The Mother-Friendly Childbirth Initiative
References for Mother-Friendly Childbirth Initiative Step 9:
Discourages non-religious circumcision of the newborn.
References:
- Stevens, B., Johnston, C., & Grunan, R., (1995). Issues of assessment of pain and discomfort in neonates. Journal of Obstetric, Gynecologic and Neonatal Nursing, 24(9), 849-855. (abstract)
- Porter, F., Wolf, C., & Miller, J. P. (1999). Procedural pain in newborn infants: The influence of intensity and development. Pediatrics, 104(1), e13. (abstract)
- Lawrence, J., Alock, D., McGrath, P., Kay, J., MacMurray, S., & Dulberg, C. (1993). The development of a tool to assess neonatal pain. Neonatal Network, 12(6), 59-66. (abstract)
- To, T., Agha, P., Dick, P., & Feldman, W. (1999). Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Journal of Urology, 162(4), 1562. (abstract)
- Additional articles that support non-circumcision (not abstracted)
Abstract 1:
Stevens, B., Johnston, C., & Grunan, R., (1995). Issues of assessment of pain and discomfort in neonates. Journal of Obstetric, Gynecologic and Neonatal Nursing, 24(9), 849-855.
Premise: Infant pain is important to understand.
Research Hypothesis: Pain in the infant is not assessed adequately or accurately.
Background: One longstanding misconception about infant pain is that it is not remembered and therefore not significant.
Subjects:Infants from various studies were included in this article.
Review Topics:This is a review article on infant pain. The article summarizes research on infant response by physiologic/autonomic indicators such as heart rate, respiration rate, vagal tone, oxygen saturation, blood pressure, palmar sweating, transcutaneous saturation levels, PO2 levels, intracranial pressure, and cortisol levels. The article also discusses behavioral indicators such as facial expressions, crying, and body movements. The article explores pain transmission mechanisms and the infant’s ability for memory of pain.
Findings: After reviewing 54 studies, the article’s findings were that:
- Infants have the anatomic and functional capacity for mounting a response to noxious stimuli and pain perception at birth;
- Infants are capable of remembering pain as shown by the fact that alterations in sleep, feeding patterns, and maternal-infant interactions persist long after the noxious stimuli have ended;
- Full-term infants display gross motor withdrawal from painful stimuli, whereas ill or preterm infants may respond by becoming limp and flaccid;
- Preterm infants have less capacity for recovery after acute procedure-induced pain than do healthy infants; and
- Professionals can reduce infant pain through skilled execution of procedures and developing guidelines for effective administration of analgesics.
The article concluded that pain assessment is difficult for caregivers and parents. Good assessment of infant pain is a step in maintaining infants in a comfortable, pain-free environment. The frequency of painful procedures should be carefully ordered and delivered in order to better manage infant pain.
Research reviewed by Kay Liska, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 2:
Porter, F., Wolf, C., & Miller, J. P. (1999). Procedural pain in newborn infants: The influence of intensity and development. Pediatrics, 104(1), e13.
Premise: Even at very early prematurity, infants respond to pain and can differentiate between stimulus intensity.
Research Question: Does infant response to painful stimuli differ as a function of the intensity or invasiveness of the procedure and does it differ by gestational age at birth? How do clinicians rate the pain for various procedures?
Background:Infant pain is often poorly managed and dismissed.
Subjects:The study included 152 infants; 135 of these infants were studied at least two times (ranges 2-27). Both premature infants <28 weeks gestation and term infants within the first postnatal week of life were studied.
Study Design: Informed consent was obtained from the mothers of the eligible infants based on the set criteria. The infants were grouped by gestational age and did not have major congenital anomalies or cardiac defects. The population included premature infants, full-term infants, and healthy and sick infants. The infants were studied during their hospitalization and during medical/nursing procedures. The procedures were documented as mildly, moderately, or highly invasive. Procedures were also categorized by duration, site of procedure, and depth and extent of tissue damage. To measure the outcome before the procedure, three electrodes were placed on the chest, along with a pulse oximeter and blood pressure cuff. Input was collected at the bedside by a documenting computer. Information was collected during four stages: a) the baseline period, b) the preparatory period, c) during the procedure, and d) during the recovery period. Current medications were also documented. Procedures included gavage tube insertion, physical examinations, nose cultures, umbilical arterial catheter insertion (mild), venous punctures and heel sticks (moderate), lumbar puncture, circumcision, and eye exams for retinopathy (highly invasive).
