From cartoon-character band-aids
to a kiss to 'make it all better,' we employ many tricks
to make it easier for kids to deal with pain. However,
when it comes to circumcisions, we could be doing much
better. Data presented at the American Academy of Pediatrics
(AAP) conference held October 9 to 13 in San Francisco
indicated that most circumcisions are not accompanied
by the use of pain muting analgesics, either before the
procedure or afterwards. The findings fly in the face
of a 1999 AAP policy statement recommending that "adequate
analgesia should be provided if neonatal circumcision
is performed."
In the study, 400 charts were reviewed.
Of the 191 male infants, 107 (56%) were circumcised
by obstetricians. The use of analgesia was noted on
the charts of only eight of the 107 boys. In seven babies,
a dorsal penile nerve block was used while a subcutaneous
ring block was employed in a lone infant. None of the
circumcised kids received any medication afterwards.
Moreover, there was no record of discussions with any
parent about pain management.
This number seemed so low that
lead author Dr Praveen Kumar, of Northwestern University
Memorial Hospital and Children's Memorial Hospital in
Chicago, wondered if pain relief had been used but not
documented. Pharmacy records revealed that analgesia
was ordered in 35 to 40% of procedures, and nursing
records indicated it was used in 29% of the circumcisions.
"So, I estimate that analgesia is actually used in about
a third of procedures," concluded Dr Kumar.
While a third is better than 7.5%,
it's still far from the blanket coverage advocated by
the AAP. The results of this study may not necessarily
be broadly applicable as circumcision rates may vary
by institution. Dr Myles Abbott, chair of the AAP scientific
program committee at the recent meeting, commented that,
of the some 7,500 deliveries each year at his Berkeley,
CA hospital, "I think we are talking about using [circumcision]
in almost all kids." However, Dr Kumar noted that the
centre in Chicago where the research data was collected
"is a large tertiary medical centre in a large urban
area, which gives some weight to the findings."
Circumcision itself remains controversial,
with "the overall evidence of the benefits and harms
of circumcision" being "evenly balanced," according
to the Canadian Paediatric Society. Should circumcision
be in the works, however, no such controversy surrounds
the use of analgesics. It merely requires implementing
what's known to be good practice.
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