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A COMPARISON OF PAIN SCORES WITH OR WITHOUT LOCAL ANAESTHESIA IN NEONATAL CIRCUMCISION USING PLASTIBELL TECHNIQUE AT PLATEAU STATE SPECIALIST HOSPITAL, JOS, NIGERIA
TABLE OF CONTENTS
ACKNOWLEDGEMENT …………………………………………………………………………………………………………… i
DEDICATION ………………………………………………………………………………………………………………………… ii
CERTIFICATION ……………………………………………………………………………………………………………………. iii
LIST OF ABBREVIATIONS …………………………………………………………………………………………………….. iv
TABLE OF CONTENTS …………………………………………………………………………………………………………… v
LIST OF TABLES …………………………………………………………………………………………………………………. viii
LIST OF FIGURES ………………………………………………………………………………………………………………… ix
ABSTRACT …………………………………………………………………………………………………………………………… 1 CHAPTER ONE: INTRODUCTION …………………………………………………………………………………………… 3
1.1 INTRODUCTION ………………………………………………………………………………………………………………. 3
1.2 STATEMENT OF THE PROBLEM AND PROBLEM ANALYSIS. ……………………………………………. 6
1.3 AIM …………………………………………………………………………………………………………………………………. 6
1.4 OBJECTIVES …………………………………………………………………………………………………………………… 6
1.5 RATIONALE FOR THE STUDY…………………………………………………………………………………………… 7
1.6 RELEVANCE OF THE STUDY TO FAMILY MEDICINE. ………………………………………………………. 7 CHAPTER TWO: LITERATURE REVIEW ………………………………………………………………………………….. 9
2.1 HISTORY OF CIRCUMCISION. ………………………………………………………………………………………….. 9
2.2 EPIDEMIOLOGY OF CIRCUMCISION. ………………………………………………………………………………. 14
2.3 CIRCUMCISION TECHNIQUES. ……………………………………………………………………………………….. 19
2.4 NEONATAL PAIN RESPONSE DURING CIRCUMCISION. …………………………………………………… 24
2.5 PAIN ASSESSMENT TOOLS. …………………………………………………………………………………………… 32
2.6 PAIN MANAGEMENT IN NEONATES. …………………………………………………………………………….. 37
2.7 ANAESTHESIA FOR NEONATAL CIRCUMCISION. ……………………………………………………………. 44
2.8 COMPLICATIONS OF NEONATAL CIRCUMCISION. ………………………………………………………….. 47 CHAPTER THREE: MATERIALS AND METHODS …………………………………………………………………… 59
3.1 STUDY ENVIRONMENT. …………………………………………………………………………………………………. 59
3.2. STUDY POPULATION. …………………………………………………………………………………………………… 59
3.3 STUDY DESIGN. …………………………………………………………………………………………………………….. 59
3.4 THE SAMPLE SIZE. ………………………………………………………………………………………………………… 60
3.5 SAMPLING METHOD. ……………………………………………………………………………………………………… 60
3.6 INCLUSION CRITERIA. …………………………………………………………………………………………………… 61
3.7 EXCLUSION CRITERIA. ………………………………………………………………………………………………….. 61
3.8 METHOD AND INSTRUMENT OF DATA COLLECTION. ……………………………………………………… 61
3.9 METHOD OF DATA ANALYSIS. ……………………………………………………………………………………….. 65
3.10 ETHICAL CONSIDERATION. ………………………………………………………………………………………….. 65
CHAPTER FOUR: RESULTS. ………………………………………………………………………………………………… 66
4.1 PHYSICAL CHARACTERISTICS OF THE NEONATES………………………………………………………… 66
4.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE PARENTS. ……………………………………… 67
4.3 NEONATAL INFANT PAIN SCORES. ………………………………………………………………………………… 68
4.4 COMPARISON OF MEAN NEONATAL INFANT PAIN SCORES. ………………………………………….. 70
4.5 PHYSIOLOGICAL CHANGES DURING CIRUMCISION. ………………………………………………………. 74
4.6 DURATION OF CIRCUMCISION ………………………………………………………………………………………. 76
4.7 COMPLICATIONS OF NEONATAL CIRCUMCISION …………………………………………………………… 77
4.8 REASONS FOR CIRCUMCISION. …………………………………………………………………………………….. 79 CHAPTER FIVE: DISCUSSION …………………………………………………………………………………………….. 80
5.1 PHYSICAL CHARACTERISTICS OF NEONATES ……………………………………………………………….. 80
5.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE PARENTS. ……………………………………… 81