Findings: Both full-term and preterm infants demonstrated increased magnitude responses to increasingly invasive procedures. Thus, infants not only respond to noxious stimuli, but also differentiate their intensity.
Research reviewed by Kay Liska, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 3:
Lawrence, J., Alock, D., McGrath, P., Kay, J., MacMurray, S., & Dulberg, C. (1993). The development of a tool to assess neonatal pain. Neonatal Network, 12(6), 59-66.
Premise: It is important to be able to accurately assess neonatal pain because not all pain can be avoided.
Research Question: What is the reliability and validity of a tool to examine the reliability and validity of a tool to measure neonatal pain?
Background: Health professionals are acknowledging infant pain and taking an active role in managing infants’ pain.
Subjects: The Neonatal Infant Pain Scale (NIPS) was used to evaluate pain in 38 neonates during 90 procedures. No single infant was used for more than three procedures. Infants that received analgesics within three hours were excluded.
Study Design:The procedures were videotaped using ambient lighting. The infant was taped for two minutes prior to the needle stick and three minutes after the completion of the procedure. The infant’s response was rated on the NIPS (0-7) based on facial expression, crying, breathing patterns, flexion of arms and legs, and state of arousal.
Findings: The NIPS had a high internal consistency with Alphas of .95, .87, and .88 before, during, and after the procedure. Inner rater-reliability was .92 to .97. Concurrent validity within a visual analog scale was .53 to .84. The NIPS was judged to be an objective reliable tool to assess infant pain.
Research reviewed by Kay Liska, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 4:
To, T., Agha, P., Dick, P., & Feldman, W. (1999). Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Journal of Urology, 162(4), 1562.
Premise: Only a minimally reduced risk of urinary infection exists in circumcised infants.
Research Question: Does a greater incidence of urinary tract infection (UTI) occur in uncircumcised males?
Variables: Incidence of UTI in newborn males born between 1993 and 1994 at one year follow up.
Subjects: A total of 69,100 male neonates born in Ontario, Canada, between April 1993 and March 1994.
Data Collection: Hospital discharge data used in a population-based cohort study.
Findings: Of 69,100 eligible boys, 30,105 (43.6%) were circumcised and 38,995 (56.4%) were uncircumcised. Admissions for UTI were 1.88 per 1,000 (247 cases at the end of follow-up). Findings support the notion that circumcision may protect boys from UTI. At one year, hospital admissions for circumcised infants were 83 and uncircumcised infants were 247. The researchers concluded that 195 infants would need to be circumcised to prevent one hospital admission. This rate is similar to Australia and lower than previous figures in the United States. Realization that the actual number are lower than previously thought led the American Academy of Pediatrics to conclude that the difference is not great enough to advocate routine circumcision for male infants.
Research reviewed by Luella Bell, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Additional articles that support non-circumcision (not abstracted):
Goldman R. The psychological impact of circumcision. BJU International 1999;83 Suppl. 1:93-103. (http://www.cirp.org/library/psych/goldman1/)
Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal 1999; 29(3):215-221. (http://www.cirp.org/library/psych/rhinehart1/)
Williams N, Kapila L. Complications of Circumcision. Brit J Surg 1993; 80:1231-1236. ( http://www.cirp.org/library/complications/williams-kapila/)
The following as yet unpublished article (do a search for the article title at the Circumcision Information Research Pages website (http://www.cirp.org/) after mid 2002):
Boyle G.J., Goldman R., Svoboda, J. & Fernandez, E. (2002) Male Circumcision: Pain, Trauma, and Psychosexual Sequelae. J Health Psychol. In Press.
An earlier article by two of the same authors is:
Boyle G.J., Goldman R., Svoboda, J., Price, C.P., & Turner, J. N. (2000). Circumcision of Healthy Boys: Criminal Assault? Journal of Law and Medicine 7 February, 301-310 (http://www.cirp.org/library/legal/boyle1/)