08 ± 0.21
*P value <.05.
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Figure. Mean adjusted
postop-erative comfort scores after
neona-tal circumcision: a comparison of
acetaminophen (n = 23) and
pla-cebo (n = 21) analgesia.
C
0
U U)
E 0 0 .
C
-1
-2
-3
.4
#{149}6
. 30Minutes
a acetaminophen . placebo
the determinations (Figure and Table 4). Reanalysis of
the data, however, via analysis of variance, with the
previous comfort score treated as a covariate,
dem-onstrated that the acetaminophen group was
signifi-cantly more comfortable than the placebo group at the
6-hour postoperative score (P < .05). The 6-hour score
occurred 2 hours after a dose of acetaminophen and
at the time of maximal effect for the analgesic.’5’16
There were no significant differences between the
groups for comfort scores at any other postoperative
time using this method of analysis.
Preoperatively, all neonates fed well. Neonate
feed-ing behavior after circumcision deteriorated in
neo-nates in both groups. Of those breast-fed, 2 of 1 1 (18%)
in the acetaminophen group and 3 of 8 (37%) in the
placebo group either were judged to have breast-fed
poorly or required formula feedings after
circumci-sion. Of neonates who were formula-fed, 4 of 12(33%)
in the acetaminophen group and 2 of 13 (15%) in the
placebo group fed poorly after circumcision.
Acet-aminophen did not significantly influence feeding
changes for either breast-fed or formula-fed neonates.
DISCUSSION
Numerous studies have shown that circumcision
causes severe intraoperative pain as measured by
changes in crying,8 heart rate, respiratory rate,
tran-scutaneous Po2,’2’2#{176}and cortiso! levels.9 Adequate
an-esthesia such as that provided by local anesthesia
with lidocaine or dorsal penile nerve block has been
shown to ameliorate changes in each of these
parameters.9”2’2123 Additionally, simple interventions
like sucrose-flavored pacifiers have been shown to
de-crease crying time.24 In the current study the observed
changes in intraoperative heart rate, respiratory rate,
and crying times were consistent with severe
intra-operative pain, and no clinically relevant differences
between the study groups for any of the
intraopera-tive pain measures were observed. Although
differ-ences were observed between groups for adjusted
mean heart rates in the final two stages of the
cir-cumcision procedure, they were unexpected because
they occurred during the least invasive portions of the
procedure, contrasted to all other outcome measures,
were not believed to be clinically relevant, and may
have been the result of analysis of multiple measures.
Acetaminophen, an analgesic of only mild to
mod-erate potency, thus seems to be an ineffective
anal-gesic for the management of the intraoperative pain
associated with circumcision in the newborn.
Both groups of neonates showed significant
dete-rioration in their comfort scores at all postoperative
assessments. Although the number of neonates
re-maining in the hospital for the 24-hour assessment
was small, postoperative scores in both groups at this
time had not returned to preoperative values. Other
studies have documented changes in the Brazelton
Neonatal Behavioral Assessment secondary to
cir-cumcision that have persisted for at least 24 hours.6’1’
The overall deterioration in comfort scores observed
in this study is consistent with these observations.
The results of this study also suggest that
acet-aminophen is ineffective for pain management in the
immediate postoperative period (ie, the first 2 hours
postcircumcision). Clinical experience with
circumci-sion pain in older children validates this conclusion as
TABLE 4. Mean Preoperative an d Postoperative Comfort Scores
Preoperative 30 mm 60 mm 90 mm 120 mm 6 h 24 h
Acetaminophen Placebo
Adjusted for preoperative value
Acetaminophen Placebo
18.4 ± 1.3 18.4 ± 1.5
14.9 ± 2.0 14.7 ± 2.5
-3.5 ± 2.2 -3.7 ± 2.6
15.5 ± 2.6 15.0 ± 3.0
-2.9 ± 3.1 -3.4 ± 2.8
15.0 ± 1.8 15.5 ± 2.0
-3.0 ± 2.1 -2.7 ± 2.0
15.9 ± 2.0 15.8 ± 2.2
-2.5 ± 2.5 -2.6 ± 2.5
17.1 ± 1.6* 16.3 ± 2.3*
-1.2 ± 2.0* -2.0 ± 2,8*
16.7 ± 3.Ot 17.0 ± 1.9t
* value <.05.
regional anesthesia, potent nonsteroidal drugs, and
narcotic analgesics are often used for postoperative
pain control for circumcision outside the neonatal
period?-5-27
There was significant improvement, however, in
the group of neonates who received acetaminophen 6
hours postoperatively. It thus seems that
acetamino-phen may provide some analgesia in circumcised
neonates after the immediate postoperative period.
