Hello, I am Debra Neiman, RN BSN. I have worked in Neonatal Care, at Beauregard Memorial Hospital, DeRidder for over four years. My college experience at Louisiana State University at Alexandria, resulted in a great deal of research papers, which are gathering dust in my office. My curriculum at Northwestern State University also added to this wealth of information. I hereby begin this series to provide a way to get this information to those in the nursing field and any other person with a passing interest in these subjects. Feel free to reference or use this information in your practice. However, Please respect my Copyright and do not "BORROW" for your HOMEWORK assignment.

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INDEX:

CHAPTER ONE - INTRODUCTION

CHAPTER TWO - LITERATURE REVIEW

• Rationale for Circumcision
• Myths & Attitudes
• Newborn Pain Response
• Nonpharmacological Pain Management
• Anesthetic & Pharmacological Measures
• Assessment Tools
• Summary

CHAPTER THREE - METHODOLOGY

REFERENCES

APPENDICES:

• A - Postoperative Comfort Scale
• B - Consent Forms For Study
• C - Circumcision Consent Form
• D - Research Log Sample Sheet

The practice of circumcision has roots in antiquity and has been found in Egyptian mummies (2300 B.C.). Origins of circumcision are unknown, but may have been performed as puberty rites, tribal awareness, or in place of castration to mark slaves. The practice of circumcision may help to control the incidence of balanitis (infection of the glans of the penis) in desert regions where sand irritates the foreskin. Uncircumcised American soldiers serving in desert conditions during World War II had increased incidence of balanitis. The increase rate of newborn circumcision after World War II may be attributed to this experience. Circumcision of newborns in the United States today is almost a universal practice with better than 90% of male infants being circumcised ( Tedder, 1987).

Reasons given for the circumcision of newborns are to treat phimosis (tightness of the foreskin), reduce cancer risk, prevent infections such as balanitis, promote genital hygiene, to enhance sexuality, and to adhere to religious and social traditions (Schoen et al., 1988).

Many parents ask for and consent to the procedure for their newborns without discussion of options available. Parents give consent even when informed that anesthesia is not used.

Physicians surveyed in a 1990 study indicate that the majority of newborn circumcisions were completed without analgesia or anesthesia. Only 17 (24%) of 74 physicians performing circumcision on newborns report the use of analgesia. Oral ethanol was reported by 14 (20%) physicians and 3 (4%) physicians used dorsal penile nerve block. The rationale for those not utilizing analgesia was lack of familiarity with the technique of dorsal penile nerve block, concern over the side affect of analgesics, and lack of familiarity of analgesia use among neonates. Recent studies document the pain response and effects in neonates (Weatherstone et al., 1993; Masciello, 1990; Stang et al., 1988; & Anand et al, 1987).

However, myths about pain response in neonates still persist. The number of physicians in the 1990 survey reporting the belief that neonates to do feel pain is 7 (20%) and 20 (35%) cited newborns may feel but not remember pain ( Wellington & Rieder, 1993). Attitudes about newborn pain response may have changed, but observation shows that clinical practice continues to ignore treatment of newborn circumcision pain.

Numerous studies reviewed by Anand in 1987 have demonstrated that newborns undergoing circumcision without anesthesia or analgesia experience pain. Anatomical and functional requirements for pain perception are present in even the premature newborn. Although newborns have incomplete myelination, this does not mean they do not feel pain. The slower conduction velocity in the nerve tracts is offset by the shorter interneuron and neuromuscular distances in the newborn. Pain pathways in the brainstem and thalamus are completely myelinated by 30 weeks gestation. Functional maturity of the cerebral cortex is supported by EEG patterns and by visual and auditory patterns recorded in newborns less than 30 weeks gestation. Glucose utilization in the sensory areas of neonatal brains indicate maximal metabolic activity (Anand et al., 1987 ).

Newborn pain is observed through physiological responses such as heart rate, arrhythmias, respiratory rate, and oxygen saturation. Behavioral responses to pain include simple motor responses, facial expressions, crying, and complex behavioral responses. Hormonal and metabolic changes include serum cortisol, epinephrine, and norepinephrine level increases in response to painful stimuli (Wellington & Reider, 1993; & Anand et al, 1987). Changes in these variables indicate the newborn has distress often lasting more than 22 hours after the circumcision procedure ( Wellington & Reider, 1993).

