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We thank Dr.s Malgieri and Kendall for their constructive comment.
To address their concerns; no other anesthesia was provided pre, during or post-circumcision outside of what was included in the study i.e. EMLA cream, 2 mg/kg of 1% lidocaine for each of the local blocks and sucrose. It is not customary to provide post-circumcision analgesia in the normal nursery of our hospital. During the course of our study, none of the participating newborns were given a post-circumcision analgesic. As for the last point-- if we have understood the question correctly; table 3 represents the pain score for stages 1-6. The average procedural time was 6.30 minutes, giving each stage approximately 1 minute; understandably, one stage would blend into the other, as was observed by the reviewers vis-a-vis the baby’s NIPS indicators (expression, movement, breathing, and state of arousal).
We read with great interest the article of Sharara-Chami et al. in a recent issue of the journal.1 The authors should be congratulated for performing a well-designed randomized trial to investigate an important issue (e.g. neonatal pain ) that commonly impacts patients and parents.2 The use of EMLA cream and field blocks are inexpensive and safe solutions to reduce pain for circumcision.
Nonetheless, there are some methodological concerns that need to be clarified in order to confirm the validity of the findings of Sharara-Chami et al. First, we were wondering if any other type of anesthesia was provided by the authors as this can potentially alter postsurgical analgesic outcomes.3 Secondly, it would be important to present if any of the groups required postoperative analgesics as pain may affect these patients for a longer period than the one evaluated by the authors and could alter the outcomes if given preoperatively.4 Lastly, the authors examined pain scores across multiple time points, therefore, the statistical analysis should have been adjusted for multiple comparisons not only between groups, but also due to multiple “primary” outcomes (stage 1 through stage 6).5
We would welcome some clarifications from the authors to establish the validity of this important study.
1) Sharara-Chami R, Lakissian Z, Charafeddine L, Milad N, El-Hout Y. Combination Analgesia for Neonatal Circumcision: A Randomized Controlled Trial. Pediatrics. 2017 Dec;140(6). p...
1) Sharara-Chami R, Lakissian Z, Charafeddine L, Milad N, El-Hout Y. Combination Analgesia for Neonatal Circumcision: A Randomized Controlled Trial. Pediatrics. 2017 Dec;140(6). pii: e20171935. doi: 10.1542/peds.2017-1935. Epub 2017 Nov 17.
2) Di Pietro ML, Teleman AA, Di Pietro ML, Poscia A, González-Melado FJ, Panocchia N. Preventive Newborn Male Circumcision: What Is the Child's Best Interest? Cuad Bioet. 2017 ;28:303-316.
3) Ahiskalioglu A, Yayik AM, Ahiskalioglu EO, Ekinci M, Gölboyu BE, Celik EC, Alici HA, Oral A, Demirdogen SO. Ultrasound-guided versus conventional injection for caudal block in children: A prospective randomized clinical study. J Clin Anesth. 2017;44:91-96.
4) Shah RD, Suresh S. Acute pain management in the pediatric ambulatory setting: How do we optimize the child’s postoperative experience? J Clin Anesth. 2017;40:103-104.
5) Le May S, Ali S, Plint AC, Mâsse B, Neto G, Auclair MC, Drendel AL, Ballard A, Khadra C, Villeneuve E, Parent S, McGrath PJ, Leclair G, Gouin S; Pediatric Emergency Research Canada (PERC). Oral Analgesics Utilization for Children With Musculoskeletal Injury (OUCH Trial): An RCT. Pediatrics. 2017 Nov;140(5). pii: e20170186. doi: 10.1542/peds.2017-0186. Epub 2017 Oct 11.
I have used dorsal penile block along with sucrose and Elamax cream (Lidocaine 4% topical) in my rural pediatric practice in Ottawa Illinois for the last several years and the combination approach works well and majority of neonates sleep through the procedure. I give DPN and take a little finger off the hand glove and make a slit at the distal end and a linear cut along the one side just half the way put the cream on penis and slide the glove finger on and leave it for 20 minutes. Baby gets sucrose while getting injections as well as during procedure which at times I think baby does not need it because they are sleeping through the whole thing! The combination works impressively.
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