Behavioral Effects of Circumcision with and without AnesthesiaSUZANNE DIXON, M.D., JOEL SNYDER, M.D.,
RICHARD HOLVE, M.D., PATRICIA BROMBERGER, M.D.
Department of Pediatrics and Department of Community Medicine,
University of California, San Diego School of Medicine
Address for reprints: Suzanne Dixon, M.D.,
Division of General Pediatrics
(H-664), UCSD Medical Center,
225 Dickinson St.
San Diego, California 92103.
Dr Holve is currently at the Department of Family Medicine, Bucksport Regional Medical Center, Bucksport, Maine.
Dr. Bromherger is currently at the Division of Neonatology/Perinatology, Kaiser Permanente Medical Center, San Diego, California.ABSTRACT. The behavior of full-term neonates undergoing circumcision with and without local anesthesia was examined using the Brazelton Neonatal Assessment Scale (BNAS). Evaluations were done blindly pre- and post- circumcision and on the day following the procedure. Infants receiving lidocaine in a dorsal penile nerve block (DPNB) remained more attentive to animate and inanimate stimuli following circumcision and demonstrated a greater ability to quiet themselves when disturbed. The smoothness and maturity of motor behaviors showed the expected rate of improvement or recovery curve in the anesthetized group, while the control group's behavior did not. Behavioral differences were still evident on the day following the procedure. This report adds to the growing body of data that indicate that circumcision is a painful procedure that disrupts the course of behavioral recovery following birth. These disruptions can be lessened by the use of local anesthesia to relieve pain and stress during the procedure without any additional morbidity. These data support the use of DPNB during anesthesia for routine neonatal circumcisions still requested by the majority of parents in the country.
Neonatal circumcision has remained a common practice in spite of efforts by the American Academy of Pediatrics and others to halt its use as a routine medical procedure.1-6 The few studies that have explored the effects of this procedure on the neonate's behavior have indicated that this is a stressful and painful event.7-11 Changes in heart rate, respiratory rate, transcutaneous pO2, adrenal cortical hormone secretion, sleep patterns, and behavioral patterns have been shown to be altered during and/or following circumcision of the full-term neonate. Indeed, circumcision has been recommended as a model for studying pain in the neonate,12 and its effects are suggested to be long lasting.13 Kirya and Werthmann14 described a simple technique for the use of local anesthesia during neonatal circumcision to minimize pain during this procedure. Williamson and Williamson12 reported a reduction in the infant's circumcision stress as indicated by several physiologic measures when a similar technique was used. It has also been demonstrated that a dorsal penile block with lidocaine reduced intraprocedure indicators of distress: crying and heart rate changes.15 The present study expands those observations to include an assessment of behavior pre- and post-circumcision in a group of infants receiving a dorsal penile block, in contrast to that of a group circumcised without the local anesthetic. The study was designed to determine whether the alterations in behavior following circumcision could be reduced through the use of a local anesthetic during the procedure.
The study population included 31 male infants who were born during a two-month period at UCSD Medical Center, San Diego, Calif. Parent(s) requested circumcision with informed consent for study participation. All were full-term appropriate for gestational age (AGA) infants of two to five days of age with an uncomplicated perinatal course. Subjects were randomly assigned to one of three groups: group 1 infants were restrained and circumcised with a Gomco clamp in the standard manner after dorsal penile nerve block (DPNB) with lidocaine (lidocaine group); eight were circumcised in a similar manner after DPNB with saline (group 2, saline control group) to control for the stress of an injection and possible effects of fluid volume compression on penile sensation. Eight were circumcised under identical circumstances without any injection (group 2, control group). The procedures were performed by a single physician who was blind to the injection content in groups 1 and 2. Heart rate and crying patterns were monitored continuously from the time of the initial restraint until completion of the procedure. The entire procedure has been described in detail elsewhere.15 Two physicians, were blind to the child's group until the end of the study. They performed behavioral