Skip to main content

Analgesia for infants’ circumcision


Male circumcision (MC) is one of the oldest and most common operations performed all over the world. It can be performed at different ages, using different surgical techniques, for different religious, cultural and medical reasons.

Our aim is to examine and compare the various methods of analgesia and different surgical procedures reported in literature that are applied in infant MC. We performed a PubMed, MEDLINE, EMBASE and Cochrane search in the papers published since 2000: 14 studies met the inclusion criteria, most of them showing that a combined pharmacological and non-pharmacological intervention is the best analgesic option, in particular when the dorsal penile nerve block is combined with other treatments. The Mogen surgical procedure seems to be the less painful surgical intervention, when compared with Gomco clamp or PlastiBell device. Only 3 papers studied groups of at least 20 babies each with the use of validated pain scales. Data show a dramatic decrease of pain with dorsal penile nerve block, plus acetaminophen associated to oral sucrose or topic analgesic cream. However, no procedure has been found to definetively eliminate pain; the gold standard procedure to make MC totally painfree has not yet been established.


The relief of human suffering is one of the most important goals for health care providers. Advances in neonatology have significantly improved neonatal morbidity and mortality; but pain, discomfort, and stress remain sad realities for babies in the neonatal intensive care unit [1]. Assessing, managing, and trying to limit these clinical realities, particularly while caring for neonates are challenging and increasingly controversial [2]. Newborns’ pain can harm the developing brain in several ways, among which is the increase of free radical production [3].

Male circumcision (MC) is one of the most painful procedures a newborn can undergo, but only in the last few years caregivers have tried to fight this kind of pain; this might be due to the pain being in some ways, a component of the ritual that for centuries has accompanied MC. Unfortunately, even during clinical trials, babies still undergo MC without analgesia [4] and the continuous production of studies for a better analgesia is the sign that a gold standard has not yet been found.

MC consists of the surgical removal of the sleeve of skin and mucosal tissue which normally covers the glans of the penis, known as the foreskin. The word ‘circumcision’ derives from the Latin circum (meaning ‘around’) and caedere (meaning ‘to cut’) [5].

For many centuries, MC has incited great fervour in opposing parties who have debated whether the medical benefits of the procedure outweigh any potential psychological side-effects resulting from it. About 30% of the total world male population is circumcised and MC remains one of the oldest and most common operations performed all over the world [6, 7]. It is one of the oldest surgical operations, with the earliest available records dating this ancient procedure back to at least 6000 years BC, and anecdotal evidence suggesting it as a rite of puberty in aboriginal tribes before 10000 BC [8].

MC is commonly conducted for religious, cultural and medical reasons; it can be performed at different ages, in neonates, infants and children, with important differences in complication rates. Neonatal MC seems to be a simple, quick procedure, healing within 1 week with a low rate of usually minor adverse events (0.2%–0.4% in the US) when performed in clinical settings by trained professionals [9]. There is a high rate of circumcision in Jewish and Muslim populations, and circumcision is quite common in the United States. Areas of Africa, Australian aborigines, and people of Eastern America also practice ritual MC. In contrast, routine MC was rarely performed in Europe, China and Central and South America, but the incidence is currently increasing due to migration [10]. Traditionally, the US medical establishment promoted MC as a preventative measure for an array of pathologies including reduced risks of penile cancer, urinary tract infections, sexually transmitted diseases, and even cervical cancer in sexual partners [11].

The three most common operative methods of MC for the newborn male include: the PlastiBell device, the Gomco clamp and the Mogen clamp [1216]. All techniques cause similar amounts of tissue destruction [16].

The aim of this review is to examine and summarize all studies in literature since the year 2000 that have compared various methods of analgesia during newborn/infant MC.


We performed a PubMed, MEDLINE, EMBASE and Cochrane search in studies published in the last 12 years using the following as keywords and MeSH terms: pain, anaesthesia/analgesia, infant, newborn, pediatric and male circumcision. We included studies in which the mean age at MC was age 11 months or less. Studies were included in our research if they compared different types of anaesthesia/analgesia or different surgical techiniques, and if they used specific pain scales.


