Penile Nerve Block Research Articles

Levobupivacaine for Postoperative Pain Management in Circumcision; Caudal Blocks or Dorsal Penile Nerve Block

In this study, we evaluated the analgesic efficacy and adverse effect profile of levobupivacaine in caudal and DPNB in postcircumcision pediatric patients. Sixty boys between 2-10 years of age undergoing circumcision were enrolled. The patients were divided into two groups: Group C (n=30) and Group P (n=30) were applied caudal block or dorsal penile nerve block (DPNB), respectively. Blocks were performed before surgery as a supplement to general anesthesia with 1 mL kg(-1) 0.25% levobupivacaine. Postoperative pain and sedation scores were assessed on the 10th and 30th minutes, and hours 1-6. The number of pain free patients in the first 6 hours, the duration of analgesia, time to first analgesic administration, walking, micturition, and total paracetamol demands, and length of stay were recorded. Demographic data were similar between groups. The number of children who spent the first 6 hours pain-free was larger in Group C than Group P (p=0.0001). The time to first analgesic (p=0.000033) and walking (p=0.004) were longer in Group C. There were 14 patients with motor block in Group C (p=0.00007). In view of AUC, FPRS, OPS and MPOPS were significantly better in Group C on the first postoperative 6 hours. Caudal block done using levobupivacaine for postoperative pain management in circumcision is more successful than penile block, however there is a significant delay in time to first walking and as might be expected there is an increased risk of motor block.

Dorsal penile nerve block for male pediatric circumcision – randomized comparison of ultrasound‐guided vs anatomical landmark technique

Dorsal penile nerve block (DPNB) is a commonly performed regional anesthetic technique for male circumcision. Traditionally, DPNB is based on an anatomical landmark technique. Recently, an ultrasound-guided technique for DPNB has been described. The aim of our study was to compare the anatomical landmark technique with this ultrasound-guided technique. The hypothesis to be tested was that ultrasound guidance of DPNB would lead to less administration of opioid when compared to the anatomical landmark technique. Boys of ASA status I/II scheduled for day case circumcision were prospectively recruited and randomized. DPNB was performed under general anesthesia using the anatomical landmark technique or ultrasound guidance. Fentanyl was administered intraoperatively and immediately postoperatively if patients demonstrated signs of pain. Similarly, oral codeine was given prior to discharge if required. The primary outcome measure was the number of patients requiring fentanyl. Secondary outcome measures included initial pain score on emergence from general anesthesia, requirement for codeine predischarge, and time to perform block. A total of 32 patients were recruited to the landmark group and 34 to the ultrasound group. There was no significant difference between the two groups in terms of fentanyl administration. The ultrasound technique took longer to perform but was associated with a reduction in codeine requirement prior to discharge. This study does not support the routine use of ultrasound for the performance of DPNB in male pediatric circumcision. Nonetheless, an associated reduction in codeine administration postoperatively suggests some benefit in terms of postoperative pain.

A comparison of pudendal block vs dorsal penile nerve block for circumcision in children: a randomised controlled trial

We compared the analgesic and anaesthetic efficacy of pudendal nerve block with that of dorsal penile nerve block in male patients aged 3-5 years of age, undergoing elective circumcision. Thirty patients had a nerve stimulator-guided pudendal nerve block with two separate injection points 1.5-2 cm from the centre of the anus, and thirty patients received a dorsal penile nerve block. The same total anaesthetic volume of 0.3 ml.kg(-1) was used in both groups. The pudendal nerve group showed significantly lower postoperative pain scores than the dorsal group (SD) (p < 0.05), and significantly fewer patients consumed analgesics in the pudendal group than the dorsal group: 0 vs 5 (17%) at 0 and 6 h, respectively. This study demonstrates the effectiveness of pudendal nerve block in comparison to the dorsal nerve block, with improved postoperative outcomes in children undergoing circumcision.