assessments on 16 infants selected blindly and at random from the three subgroups. They utilized the Brazelton Neonatal Assessment Scale (BNAS),16 a widely used instrument that consists of 27 behavioral items, each scored on a scale of 1 to 9, and 20 reflexes, scored on a 3-point scale. The scale examines the organization and integration of behavior while the infant is being presented with a series of graded positive and adversive situations. Those behaviors that are most salient in specifying the infants' internal neurobehavioral organization and social interaction are particularly highlighted in this behavioral assessment. Both examiners were trained to reliability of greater than 0.85 on all items and demonstrated interscorer reliability at that level, at the inception and conclusion of the study. All assessments were performed in a quiet darkened room, and every effort was made to bring out the best performance of the infant over the 30-minute examination, in line with the established protocol. The examinations were conducted during interfeeding periods, prior to the circumcision (exam 1), following the circumcision (exam 2), and on the day following the procedure (exam 3). Half of the infants were breastfed, and these were distributed proportionately across the groups. The infants were all circumcised two to five days after birth. Clusters of assessment items normalized so that 9 was the optimal score and were then combined in an a priori, nonweighted fashion. This approach has been used in previous reports.17,18
Circumcision was completed in a satisfactory manner in all infants. One infant developed a small unilateral hematoma after the puncture of the superficial dorsal penile vein following regional anesthesia. There were no untoward effects from this. As reported previously, infants who received the DPNB with lidocaine showed less distress during the circumcision procedure. Heart rate changes were less, and percent of time that the baby cried was decreased in the anesthetized group.15
The mean scores on the Brazelton Neonatal Assessment Scale for the three groups at three examination periods are shown in Table I. These group means are broadly within the norm of behavior expected for American samples reported elsewhere.17-19 Individual variation in the item scores precluded demonstration of any statistically significant differences between the group means. However, the changes in behavior pre- and post-circumcision at the individual level within each of the groups was tested (alpha at 0.05 level) using the Mann-Whitney and Kniskal-Wallis one-way analysis of variance. nonparametric techniques appropriate for the small sample size.20
Changes from Pre- to Post-circumcision, Exam 1 and Exam 2 The orientation response to an inanimate auditory stimulus (i.e., rattle) showed significant differences between the groups in change of behavior from exam 1 and exam 2 (Kruskal-Wallis H = 6.84, p 1.TABLE 1. Mean Scores of Brazelton Neonatal Assessment Scale Scores At Three Exam Times in Three Study Groups. Lidocaine Group Saline Group Control Group 1 2 3 1 2 3 1 2 3 Habituation Light 1 5.33 6.44 5.25 4.50 3.75 5.50 5.75 5.00 5.50 Rattle 2 5.83 6.83 6.25 6.50 6.67 7.00 5.75 8.25 5.50 Bell 3 6.00 6.83 6.00 6.50 6.00 9.00 6.00 5.75 4.00 Pin 4 2.75 3.75 4.00 4.00 3.33 2.50 2.00 2.00 3.50 Orientation Ball 5 5.33 4.79 6.50 6.75 4.25 5.00 6.50 5.75 5.00 Rattle 6 6.44 5.78 6.00 6.75 5.50 6.33 7.00 7.00 7.00 Face 7 5.78 4.78 6.50 6.50 3.75 5.00 6.00 5.25 4.50 Voice 8 6.00 5.36 6.00 7.00 6.00 6.33 6.25 6.00 6.50 Face and voice 9 6.00 5.00 6.00 6.50 3.50 5.00 6.25 5.25 4.00 Alertness 10 5.56 4.11 5.20 6.50 4.75 5.00 6.00 6.25 5.00 Tone 11 5.44 5.00 4.80 5.25 4.75 5.33 4.50 4.75 4.50 Motor maturity 12 7.00 6.67 6.40 5.50 5.25 5.67 5.00 5.75 3.00 Pull-to-sit 13 7.00 6.56 6.00 5.00 4.25 5.33 4.75 4.50 4.50 Cuddliness 14 6.11 5.56 6.40 5.75 5.50 4.67 3.25 5.50 4.50 Defensive 15 5.56 3.56 5.40 3.25 3.25 2.33 5.00 5.25 4.00 Consolability 16 6.14 5.67 6.20 8.00 7.50 5.50 7.25 7.33 6.00 Peak excitement 17 6.00 6.00 5.80 5.25 6.25 6.00 5.00 4.75 6.00 Rapidity 18 5.25 6.00 6.20 4.50 4.25 6.00 5.25 4.00 3.50 Irritability 19 5.67 5.56 5.80 4.75 6.50 5.00 6.00 4.75 5.00 Activity 20 4.67 4.44 5.00 3.75 3.75 5.00 4.25 3.50 3.50 Tremulousness 21 2.89 4.44 5.40 3.75 5.33 4.67 5.25 5.50 4.00 Startle 22 3.00 3.56 3.75 3.50 4.25 4.33 2.75 4.00 4.50 Lability of state 23 5.11 6.22 6.60 4.50 5.25 5.00 5.50 5.75 5.50 Lability of color 24 3.22 4.00 3.80 2.00 3.50 3.67 2.75 3.00 4.00 Self-quieting 25 6.71 6.88 6.20 7.25 5.50 4.00 7.00 7.25 6.00 Hand to mouth 26 4.67 4.44 6.00 4.25 4.25 4.67 4.00 6.00 5.00 Smile 1.0 * Numbers refer to first, second. and third examinations.
