Use of EMLA Cream Before Neonatal Circumcision Prevents Pain
ABSTRACT & COMMENTARY
Synopsis: Application of lidocaine-prilocaine cream to the penis before circumcision was efficacious and safe for the prevention of pain.
Source: Taddio A, et al. Efficacy and safety of lidocaine- prilocaine cream for pain during circumcision. N Engl J Med 1997;336:1197-1201.
Sixty-eight full-term males had 1 g of lidocaine-prilocaine (EMLA) or placebo cream applied to the penis under an occlusive dressing for 60-80 min before circumcision with a Gomco clamp. Behavioral (facial activity and time spent crying) and physiologic (heart rate and blood pressure) responses were recorded during the procedure. Blood samples were obtained for measurements of methemoglobinemia and plasma lidocaine and prilocaine. During circumcision the EMLA-treated infants had significantly less facial activity and crying and had smaller increases in heart rate. Lidocaine and prilocaine were detected in about 50% of treated infants, but these levels were well below toxic levels, and no increased levels of methemoglotinemia were found. The use of this medication should be considered for routine use in neonatal circumcision in order to safely reduce the pain associated with this procedure.
COMMENT BY THOMAS KENNEDY, MD, FAAP
Many physicians do not use analgesics for neonates undergoing circumcision. Reasons for withholding analgesia include an unfamiliarity with analgesic techniques and a concern about safety. Despite evidence that the infant experiences considerable pain, others also may consider neonatal circumcision a minor procedure not requiring analgesia. EMLA cream, a 5% lidocaine- prilocaine mixture, is being widely used in a variety of pediatric procedures including venipuncture, lumbar puncture, and bone marrow aspiration. It does not produce local irritation or have systemic absorption or toxicity. When the cream is applied to the skin under an occlusive dressing, local cutaneous analgesia is reliably attained. This randomized, double-blind study shows conclusively that neonates treated with EMLA cream before circumcision had less objective evidence of pain than placebo controls.
It has been increasingly accepted that the neonate experiences considerable pain during circumcision.1 There may be long-term consequences of this experience, as evidenced by increased reactions to immunization later in life by infants circumcised without analgesia. The only down side that I can determine to the use of EMLA cream before circumcision is the need to apply the cream in advance of the procedure. I think pediatricians will accept the conclusions and recommendations of this excellent paper. However, we may have to do some missionary work with our obstetrical colleagues who often perform neonatal circumcision, to say nothing of mohels.
For those of you who may be interested, an accompanying editorial by Dr. TE Wiswell outlines arguments supporting routine neonatal circumcision.1 He lists a number of benefits for which there is "substantial evidence." These include: prevention of pathological phimosis, paraphimosis, balantitis, and posthitis; reduction in urinary tract infections; reduction of the risk of penile carcinoma; and reduction in transmission of sexually transmitted diseases. He further states that there is no evidence that circumcision produces psychosocial, social, emotional, or sexual problems in later life. He believes that most complications of the surgery can be traced to poor technique or inexperience of the operator.
Reference
l. Wiswell TE. Circumcision circumspection. N Engl J Med 1997;336:1244-1245.
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