JAOA 1996; 96: 31-3.

Comparison of newborn circumcision pain to calcaneal heel puncture pain: Is 
newborn circumcision pain control clinically warranted?


 Correspondence to Mark E. Holton, DO, 2612 B Harwood Rd, Bedford, TX 
In newborns, elective male circumcision and calcaneal puncture for 
obtaining blood samples both cause pain. With elective male circumcision, 
dorsal penile nerve block (DPNB) is recommended for pain control, but no 
pain control is routinely recommended or used during calcaneal puncture. A 
prospective investigation was conducted to compare pain during elective 
circumcision (with and without DPNB) and calcaneal puncture to determine 
whether pain control should be used with the latter procedure. The study 
was conducted at a community hospital during a 4-month period. Two nurses 
observed newborn behavior during elective circumcision and routine 
calcaneal puncture and rated pain reactions by using a modified Gronigen 
Distress Scale. Ninety-one male newborns were circumcised without DPNB, and 
eight male newborns were circumcised with DPNB. Calcaneal puncture for 
blood samples was performed in 97 newborns (males and females). Pain scores 
during circumcision with and without DPNB were comparable with those during 
calcaneal puncture (2.1, 2.4, and 2.2, respectively). Pain control during 
circumcision may thus be considered, but caution should be taken that 
measures to prevent pain do not create new patient risk or additional pain. 
(Key words: Calcaneal puncture, circumcision, dorsal penile nerve block, 
newborns, pain control)

For years, newborn circumcision was performed without any medical 
indications. A 10-year study demonstrated an increased risk of urinary 
tract infection for uncircumcised male newborns.[1] The American Academy of 
Pediatrics states that circumcision "has potential medical benefits and 

Dorsal penile nerve block (DPNB) has become the most commonly recommended 
method to resolve pain with circumcision.[3,4] Proponents consider the 
procedure safe, easy, and effective in reducing stress and pain experienced 
by tbe newborn undergoing circumcision.[5] Studies have indicated that 
effects of circumcision on heart rate, respiratory rate, blocd pressure, 
oxygen saturation, serum cortisol levels, and behaviors indicating stress 
can be alleviated by using DPNB.[6-9] Specific complications with the use 
of DPNB include the risk of methemoglobinemia and procedural complications 
including gangrene of the penis and damage to the dorsal penile 

Changes in plasma cortisol levels are associated with normal diurnal 
variation and occur during normal crying. Similar variations have been 
identified with tissue damage associated with circumcision as well as with 
the calcaneal puncture commonly used for obtaining blood samples in 
newborns. Statistics indicate that newborn circumcision is slightly more 
painful than calcaneal heel puncture, but clinical observations indicate 
similar pain control scores for these procedures. If pain control is to be 
considered for newborn circumcision, caution should be taken to prevent 
additional pain or new patient risks.
During a 4-month period at a community hospital with an average delivery 
rate of 142 newborns per month, pediatricians and family practice 
physicians performed elective circumcisions with and without DPNB. Parental 
consent was obtained under guidelines of thc Texas Medical Disclosure Panel 
for Informed Consent (No Disclosure, List B guidelines),[15] Calcaneal 
punctures for blood studies were performed by certified laboratory 
technicians using the "Tenderfoot" device and recommended technique.[16] 
Behavioral scores were recorded by two registered nurses The scores were 
based on objective, global assessments of subjective newborn behavior as 
indicated by crying, screaming, agitation, and level of activity. A higher 
score reflected greater pain. The behavioral scores were based on a 
modified Gronigen Distress Scale and the Children's Hospital of Eastern 
Ontario Pain Scale,[17,18] where the degree of stress was measured using an 
ordinal scale ranging from 1 to 3 (Table 1).

One hundred and ninety-six newborns were randomized into three groups. One 
group consisted of 91 male infants who were circumcised with parental 
consent, without DPNB. The calcaneal puncture group of 97 newborns 
consisted of males (who were not circumcised) and females. Gender 
discrimination was not considered for the calcaneal puncture group (for 
blood sampling required by the Texas Newborn Screening Program). Eight male 
infants were circumcised by using DPNB with parental consent.

Interrater reliability was determined by two nurses observing the same 
newborn at the same point in time for the circumcision and the calcaneal 
puncture. The Spearman's p correlation coefficient was used for interrater 
reliability for crying during the procedure. The Mann-Whitney U test was 
used to compare the mean ranks of age, time for procedure, and pain during 
each procedure for independent groups. The Wilcoxon signed rank test was 
used to compare the mean rank for pain within each group during the 

Interrater reliability was achieved for the calcaneal puncture procedure 
but not for circumcision (Table 2). The lack of interrater reliability for 
crying during circumcision was not clear.
The age of newborn when the procedure was performed, the length of time 
required to perform the procedure, and the pain score are shown in Table 3. 
Pain (mean score) was similar during circumcision without DPNB (2.4) and 
with DPNB (2.1) and during the calcaneal puncture procedure (2.2). The 
Mann-Whitney U test indicated a significant difference in infant age and 
time to perform the procedure between newborns in the circumcision group 
and those in the calcaneal puncture group (Table 4). Because differences in 
age and time of procedure could account for differences in pain response 
between two groups, the Kniskal-Wallis one-way analysis of variance was 
used to determine if there was independence between age and pain during 
each procedure. The X2 statistic for comparison of pain as an ordinal 
measure (1 through 3) with the age of the newborn in each group was not 
significant. Therefore, since there was no relationship between age and 
time of procedure and the pain response, it was determined that any 
difference in pain response would be attributed to the procedure.
The difference in age for procedures was because circumcision often was 
performed before the actual discharge time of the newborn, whereas the 
calcaneal puncture was usually performed just before the newborn was 
discharged from the nursery. The difference in the time required to perform 
the procedures is due to the greater complexity of circumcision. The mean 
rank for pain during circumcision was 103.12, and that for calcaneal 
puncture was 93.29. These data indicate a difference between the pain with 
each procedure with a z of -5.78 (P= .0000) for the calcaneal puncture 
group and a z of -6.734 (P=.0000) for the circumcision group.