Comparison of Postoperative Analgesic Efficacy of Caudal Block versus Dorsal Penile Nerve Block with Levobupivacaine for Circumcision in Children

BackgroundCircumcision is a painful intervention frequently performed in pediatric surgery. We aim to compare the efficacy of caudal block versus dorsal penile block (DPNB) under general anesthesia for children undergoing circumcision.MethodsThis study was performed between July 1, 2009 and October 16, 2009. Fifty male children American Society of Anesthesiolgists physical status classification I, aged between 3 and 12 were included in this randomized, prospective, comparative study. Anesthetic techniques were standardized for all children. Patients were randomized into 2 groups. Using 0.25% 0.5 ml/kg levobupivacain, we performed DPNB for Group 1 and caudal block for Group 2. Postoperative analgesia was evaluated for six hours with the Flacc Pain Scale for five categories; (F) Face, (L) Legs, (A) Activity, (C) Cry, and (C) Consolability. For every child, supplemental analgesic amounts, times, and probable local or systemic complications were recorded.ResultsNo significant difference between the groups (P > 0.05) was found in mean age, body weight, anesthesia duration, FLACC pain, and sedation scores (P > 0.05). However, on subsequent measurements, a significant decrease of pain and sedation scores was noted in both the DPNB group and the caudal block group (P < 0.001). No major complication was found when using either technique.ConclusionsDPNB and caudal block provided similar postoperative analgesic effects without major complications for children under general anesthesia.

Comparing caudal and penile nerve blockade using bupivacaine in hypospadias repair surgeries in children

Caudal anaesthesia is recommended for most surgical procedures of the lower part of the body, mainly below the umbilicus. It has been well established that a dorsal penile nerve block immediately after surgery decreases postoperative pain in children undergoing hypospadias repair. This study aimed to compare caudal or penile nerve block using bupivacaine in postoperative pain control in hypospadias repair in children. After local ethical committee approval and obtaining informed parental consent, 85 American society of Anesthesiologists status I and II patients, aged 6 months to 6 years old, undergoing hypospadias repair, were prospectively enrolled in this study. The patients were randomly divided into the following two groups: Caudal block was performed in 44 and penile block was performed in 41 patients. Cardiorespiratory systems data, analgesic requirement and complications were compared between the groups. There were statistically significant haemodynamic (blood pressure and heart rate) alteration during operation in each group (P<0.01). The haemodynamic parameters were stable during operation in successful blocks in both groups. Caudal block success rate is 97.7%, whereas in penile block is 92.6%. Nineteen of 43 patients (44%) in caudal group and 29 of 41 patients (70%) in penile group received analgesia in the postoperative period and this difference was significant between the two groups (P = 0.025). Without ultrasonography and with blind block, with anatomic landmarks only, the caudal block success rate is high and if there is no contraindication for caudal block, it is the best choice in children under 6 years old (or 25 kg) for hypospadias repair.

Meatotomy Using Local Anesthesia and Sedation or General Anesthesia With or Without Penile Block in Children: A Prospective Randomized Study

Meatotomy is a simple, common procedure for the treatment of meatal stenosis. We compared the outcomes of meatotomy performed using local anesthesia and sedation, and general anesthesia with and without penile block. A prospective comparative design was used. Participants included 76 boys 1.5 to 10 years old treated for meatal stenosis at a tertiary, university affiliated, pediatric medical center in 2008. Children were randomly allocated to undergo surgery with sedation and local anesthesia, or general anesthesia with or without penile block. All procedures were performed with the same method by the same surgeon. For local anesthesia EMLA 5% cream (lidocaine 2.5% and prilocaine 2.5%) covered with an occlusive dressing was applied 1 hour preoperatively, and midazolam (in patients younger than 5 years) or nitrous oxide (older than 5 years) was used for sedation. General anesthesia was induced with inhaled sevoflurane, and ropivacaine was used for dorsal penile nerve block. There was no difference among the groups in pain level intraoperatively (no pain in 92% to 93% of patients), 24 hours postoperatively (no pain in 81% to 88%) or after 1 month, or in complication rates (bleeding in 3 patients, laryngospasm in 2). General anesthesia with penile block was associated with a trend of less dysuria. Quality of void was excellent in 87% of patients at 24 hours and in 70% at 1 month, and parental satisfaction was high (88% to 92%). Meatotomy performed using local anesthesia and sedation has an equally good outcome to meatotomy performed using general anesthesia with or without penile block.

Does ultrasound guidance improve the efficacy of dorsal penile nerve block in children?