5.3 NEONATAL INFANT PAIN SCORES …………………………………………………………………………………. 82
5.4 PHYSIOLOGICAL AND BEHAVIOURAL CHARACTERISTICS ……………………………………………… 84
5.5 COMPLICATIONS OF NEONATAL CIRCUMCISION …………………………………………………………… 86
5.6 DURATION OF SURGERY ………………………………………………………………………………………………. 87
5.7 REASONS FOR NEONATAL CIRCUMCISION ……………………………………………………………………. 87
5.8 IMPLICATIONS FOR FAMILY PHYSICIANS ………………………………………………………………………. 88
5.9 CONCLUSION ………………………………………………………………………………………………………………… 89
5.10 RECOMMENTATION. ……………………………………………………………………………………………………. 90
5.11 CONSTRAINT. ……………………………………………………………………………………………………………… 90
REFERENCES. ……………………………………………………………………………………………………………………. 91
APPENDIX A: CONSENT FORM. …………………………………………………………………………………………. 102
APPENDIX B: QUESTIONNAIRE …………………………………………………………………………………………. 104
APPENDIX C: NEONATAL/INFANT PAIN SCALE (NIPS) ………………………………………………………… 107
APPENDIX D: ETHICAL CLEARANCE ………………………………………………………………………………….. 108
APPENDIX E: CIRCUMCISION INSTRUMENTS …………………………………………………………………….. 109
LIST OF TABLES
| Table 1: Physical characteristics of Neonates | 66 |
| Table 2: Socio-demographic characteristics of parents | 67 |
| Table 3: Neonatal pain scores during surgery | 68 |
| Table 4: Mean neonatal pain scores | 70 |
| Table 5: Physiological changes during circumcision | 74 |
LIST OF FIGURES
| Figure 1: Comparison of Mean pain scores | 73 |
| Figure 2: Comparison Mean of duration of surgery | 77 |
| Figure 3: Complications of Neonatal circumcision | 78 |
| Figure 4: Reasons for circumcision | 79 |
ABSTRACT
Large number of neonates with no medical indications present for circumcision at Plateau State Specialist Hospital. There persist a wide variety of opinions among health care providers about how to treat pain in neonates. Newborns feel pain and require the same level of pain assessment and management as adult. Untreated pain in neonates may result in increased morbidity and exaggerated responses to pain in later life, and altered psychological development. It is a common place to withhold anaesthesia during neonatal circumcision because health care providers believed that neonates do not feel pain or that the pain is not significant and has no long lasting consequences.
The aim of this study was to determine whether or not anaesthesia was required for neonatal circumcision. It assessed pain scores and compared the mean pain scores and duration of surgery in neonates undergoing circumcision with or without local anesthesia.
Pain can be assessed using self-report behavioral observation, or physiological measures. Pain assessment becomes necessary when evaluating pain of circumcision. This is because pain can be prevented, reduced, managed during neonatal circumcision.
Evaluation of pain during neonatal circumcision with or without local anaesthesia was carried out in 72 neonates at Plateau State Specialist Hospital, Jos, Nigeria. They were randomly assigned to local anaesthesia and no local anaesthesia groups with computer generated random numbers and sealed in opaque unmarked envelopes containing group assignments.
The results showed that the mean neonatal pain scores were lower in those that received local anaesthesia and higher in those that did not receive local anaesthesia. This indicated that local anaesthesia usage during circumcision is associated with low neonatal pains scores compared to those who had no local anaesthesia.