Due to the early discharge of neonates, the number of
postoperative comfort scores at 24 hours were
insuf-ficient for statistical analysis, and we were unable to
evaluate acetaminophen effects after 6 hours.
One probable explanation for the observed failure
of acetaminophen to control pain in the immediate
postoperative period is that the pain of circumcision
is too severe to be controlled by a mild analgesic like
acetaminophen. Thus, even though acetaminophen is
simple and safe to administer to newborns, it may not
be indicated for the treatment of pain of circumcision
in the immediate postoperative period.
Subtherapeutic levels of acetaminophen might also
explain inadequate postoperative analgesia, as
acet-aminophen levels were not monitored.
Pharmaco-kinetic studies have been conducted in neonates,
however, and dosages similar to those used in older
children are recommended for use in neonates. These
same studies indicate that drug absorption and
half-life may be prolonged in neonates, but that syrup
forms of acetaminophen improve drug absorption.
Thus, an every 6-hour dosage schedule with
acet-aminophen infant drops was chosen for this study.’6’28
Another possible explanation for the failure to
demonstrate immediate postoperative effectiveness
of acetaminophen is that the measures of pain used
were not sufficiently sensitive to detect differences in
pain levels. However, results from the pilot series
showed that the Postoperative Comfort Score was
quite effective in discriminating circumcised neonates
from noncircumcised neonates; and as already stated,
other studies have used changes in similar parameters
to assess the pain associated with circumcision and its
control with potent analgesics.18’19 Furthermore, the
observed sharp decrease followed by a gradual
in-crease of the score postcircumcision supports the use
of this instrument for evaluating neonatal pain.
The observed deterioration in postoperative
feed-ing behavior has been documented by other
investi-gators.29 Infants feed less frequently and are less
avail-able for interaction after circumcision. Subdued, less
interactive behavior is in fact a common reaction to
stress in the neonate.6”3#{176} In this study,
acetamino-phen seemed to have no effect on this deterioration.
This change lasted for at least two feedings in the
breast-fed neonates. Because most hospital
dis-charges occurred 7 to 10 hours after circumcision, the
data are inadequate to assess the duration of the
ef-fects on feeding. Neonatal circumcisions are often
performed on the day of discharge with many
neo-nates leaving the hospital 3 to 6 hours
postopera-lively. Thus the observed deterioration in ability to
breast-feed may potentially contribute to
breast-feeding failure. Furthermore, some neonates in this
study required formula supplementation because of
maternal frustration with attempts at breast-feeding
or because the neonate was judged unable to
breast-feed postoperatively. This finding is disconcerting
be-cause early formula supplementation is associated
with decreased breast-feeding duration.3”32 Because
the vast majority of male infants in the United States
undergo unanesthetized circumcision, this
prelimi-nary observation deserves further study.
In summary, this study confirmed that
circumci-sion of the newborn causes severe and persistent pain.
Acetaminophen was not found to ameliorate either
the intraoperative or the immediate postoperative
pain of circumcision, although it may provide some
benefit after the immediate postoperative period.
Given the large numbers of newborns who undergo
this painful surgical procedure, it is imperative that
safe and easily administered methods of anesthesia
and analgesia be found and utilized.
ACKNOWLEDGMENTS
This work was supported in part, by grant 1D28PE50008-01
from the Bureau of Health Professions.
The authors would like to thank Klaus Roghmann, PhD, for his
thoughtful comments, Neil Schecter, MD, for his help in selecting
a method of assessing postoperative pain, and Marilyn Richards,
RNC, and Marifran Cooper, RNC, MSN, for their assistance
dur-ing the study.
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IS THERE A “RIGHT” OF PARENTHOOD?
A woman was enraged (recently) because her health insurance company, after
paying for two unsuccessful attempts at in vitro fertilization, had refused to
reim-burse her for further infertility treatments. “They’re depriving me of my right to
become a mother,” she said, “and I’m going to sue them.”
But where is it written that our society owes everyone the “right” to become a
parent, regardless of the financial or ethical cost? ...
Almost no one has questioned the notion of parenthood as a right and infertility
as a disaster that must be fought with all the high-tech tools of modern
medi-cine . . .but when infertility is viewed simply as one misfortune on a scale of
sorrows-less horrible, say, than mind destroying diseases or mass starvation-the
ethical balance looks quite different.
Jacoby S. Entitled to the embryo? New York Times. November 2, 1993.
1994;93;641
Pediatrics
Cynthia R. Howard, Michael L. Weitzman and Fred M. Howard
Acetaminophen Analgesia in Neonatal Circumcision: The Effect on Pain
Services
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