Penile nerve block (PNB) is a well-established technique used for circumcision; it requires the injection of local anesthetics close to the dorsal nerve of the penis. The goal of this study was to compare the efficacy of ultrasound-guided PNB versus the classical landmark-based technique (LBT) in children undergoing circumcision. Forty boys, aged 1-14 years old that were scheduled for circumcision were randomly assigned to ultrasound-guided and landmark-based groups. All patients were placed under standard anesthesia with sevoflurane. In each group, patients received the penile block with ropivacaine, 0.75 mg·kg(-1) per side, and 0.05 mg·kg(-1) at the penis base. Groups were compared for intraoperative failure rate of the block, anesthesia time, postoperative pain scale, time of first required dose of paracetamol, time to first micturition, and average duration of stay in the postanesthesia care unit. The failure rate of dorsal PNB was not statistically different between groups (P = 0.5). Ultrasound guidance improved the efficacy of the PNB compared to the LBT in terms of postoperative pain scores on arrival in the PACU (P < 0.01) and after 30 min (P < 0.01). The ultrasound-guided technique also delayed the time to the first paracetamol dose administration (P < 0.0001), but the duration of the procedure, defined as the time between anesthesia induction and the end of surgery, was increased by 10 min in the US-guided group (P = 0.001). Ultrasound-guided PNB improved the efficacy of the block compared with the LBT in terms of the postoperative pain during the first postoperative hour and the time to the first requirement for postoperative analgesia.

A preliminary study of the sensory distribution of the penile dorsal and ventral nerves: implications for effective penile block for circumcision

To determine the sensory innervation of the penis, as regional anaesthesia is often used either for postoperative analgesia or as the sole anaesthetic technique for circumcision. Since first described in 1978 the dorsal penile nerve block has become the standard technique, but some blocks are ineffective; a better understanding of the sensory innervation of the penis might improve the efficacy of the dorsal penile block technique. In 13 men undergoing circumcision with local anaesthetic, cutaneous sensation was tested before and after infiltration of the dorsal aspect of the penis, and then again after infiltration of the ventral aspect. The area of anaesthesia was mapped using pin-prick sensation. Ten of the 13 patients showed a similar pattern of sensory distribution. After the dorsal block, the dorsal aspect of the shaft of the penis and glans penis became insensate. The ventral aspect of the shaft remained sensate up to and including the frenulum. After successful ventral infiltration all sensate areas became insensate and circumcision proceeded. In one case the frenulum and distal ventral foreskin was anaesthetized after the dorsal block and ventral infiltration was not required. No patient experienced pain during circumcision. For consistently successful regional anaesthesia of the foreskin in circumcision, a dorsal block must be used. This should be combined with ventral infiltration at the site of incision. This method will avoid inconsistencies and allow pain-free circumcision using local anaesthesia in most men.

A Retrospective Audit of three Different Regional Anaesthetic Techniques for Circumcision in Children

Postoperative analgesia for male circumcision surgery has been traditionally provided by a landmark-based dorsal penile nerve block (DPNB-LM) or by caudal epidural analgesia (CEA). In this study we report on a retrospective analysis of the effectiveness and safety of CEA, DPNB-LM and ultrasound-guided dorsal penile nerve block (DPNB-US) in our institution over a six-year period. Information was gathered from each patient's medical record. A total of 216 circumcisions were performed on patients aged from five months to 15 years. One hundred and fifteen patients received CEA, 46 DPNB-LM and 55 DPNB-US. Patients in the DPNB-LM group required rescue morphine administration in the recovery unit more frequently (30.4%) than either the DPNB-US (3.5%) or CEA groups (3.6%). Similarly, the DPNB-LM group required a larger total dose of morphine, and had longer recovery ward stays than CEA or DPNB-US groups. Time to first analgesia was greatest for the CEA group while there was no significant difference between time to first analgesia for DPNB-LM and DPNB-US. Sixty-three percent of patients in the DPNB-LM group, 1.7% of CEA and 5.5% of the DPNB-US required intraoperative opiates (P < 0.0001). There was no difference in time to hospital discharge.

Selected abstracts from the Annual Meeting, Society of Paediatric Anaesthetists in New Zealand and Australia (SPANZA). Held 6–9 November 2008 in the Hunter Valley, NSW, Australia. A retrospective analysis of three different regional anaesthetic techniques for male circumcision