The investigator therefore endorses the use of local anaesthesia for neonatal circumcision. Unless another method is proven to be as effective, local anaesthesia should be used for all circumcisions.
CHAPTER ONE: INTRODUCTION
1.1 INTRODUCTION
Circumcision in the male is the removal of the foreskin that covers the glans of the penis. The practice of circumcision has roots in antiquity. Origins of circumcision are unknown but may have been performed as pubertal, tribal rites, religious rites or part of general societal norm.1 For example; it is a commandment in Judaism and Islam.
Circumcision has been performed in Africa for the past 5000 years with depictions found in stone age cave drawings, ancient Egyptians tombs and mummies.2 The technique for circumcision was illustrated in bass drawings on the wall of the temple of Anchama-Hor at Saqqara during the 5thBass dynasty [24000BC] .2At first the procedure in Egypt was limited to members of the priesthood but was later adopted by the royalty, nobility and finally it became a universal practice. Some anthropologists believe that circumcision originated independently in different cultures, because of the fact that many of the males of the New World were circumcised when they were discovered by Columbus.2
Circumcision was introduced in Western countries as a method of treating and preventing masturbation in the 1800s.4 The procedure became more widespread between 1920 and 1950.5
In West African groups such as the Dogon and Dowayo, it is taken to represent a removal of feminine aspect of the male, turning boys into fully masculine males.6 However, in most West African traditional societies, it has become medicalised and simply performed in infancy without ado or any particular cultural significance.7 Among the Urhobo people of Southern Nigeria it is symbolic of a boy entering into manhood.8 For Nilotic peoples such as the Kalcin and Masai, circumcision is a rite of passage to adulthood observed collectively by a number of boys every few years, and boys circumcised at the same time are regarded as members of a single age
set.9
When discussing elective, non-religio-ritualistic neonatal circumcision, some explain their views in terms of the perceived medical benefits of the procedure 10 (i.e. reduced incidence of urinary tract infection in infant males, decreased incidence of penile cancer in adult males, and possibly decreased susceptibility to certain sexually transmissible diseases, including human immunodeficiency virus).11 Circumcision is recommended by some physicians to treat medical conditions in males, such as phimosis, chronic inflammation of the penis, and penile cancer12 while other physicians believe there are less invasive treatments for phimosis that can be tried first.13 Such less invasive treatments include topical application of steroid cream/ointment and use of emollient creams.14
Circumcision is a surgical procedure. While the risks of circumcision-related complications are very low15 ,the complications resulting from a poorly carried out circumcision, such as postoperative bleeding, or infection can be catastrophic.16 Bleeding and infection are the most common complications of the procedure, according to the AMA, although in the majority of cases, bleeding is minor and hemostasis can be achieved by pressure application.17 Kaplan identified long term complications, including urinary fistulas, chordee, cysts, lymphoedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence and removal of too much tissue, sometimes causing secondary phimosis.18 He stated that virtually all of these complications are preventable with only a modicum of care. Unfortunately, most often such complications occur at the hands of inexperienced operators.19
Although neonatal circumcision is a painful and stressful operation, there is the belief that infants do not experience pain with the same intensity as adult.20 several techniques are employed for neonatal circumcision such as Gomco clamp, Mogen clamp, Taraklamp, plastibell technique, etc. The plastibell technique is considered less painful compared with other techniques hence its choice for this study.
Physiological changes associated with pain include: cardiovascular variables such as transcutaneous partial pressure of oxygen, and palmer sweating observed in neonates undergoing painful clinical procedures.21 In newborns undergoing circumcision or heel lancing marked increases in the heart rate and blood pressure occurred during and after the circumcision.22 The magnitude of changes in the heart rate was related to the intensity and duration of the stimulus and to individual temperaments of the babies.23 Hormonal and metabolic changes have been measured primarily in neonates undergoing circumcision, plasma cortisol levels increased markedly during circumcision.24
The behavioral changes associated with pain include: (a) Simple motor response, early studies of the motor responses of newborn infants to pinpricks reported that babies responded with a” diffuse body movement rather than a purposeful withdrawal of limbs.24 (b) Facial expression such as associated with pleasure, pain, sadness, and surprise in infants. These have been objectively validated in studies of infants being immunized 16-18. (c) Crying is the primary method of communication and also elicited by stimuli other than pain. Several studies have classified infant crying according to distress indicated and its spectrographic properties.24 Long-term painful experiences in neonate, could possibly have some psychological sequel.22 Numerous evidence suggest that even in the human fetus pain pathways as well as cortical and subcortical centers necessary for pain perception are well developed and the neurochemical system that are known to be associated with pain transmission and modulation are also intact and functional.19,23 Recent data suggest that a painful experience in the newborn influence how pain is perceived later in
life.