- Committee on Fetus and Newborn: Report of the Ad Hoc Task Force on Circumcision. Pediatrics 56:610-611, 1975
- Kaplan GW: Circumcision-An overview.Curr Probl Pediatr 7:1-33, 1977
- Schwark TE: Do edicts have any effect on circumcision rates? Pediatrics 60:563, 1977
- Grimes DA: Routine circumcision of the newborn infant: A reappraisal. Am J Obstet Gynecol 1978; 130(2): 125-129.
- Herrera AJ, Hsu AS, Salcedo UT, and Ruiz MP. The role of parental information in the incidence of circumcision Pediatrics 70:597-598, 1982
- Metcalf TJ, Osborn LM, Mariani EM: Circumcision: A study of current practices. Clin Pediatr 22:575-579, 1983
- Emde R, Harmon R, Metcalf D, et al: Stress and neonatal sleep. Psychosom Med 33:491-497, 1971
- Talbert LM, Kraybill EN, Potter HD: Adrenocortical response to circumcision in the neonate. Obstet Gynecol 48:208-210, 1976
- Marshall PE, Stratton WC Moore JA, et al: Circumcision Effects upon newborn behavior: A controlled, blind observational study. Pediatr Res 13:334, 1979
- Marshall RE, Stratton WC, Moore JA et al: Circumcision. I. Effects upon newborn behavior. Infant Behav Dev 3:1-14,1980
- Rawlings DJ, Miller PA. Engel RR: The effect of circumcision on transcutaneous PO2 in term infants. Am J Dis Child 134:676-678, 1980.
- Williamson PS. Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 71:36-40, 1983
- Richards MPM, Bernal J, Brackbill Y: Early behavior differences: Gender or circumcision. Dev Psychobiol 9:89-95, 1975
- Kirya C, Werthmann MW: Neonatal circumcision and penile dorsal nerve block: A painless procedure. J Pediatr 92:998-1000, 1978
- Holve R, Bromberger P, Weinstein H. et al: Regional anesthesia during newborn circumcision. Clin Pediatr 22:813-818, 1984
- Brazelton TB: Neonatal Behavioral Assessment Scale. Philadelphia. JB Lippincott, 1973
- Lester BM: Issues in neonatal behavioral assessment, in Sell E. (ed): Followup of the High Risk Newborn: A Practical Approach. Springfield, Ill Charles C Thomas, 1980
- Lester BM. Emory EK. Hoffman SE, et al: A multivariate study of the effects of high risk factors on performance on the Brazelton Neonatal Assessment Scale. Child Dev 47:515-517, 1976.
- Tronick E, Als H, Brazelton TB: Early development of neonatal and infant behavior, in Falkner. and Tanner JM (eds): Human Growth. Vol 3. New York. Plenum Publishing, 1979.
- Siegel S: Nonparametric Statistics for the Behavioral Sciences New York. McGraw-Hill. 1956.
- Brazelton TB: Assessment of the infant at risk. Clin Obstet Gynecol 15:361-375. 1973.
- Brazelton TB. Koslowski B. Main M: The origins of reciprocity: The early mother-infant interaction. in Lewis M. Rosenblum 1 (eds): The Effect of the Infant on his Caregiver. New York, John Wiley & Sons. 1974.
- Marshall RE. Porter FL. Rogers AG, et al: Circumcision II. effects upon mother infant interaction. Early Hum Dev 7:367-374, 1982
- Laus HM. Kennell JH: Maternal-Infant Bonding. St. Louis, CV Mosby. 1976
- Lewis M. Rosenblum L: The Effects of the Infant on Its Caregiver. New York, John Wiley & Sons. 1974
- Thoman EB: A rejecting baby affects mother-infant synchrony in Porter R. O'Connor M (eds): Parent-Infant Interaction. Ciba Foundation Symposium 33. Amsterdam, Elsevier. 1975, pp 177. 200
- Osofsky J: Neonatal characteristics and mother-infant interaction in two observational situations. Child Dev 47:1138-1147, 1976
- Stern D: The first relationship, in Infant and Mother Developing Child Series. Cambridge. Mass, Harvard University Press 1977
- Lipsett LP. Field TM: Infant Behavior and Development: Perinatal Risk and Newborn Behavior. Norwood, NJ, Ablex, 1982
- Stein MT. Marx M, Taggert SL, et al: Routine neonatal circumcision: The gap between contemporary policy and practice. J Fam Pract 15:47-53, 1982
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