Postoperative analgesia for male circumcision surgery has been traditionally provided by a landmark based Dorsal Penile Nerve Block (DPNB‐LM) (1) or by Caudal Epidural Analgesia (CEA). In this study we report on a retrospective analysis of the effectiveness and safety of CEA, DPNB‐LM and Dorsal Penile Nerve block – Ultrasound guided (DPNB‐US) in our institution over a 6 year period. Information was gathered from each patient's medical record. A total of 216 circumcisions were performed on patients aged from 5 months to 15 years. A total of 115 patients received CEA, 46 DPNB‐LM and 55 DPNB‐LM. Patients in the DPNB‐LM group required rescue morphine administration in the Recovery unit more frequently (30.4%) than either the DPNB‐US (3.5%) or CEA groups (3.6%). Similarly, the DPNB‐LM group required a larger total dose of morphine, and had longer recovery ward stays than CEA or DPNB‐US groups. Time to first analgesia was greatest for the CEA group whilst there was no significant difference between time to first analgesia for DPNB‐LM and DPNB‐US. About 63% of patients in the DPNB‐LM group, 1.7% of CEA and 5.5% of the DPNB‐US required intraoperative opiates (P&lt;0.0001). There was no difference in time to hospital discharge. Patient demographics, premedication and procedure duration CEA n = 115 DPNB‐LM n = 46 DPNB‐US n = 55 P‐value (mean comparison byanova, proportions by Chi‐square) ASA 1 (n) (%) 106 (92.2) 41 (89.1) 46 (83.6) 0.5 Mean weight in (kg) ±sd 14 ± 6 23 ± 17 21 ± 17 &lt;0.0001 Mean age (years) ±sd 3 ± 2 5 ± 4 5 ± 4 &lt;0.0001 Paracetamol premedication (n) (%) 109 (95) 46 (100) 49 (89) 0.06 Midazolam premedication (n) (%) 92 (80) 29 (63) 39 (71) 0.07 Mean duration of procedure in (min) ±sd 49 ± 11 50 ± 14 51 ± 12 0.64 Outcomes Outcomes CEA n = 115 DPNB‐LM n = 46 DPNB‐US n = 55 P‐value Difference (confidence interval) and individual P‐value after correction for multiple comparison Patients requiring morphine in recovery (%) 4 (3.6) 14 (30.4) 2 (3.5) &lt;0.0001 Mean morphine in recovery (μg/kg ±sd) 1.7 ± 10.1 16.9 ± 39.2 0.5 ± 2.7 &lt;0.001 DPNB‐LM v Caudal 15.2 (7.1‐23.2) (P&lt;0.0001) DPNB‐LM v DPNB‐US 16.4 (7.2‐25.6) (P=0.0001) DPNB‐US v Caudal 1.2 (‐6.3‐8.8) (P=0.9) Mean Duration of recovery ward stay (min) ±sd 69 ± 23 84 ± 49 62 ± 16 0.0009 DPNB‐LM v Caudal 14.8 (2.6‐26.9) (P=0.01) DPNB‐LM v DPNB‐US 22.1 (8.2‐36.0) (P=0.0007) DPNB‐US v Caudal 7.3 (‐4.1‐18.7) (P=0.3) Mean Time to first analgesia (min) ±sd 179 ± 89 90 ± 76 132 ± 68 0.0004 DPNB‐LM v Caudal 89.5 (38.2‐140.8) (P=0.0002) DPNB‐LM v DPNB‐US 42.1 (11.1‐95.2) (P=0.2) DPNB‐US v Caudal 47.4 (‐3.8‐98.7) (P=0.0.08) Intraoperative opiates (n) (%) 2 (1.7%) 29 (63%) 3 (5.5%) &lt;0.0001 Mean Time to hospital discharge (min) ±sd 273 ± 137 296 ± 189 250 ± 158 0.3 PONV requiring treatment (n) 10 5 0 0.06 Reference1 Sandeman DJ, Dilley AV. Ultrasound guided dorsal penile nerve block in children. Anaesth Int Care 2007; 35(2): 266–269.

HAVE INGUINAL INCISION AND LAPARASCOPY FOR UNDESCENDED IMPALPABLE TESTES BECOME OBSOLETE?