Among a total of 77 papers found, published to 2000, only 14 (Table 1) of these met the following inclusion criteria: comparison in relation to various analgesic methods or different surgical procedures and evaluation of newborns’ pain assessment, using specific or non-specific pain scales.

Table 1 Papers meeting the inclusion criteria, collected in chronological order

In the papers, that fulfilled the inclusion criteria, different surgical procedures were used: Gomco clamp, Mogen clamp and PlastiBell device [1216], explained and summarized in Table 2.

Table 2 Surgical procedures of MC

Table 3 shows the papers [1730] that compared different analgesic methods.

Table 3 Papers that compared different analgesic methods

Main pharmacological strategies were:

EMLA cream: eutectic mixture of local anesthetics, with 2.5% lidocaine and 2.5% prilocaine, that produces dermal analgesia, applied as a topical cream to the distal half of the penis beneath an occlusive dressing 60–90 minutes before the procedure [31];

dorsal penile nerve block (DPNB): regional anaesthesia often obtained with 0.4 ml of 1% lidocaine injected into the fascia beneath the base of the penis at the 10:00 and 2:00 positions using a 27-gauge needle [14, 32];

subcutaneous penile ring block (RB): 0.8 ml of 1% lidocaine without epinephrine, injected in a circumferential ring around either the midshaft or at the level of the corona [14, 33, 34].

Other pharmacological interventions used were: acetaminophen, lidocaine cream, fentanyl, tylenol; non-pharmacological measures were: breast milk, 20% sucrose solution, 50% dextrose solution, non-nutritive sucking (NNS), audio-stimulation with music [3236].

Seven papers [17, 1923, 29] considered DPNB, five of which showed the efficacy of DPNB [17, 20, 22, 23, 29] as preoperative analgesia: one of these considered it in combination with NNS and tylenol [22], and one showed the use of DPNB associated to RB and sucrose solution to be more effective [23]. Five studies compared the use of EMLA with other analgesics [1921, 23, 28], only one [28] showed its analgesic effect, especially in combination to music. Two papers [24, 27] compared acetaminophen with placebo, but they gave contrasting results. Two studies [18, 23] showed the efficacy of RB, one [23] in association with DPNB and oral sucrose. Two papers [19, 21] evaluated the use of lidocaine cream, but both did not find any analgesic efficacy. One study considered the use of milk [18], one evaluated the use of dextrose solution [29] and one considered the use of fentanyl [17], but none of these had proved effective to decrease the pain response. Seven articles [18, 19, 21, 22, 24, 27, 29] analyzed analgesic treatments when using the Gomco technique. Two papers [19, 21] underlined that there was no significant analgesic difference between DPNB, EMLA and lidocaine cream; one of them showed the effectiveness of NNS, in combination to tylenol and DPNB, to decrease the pain response [22]; one paper showed the efficacy of DPNB compared with oral dextrose [29]; one study showed the RB utility as preoperative analgesic [18], and two papers [24, 27] gave no univocal conclusions in the case of acetaminophen: one [27] excluded any analgesic effect, compared to placebo, but another paper [24] showed its analgesic efficacy. Four papers [17, 20, 23, 28] did not disclose which surgical procedure was used. One showed the effectiveness of EMLA cream in association with music to decrease the pain response [28]; one paper showed that DPNB was more effective than EMLA cream [20]; one study showed major analgesic effect using oral sucrose in combination with other common analgesics, especially with RB and DPNB at the same time [23]; one paper suggested the use of ultrasound DPNB because it was associated with a reduction in terms of analgesic postoperative requirement [17].

Only three papers [25, 26, 30] compared different surgical techniques to perform MC, as shown in Table 4; all three studies found a greater analgesic effectiveness of Mogen clamp than both Gomco and PlastiBell. In particular, two of these papers [26, 30] compared Mogen with Gomco clamp and both found a best analgesic effect of Mogen in terms of performing time and to decrease the pain response, if associated with preoperative analgesia, especially using a combination of analgesics (DPNB with EMLA and acetaminophen [30], and EMLA with sucrose solution [26]). One paper compared the use of the Mogen clamp with the Plastibell device [25], showing that the Mogen procedure is associated with less pain, stress and discomfort.