Newborns experience pain with many procedures such as phytonadione 
injection, hepatitis B vaccine injection, venipuncture, bladder tap, and 
other procedures, but there are no recommendations for pain control with 
those procedures as there is for circumcision. In this study, mean pain 
scores were similar during circumcision without DPNB and with DPNB and 
during the calcaneal puncture procedure (2.4, 2.1, and 2.2, respectively). 
Consideration must be taken in evaluating the score for circumcision with 
DPNB because of the small sample number. On the basis of pain scores in 
this study, newborn circumcision is slightly more painful than calcaneal 
heel puncture. The decision for newborn circumcision pain control should be 
considered within the context of similar pain experienced by the newborn 
with calcaneal heel puncture. If pain control is not considered for newborn 
calcaneal heel puncture, pain control should not be considered for newborn 
circumcision, especially if the pain control procedure causes additional 
pain or patient risk. Parents of newborns should be reassured that any pain 
the newborn may experience during circumcision (or other procedures) is 
short lived and will not significantly affect the newborn's well-being.

1. Wiswell TE, Enzinauer RW, Holton ME, Cornish JD, Hankins CT: Declining 
frequency of circumcision: Implications for changes in the absolute 
incidence and male to female sex ratio of urinary tract infection in early 
infancy. Pediatrics 1987;79:338-342.
2. American Academy of Pediatrics Committee on Fetus and Newborn: Report of 
the Ad Hoc Task Force on Circumcision: Pediatrics 1975;56:610-611.
3. Kirya C, Werthmann MW: Neonatal circumcision and penile dorsal nerve 
block: A painless procedure. J Pediatr 1978;92:998-1000.
4. Poma PA: Painless neonatal circumcision. Int J Gynaecol Obstet 
5. Stang HJ. Gunner MR, Snellman L, Condon LM, Kestenbaum R: Local 
anesthesia for neonatal circumcision; Effects on distress and cortisol 
response. JAMA 1988;259:1507-1511.
6. Maxwell LG, Yaster M, Wetzel RD, Niebyl R: Penile nerve block for 
newborn circumcision. Obstet Gynecol 1987;70:415-419.
7. Holve I, Bromberger PJ, Groveman Snyder M: Regional Anes-thesia during 
newborn circumcision. Clin Pediatr 1983;22:813-818.
8. Talbert L, Kraybill EN, Potter HD: Adrenal cortical response to 
circumcision in the neonate. Obstet Gynecol 1976;48:208-210.
9. Rawlings DJ, Miller A, Engel RR: The effects of circumcision on 
transcutaneous PO2 in term infants. Am J Dis Child 1980;134:676-678.
10. Mandel S: Methemoglobinemia following neonatal circumcision. JAMA 
11. Olson M, McEvoy K: Methemoglobinemia induced by local anesthetics. Am J 
Hosp Pharm 1981;38:88-93.
12. Sara CA. Lowrv CJ: A complication of circumcision and dorsal nerve 
block of the penis. Anaesth Intensive Care 1985;13:79-85.
13. Schoen EJ: Dorsal penile nerve block for circumcision. JAMA 
14. Anders TF, Sachar EJ, Kream J, Roffwarg HP, Howard P, Hellman L: 
Behavioral state and plasma cortisol response in the human newborn. 
Pediatrics 1979;46:532-537.
15. Texas Medical Disclosure Panel Informed Consent. Austin, Tex, Texas 
Department of Health, 1988.
16. Burns ER: Development and evaluation of a new instrument for safe 
heel-stick sampling of neonates. Lab Med 1989;20:481-483.
17. Jay SM, Katz ER, Elliott CH, Siegel SE: Cognitive behavioral 
pharmacologic intervention for children's distress during painful medical 
procedures. J Child Clin Psychol 1987;55:860-865.
18. McGrath PJ, Johnson G, Goodman JT, et al: The CHEOPS: A behavioral 
scale to measure postoperative pain in children, in Fields HL, Dubner R, 
Cervero F (eds): Advances in Pain Research and Therapy. New York, NY, Raven 
Press, 1985, pp395-402.
Table 1
Pain Responses
1 No distress; calm; no crying
2 Moderate distress; crying; increased activity
3 Extreme distress; screaming; extreme activity

Table 2
Interrater Reliability of Observations of Pain Response
 Spearman's p
 populationObservation correlation 
variable coefficient P value

Crying during
circumcision .48 .12
Crying during
cacaneai puncture .86 .001*
* Significant at a=.01.

Table 3
Means for All Variables
 Procedure (age, h)
 Circumcision Calcaneal
Variable (32.9) puncture (40.7)
Time for
procedure, min 5.2 3.6
Pain score 2.4,* 2.1+ 2.2
*Without dorsal penile nerve block (DPNB).
+With DPNB.

Table 4 Whitney U Statistic 

Variable Circumcision* puncture* Z value
Age, h 73.74 113.98 -5.09 .0000+Time for 
procedure, h . 119.34 71.20 -6.2300 .0000+Pain 
scores 103.12 93.28 -2.3771 .0175+
*Mean rank.
+Significant at a=.01.