JAOA 1996; 96: 31-3. Comparison of newborn circumcision pain to calcaneal heel puncture pain: Is newborn circumcision pain control clinically warranted? MARK E. HOLTON, DO Correspondence to Mark E. Holton, DO, 2612 B Harwood Rd, Bedford, TX 76021-3700. 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 advantages."[2] 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 nerve.[10-13] 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. Methods 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 procedure. Results 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. Discussion 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. References 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 1980;18:308-309. 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 1989;261:702. 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 1989;262:701. 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 Score/description 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 Procedure Calcaneal P 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.