Table 4 Papers that compared different surgical procedures to perform MC

Only 7 papers enrolled twenty or more babies for each study-group [22, 2427, 29, 30].

Table 5 shows the papers in which twenty or more babies were enrolled in each study-group and used validated pain scales and respective pain scale scores, with the data available [22, 24, 30].

Table 5 Comparison among the papers that had twenty or more babies in each study-group and simultaneously used the specific pain scale and respective pain scale scores available

In Table 6 we report the rates of acute and long-term adverse events occurring in neonatal MC, as reported in literature [30, 3744]. As shown there, the Gomco clamp and the Plastibell device are associated to complications, including acute complications, such as bleeding or infection, or long-term adverse events, such as adhesions and meatal stenosis. No data about complications of the Mogen technique are available, and are reported as “rare” [37].

Table 6 Frequency of acute and long-term adverse events in neonatal circumcision


Our data discloses large heterogeneity with regard to size of the samples, pain scales, combinations of pharmacological and non-pharmacological analgesia and surgical techniques. Some studies did not specify the MC procedure applied, and others used non-specific infants’ pain assessments (e.g. crying time, heart rate, respiratory rate). Therefore, it was not possible to compare the data of the different studies because only 7 papers enrolled twenty or more babies for each study-group [22, 2427, 29, 30]. Only three papers [22, 24, 30] fulfilled both the conditions of enrolling this number of babies and of using a validated and specific pain scale. The use of a validated pain scale is important because other ways of assessment of pain (e.g. crying time) are neither specific nor sensitive enough.

Among three papers [22, 24, 30] collected in Table 5, no authors compared the same analgesic methods using the same pain scale; whereby, it is impossible to compare them to make a meta-analysis. This selected data shows that the use of DPNB, in association to tylenol and NNS [22] and DPNB in association to EMLA and acetaminophen [30] reduce the pain response, but not totally. Acetaminophen [24] seems to be more effective (its main pain score compared with the upper limit of the scale is very low), but it is surprising that the main pain scale score is so low using placebo [24].

In particular, DPNB appears to be more effective in association with tylenol and NNS [22] and in combination with RB and oral sucrose solution [23]. Moreover, the Mogen clamp surgical procedure seems to be less painful than the other techniques [25, 26, 30]. This data confirms the previous analysis of data available to 2001 [45], when DPNB was shown to be the most effective analgesic method. Our data is similar to that of 2001 [45] also with regard to the effectiveness of the Mogen clamp.

We have reported in Table 6 the clinical drawbacks of the different surgical techniques: the Mogen techniques seems to be the safest. In Table 5 we reported the level of pain in the most reliable studies we retrieved. No study guarantees a complete analgesia, with the exception of one [24], whose limits we have previously described.

Recently, a non-pharmacological technique used for the relief of pain both in term and preterm infants, called “Sensorial Saturation” (SS) has been proposed and validated. It consists in attracting the baby’s attention with positive stimuli (tactile, auditory, gustatory and visual), so as to reduce up to nullify the perception of painful stimuli. This technique is based on neuro-physiological concepts, according to which the newborn's brain is able to “filter” the peripheral stimuli through the “gate control system”. In this way, the above stimuli “saturate” the central receptors, resulting in a “sensorial jam” that excludes painful stimuli. Several studies [46, 47] show the effectiveness of the SS, also used in national and international analgesia protocols. SS is not only a "technique", but a way of being with the child, involving parents and making them the protagonists of the medical event. We propose (Table 7) a new analgesic approach for infantile MC using SS in association with DPNB.

Table 7 Five steps for the analgesia for neonatal MC

In conclusion, more research is required to find a better analgesic approach, in order to make infantile MC a totally painless procedure without stress or discomfort for newborns. Present methods do not yet guarantee a total analgesia during this procedure.