The persistence of these behavioral changes imply the presence of pain memory. While pain is not truly remembered, even in adults, the experiences associated with pain are recalled. These responses or associations may disrupt the newborn's adaptation to the postnatal environment, parent-infant bonding, and feeding schedules.

The U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research (AHCPR) published Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline in 1992. AHCPR publication (1992) Acute Pain Management in Infants, Children, and Adolescents: Operative and Medical Procedures. Quick Reference Guide for Clinicians, further defines pain management in infants. These documents apply to newborns, and specify that neonates and infants experience pain and require adequate analgesia after surgery (Bell, 1994).

Nurses have sought to determine the efficacy of various nonpharmacological therapies to reduce pain and comfort newborns in several research studies. These interventions include facilitated tucking (Corf, Seideman, Venkataraman, Lutes, & Yates, 1995), pacifier sucking, music, intrauterine sounds (Marchette, Main, Redick, Bagg, & Leatherland, 1991) and sucrose water (Blass & Hoffmeyer, 1991). However, nonpharmacological therapies have demonstrated limited affect against the severe and acute pain of the intraoperative and immediate postoperative periods of circumcision.

Research documents the safety and efficacy of local anesthesia for prevention of circumcision pain in newborns, including (DPNB) dorsal penile nerve block ( Fontaine et al., 1994; Wellington & Rieder, 1993; Stang, et al, 1988; & Williamson & Williamson, 1988). Researchers seeking a simpler procedure studied the effects of local subcutaneous lidocaine injection into the foreskin and compared this technique to DPNB. The results demonstrated that the local anesthesia demonstrated greater efficacy than DPNB (Masciello, 1990). The use of local subcutaneous injection of lidocaine is the anesthesia chosen for this research proposal.

Topical application of 30% lidocaine cream (in an acid mantle base) was shown to be a safe and efficacious anesthetic for circumcision and has been used in an anesthetic skin patch in older children and adults since 1964 ( Weatherstone et at., 1993).

The use of Acetaminophen analgesia for circumcision pain was demonstrated not to be effective in the intraoperative and immediate postoperative period (Howard et al., 1994).

Nurses concerned by their advocacy of newborn patients and the pain involved with unanesthetized circumcision, find a lack of power to change the policy of clinical practice. The policy for anesthesia use is controlled by the physicians performing the procedures. A significant barrier to providing for pain relief during newborn circumcision has been the lack of a definitive measure of newborn pain.

Physiological and biochemical measurements of pain and behavioral responses have been studied in conjunction with neonatal pain. Nurses need a noninvasive objective tool to use for assessment of pain and pain reduction effectiveness in the nonverbal newborn patient. Valid tools such as the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) are used with children ages one to seven, but are not effective with newborns. Several objective scales have been studied including the (NIPS) Neonatal Infant Pain Scale which scores facial expression, cry, breathing patterns, arm and leg flexion, and state of arousal ( Lawrence et al., 1993). The (NFCS) Neonatal Facial Coding System from Grunau and Craig (1987) assesses nine facial features for pain response, however, facial activity increases with gestational age and may not reflect premature infant pain ( Bell, 1994).

The Postoperative Comfort Scale has been demonstrated to rate the postoperative pain of infants in several studies ( Bell, 1994; Howard, Howard, & Weitzman, 1994; Weatherstone et al, 1993). The tool provides a comfort score determined from 10 behaviors rated on a scale of 0 (poor) to 1 (mediocre) to 2 (satisfactory). Each behavioral scale is specifically defined. A total score of 15 to 20 has been correlated with adequate pain management in newborns (Bell, 1994).

The Postoperative Comfort Scale has been chosen for the tool to be evaluated in this research proposal. Use of an objective pain evaluation tool in newborn units will provide a score to communicate need for pain control and effective of pain therapy, especially during newborn circumcision.

This chapter discussed the history of circumcision, attitudes of physicians about newborn pain response, the treatment of newborn pain, and the research based clinical practice guidelines for newborn pain management. The pharmacological and nonpharmacological measures used to provide pain relief and comfort for newborns was explored. Various assessment tools being researched for rating newborn pain were discussed. Chapter III will discuss the methodology of this research proposal: to study the validity and reliability of one of these objective assessment tools, the Postoperative Comfort Scale, to rate circumcision pain in the newborn.

Copyright, ©1997 Debra Kay Neiman, RN BSN
E-Mail me at: crystalblue@usa.net