INTRODUCTION AND OBJECTIVE: Dorsal penile block is a widely performed procedure for peri-operative local anesthesia prior to minor penile surgery. Multiple studies have demonstrated improved periand post-operative analgesia attributed to the use of dorsal penile block. Due to its potency and long duration of action, bupivacaine is a commonly used agent, though it has been associated with cardiac toxicity when administered in high doses or inadvertently injected intravenously. Pediatric patients may be at particular risk for this complication due to the larger relative doses used in young children. We reviewed the operative records of all outpatient penile surgery cases over an 18 month period to look for signs of cardiac toxicity associated with the penile block. METHODS: After obtaining Instutional Review Board approval, we reviewed the records of all children who underwent penile surgery with a dorsal penile nerve block at Children’s Hospital Boston between January 2007 and June 2008. Dorsal penile blocks were performed in standard fashion prior to the surgical procedure using a 25-gauge needle inserted inferior to the pubic symphysis. The amount of bupivacaine used was determined by patient weight (maximum of 1 mL/kg of 0.25% bupivacaine). RESULTS: Four patients were noted to have evidence of cardiac toxicity with bupivacaine (Table 1). Two patients developed apnea and transient ECG changes (widened QRS with peaked T waves) that resolved spontaneously and were discharged home on the same day. One of these patients had received only a small portion of the total bupivacaine dose when these changes were noted, suggesting inadvertent intravascular injection. Two patients developed profound cardiac effects, one demonstrating ECG evidence of ST depression and decreased LV function on echocardiogram, and the other developed sustained atrial flutter. CONCLUSIONS: Dorsal penile blockade is widely used in pediatric urology for penile surgery. Although useful as a long-acting agent for regional anesthesia, bupivacaine is associated with cardiac toxicity and must be administered cautiously with close cardiac monitoring during surgery.

Utilidad del BIS® y AEP Monitor/2® para el mantenimiento de la anestesia combinada sevoflurano-regional, comparada con la práctica estándar en población pediátrica

To compare the indices computed by a bispectral (BIS) monitor and an auditory evoked potential (AEP) monitor during maintenance of anesthesia in pediatric patients. A secondary objective was to compare anesthetic consumption and recovery times. Patients aged 6 months to 12 years under inhaled anesthesia with sevoflurane were administered a penile or caudal nerve block. BIS and AEP monitoring was then started. The patients were randomized to 3 groups in which the sevoflurane dosage was guided by the BIS index, the A-line ARX index (AAI), or standard procedures (control group). The BIS index, the AAI, the fraction of expired sevoflurane, hemodynamic parameters, and recovery time were the variables recorded for all patients. Thirty-five patients were enrolled. Significant differences between the 2 monitor groups were observed. The mean (SD) AAI was lower in patients whose dosage was controlled by the BIS index (19 [2]) than in those whose dosage was based on the AEP monitor's reading (22 [4]) (P=.04). According to a Bland and Altman plot, there was good agreement between the BIS index and the AAI except for the highest and, in particular, the lowest values. The volumes of sevoflurane used and the recovery times were similar between groups. There was a positive correlation between the 2 indices (Pearson correlation coefficient, 0.207; P<.001). BIS monitoring provided a more stable index than did AEP monitoring and BIS-index guidance achieved a deeper level of hypnosis. There was good correlation between the 2 indices during maintenance of anesthesia. Neither monitor offered advantages over standard procedures with regard to movement, volume of anesthetic consumed, or recovery time.

A Review of Systematic Reviews on Pain Interventions in Hospitalized Infants

Hospitalized infants undergo multiple, repeated painful procedures. Despite continued efforts to prevent procedural pain and improve pain management, clinical guidelines and standards frequently do not reflect the highest quality evidence from systematic reviews. To critically appraise all systematic reviews on the effectiveness of procedural pain interventions in hospitalized infants. A structured review was conducted on published systematic reviews and meta-analyses of pharmacological and nonpharmacological interventions of acute procedural pain in hospitalized infants. Searches were completed in the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL and PsycINFO. Two reviewers independently selected articles for review and rated the methodological quality of the included reviews using a validated seven-point quality assessment measure. Any discrepancies were resolved by a third reviewer. Of 1469 potential systematic reviews on interventions for painful procedures in hospitalized infants, 11 high-quality reviews were included in the analysis. Pharmacological interventions supported by research evidence included premedication for intubation, dorsal penile nerve block and EMLA (AstraZeneca Canada, Inc) for circumcision, and sucrose for single painful procedures. Non-nutritive sucking, swaddling, holding, touching, positioning, facilitative tucking, breast feeding and supplemental breast milk were nonpharmacological interventions supported for procedural pain. There is a growing number of high-quality reviews supporting procedural pain management in infants. Ongoing research of single, repeated and combined pharmacological and nonpharmacological interventions is required to provide the highest quality evidence to clinicians for decision-making on optimal pain management.

Caudal anaesthesia as a treatment for penile ischaemia following circumcision

We report an ischaemic penile glans following circumcision and a dorsal penile nerve block in a 9-year-old boy. Ischaemia of the glans penis is a rare complication associated independently with both circumcision and dorsal penile nerve blocks. There are a number of pathophysiological mechanisms of this ischaemia and its management is varied and not well recorded. We report the successful management of this complication using a caudal epidural block and also discuss technical aspects of penile nerve blocks.

Ultrasound Guided Dorsal Penile Nerve Block in Children

We describe a technique for using a portable ultrasound scanner (38 mm broadband (10-5 MHz) linear array transducer (Sonosite Titan SonoSite, Inc. 21919 30th Drive SE Bothell, WA.)) to guide dorsal penile nerve block in children under general anaesthesia. Real-time scanning is used to guide bilateral injections into the sub-pubic space, deep to Scarpa's fascia either side of the midline fundiform ligament. Scanning can confirm that the local anaesthetic has spread to contact the deep fascia on each side. A subcutaneous wheal of local anaesthetic along the penoscrotal junction completes the block.

CPT Code Changes for 2007

<i>CPT</i> Code Changes for 2007

Penile nerve block with levobupivacaine 0.25% or ropivacaine 0.25% produced similar analgesic effects in children after circumcision

Penile nerve block with levobupivacaine 0.25% or ropivacaine 0.25% produced similar analgesic effects in children after circumcision

An unusual complication of dorsal penile nerve block for circumcision

An unusual complication of dorsal penile nerve block for circumcision

A video study of pain relief during newborn male circumcision.

The purpose of this investigation was to compare the effectiveness of dorsal penile nerve block and topical lidocaine-prilocaine anesthesia techniques for pain relief during circumcision. In total, 18 healthy term newborn males were divided based on anesthesia. The topical lidocaine-prilocaine group had six males undergoing circumcision and three males undergoing a sham procedure. The dorsal penile nerve block group had six males undergoing circumcision and three males undergoing a sham procedure. The procedures were videotaped and viewed by 90 noninvestigator reviewers who scored the infants' pain using the Neonatal Infant Pain Scale and a numeric pain scale. Statistical analysis utilized a P-value of <0.05 as significant. The median Neonatal Infant Pain Scale and numeric pain scores were significantly lower in the dorsal penile nerve block group than in the topical lidocaine-prilocaine group or the sham group (Neonatal Infant Pain Scale: 1.0 (range 0-6) versus 6.0 (range 2-6) versus 4.0 (range 0-6), P < 0.001, respectively; numeric pain scale: 2.0 (range 0-10) versus 8.0 (range 1-10) versus 4.0 (range 0-10), P < 0.001, respectively). In the sham group, procedures with the dorsal penile nerve block had significantly lower pain scores than those with topical lidocaine-prilocaine (Neonatal Infant Pain Scale: 1.0 (range 0-6) versus 5.0 (range 2- 6), P < 0.001; numeric pain scale: 1.0 (0-8) versus 6.0 (range 0-10), P < 0.001). When reviewers were divided by medical background, gender or parental status, no differences in pain scores were observed. The dorsal penile nerve block anesthesia technique for newborn male circumcision was significantly more effective for pain relief than topical lidocaine-prilocaine.

The use of non-nutritive sucking to decrease the physiologic pain response during neonatal circumcision: A randomized controlled trial

The purpose of this research was to study the effects on the physiologic pain response of the neonate during circumcision with the use of a gloved human finger. This was a randomized controlled trial analyzing the effect of non-nutritive sucking (NNS) on pain response during circumcision. Term neonates were randomized to 2 groups. All infants received oral Tylenol and a dorsal penile nerve block (DPNB) before the circumcision. The study group was offered the addition of NNS before the DPNB and throughout the procedure. The primary outcome measured was heart rate during the circumcision. Other variables studied included crying time and salivary cortisol levels. Each circumcision was filmed to calculate pain profile scores using the Premature Infant Pain Profile. Variables were compared using Student t test, chi-square, and Wilcoxon test. A P value of < .05 was considered significant. Forty-four infants met inclusion criteria. Twenty-two infants were randomized to each arm. No difference in mean heart rate during the procedure was apparent. A significant decrease in crying time, 90-minute post-procedure salivary cortisol level, and post-penile clamping pain score was noted in the study group (all P values < .01). NNS significantly decreases some elements of measurable physiologic pain response of the neonate during circumcision. This method is a useful and inexpensive addition to DPNB and oral analgesics.