  1. Bellieni CV, Buonocore G: Neonatal pain treatment: ethical to be effective. J Perinatol. 2008, 28 (2): 87-88. 10.1038/

    Article  CAS  PubMed  Google Scholar 

  2. Bellieni CV, Tei M, Stazzoni G, Bertrando S, Cornacchione S, Buonocore G: Use of fetal analgesia during prenatal surgery. J Matern Fetal Neonatal Med. 2013, 26 (1): 90-95. 10.3109/14767058.2012.718392.

    Article  PubMed  Google Scholar 

  3. Bellieni CV, Iantorno L, Perrone S, Rodriguez A, Longini M, Capitani S, Buonocore G: Even routine painful procedures can be harmful for the newborn. Pain. 2009, 147 (1–3): 128-131.

    Article  CAS  PubMed  Google Scholar 

  4. Bellieni CV, Rocchi R, Buonocore G: The ethics of pain clinical trials on persons lacking judgment ability: much to improve. Pain Med. 2012, 13 (3): 427-433. 10.1111/j.1526-4637.2011.01325.x.

    Article  PubMed  Google Scholar 

  5. Nelson CP, Dunn R, Wan J, Wei JT: The increasiong incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol. 2005, 173 (3): 978-981. 10.1097/01.ju.0000145758.80937.7d.

    Article  PubMed  Google Scholar 

  6. Proceedings of the Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO): Male circumcision: global trends and determinants of prevalence, safety and acceptability (UNAIDS/WHO). 2007, Geneva, Switzerland: WHO Press

    Google Scholar 

  7. Puig Sola C, Garcia-Algar O, Vall Combelles O: Childhood circumcision: review of the evidence. An Pediatr (Barc). 2003, 59: 448-453.

    Article  CAS  Google Scholar 

  8. Wilkinson GB: Circumcision: one of the oldest known surgical procedures. Urol Nurs. 1997, 17: 125-126.

    CAS  PubMed  Google Scholar 

  9. Parigi GB: Destiny of prepuce between Quran and DRG. Pediatr Med Chir. 2003, 25: 96-100.

    CAS  PubMed  Google Scholar 

  10. Morris BJ: Why circumcision is a biomedical imperative for the 21(st) century. BioEssays. 2007, 29 (11): 1147-1158. 10.1002/bies.20654.

    Article  PubMed  Google Scholar 

  11. Proceedings of the Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO): Version 2.5B (WHO, UNAIDS, JHPIEGO). Manual for male circumcision under local anaesthesia. 2007, Geneva, Switzerland: WHO Press

    Google Scholar 

  12. Cuckow PM: Foreskin. Pediatric Urology. Edited by: Gearhart JP. 2010, Elsevier Inc, Second Edition

    Google Scholar 

  13. Paix BR, Peterson SE: Circumcision of neonates and children without appropriate anaesthesia is unacceptable practice. Anaesth Intensive Care. 2012, 40 (3): 511-516.

    CAS  PubMed  Google Scholar 

  14. Lannon CM, Bailey AGB, Fleischman AR: American Academy of Pediatrics, Task Force on Circumcision: circumcision policy statement. Pediatrics. 1999, 103 (3): 686-693.

    Article  Google Scholar 

  15. Morgan WKC: The rape of the phallus. JAMA. 1965, 193: 123-124.

    Article  Google Scholar 

  16. Wallerstein E: Circumcision: the uniquely American medical enigma. Urol Clin North Am. 1985, 12 (1): 123-132.

    CAS  PubMed  Google Scholar 

  17. O'Sullivan MJ, Mislovic B, Alexander E: Dorsal penile nerve bock for male pediatric circumcision: a randomized comparison of ultrasound-guided vs anatomical landmark technique. Paediatr Anaesth. 2011, 21 (12): 1214-1218. 10.1111/j.1460-9592.2011.03722.x.

    Article  PubMed  Google Scholar 

  18. Banieghbal B: Optimal time for neonatal circumcision: An observation-based study. J Pediatr Urol. 2009, 5: 359-362. 10.1016/j.jpurol.2009.01.002.