1.2 STATEMENT OF THE PROBLEM AND PROBLEM ANALYSIS.
There persists a wide variety of opinions among health care providers about how to treat pain in our neonates. Newborns feel pain and require the same level of pain assessment and management as adults. Untreated pain in neonates may result in increased morbidity and exaggerated responses to pain in later life, and altered psychosocial development. Withholding anesthesia is commonplace during neonatal circumcision because health care practitioners believed that newborns do not feel pain, or if they do, that the pain is not significant and has no long-lasting consequences. The traditional view that newborns do not feel pain was supported by the belief that pain transmission required complete nerve myelinization and a mature cerebral cortex to interpret the pain signal. However, although the newborn’s peripheral nerves are unmyelinated, complete myelinization is not a prerequisite to pain transmission.
There is need to generate data to recommend or obviate the need for local anesthesia during neonatal circumcision. This study is intended to compare pain scores of neonatal circumcision with or without local anesthesia and make recommendation for practice.
1.3 AIM
To determine whether or not anaesthesia is required for neonatal circumcision by assessing pain scores during neonatal circumcision with or without local anaesthesia
1.4 OBJECTIVES
1 To assess the pain scores in neonates undergoing circumcision with, or without local anaesthesia.
- To compare the mean pain scores in neonates undergoing circumcision with or without local anesthesia.
- To compare the mean duration of surgery in neonates undergoing circumcision with or without local anesthesia.
- To make appropriate recommendations on the use of local anesthesia during neonatal circumcision.
1.5 RATIONALE FOR THE STUDY.
A large number of neonates with no medical indications present for circumcision at Plateau State Specialist Hospital.
Acute pain is one of the most common adverse stimuli experienced by infants as a result of injury, illness or during medical procedures.19 It is associated with increased anxiety, avoidance, somatic symptoms and increased parental distress.20
Pain can be assessed using self-report, behavioral observation, or physiological measures.24 Pain assessment becomes necessary when evaluating the practice of circumcision. This is because pain can be prevented, reduced, and managed during neonatal circumcision to alleviate neonatal and parental anxiety, somatic symptoms and distress associated with the procedure. It will improve the quality of care for male newborns undergoing circumcision.
1.6 RELEVANCE OF THE STUDY TO FAMILY MEDICINE.
Family medicine as a discipline identifies with the following principles. The family physician is committed to the person and seeks to understand the context of the illness; every contact is seen as an opportunity for disease prevention and for health education; importance is attached to the subjective aspects of medicine.
Anaesthesia is generally not administered for neonatal circumcision for a variety of reasons; among them are the consideration that the procedure is of relatively short duration of intervention and the perceived lack of importance of the pain. It is now recognized that neonates are capable of both perceiving and exhibiting reproducible response to pain and that pain in neonates may have long-term effects, for instance, on pain memories.
Evaluation of pain scores will provide information to the practicing family physicians and create awareness about rating, and treatment of pain during neonatal circumcision. This study is of particular relevance in helping to modify attitudes of Family physicians towards neonatal circumcision.
A COMPARISON OF PAIN SCORES WITH OR WITHOUT LOCAL ANAESTHESIA IN NEONATAL CIRCUMCISION USING PLASTIBELL TECHNIQUE AT PLATEAU STATE SPECIALIST HOSPITAL, JOS, NIGERIA
