The issue of whether or not to circumcise a male infant one week after birth (when medically permissible) is essentially nonexistent in Israel. In an atmosphere of celebration and feasting, the procedure ("brit mila") has been carried out for over 4,000 years by non-physicians ("mohelim"). A mohel uses no anesthesia when performing the circumcision. The baby is given a few drops of sacramental wine and the mohel applies tight bandaging to the wound. The past few years, however, have witnessed a small but growing trend of young couples who seek to have their newborns circumcised by doctors using some kind of anesthesia in order to obviate the baby's pain and discomfort as well as their own anxiety. This cultural change has elicited interest among Israeli doctors in seeking optimal management of their newborn patients.
Anesthesia is not routinely administered for neonatal circumcision for a variety of reasons, among them the relatively short duration of the intervention, the perceived lack of importance of the pain, and concerns of toxicity from the medications [1]. It is now recognized that neonates are capable of both perceiving and exhibiting reproducible responses to pain, and that pain in neonates may have long-term effects (e.g., "pain memories") [2,3]. The routine use of analgesia during neonatal circumcision is now considered essential by the American Academy of Pediatrics [4].
A topical application of eutectic mixture of the local anesthetics, lidocaine and prilocaine (EMLA, Astra Pharma Inc. Sweden) had achieved considerable popularity for its ability to diminish pain associated with circumcision. In a review of the Cochrane database [5], however, its use was not shown to have any special advantage over other analgesic techniques with proven efficacy, such as regional nerve block with local anesthetic medications (e.g., lidocaine injection). We had been using lidocaine for dorsal penile nerve block (DPNB) in our service, and recently introduced bupivacaine because it has the important advantage of a longer duration of action compared to other local anesthetics [6]. In order to evaluate the clinical significance of this modification, we used the requirement of post-operative analgesia as a tool to assess long-term analgesic efficacy of analgesic medications in general [7], as well as specifically the requirement of acetaminophen after neonatal circumcision [8]. In the current study, we evaluated the duration of the long-term analgesic effect of bupivacaine in infants undergoing neonatal circumcision. We hypothesized that infants treated with bupivacaine will require less acetaminophen than infants treated with lidocaine.
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