    Article  CAS  PubMed  Google Scholar 

  19. Lehr VT, Zeskind PS, Ofenstein JP, Cepeda E, Warrier I, Aranda JV: Neonatal facial coding system scores and spectral characteristics of infant crying during newborn circumcision. Clin J Pain. 2007, 23 (5): 417-424. 10.1097/AJP.0b013e31805476f2.

    Article  PubMed  Google Scholar 

  20. Garry DJ, Swoboda E, Elimian A, Figueroa R: A video study of pain relief during newborn male circumcision. J Perinatol. 2006, 26 (2): 106-110. 10.1038/

    Article  CAS  PubMed  Google Scholar 

  21. Lehr VT, Cepeda E, Frattarelli DAC, Thomas R, LaMothe J, Aranda JV: Lidocaine 4% cream compared with lidocaine 2.5% and prilocaine 2.5% or dorsal penile ring block for circumcision. Am J Perinatol. 2005, 22 (5): 231-237. 10.1055/s-2005-871655.

    Article  PubMed  Google Scholar 

  22. South MM, Strauss RA, South AP, Boggess JF, Thorp JM: The use of non-nutritive sucking to decrease the physiologic pain response during neonatal circumcision: a randomized controlled trial. Am J Obstet Gynecol. 2005, 193 (2): 537-542. 10.1016/j.ajog.2005.03.060.

    Article  PubMed  Google Scholar 

  23. Razmus IS, Dalton ME, Wilson D: Pain management for newborn circumcision. Pediatr Nurs. 2004, 30 (5): 414-7,427.

    PubMed  Google Scholar 

  24. Malnory M, Johnson TS, Kirby RS: Newborn behavioral and physiological responses to circumcision. MCN Am J Materna Child Nurs. 2003, 28 (5): 313-317. 10.1097/00005721-200309000-00009.

    Article  Google Scholar 

  25. Taeusch HW, Martinez AM, Partridge JC, Sniderman S, Armstrong-Wells J, Fuentes-Afflick E: Pain during Mogen or PlastiBell circumcision. J Perinatol. 2002, 22 (3): 214-218. 10.1038/

    Article  PubMed  Google Scholar 

  26. Kaufman GE, Cimo S, Miller LW, Blass EM: An evaluation of the effects of sucrose on neonatal pain with 2 commonly used circumcision methods. Am J Obstet Gynecol. 2002, 186 (3): 564-568. 10.1067/mob.2002.121621.

    Article  CAS  PubMed  Google Scholar 

  27. Macke JK: Analgesia for circumcision: effects on newborn behavior and mother/infant interaction. J Obstet Gynecol Neonatal Nurs. 2001, 30 (5): 507-514. 10.1111/j.1552-6909.2001.tb01570.x.

    Article  CAS  PubMed  Google Scholar 

  28. Joyce BA, Keck JF, Gerkensmeyer J: Evaluation of pain management interventions for neonatal circumcision pain. J Pediatr Health Care. 2001, 15 (3): 105-114.

    Article  CAS  PubMed  Google Scholar 

  29. Kass FC, Holman JR: Oral glucose solution for analgesia in infant circumcision. J Fam Pract. 2001, 50 (9): 785-788.

    CAS  PubMed  Google Scholar 

  30. Taddio A, Pollock N, Gilbert-MacLeod C, Ohlsson K, Koren G: Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med. 2000, 154 (6): 620-623. 10.1001/archpedi.154.6.620.

    Article  CAS  PubMed  Google Scholar 

  31. Anand K: The biology of pain perception in newborn infants. Advances in Pain Research Therapy. 1990, 15: 113-122.

    Google Scholar 

  32. Stang HJ, Snellman LW, Conroy MM, Liebo R, Brodersen L: Beyond dorsal penile nerve block: a more humane circumcison. Pediatrics. 1997, 100: 1-6. 10.1542/peds.100.1.1.

    Article  Google Scholar 

  33. Marchett L, Main R, Redick E: Pain reduction during neonatal circumcision. Pediatr Nurs. 1989, 15: 207-210.

    Google Scholar 

  34. Dixon S, Snyder J, Holve R, Bromberger P: Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr. 1984, 5: 246-250.

    Article  CAS  PubMed  Google Scholar 

  35. Franck L: A national survey of the assessment and treatment of pain and agitation in the neonatal intensive care unit. Journal of Obstetrical, Gynecological and Neonatal Nursing. 1987, 6: 387-393.

    Article  Google Scholar 

  36. Benini F, Johnston CC, Faucher D, Aranda JV: Topical anesthesia during circumcision in newborn infants. JAMA. 1993, 270: 850-853. 10.1001/jama.1993.03510070072039.

    Article  CAS  PubMed  Google Scholar 

  37. Blank S, Brady M, Buerk E, Carlo W, Diekema D, Freedman A, Maxwell L, Wegner S, LeBaron C, Atwood L, Craigo S, Flinn SK, Janowsky EC, Zimmerman EP: Male circumcision. American Academy of Pediatrics Task Force on Circumcision. Paediatrics. 2012, 130 (3): e756-e785.

    Google Scholar 

  38. Strimling BS: Partial amputation of glans penis during Mogen clamp circumcision. Pediatrics. 1996, 97 (6 pt 1): 906-907.

    CAS  PubMed  Google Scholar 

  39. Patel HI, Moriarty KP, Brisson PA, Feins NR: Genitourinary injuries in the newborn. J Pediatr Surg. 2001, 36 (1): 235-239. 10.1053/jpsu.2001.20062.

    Article  CAS  PubMed  Google Scholar 

  40. Duncan ND, Dundas SE, Brown B: Pinnock- Ramsaran C, Badal G: Newborn circumcision using the Plastibell device: an audit of practice. West Indian Med J. 2004, 53 (1): 23-26.

    CAS  PubMed  Google Scholar 

  41. Lazarus J, Alexander A, Rode H: Circumcision complications associated with the Plastibell device. S Afr Med J. 2007, 97 (3): 192-193.

    CAS  PubMed  Google Scholar 

  42. Beniamin F, Castagnetti M, Rigamonti W: Surgical management of penile amputation in children. J Pediatr Surg. 2008, 43: 1939-1943. 10.1016/j.jpedsurg.2008.05.028.

    Article  PubMed  Google Scholar 

  43. De Lagausie P, Jehanno P: Six years followup of a penis replantation in a child. J Pediatr Surg. 2008, 43: E11-E12.

    Article  PubMed  Google Scholar 

  44. Perovic SV, Djinovic RP, Bumbasirevic MZ, Santucci RA, Djordjevic ML, Kourbatov D: Severe penile injuries: a problem of severity and reconstruction. BJU Int. 2009, 104: 676-687. 10.1111/j.1464-410X.2008.08343.x.

    Article  PubMed  Google Scholar 

  45. Taddio A: Pain management for neonatal circumcision. Paediatr Drugs. 2001, 3 (2): 101-111. 10.2165/00128072-200103020-00003.

    Article  CAS  PubMed  Google Scholar 

  46. Bellien CV, Aloisi AM, Ceccarelli D, Valenti M, Arrighi D, Muraca MC, Temperini L, Pallari B, Lanini A, Buonocore G: Intramuscolar injections in newborns: analgesic treatment and sex-linked response. J Maternal Fetal Neonatal Med. 2012, Epub ahead of print]

    Google Scholar 

  47. Bellieni CV, Tei M, Coccina F, Buonocore G: Sensorial saturation for infants’ pain. J Matern Fetal Neonatal Med. 2012, 25 (Suppl 1): 79-81.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Carlo V Bellieni.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

CVB and GA performed the analysis of the literature. GB collaborated in the discussion. All authors read and approved the final manuscript.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article

Bellieni, C.V., Alagna, M.G. & Buonocore, G. Analgesia for infants’ circumcision. Ital J Pediatr 39, 38 (2013).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: